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Lancet 2008; 371:243-60 Published Online January 17, 2008 DOI:10.1016/S0140-6736(07)61690-0 This is the first in a Series of five papers about maternal and child undernutrition Key messages * Maternal and child undernutrition is the underlying cause of 3-5 million deaths, 35% of the disease burden in children younger than 5 years and 11% of total global DALYs * The number of global deaths and DALYs in children less than 5 years old attributed to stunting, severe wasting, and intrauterine growth restriction constitutes the largest percentage of any risk factor in this age group * Vitamin A and zinc deficiencies have by far the largest remaining disease burden among the micronutrients considered * Iodine and iron deficiencies have small disease burdens, partly because of intervention programmes, but sustained effort is needed to further reduce their burden * Suboptimum breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, results in 1-4 million deaths and 10% of disease burden in children younger than 5 years * Maternal short stature and iron deficiency anaemia increase the risk of death of the mother at delivery, accounting for at least 20% of maternal mortality

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Panel 1: Disparities in stunting and dietary diversity This Series of papers on maternal and child nutrition builds on a framework that recognises the underlying causes of undernutrition, including the environmental, economic, and political contextual factors, in particular poverty. Figure 4A shows the disparities in stunting prevalence between the top and bottom wealth quintiles of the population, based on data from Demographic and Health Surveys for 11 of the 36 focus countries. In most countries the poor children have about twice as much stunting as the wealthier children. The three proximate determinants of child nutritional status include food security, adequate care, and health. Each of these is strongly affected by poverty. For example, animal- source foods are an important component of child diets, as a major source of protein and micronutrients; low intake of these foods is a risk factor for stunting. Figure 4B shows the gap between the proportions of children in the top and bottom wealth quintiles who received these foods in the 24 h before the survey, in selected countries with available data. Wide gaps are evident in most countries. Like stunting, micronutrient deficiencies are also linked to poverty. In India, for example, anaemia affects 79% of children in the lowest wealth quintile, compared with the still high prevalence of 64% in the top quintile.29

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Figure 4: Stunting and dietary diversity (A) Children aged 0-59 months who were stunted. Bars show the gap between prevalence in the poorest (red) and least poor (blue) wealth quintiles. (B) Children aged 12-23 months who ate meat, fish, poultry, or eggs in the 24 h before the survey. Bars show the gap between intake in the poorest (red) and least poor (blue) wealth quintiles.

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Panel 2: Specific assumptions for calculating the population attributable fraction for multiple nutritional risks The hazardous effects of one risk are not mediated through other risks This assumption might not hold for zinc deficiency because some of its hazardous effects are mediated through reducing growth. On the basis of the effects of zinc supplementation on linear growth,"7 and the model used to estimate intervention effects,28 it is estimated that around 46% of the excess risk for zinc deficiency is mediated through stunting. There would be no mediation via stunting for vitamin A deficiency"8 or iron deficiency,129 because of their lack of effects on growth. The proportional risks for one risk do not depend on exposure to other risks This assumption seems to be valid in that there has been no effect modification found in factorial design trials of vitamin A, zinc supplementation, or both,130131 and no difference in effect of vitamin A supplementation by baseline nutritional status by various anthropometric measures.37'32 Likewise, no significant differences have been seen with the effects of zinc supplementation on infectious disease morbidity in children with better or worse nutritional status.133 Exposures to these risks are uncorrelated The data from the cohort studies used to estimate odds ratios show that there was a small positive correlation between severe wasting and stunting (the prevalences of severe wasting in children with height-for-ageZ scores below and above -2 were 4-7% and 2-9%, respectively). There was also a positive correlation between stunting and zinc deficiency, but this is accounted for in the mediated effect mentioned above. Correlation was not incorporated in the calculations, which results in a slight underestimation of the combined effects, but previous sensitivity analyses have shown that the underestimation is small for these risks.126

