PHA-Exch> Lancet: Nutrition-the Forgotten MDG - food for thought

Thu Feb 7 05:02:46 PST 2008

From: Ruggiero, Mrs. Ana Lucia (WDC) <ruglucia at paho.org>
crossposted from: EQUIDAD at listserv.paho.org

 *The Lancet: Maternal and Child Undernutrition*

*Website: *http://go.worldbank.org/7Q8VB5QK90**

*The series is indeed worrisome: It mostly looks at malnutrition like a
technical challenge reduceable to a series of maternal and child
interventions ("4 or 5" we are told) requiring primarily technical expertise
and a reorganization of a yet to be defined 'international nutrition
system'; it further suggests targeting the most affected (an aproach that
vitimizes the sufferers). No serious attempt is made to highlight the need
to act upon the social deteminants of malnutrition (linked to poverty) and
not a word is uttered about the internationally sanctioned right to adequate
nutrition! *

*Is The Lancet still in the 80s??  Does the co-authorship and co-financing
of the series by the WB have something to do with this vision that is
passee'? What are more enlightened nutrition professionals to do about this?
I am afraid a letter to The Lancet will be quite useless...*

*Claudio *

The new *Lancet* series on nutrition <http://www.globalnutritionseries.org/>,
co-authored and co-financed by the World Bank, depicts the lamentable state
of under-nutrition worldwide, and a corresponding negligence on the part of
the development community to meet the challenge decisively. Under-nutrition
represents the non-income face of poverty. And the world is off track on
meeting this goal.

More than a third of child deaths and 11% of the total disease burden
worldwide are due to maternal and child undernutrition. These and other
stark findings are the conclusions of an international collaboration of
investigators publishing their findings in The Lancet's maternal and child
undernutrition series.

*The series was launched in London on January 16, 2008 at the Science and
Media Centre

**Nutrition has slipped through the
gap*<http://www.thelancet.com/journals/lancet/article/PIIS0140673607618698/fulltext>
Nutrition is a desperately neglected aspect of maternal, newborn, and child
health. The reasons for this neglect are understandable but not justifiable.
In a comment that opens the maternal and child undernutrition series, *The
Lancet* Editor Dr Richard Horton draws together the themes of the series,
and calls on agencies, donors and political leaders to step up to this very
serious challenge. He says "Undernutrition is the largely preventable cause
of over a third - 3.5 million - of all child deaths. Stunting, severe waste
wasting and intrauterine growth restriction are among the most important
problems. There is a golden interval for intervention: from pregnancy to 2
years of age. After age 2 years, undernutrition will have caused
irreversible damage for future development towards adulthood". The comment
concludes by saying that the international nutrition system is broken.
Leadership is absent, resources are too few, capacity is fragile, and
emergency response systems are urgently needed.

*Over a third of child deaths and 11% of global disease burden due to
maternal and child
undernutrition*<http://www.thelancet.com/journals/lancet/article/PIIS0140673607616900/fulltext>
More than one third of child deaths and 11% of the total disease burden
worldwide are due to maternal and child undernutrition. Authors of the first
paper in the series say "Maternal and child undernutrition is highly
prevalent in low-income and middle-income countries, resulting in
substantial increases in mortality and overall disease burden." By doing an
analysis that accounted for co-exposure of nutrition-related factors, the
authors found that these factors were together responsible for 35% of child
deaths globally and 11% of the total disease burden. The paper concludes by
making a compelling case for the urgent implementation of interventions to
reduce their occurrence or ameliorate their consequences.

*Poor fetal growth or stunting in first two years of life leads to huge
negative consequences in later
life*<http://www.thelancet.com/journals/lancet/article/PIIS0140673607616924/fulltext>
Authors of the second paper of the series conclude that poor fetal growth or
stunting in the first two years of life can lead to irreversible damage,
including shorter adult height, lower attained schooling, reduced adult
income and decreased offspring birthweight for women. The researchers
analysed the association between child and maternal undernutrition with
human capitol and risk of adult disease in low-and-middle-income countries,
focussing on five long-standing studies in Brazil, Guatemala, India, the
Philippines, and South Africa. They showed that indicators of undernutrition
at age two years were related to adult outcomes. Further, they found that
children who are undernourished in the first two years of life, and who put
on weight rapidly later in childhood and in adolescence are at a high risk
of chronic diseases related to nutrition. But they found no evidence that
rapid weight gain or height gain in the first two years life increases the
risk of chronic disease, even in children with poor fetal growth. The
authors conclude by saying "...damage suffered in early life leads to
permanent impairment, and might also affect future generations. Its
prevention will probably bring about important health, educational, and
economic benefits."

