Achieving Freedom from Maternal and Child Undernutrition: An Update on The Lancet Series

1. 34th Session of the Standing Committee on Nutrition: Working Together Third Session Monday, 26 February Achieving Freedom from Maternal and Child Undernutrition: An Update on The Lancet Series   Saul S. Morris London School of Hygiene & Tropical Medicine (Honorary)

2. Outline • Series basics • Progress in the three streams of series activity • Revised timeline • Talk to us!

3. Series Basics

4. Series objectives • Provide evidence of the importance and determinants of maternal and child undernutrition in global health • Provide evidence of the effectiveness of nutrition interventions and programs with respect to mortality, morbidity and human potential • Place nutrition interventions within a broader context of policies and programs that may affect nutrition and health

5. Series objectives - 2 • Assess the correspondence between existing priorities and funding and opportunities for nutritional interventions to improve health and nutrition • Provide recommendations on national/subnational actions with respect to nutritional interventions • Provide recommendations for improved institutional arrangements and policies relating to nutrition at global level

6. of activity Streams Broad engagement of the global nutrition and health communities and interaction with the global food community Stream 1 Technical reviews, analyses, and writing the series contents Stream 2 Wide dissemination of and advocacy based on series findings Stream 3

7. Linda Adair Tahmeed Ahmad Lindsay Allen Zulfiqar Bhutta* Robert Black** Martin Bloem Jennifer Bryce* Laura Caulfield Denise Coitinho Simon Cousens Ian Darnton-Hill Mercedes de Onis Majid Ezzati Bruce Cogill Boitshepo Giyose Pedro Hallal Betty Kirkwood Reynaldo Martorell Saul Morris* David Pelletier Per Pinstrup-Anderson Linda Richter Juan Rivera Marie Ruel Harshpal Sachdev Meera Shekar Roger Shrimpton Ricardo Uauy Cesar Victora* The Maternal and Child Undernutrition Study Group With contributions from many others who will be acknowledged in the individual papers. *Writing team leader for one of the series papers; **Series Coordinator and writing team leader.

8. Conceptual framework for the series Short-term consequences: Mortality, morbidity, disability Long-term consequences: Adult size, intellectual ability, economic productivity, reproductive performance, metabolic and cardiovascular disease Maternal & child undernutrition Inadequate dietary intake Immediatecauses Disease Household food insecurity Inadequate care Unhealthy household environment & lack of health services Underlyingcauses Income poverty: employment, self-employment, dwelling, assets, remittances, pensions, transfers, etc. Lack of capital: financial, human, physical, social and natural Basiccauses Social, economic and political context Adapted from UNICEF, 1998

9. Terminology • Undernutrition = stunting, wasting and deficiencies in essential vitamins and minerals • Malnutrition = undernutrition or obesity • Disability-Adjusted Life Years (DALYs) = a standardised approach to epidemiological assessment that includes estimates of the burden of a disorder in terms of mortality, incidence, average age of onset, duration, and disability severity. • Focus countries for the series • Stunting prevalence > 20% • Rank order by number of stunted children, and begin counting with the country with the greatest number • 36 countries that account for 90% of stunted children worldwide (Papers 1, 3 and coverage in 4) • 20 countries accounting for 80% of stunted children worldwide (Papers 4 & 5)

10. Progress in the three of series activity streams

11. Broad engagement of the global nutrition and health communities, and interaction with the global food community Stream 1 • Individual papers in the series • Contributions from dozens of individuals • provision of data • analyses • technical consultations  

12. Broad engagement of the global nutrition and health communities, and interaction with the global food community - 2 Stream 1 • The series as a whole • Consultative meeting, Baltimore, March 2006 • Announcement at March 2006 SCN meeting • Invitation for comment, SCN News (mid-2006) • Meeting, UNICEF Innocenti Centre, September 2006 • Individual and small-group interviews • Requests for inputs in series Updates • Meeting, Bellagio, November 2006 • Presentation and discussions today And in the future • Review and comment on draft papers • The Lancet peer review process

13. Broad engagement of the global nutrition and health communities, and interaction with the global food community - 3 Stream 1 • Coordination with other nutrition-related events and initiatives • The Ending Child Hunger and Undernutrition Initiative • The “Hunger and Health” Report under development by the World Food Programme • Nutrition partners through presentation at meetings and individual discussions

14. Broad engagement of the global nutrition and health communities, and interaction with the global food community - 4 Stream 1 • Publication of related papers in The Lancet • What? • Original research • Of particular interest: • Large-scale effectiveness evaluations • New evidence linking undernutrition to relevant actions in sectors other than health • Financial/economic costs of acting at scale to address undernutrition • When? • By 1 May 2007 • Where? • http://ees.elsevier.com/thelancet/

