Elsevier

The Lancet

Volume 382, Issue 9890, 3–9 August 2013, Pages 427-451
The Lancet

Series
Maternal and child undernutrition and overweight in low-income and middle-income countries

https://doi.org/10.1016/S0140-6736(13)60937-XGet rights and content

Summary

Maternal and child malnutrition in low-income and middle-income countries encompasses both undernutrition and a growing problem with overweight and obesity. Low body-mass index, indicative of maternal undernutrition, has declined somewhat in the past two decades but continues to be prevalent in Asia and Africa. Prevalence of maternal overweight has had a steady increase since 1980 and exceeds that of underweight in all regions. Prevalence of stunting of linear growth of children younger than 5 years has decreased during the past two decades, but is higher in south Asia and sub-Saharan Africa than elsewhere and globally affected at least 165 million children in 2011; wasting affected at least 52 million children. Deficiencies of vitamin A and zinc result in deaths; deficiencies of iodine and iron, together with stunting, can contribute to children not reaching their developmental potential. Maternal undernutrition contributes to fetal growth restriction, which increases the risk of neonatal deaths and, for survivors, of stunting by 2 years of age. Suboptimum breastfeeding results in an increased risk for mortality in the first 2 years of life. We estimate that undernutrition in the aggregate—including fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc along with suboptimum breastfeeding—is a cause of 3·1 million child deaths annually or 45% of all child deaths in 2011. Maternal overweight and obesity result in increased maternal morbidity and infant mortality. Childhood overweight is becoming an increasingly important contributor to adult obesity, diabetes, and non-communicable diseases. The high present and future disease burden caused by malnutrition in women of reproductive age, pregnancy, and children in the first 2 years of life should lead to interventions focused on these groups.

Introduction

Maternal and child malnutrition, encompassing both undernutrition and overweight, are global problems with important consequences for survival, incidence of acute and chronic diseases, healthy development, and the economic productivity of individuals and societies. Maternal and child undernutrition, including stunting, wasting, and deficiencies of essential vitamins and minerals, was the subject of a Series1, 2, 3, 4, 5 in The Lancet in 2008, which quantified their prevalence, short-term and long-term consequences, and potential for reduction through high and equitable coverage of proven nutrition interventions. The Series identified the need to focus on the crucial period of pregnancy and the first 2 years of life—the 1000 days from conception to a child’s second birthday during which good nutrition and healthy growth have lasting benefits throughout life. The 2008 Series also called for greater national priority for nutrition programmes, more integration with health programmes, enhanced intersectoral approaches, and more focus and coordination in the global nutrition system of international agencies, donors, academia, civil society, and the private sector. 5 years after that series, we intend not only to reassess the problems of maternal and child undernutrition, but also to examine the growing problems of overweight and obesity for women and children and their consequences in low-income and middle-income countries (LMICs). Many of these countries are said to suffer the so-called double burden of malnutrition, with continuing stunting of growth and deficiencies of essential nutrients along with obesity in national populations and within families. We also want to assess national progress in nutrition programmes and international actions consistent with our previous recommendations.

Key messages

  • Iron and calcium deficiencies contribute substantially to maternal deaths

  • Maternal iron deficiency is associated with babies with low weight (<2500 g) at birth

  • Maternal and child undernutrition, and unstimulating household environments, contribute to deficits in children’s development and health and productivity in adulthood

  • Maternal overweight and obesity are associated with maternal morbidity, preterm birth, and increased infant mortality

  • Fetal growth restriction is associated with maternal short stature and underweight and causes 12% of child deaths

  • Stunting prevalence is slowly decreasing globally, but affected at least 165 million children younger than 5 years in 2011; wasting affected at least 52 million children

  • Suboptimum breastfeeding results in more than 800 000 child deaths annually

  • Undernutrition, including fetal growth restriction, suboptimum breastfeeding, stunting, wasting, and deficiencies of vitamin A and zinc, cause 45% of child deaths, resulting in 3·1 million deaths annually

  • Prevalence of overweight and obesity is increasing in children younger than 5 years globally and is an important contributor to diabetes and other chronic diseases in adulthood

