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

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

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

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

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

Adolescent Nutrition

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

Maternal Nutrition

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

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

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

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

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

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

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

Child Nutrition

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

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

Child Obesity on the Rise

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

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

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

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

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

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.

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

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