1. The Lancet Series on Maternal and Child Nutrition
Launch Symposium
6 June, 2013
Imperial College – St Mary’s Campus
Rothschild Lecture Hall, School of Medicine
Norfolk Place, London

2. Prevalences and Consequences
Maternal and Child Undernutrition and Overweight in Low-and Middle-Income Countries:
Prevalences and Consequences
Robert E Black1, Cesar G Victora2, Susan P Walker3, Zulfiqar A Bhutta4, Parul Christian1, Mercedes de Onis5, Majid Ezzati6, Sally Grantham-McGregor3,7, Joanne Katz1, Reynaldo Martorell8, Ricardo Uauy9 and the Maternal and Child Nutrition Study Group
1 Johns Hopkins University
2 Universidad de Federal de Pelotas
3 The University of the West Indies
4 The Aga Khan University and Medical Center
5 World Health Organization
6 Imperial College of London
7 University College London
8 Emory University
9 London School of Hygiene and Tropical Medicine

3. Series Background
2008 Series identified need to focus on critical period during pregnancy and first two years of life, the 1,000 days in which good nutrition and healthy growth have lifelong benefits
2008 Series also called for greater priority for national nutrition programmes, stronger integration with health programmes, enhanced inter-sectoral approaches and more focus and coordination in the global nutrition system
Five years on, we re-evaluate problems of maternal and child undernutrition, consider growing problem of overweight and obesity for women and children and assess the current and needed national and global response
2008 Series Executive Summary

4. Series Overview
Paper 1: prevalence and consequences of nutritional conditions during life course from adolescence (for girls) through pregnancy to childhood and implications for adult health
Paper 2: evidence supporting nutrition-specific interventions, health impact and cost of scaling up
Paper 3: nutrition-sensitive interventions and approaches and their potential to improve nutrition
Paper 4: the features of an enabling environment for nutrition and how they can be favourably influenced
Comment: examines what is currently being done, and what should be done nationally and internationally
Insert Series cover/exec summary
2013 Series Executive Summary

5. Framework for Actions to Achieve Optimum Fetal and Child Nutrition and Development

6. Adolescent Nutrition

7. Adolescent Nutrition: Important for Girls, and for the Future Generation
As many as half of all adolescent girls in some countries are stunted, increasing risk of complications in pregnancy and delivery and of poor fetal growth

8. Maternal Nutrition

9. Trends in Thinness and Obesity for Women Aged 20-29 Years in UN Regions and Globally (1980-2008)
Prevalence of low BMI in adult women has decreased in Africa/Asia since 1980, but remains higher than 10%
Maternal overweight and obesity has increased steadily since 1980;
resulting in increased maternal morbidity and infant mortality

10. Prevalence of Vitamin A and Iodine Deficiencies, Inadequate Zinc Intake, and Iron Deficiency Anaemia

11. Iron and Calcium Deficiencies Contribute to Maternal Deaths
Series confirms anaemia is a risk factor for maternal deaths, most likely due to haemorrhage, the leading cause of maternal deaths (23% of total deaths)
Calcium deficiency increases the risk of pre-eclampsia, currently the second leading cause of maternal death (19% of total deaths)
Addressing these deficiencies could result in substantial reduction of maternal deaths

12. Evidence Highlights Importance of Nutritional Status in Women Before and During Pregnancy
Short maternal stature may lead to obstructed labour and maternal and fetal or neonatal death Maternal stunting and low Body Mass Index increases the risk of fetal growth restriction (small for gestational age) Maternal obesity leads to gestational diabetes, pre-eclampsia, haemorrhage and higher risk of neonatal and infant death

13. Prevalence of SGA Births
32.4 million babies were born SGA in 2011; 27% of all births in LMICs

14. Risks of SGA for Mortality and Preterm Birth for Neonatal Mortality
Reductions in child mortality could be achieved by targeting interventions to reach babies born too small or too soon

15. Risk of SGA for Stunting
20% of stunting by
24 months can be attributed to being SGA

16. Child Nutrition

17. Stunting Rate is Slowly Decreasing
Figure 4
165 million children under five are stunted (25.7%)
2.1% annual rate of reduction is not fast enough to reach WHA target

18. 52 million children under 5 are wasted, 19 million severely wasted
Prevalence of Wasting and Severe Wasting in Children <5 Years Old by UN Regions, 2011
52 million children under 5 are wasted,
19 million severely wasted