  • Undernutrition during pregnancy, affecting fetal growth, and the first 2 years of life is a major determinant of both stunting of linear growth and subsequent obesity and non-communicable diseases in adulthood

The present Series is guided by a framework (figure 1) that shows the means to optimum fetal and child growth and development, rather than the determinants of undernutrition as shown in the conceptual model developed by UNICEF and used in the 2008 Series.1 This new framework shows the dietary, behavioural, and health determinants of optimum nutrition, growth, and development and how they are affected by underlying food security, caregiving resources, and environmental conditions, which are in turn shaped by economic and social conditions, national and global contexts, resources, and governance. This Series examines how these determinants can be changed to enhance growth and development. These changes include nutrition-specific interventions that address the immediate causes of suboptimum growth and development. The framework shows the potential effects of nutrition-sensitive interventions that address the underlying determinants of malnutrition and incorporate specific nutrition goals and actions. It also shows the ways that an enabling environment can be built to support interventions and programmes to enhance growth and development and their health consequences. In the first paper we assess the prevalence of nutritional conditions and their health and development consequences. We deem a life-course perspective to be essential to conceptualise the nutritional effects and benefits of interventions. The nutritional status of women at the time of conception and during pregnancy is important for fetal growth and development, and these factors, along with nutritional status in the first 2 years of life, are important determinants of both undernutrition in childhood and obesity and related diseases in adulthood. Thus, we organise this paper to consider prevalence and consequences of nutritional conditions during the life course from adolescence to pregnancy to childhood and discuss the implications for adult health. In the second paper, we describe evidence supporting nutrition-specific interventions and the health effects and costs of increasing their population coverage. In the third paper we examine nutrition-sensitive interventions and approaches and their potential to improve nutrition. In the fourth paper we examine the features of an enabling environment that are needed to provide support for nutrition programmes and how they can be favourably changed. Finally, in a Comment6 we will examine the desired national and global response to address nutritional and developmental needs of women and children in LMICs.

Section snippets

Adolescent nutrition

Adolescent nutrition is important to the health of girls and is relevant to maternal nutrition. There are 1·2 billion adolescents (aged 10–19 years) in the world, 90% of whom live in LMICs. Adolescents make up 12% of the population in industrialised countries, compared with 19% in LMICs (appendix p 2 shows values for ten countries studied in depth).7 Adolescence is a period of rapid growth and maturation from childhood to adulthood. Indeed, some researchers have argued that adolescence is a

Maternal nutrition

Prevalence of low BMI (<18·5 kg/m2) in adult women has decreased in Africa and Asia since 1980, but remains higher than 10% in these two large developing regions (figure 2). During the same period, prevalence of overweight (BMI ≥25 kg/m2) and obesity (BMI ≥30 kg/m2) has been rising in all regions, together reaching more than 70% in the Americas and the Caribbean and more than 40% in Africa by 2008.16, 17

Few studies have examined the risk of maternal mortality in relation to maternal

Anaemia and iron

Anaemia (haemoglobin <110 g/L), which might be attributable to low consumption or absorption in the diet or to blood loss, such as from intestinal worms, is highly prevalent during pregnancy. This Series focuses on anaemia amenable to correction with iron supplementation.42 To establish the importance of iron deficiency as a cause of maternal anaemia we used the results of trials of iron supplementation to work out the shift in the population haemoglobin distribution. A meta-analysis of the

Maternal characteristics

The 2008 Maternal and Child Undernutrition Series examined the association of maternal nutritional status (BMI and short stature) and fetal growth restriction, defined as low birthweight at term. Here, we use data from nine (height) and seven (BMI) population-based cohort studies and WHO perinatal facility-based data for 24 countries to examine associations separately for term and preterm SGA in LMICs.112, 113, 114, 115, 116, 117, 118, 119, 120, 121 Maternal stunting (height <145 cm) put

Fetal growth restriction

Previous global and regional estimates of fetal growth restriction used the term low birthweight as a proxy for being SGA in the absence of population-based birthweight and gestational age data at that time.1 Through recent analyses, we now have estimates of SGA prevalence from 22 population-based cohort studies and 23 countries with facility-based data,114 which were used to model SGA as a function of low birthweight and other covariates (neonatal mortality rate, representativeness of facility