15. Paper 1:Maternal and child undernutrition: Global and regional exposures & health consequences Stream 2 • Systematic literature searches • Re-analysis of existing data sets to develop new estimates of: • prevalence and overlap of stunting and wasting among children < 5y • underweight, stunting and wasting as risk factors for cause-specific deaths due to infectious diseases and disability among children < 5y • the prevalence of low birth weight (at term), and its association with neonatal mortality from birth asphyxia and infections • risks associated with deficiencies in vitamin A, zinc, iron, iodine and other micronutrients • risks associated with suboptimal breastfeeding and complementary feeding • global and regional disease burden (deaths and DALYs)

16. Paper 2:Maternal and child undernutrition:  long-term consequences for adult health? Stream 2 • Systematic literature searches on associations with • Human capital (height, schooling, income, etc) • Risk factors for chronic disease (blood pressure, glucose, overweight, etc) • Chronic diseases (cardiovascular disease, cancer, mental illness, etc) • Re-analysis of data sets from 5 long-running cohort studies in Brazil, Guatemala, India, Philippines and South Africa on associations between MCU, human capital and risk factors for chronic diseases

17. Paper 3:Global review of nutrition interventions and programs: What works? Stream 2 • Systematic review of global evidence-base on interventions addressing maternal and child undernutrition • More in-depth literature searches by 6 review groups in Karachi, Delhi, Dhaka, Pelotas, Davis and London • Outcomes evaluated • Growth • Micronutrient status & related functional outcomes • Mortality • Morbidity • Birth outcomes • Modeled estimates of stunting and DALYs avertable

18. Paper 4:What can be done at national level to reduce maternal and child undernutrition? Stream 2 • Selective literature reviews: policy development and implementation; World Bank projects addressing nutrition; large-scale programs (from paper 3 review) • Survey of current nutrition policies and program implementation in: (1) 20 countries with stunting prevalence > 20% and 80% of the stunted children; (2) selected countries not included in (1). • Re-analysis of existing data • describe types of food eaten by children in the focus countries • examine coverage levels in 36 high-burden countries for interventions found important in paper 3 review • Focus groups/interviews with policy leaders in developing countries

19. Paper 5:Effective international action against undernutrition: Why has it proven so difficult and what can be done to accelerate progress? Stream 2 • Systematic reviews • all research output related to nutrition in 6-mo period • linkages between nutrition outcomes & global change processes • media coverage • Quantitative analysis of financial flows for nutrition • Semi-structured key informant interviews and document review • international organizations • bilateral donors and foundations • universities and international research centers • private sector • NGOs • Problem tree analysis based on program and institutional reviews

20. Stream 3 Wide dissemination and advocacy based on series findings • Planned launches • London (The Lancet) • Washington D.C. (GMMB/Gates) • In high-undernutrition-burden countries (Gates & partners at country level) • Executive summary • Format accessible to policy makers • Available at time of series publication • Series publication as freestanding booklet • Planned launches • London (The Lancet) • Washington D.C. (GMMB/Gates) • In high-undernutrition-burden countries (Gates & partners at country level) • Executive summary • Format accessible to policy makers • Available at time of series publication • Series publication as freestanding booklet • Planned launches • London (The Lancet) • Washington D.C. (GMMB/Gates) • In high-undernutrition-burden countries (Gates & partners at country level) • Executive summary • Format accessible to policy makers • Available at time of series publication • Series publication as freestanding booklet • Planned launches • London (The Lancet) • Washington D.C. (GMMB/Gates) • In high-undernutrition-burden countries (Gates & partners at country level) • Executive summary • Format accessible to policy makers • Available at time of series publication • Series publication as freestanding booklet • Planned launches • London (The Lancet) • Washington D.C. (GMMB/Gates) • In high-undernutrition-burden countries (Gates & partners at country level) • Executive summary • Format accessible to policy makers • Available at time of series publication • Series publication as freestanding booklet • Planned launches • London (The Lancet) • Washington D.C. (GMMB/Gates) • In high-undernutrition-burden countries (Gates & partners at country level) • Executive summary • Format accessible to policy makers • Available at time of series publication • Series publication as freestanding booklet

21. Revised Timeline

22. 2007 Results from papers 1 & 3 March Full drafts for internal review May Papers submitted July Lancet peer reviews Papers revised & resubmitted Sep Publication Nov

23. Talk to us! • Key issues relating to country programs: • Who are the key actors (now and potential) at country level? • What is the role of nutrition policies and plans? • What are practical steps for governments, partners and the private sector to strengthen undernutrition actions at country level? • What country-level needs should be met by the international nutrition community? • Key issues relating to the international system: • How can the UN system be made more effective at country level? • How can the SCN increase its focus on results? • What kind of partnership could best bring different groups together? • How to move towards a more streamlined organizational set-up? • How to increase the focus on capacity building?