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Panel 3: Research needs * Development of methods to assess nutritional status and its determinants * Prevalence of deficiencies of vitamin A, zinc, iron, and iodine in subnational populations * Consequences of nutritional deficiencies for mortality from HIV/AIDS, malaria, and other important infectious diseases * Consequences of nutritional deficiencies for immune competence, brain development, cognitive ability, and other possible effects

* Overlap of micronutrients and their joint effects on mortality and morbidity * Development of international fetal and newborn growth standards

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146 Sinkala M, Kuhn L, Kankasa C, et al, and Zambia Exdusive Breastfeeding Study Group. No benefit of early cessation of breastfeeding at

4 months on HIV-free survival of infants born to HIV-infected mothers in Zambia: the Zambia Exclusive Breastfeeding Study. Los Angdes: 14th Conference on Retroviruses and Opportunistic Infections, 2007 (abstr) 147 Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. Am J Clin Nutr 1998; 68 (2 suppl): 447S-63S.

[Author Affiliation]

Robert E Black, Lindsay H Allen, Zutfiqar A Bhutto, Laura E Cautpeld, Mercedes de Onis, Majid Ezzati, Colin Mathers, Juan Rivera, for the Maternal and Child Undernutrition Study Group*

[Author Affiliation]

* Members listed at end of paper Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (Prof R E Black MD, Prof L E Caulfield PhD); USDA, ARS Western Human Nutrition Research Center, Davis, CA, USA (Prof LH Allen PhD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta, MD); World Health Organization, Geneva, Switzerland (M de Onis MD, C Mathers PhD); Harvard School of Public Hearth, Boston, MA, USA (MEzzati PhD); and Mexico National Institute of Public Hearth, Cuerna vaca, Mexico (Prof J Rivera PhD) Correspondence to: Robert Black, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA rblack@jhspii.edu

Re f e r e n ce s

References (146)

I n d e x in g ( d ocu m e n t d e t a ils) Subjects:

Health risk assessment , Nutrition , Pregnancy , Public health , Children & youth , Womens health ,

Childbirth & labor , Socioeconomic factors , Risk factors , Disease , Chronic illnesses

MeSH subjects:

Child Mortality (major), Child Welfare -- economics , Child Welfare -- statistics & numerical data (major), Child, Preschool , Female , Humans , Infant , Iodine -- deficiency , Iron -- deficiency , Malnutrition (major), Malnutrition -- complications , Malnutrition -- epidemiology , Malnutrition -- mortality , Maternal Mortality (major), Maternal Welfare -- economics , Maternal Welfare -- statistics & numerical data (major), Nutritional Status , Poverty (major), Prevalence , Severity of Illness Index , Vitamin A Deficiency -- complications , Vitamin A Deficiency -- epidemiology (major), Wasting Syndrome -- classification , Wasting Syndrome -- epidemiology , Wasting Syndrome -- etiology (major), World Health (major)

Author(s):

Robert E Black , Lindsay H Allen , Zulfiqar A Bhutta , Laura E Caulfield , Mercedes de Onis , Majid Ezzati ,

Colin Mathers , Juan Rivera

Author Affiliation:

Robert E Black, Lindsay H Allen, Zutfiqar A Bhutto, Laura E Cautpeld, Mercedes de Onis, Majid Ezzati, Colin Mathers, Juan Rivera, for the Maternal and Child Undernutrition Study Group*

* Members listed at end of paper Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (Prof R E Black MD, Prof L E Caulfield PhD); USDA, ARS Western Human Nutrition Research Center, Davis, CA, USA (Prof LH Allen PhD); Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta, MD); World Health Organization, Geneva, Switzerland (M de Onis MD, C Mathers PhD); Harvard School of Public Hearth, Boston, MA, USA (MEzzati PhD); and Mexico National Institute of Public Hearth, Cuerna vaca, Mexico (Prof J Rivera PhD) Correspondence to: Robert Black, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA rblack@jhspii.edu

Corporate/Institutional author: Maternal and Child Undernutrition Study Group

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Publication title:

The Lancet . London: Jan 19-Jan 25, 2008 . Vol. 371, Iss. 9608; pg. 243, 18 pgs

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1420489191

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