Stunting, underweight, and wasting

Panel 12, 145, 146, 147, 148, 149, 150, 151, 152, 153 describes the determinants of stunting and overweight in children. Estimates of the prevalence of stunting, underweight, and wasting worldwide and for UN subregions are based on analyses jointly done by UNICEF, WHO, and the World Bank154 of 639 national surveys from 142 countries in the WHO database, using standard methods.1, 155, 156 In 2011, globally, 165 million children younger than 5 years had a height-for-age Z score (HAZ) of −2 or

Anaemia and iron

The percentages of children with anaemia (haemoglobin <110 g/L) and severe anaemia (haemoglobin <70 g/L) due to inadequate iron, (ie, anaemia that is correctable by oral iron supplements, calculated as described earlier) are 18·1% and 1·5%, respectively. The prevalence is highest in Africa and Asia for all IDA and in Africa for severe IDA (table 1). However, the proportion of all childhood anaemia corrected by iron supplementation ranges from 63% in Europe to 34% in Africa where there are other

Breastfeeding practices

Present recommendations are that babies should be put on the breast within 1 h after birth, be exclusively breastfed for the first 6 months, and for an additional 18 months or longer, be breastfed along with complementary foods. There are no recently published systematic compilations of data for breastfeeding patterns so we analysed data from 78 countries with surveys done in LMICs during 2000–10 (appendix p 20). Early initiation of breastfeeding (within 1 h) is highest in Latin America (mean

Joint effects of nutritional conditions on child mortality

To estimate the population attributable fraction and the number of deaths attributable to several risk factors, we used Comparative Risk Assessment methods.206 We calculated attributable deaths from four specific causes of mortality (diarrhoea; measles; pneumonia; and other infections, excluding malaria) associated with different nutritional status measures. In the neonatal period all deaths were deemed to be associated only with suboptimum breastfeeding and fetal growth restriction. The

Effects of fetal and early childhood undernutrition on adult health

In The Lancet’s 2008 Series on maternal and child undernutrition,2 consequences of early childhood nutrition on adult health and body composition were assessed by reviewing the scientific literature and doing meta-analyses of five birth cohorts from LMICs (India, the Philippines, South Africa, Guatemala, Brazil), an effort that gave rise to the COHORTS collaboration.208 On the one hand, the conclusions were that small size at birth and at 2 years of age (particularly height) were associated

Discussion

Nutrition has profound effects on health throughout the human life course and is inextricably linked with cognitive and social development, especially in early childhood. In settings with insufficient material and social resources, children are not able to achieve their full growth and developmental potential. Consequences range broadly from raised rates of death from infectious diseases and decreased learning capacity in childhood to increased non-communicable diseases in adulthood.

Nutrition

References (229)

  • P Christian et al.

    Risk factors for pregnancy-related mortality: a prospective study in rural Nepal

    Public Health

    (2008)
  • E Sheiner et al.

    Short stature—an independent risk factor for cesarean delivery

    Eur J Obstet Gynecol Reprod Biol

    (2005)
  • A Koyanagi et al.

    Macrosomia in 23 developing countries: an analysis of a multicountry, facility-based, cross-sectional survey

    Lancet

    (2013)
  • RP Gunatilake et al.

    Obesity and pregnancy: clinical management of the obese gravida

    Am J Obstet Gynecol

    (2011)
  • JA Cresswell et al.

    Effect of maternal obesity on neonatal death in sub-Saharan Africa: multivariable analysis of 27 national datasets

    Lancet

    (2012)
  • R Temple et al.

    Type 2 diabetes in pregnancy—an increasing problem

    Best Pract Res Clin Endocrinol Metwab

    (2010)
  • W McGuire et al.

    Maternal obesity: consequences for children, challenges for clinicians and carers

    Semin Fetal Neonatal Med

    (2010)
  • M Andersson et al.

    Global iodine status in 2011 and trends over the past decade

    J Nutr

    (2012)
  • KM Rasmussen et al.

    New evidence that iron supplementation during pregnancy improves birth weight: new scientific questions

    Am J Clin Nutr

    (2003)
  • MJ Dibley et al.

    Iron and folic acid supplements in pregnancy improve child survival in Indonesia

    Am J Clin Nutr

    (2012)
  • JL Beard et al.

