Source: All Africa
A new Lancet series on maternal and child nutrition examines the problems associated with undernutrition and successful interventions. A similar report released by Lancet in 2008 was critical in helping push nutrition higher on the development agenda.

It highlighted the importance of nutrition in the first 1,000 days of life as critical to a child's development. AllAfrica spoke with Professor Robert Black of Johns Hopkins University, Bloomberg School of Public Health, about the latest Lancet series. Dr Black is the lead author of the series.

What are some of the key findings?

In regard to the consequences of undernutrition we have quantified again the number of children who are stunted - 165 million - and the number who have wasting - more than 50 million - and so these are very serious problems for the world. They result in higher mortality - nearly half of all child deaths could be attributed to undernutrition - as we call it the synergy of nutrition and infection that leads to deaths.

What we tried to also speak to in the series is the consequences of undernutrition for child development and cognitive abilities and later adult learning potential.

We also talk a bit about the emerging problems of being overweight and obesity. Some of that has an origin as well in the first 1,000 days. So the same interventions that may reduce undernutrition may have benefits for reducing later problems with obesity and chronic disease.

What are the main differences in this series compared to the one in 2008?

One is the greater emphasis on the problems that arise from poor nutrition at the time of conception or pregnancy. I think the new evidence that we present is even more important than we said previously. The problems of foetal growth restriction have been maybe underestimated in the past and we've now said that the number of deaths attributed to that is more than double in the neonatal period alone.

And that takes it back to the need for better nutrition for adolescent girls before they become pregnant, better nutrition during pregnancy that will affect both the mother's health and complications from pregnancy and also foetal growth. Those are important new findings in terms of the disease burden.

There is an emphasis in the series on the need for data and consistency measurement and reporting of outcomes of interventions. Can you elaborate?

There are two different aspects. One is nutrition-specific interventions where we talk about 10 interventions that would have major effects. For those I think we have absolute certainty that there are benefits on nutrition. So the evidence there is very sound. We say these are proven interventions, they're good value for money to implement.
The magnitude of the problem and the need for each of these interventions probably varies by country but they're very generalized. There are problems with zinc everywhere, problems with protein energy in pregnancy. These are general issues. But the need for evidence is primarily in regard to implementation, so we know they work. Some of this comes from randomized trials or efficacy studies.

The need for evidence for those is in regard to how, in given settings with different contexts, they can be scaled up to reach the population that needs to receive them.

That could include the poorest or the most remote or the most disadvantaged or discriminated against. There are many aspects of reaching populations in need. So I think the need for evidence is really an implementation of what we know works.

Where we also talk about the need for evidence is on nutrition-sensitive approaches and interventions and programmes, such as agriculture, social protection or the links with early childhood development, for example.

I'll take agriculture as an example. There are certainly benefits of improving agriculture to households, improving income, but the evidence is still rather mixed or limited that the improvement of agriculture has had very direct benefits particularly in the 1,000-day period of pregnancy and maternal nutrition and for early childhood nutrition.

So what we talk about is the need for more evidence that can really enhance their benefit in regard to nutrition. We think it's possible. There are a number of pathways by which agriculture programmes should be able to do that.

But the evidence to date has been rather limited, and primarily related to intermediate measures of somewhat better dietary quality, dietary diversity, but not much evidence that this changes the major nutritional status of children.

The series says innovative delivery strategies, especially community-based delivery platforms, are promising for scaling up coverage of nutrition interventions and have the potential to reach poor populations through demand creation and household service delivery. Can you tell us more about these strategies in Africa?

A major delivery platform is the use of community health workers. Africa has implemented many nationwide programmes of more professionalized community health workers.

There's a long history of community health worker programmes, often small ones, even volunteers, recruited by NGOS. But when I say professionalized I mean settings like Ethiopia that has some 20,000 health extension workers who receive sound training, who have health posts to work from, who have supplies provided by the government and are paid, albeit modestly.
Almost all of the 10 interventions that we talk about as proven really can be and are being delivered by community health workers and to me that's the major delivery platform for these nutrition services. We're talking about promoting breastfeeding, promoting complementary feeding, providing vitamin A, providing zinc, providing food supplements in pregnancy if necessary, perhaps providing and overseeing the use of multiple micronutrients in pregnancy.

All of these things are very possible for community health workers to do, and in fact they are doing in many places. Even the management of severe acute malnutrition is being identified by community health workers, as in Ethiopia. They have ready-to-use therapeutic foods and provide community-based management of uncomplicated severe malnutrition. The biggest delivery platform is professional community health workers - and Africa is really pioneering the use of it.

How about micronutrient interventions?

The approaches being taken now to enhance the vitamin and mineral content primarily involve traditional breeding of crops to increase their nutrient content. Ideally these crops would also have higher yield for the farmers and greater benefits in other ways. So there are a number of these that are in evaluation. The only one that been proven to have benefit in regard to a single micronutrient is the orange sweet potato. That is a success.

The others are all still in evaluation. They are promising in regard to the content of foods, in regard to iron or zinc, or others on vitamin A, but until we have the demonstration on benefits from the field studies that are under way they won't be released and promoted yet. There's fortified wheat with zinc, zinc in rice, iron in beans or iron in pearl millet. These are all in evaluation now.

The UN secretary-general's high-level panel report on the post-2015 development agenda - after the current Millennium Development Goals (MDGs) expire - came out last week. How do think it addresses malnutrition? Were you satisfied?

Absolutely. In the MDGs undernutrition was in the poverty goal and with one indicator of underweight so it was not highlighted as a separate goal. The high-level panel does recommend that food security and nutrition be a separate goal and I would be very happy to see that.

The list suggested indicators for that and I was also happy to see stunting as an indicator, which I think the world now believes very much is a better indicator than underweight. So it includes possible indicators of stunting, wasting and anaemia. I think the high-level panel got it right as far as nutrition. I don't have a problem with it being combined with food security because there are clear relationships, but as long as it has separate nutrition indicators.

Photo: Laura Newman/PATH