*Maternal and child nutrition interventions could prevent a quarter of child
deaths in poor communities*<http://www.thelancet.com/journals/lancet/article/PIIS0140673607616936/fulltext>
Implementation of existing maternal and child nutrition-related
interventions could prevent a quarter of all child deaths in the 36
countries with the highest burden of undernutrition. Breastfeeding
counselling and vitamin A supplementation are currently the nutrition
strategies with the greatest potential to cut child deaths, comment the
authors of the third paper in the series. The authors studied how a variety
of nutritional factors affected children's growth patterns and risk of
death. In populations with enough food, education about complimentary
feeding increased the height-for-age score, while provision of food
supplements increased the score further in food-insecure populations.
Further, the authors also found that management of severe acute malnutrition
using WHO guidelines can reduce case-fatalities related to this condition by
55%, but this requires admission to a health facility. The authors add that
nutrition strategies on their own are not enough, concluding by saying
"Attention to the continuum of maternal and child undernutrition is
essential to attainment of several of the Millennium Development Goals and
must be prioritised globally and within countries... What is needed is the
technical expertise and the political will to combat undernutrition in the
very countries that need it most."

*80% of world's undernourished children live in just 20
countries*<http://www.thelancet.com/journals/lancet/article/PIIS0140673607616948/fulltext>
Authors of the fourth paper in the series highlight how 80% of the world's
undernourished children live in just 20 countries, and intensified nutrition
action in these countries can lead to achievement of the first Millennium
Development Goal and greatly increase the chances of achieving goals for
child and maternal mortality. They address seven key challenges for
addressing undernutrition at national level, including; getting nutrition on
the list of priorities, and also keeping it there. The paper looks at the
varied situation within and across Latin American countries, which as a
whole have experienced a large drop in stunting, being underweight, and
wasting; and China, where a multisectoral approach has seen rapid
nutritional improvement. The authors caution that nutrition resources should
not be used to support actions unlikely to be effective in real life setting
of a particular country, nor to support actions that have not been proven to
have a direct effect on undernutrition They conclude by asking "What can be
done?...there are no simple prescriptions to reduce undernutrition, although
high coverage with four or five of the proven interventions would certainly
have a sizeable effect", charging leaders at country level to review their
existing strategies and programmes.

*The international nutrition system: fragmented, dysfunctional and
desperately in need of
reform*<http://www.thelancet.com/journals/lancet/article/PIIS014067360761695X/fulltext>
The final paper in the series states that the international nutrition system
- made up of international and donor organisations, academia, civil society,
and the private sector - is fragmented and dysfunctional, and needs reform,
say authors of the fifth and final paper in the series. They say:
"Financial, intellectual, and personal linkages bind these organisations
loosely together as components of an international nutrition system... we
argue that such a system should deliver in four functional areas:
stewardship, mobilisation of financial resources, direct provision of
nutrition services at times of natural disaster or conflict, and human and
institutional resource strengthening." Their analysis of evidence to date
finds that currently, there are substantial shortcomings in each of the
areas above. Fragmentation, lack of evidence for prioritised action,
institutional inertia, and failure to join up with promising developments in
parallel sectors are recurrent themes. Many problems are systemic within
organisations in the field. They suggest five priority areas for action to
create a much stronger international nutrition system, and call for research
leadership in areas that matter. The authors conclude by saying "The moment
is ripe for these reforms. Their implementation would transform the
political salience of undernutrition, and offer the chance of a better, more
productive life to the 67 million children born each year in the countries
most severely afflicted by undernutrition."