    Maternal iron deficiency anemia affects postpartum emotions and cognition

    J Nutr

    (2005)
  • EM Perez et al.

    Mother-infant interactions and infant development are altered by maternal iron deficiency anemia

    J Nutr

    (2005)
  • AL Frith et al.

    Micronutrient supplementation affects maternal-infant feeding interactions and maternal distress in Bangladesh

    Am J Clin Nutr

    (2009)
  • P Christian et al.

    Vitamin A or β-carotene supplementation reduces but does not eliminate maternal night blindness in Nepal

    J Nutr

    (1998)
  • JM Tielsch et al.

    Maternal night blindness during pregnancy is associated with low birthweight, morbidity, and poor growth in South India

    J Nutr

    (2008)
  • P Christian et al.

    Maternal night blindness increases risk of mortality in the first 6 months of life among infants in Nepal

    J Nutr

    (2001)
  • P Christian et al.

    Effects of vitamin A and beta-carotene supplementation on birth size and length of gestation in rural Bangladesh: a cluster-randomized trial

    Am J Clin Nutr

    (2013)
  • J Katz et al.

    Maternal low-dose vitamin A or beta-carotene supplementation has no effect on fetal loss and early infant mortality: a randomized cluster trial in Nepal

    Am J Clin Nutr

    (2000)
  • P Pharoah et al.

    Neurological damage to the fetus resulting from severe iodine deficiency during pregnancy

    Lancet

    (1971)
  • J Villar et al.

    Epidemiologic observations on the relationship between calcium intake and eclampsia

    Int J Gynecol Obstet

    (1983)
  • L Duley

    The global impact of pre-eclampsia and eclampsia

    Semin Perinatol

    (2009)
  • L Davis et al.

    Vitamin D insufficiency is prevalent among pregnant African American adolescents

    J Pediatr Adoles Gynecol

    (2010)
  • Maternal and child nutrition: building momentum for impact

    Lancet

    (2013)
  • Progress for children: a report card on maternal mortality

    (2008)
  • Kozuki N, Lee AC, Vogel J, et al. The association of parity and maternal age with small-for-gestational age, preterm...
  • CM Gibbs et al.

    The impact of early age at first childbirth on maternal and infant health

    Paediatr Perinat Epidemiol

    (2012)
  • Ministerio de Salud Pública y Asistencia Social, Instituto Nacional de Estadística, Centros de Control y Prevención de...
  • GA Stevens et al.

    National, regional, and global trends in adult overweight and obesity prevalences

    Popul Health Metr

    (2012)
  • Maternal anthropometry and pregnancy outcomes. A WHO collaborative study

    Bull World Health Organ

    (1995)
  • B Dujardin et al.

    The value of maternal height as a risk factor of dystocia: a meta-analysis

    Trop Med Int Health

    (1996)
  • C Mazouni et al.

    Maternal and anthropomorphic risk factors for shoulder dystocia

    Acta Obstet Gynecol Scand

    (2006)
  • BCP Chan et al.

    The impact of maternal height on intrapartum operative delivery: a reappraisal

    J Obstet Gynaecol Res

    (2009)
  • RJ Van Lieshout et al.

    Pre-pregnancy and pregnancy obesity and neurodevelopmental outcomes in offspring: a systematic review

    Obes Rev

    (2011)
  • MR Torloni et al.

    Prepregnancy BMI and the risk of gestational diabetes: a systematic review of the literature with meta-analysis

    Obes Rev

    (2009)
  • E Tsoi et al.

    Obesity in pregnancy: a major healthcare issue

    Postgrad Med J

    (2010)
  • S Sohlberg et al.

    Maternal body mass index, height, and risks of preeclampsia

    Am J Hypertens

    (2012)
  • TE O’Brien et al.

    Maternal body mass index and the risk of preeclampsia: a systematic overview

    Epidemiology

    (2003)
  • A Aviram et al.

    Maternal obesity: implications for pregnancy outcome and long-term risks-a link to maternal nutrition

    Int J Gynaecol Obstet

    (2011)
  • JE Norman et al.

    The consequences of obesity and excess weight gain in pregnancy

    Proc Nutr Soc

    (2011)
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