This blog post is by RESULTS Nutrition Advocacy Officer, Kat Pittore.
Last week the second Lancet series on maternal and child undernutrition was released, adding new evidence, and providing new analysis on the impact of various nutrition interventions. As a nutritionist, I had been eagerly awaiting the launch for months, waiting for the newest evidence to be released. What does this mean for the nutrition community? What new evidence has been generated and how can it be used to inform our work? What other evidence is needed?
The first Lancet series on maternal and child undernutrition was published in 2008 and provided, for the first time, a synthesis of the scientific evidence on nutrition interventions. One of the difficulties with public health research is that there are thousands of studies available on very specific topics with different groups of the population, for example one study will compare the effect of providing iron to pregnant women in India, another will look at the effects of providing pregnant women in Tanzania with iron and folic acid supplements. The outcomes that studies look at will also be different, even studies measuring similar outcomes, for example, when looking at the effects in stunting (a child being too short for age) some studies will look at how much a child’s growth has improved whereas some will only look at the number of children who move from stunted to non-stunted. In such a confusing landscape, it is difficult even for a nutritionist like myself to be able to decided what interventions are the most effective and what we need to be advocating for.
The first Lancet series on maternal and undernutrition took all the available studies on key issues including: most effective nutrition interventions, countries and regions with the highest burden of undernutrition, the long term consequences of undernutrition for adult health and why progress on ending undernutrition has been so slow. It brought all the studies together to create a scientific consensus on what needs to be done.
The 2008 series identified that undernutrition was responsible for 2.2 million deaths in children under 5 each year, or 35% of all under 5 deaths. It also identified 13 key interventions, especially counseling on optimal breastfeeding practices and supplementation or fortification with vitamin A and zinc that could effectively be scaled up to reduce undernutirtion. Critically it identified the need to focus on the first 1000 days, from conception to age 2, in which nutrition interventions have the greatest impact. This “window of opportunity” became critical for both programming and advocacy efforts.
The first series was a critical first step, and provided necessary consensus in the nutrition community to raise the issue of undernutrition and be able to show tangible benefits to investing in certain interventions, as well as the consequences of failing to act. However, much has changed in the last 5 years and the new series that came out last week uses new data to look at how we can effectively tackle undernutrition in a changing landscape.
The first paper in the 2013 series examines the consequences of undernutrition, critically that 3.1 million child deaths, or 45% of all under 5 deaths each year, are caused by undernutriton. This number is significantly higher than the number given in the 2008 series. This is because overall the number of under 5 deaths has decreased, however, nutrition has not been invested in as much as needed, meaning that a greater percentage of a smaller number of deaths are caused by undernutrition. Another change from the earlier series is the inclusion of the growing problem of maternal and child overweight and obesity, which can cause complications during pregnancy and childbirth. Child undernutrition and stunting can also be risk factors for later poor heath – undernourished children are more susceptible to illness and chronic diseases such as diabetes and heart disease later in life.
The second paper seeks to quantify not just the interventions that are needed, but how much the cost. It looks at how much it would cost to implement ten specific nutrition interventions if they were “implemented at scale” which means that at least 90% if the population has access to a service. It was estimated that if we are able to scale up the 10 highly effective interventions in 34 key countries (the ones with most of the undernourished children) we could prevent at least 20% of stunting and 61% of severe wasting (wasting is when a child is too thin for their height and is at a high risk of dying). They estimated that this would cost $9.6 billion per year, of which$ 3-4 billion per year would be need from donors, with the rest coming from countries affected by undernutrition.
The third paper adds significant new data to the nutrition literature, seeking to explore the impact of “nutrition sensitive” programmes. These are programmes which impact nutrition status, but are not directly related to nutrition. The paper focuses on 4 areas of nutrition sensitive policies: agriculture, social safety nets, early child development and schooling. These areas were chosen specifically because of the possibility of having a large impact on nutrition as well as the possibility for the programmes to be effectively scaled up.
Overall, the review found that while nutrition sensitive policies have great potential to impact nutritional outcomes, they currently are not being targeted effectively as they could be to reach very young children. Nor do they always improve women’s empowerment. These two weaknesses means the proven impact is not as positive as would be desired. A key point said by one of the researchers at the launch is- “lack of evidence of impact does not constitute evidence of lack of impact” Put another way this means that because we do not yet have enough evidence to demonstrate nutrition sensitive policies are effective, it does not mean that they have no impact, only that more research is necessary.
The final paper emphasises that nutrition is not a non-political issues, and that high level political commitment is necessary to ensure that commitments made are implemented. Some key issues identified in the paper include the need for economic growth, but how economic growth alone is not enough to reduce undernutrition. Another important point is the need to create an enabling environment by increasing political will. The paper also looked at some more contentious issues such as what the role of the private sector should be, and how to ensure that the private sector operates in a responsible way, especially given its troubled past history with marketing of breast-milk substitutes.
The new series comes at a key point in time, increasing evidence for action in the same week that 24 countries and 66 other organizations came together to pledge money and resources towards ending undernutrition. The new evidence strengthens the argument for the need to invest in nutrition now, and provides us with evidence on tangible ways to do so.
The views and opinions expressed are those of the author and do not necessarily reflect the views of RESULTS