19. Child Obesity on the Rise

20. Micronutrient Deficiencies
Deficiencies of essential vitamins and minerals continue to be widespread and have significant adverse effects on child survival and development, as well as maternal health
Deficiencies of vitamin A and zinc adversely affect child health and survival, and deficiencies of iodine and iron, together with stunting, contribute to children not reaching their developmental potential
Significant progress has been made in addressing vitamin A deficiency but efforts must continue at current coverage levels to avoid backsliding because dietary intake of vitamin A is still inadequate

21. Other Infectious Deaths
When Coupled with Infectious Diseases, Wasting Increases Hazard of Death
 Weight-for-Length
Z-Score
All Deaths HR
(95% CI)
Pneumonia Deaths
Diarrhoea Deaths
Measles Deaths
Other Infectious Deaths
< -3
11.6
(9.8, 13.8)
9.7
(6.1, 15.4)
12.3
(9.2, 16.6)
9.6
(5.1, 18.0)
11.2
(5.9, 21.3)
-3 to < -2
3.4
(2.9, 4.0)
4.7
(3.1, 7.1)
(2.5, 4.6)
2.6
(1.3, 5.1)
2.7
(1.4, 5.5)
-2 to < -1
1.6
(1.4, 1.9)
1.9
(1.3, 2.8)
(1.2, 2.1)
1.0
(0.6, 1.9)
1.7
(1.0, 2.8)
≥ -1
NEED TO INSERT

22. Height/Length-for-Age Other Infectious Deaths
When Coupled with Infectious Diseases, Stunting Increases Hazard of Death
 Height/Length-for-Age
Z-Score
All Deaths HR
(95% CI)
Pneumonia Deaths
Diarrhoea Deaths
Measles Deaths
Other Infectious Deaths
< -3
5.5
(4.6, 6.5)
6.4
(4.2, 9.8)
6.3
(4.6, 8.7)
6.0
(3.0, 12.0)
3.0
(1.6, 5.8)
-3 to < -2
2.3
(1.9, 2.7)
2·2
(1.4, 3.4)
2.4
(1.7, 3.3)
2.8
(1.4, 5.6)
1.9
(1.0, 3.6)
-2 to < -1
1.5
(1.2, 1.7)
1.6
(1.0, 2.4)
1.7
(1.2, 2.3)
1.3
(0.6, 2.6)
0.9
(0.5, 1.9)
> -1
1.0
NEED TO INSERT

23. Prevalence of Stunting and Overweight for Highest and Lowest Wealth Quintiles in Selected Countries

24. Breastfeeding Practices by UN Region During 2000-2010
Exclusive breastfeeding only about 30% or less in major UN regions

25. Child Mortality Due to Nutritional Disorders
Attributable deaths with UN prevalences*
Proportion of total deaths of children younger than 5 years
Fetal growth restriction (<1 month)
817,000
11.8%
Stunting (1-59 months)
1,017,000*
14.7%
Underweight (1-59 months)
999,000*
14.4%
Wasting (1-59 months)
Severe Wasting (1-59 months)
875,000*
516,000*
12.6%
7.4%
Zinc deficiency (12-59 months)
116,000
1.7%
Vitamin A deficiency (6-59 months)
157,000
2.3%
Suboptimum breastfeeding (0-23 months)
804,000
11.6%
Joint effects of fetal growth restriction and suboptimum breastfeeding in neonates
1,348,000
19.4%
Joint effects of fetal growth restriction, suboptimum breastfeeding, stunting, wasting, and vitamin A and zinc deficiencies (<5 years)
3,097,000
44.7%
Data are to the nearest thousand. *Prevalence estimates from the UN.

26. Child Deaths Attributed to Nutritional Conditions
Undernutrition (fetal growth restriction, sub-optimal breastfeeding, stunting, wasting and deficiencies of vitamin A and zinc) is responsible for 45% of all under five child deaths, representing more than 3 million deaths each year (3.1 million of the 6.9 million child deaths in 2011) Fetal growth restriction and sub-optimal breastfeeding together are responsible for more than 1.3 million deaths, or 19.4% of all under five child deaths, representing 43.5% of all nutrition- related deaths Deficiencies of vitamin A and zinc are responsible for nearly 300,000 child deaths

27. Paper 1 Key Messages
Short stature, low BMI and vitamin and mineral deficiencies in pregnancy contribute to maternal morbidity and mortality, fetal growth restriction, infant mortality and stunted growth and development
Stunting of growth in the first 2 years of life affects 165 million children who have elevated risk of mortality, cognitive deficits and increased risk of adult obesity and non-communicable diseases
Vitamin A and zinc deficiencies in young children increase the risk of death from infection and other micronutrients have important developmental consequences
This new evidence strengthens the case for a continued focus on the critical 1,000 day window during pregnancy and the first two years of life, highlighting the importance of intervening early in pregnancy and even prior to conception