Lancet launches third series on child and maternal malnutrition

The Lancet has released its third series of papers on maternal and child undernutrition, finding that previous interventions were effective but still lacked delivery and financing at the scale needed to eliminate the problem.

The three-paper series, published Monday, follows papers released in 2008 and 2013 that helped galvanize support for evidence-based, multisectoral nutrition interventions. The original two sets stressed the importance of proper nutrition in the first 1,000 days of a child’s life and support for maternal nutrition while pregnant and breastfeeding. The new papers examine existing evidence, as well as progress on stunting, wasting, and micronutrient deficiencies, and lay out an “agenda for action” to accelerate progress toward global nutrition goals.

“Far too many countries are making insufficient progress. … Why is progress so slow so many years after the previous Lancet series refined our understanding of what works for undernutrition?” said Rebecca Heidkamp of the Johns Hopkins Bloomberg School of Public Health, co-author of one of the three papers, at a launch event Monday.

“One explanation is that while we may know what works, we are still not actually delivering those interventions to the populations that need them. Coverage of direct nutrition interventions has been slow to change. … One of the most exciting advances since 2013 is the new, real-world evidence that supports multisector approaches to addressing undernutrition.”

The first paper reviewed progress on undernutrition goals in 50 low- and middle-income countries with data from 2000 to 2015. It found that childhood stunting fell but remains a public health problem in low-income countries, along with wasting. New evidence shows that stunting and wasting can exist in part at birth and peak in the first six months of a child’s life. This is one reason to maintain a focus on the first 1,000 days, the paper said.

It also found an “unacceptable data gap” around the micronutrient status of women, with anemia rates still high in many countries.

“If we turn to women, we have much less data,” said Dr. Cesar Victoria of the Federal University of Pelotas in Brazil, a co-author of the first paper. To get a sense of where things stood for women, he said, researchers extrapolated from separate studies on micronutrient deficiency in Nepal and Bangladesh.

The second paper examined evidence supporting 10 existing undernutrition interventions, both direct and indirect, as well as some “emerging interventions” that have shown positive effects on child growth. But there were still evidence gaps on how to tackle malnutrition in schoolchildren and adolescents, as well as a need for more multisectoral action and coordination to address diverse causes of malnutrition.

Health care and data system strengthening, as well as monitoring and evaluation, will be key to handling the problem, the paper said. It divided nutrition interventions into four categories by the strength of evidence for their implementation, with long-standing interventions such as breastfeeding promotion and vitamin A supplementation showing “strong evidence,” while newer interventions such as probiotics for low-weight newborns had “emerging evidence.”

The third paper outlined steps that it said must be taken if the 2025 World Health Assembly targets and the 2030 Sustainable Development Goals for child and maternal malnutrition are to be met. It identified some new interventions since the last series in 2013 on the first 1,000 days that “require renewed commitment, implementation research, and increased funding from both domestic and global actors.”

“An analysis of the data from 2015 to 2017 shows that while donor spending on direct nutrition interventions increased, it was still short of projections. And most concerning was that there was evidence in several countries that domestic investment actually fell over the same period,” Heidkamp said. “Since 2013, we’ve seen the launch of innovation funding mechanisms like The Power of Nutrition, but particularly in light of COVID-19 we need to be even more innovative about how we do more with less.”

While the efficacy of many interventions has only improved since 2013, the third paper said that there is not enough companion evidence on cost-effectiveness to allow governments to plan sufficiently to implement them. It encouraged a more aggressive scaling-up of interventions that are known to work and better tracking of relevant nutrition indicators to measure progress.

Shawn Baker, chief nutritionist at the U.S. Agency for International Development, said The Lancet’s series caused a “revolution” in nutrition and has been integral to how the agency develops nutrition programming, since its Feed the Future initiative was being formed as the first series was published in 2008. The international community must identify specific gaps that remain, such as micronutrient malnutrition and food fortification, as well as a lack of progress on women’s nutrition.

“It’s very reassuring to see the evidence in this series of when you actually bring sectors together in the right way, you can see improvement in reducing all forms of malnutrition,” Baker said. “It really reaffirms what we know works in nutrition and the people we need to focus on. It reinforces in fact areas we’ve neglected and we really need to double down efforts on.”

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