now Bob you will know but let me just let me just say a few utterances about Bob bulbs official entitlement is the Edgar Berman share professor and chair of the department of international health at Johns Hopkins School of Public Health but there is almost nothing significant about child health that takes place in the world today without the imprint of fallbacks hand on it somewhere has been and continues to be an incredible international leader in China and what Bob does is and this is so important to do good science he constructs collaborations it’s not about him and it’s not about Johns Hopkins it’s about the collaboration and sustaining the collaboration to bring the best scientists together to do the highest possible operate the highest impact I’ve had special privileges and pleasure of working with Bob now actually for over a decade and every time we’ve interacted and work together he always delivers with a very kind introduction you’re right I can’t preserve my hands off of things that I think are important and this is one so redoing this this series I thoughts and unfortunately the the people I could get to help with it thought was not only important but extremely timely and and we did pull it together so what I’d like to talk about is newspaper one of this line and I show here the authorship of the streak and certainly wishes to acknowledge all of the authors of this line that that contributed to it and while I’m at it and may not have another chance later to thank the staff of The Lancet the editorial faculty since they are do an enormous amount of work for these series and and “weve had” some excellent editorial auxiliaries to get this together in what was for them and for us I’m sure a reasonably unreasonable timeframe but it did come together as Richard said we we did want to time it around now because we knew of the nutrition for expansion occasion that’s coming on the eighth in 2 day and many other activities leading up to the g8 discussions on food defence nutrition so abduct the moment I guess we decided this would be the time so as I’m sure you know there was a previous Series in 2008 that that streaks determined a critical period of the time since thought and to the second birthday it’s called the thousand periods in which good nutrition and healthy growth have both immediate and lifelong upshots that lines also called for stronger national platforms more integration of health and nutrition programs very much asked for better intersect oral and interagency cooperation within the nutrition system and I thoughts now 5 years later in 2013 we have an opportunity to look at what progress has been impelled how much of the burden related to under nutrition remains and and what are its consequences what are new interventions and programs that might might address these these problems but too to what extension has there been a movement for deepen and a better coordination both national and international so that would be universally the content of the sequence just so you know and it’s on your agenda won’t go into it there are four articles of the sequence that are now exhausted online in The Lancet and specific comments as we say a call to action comment that also appears from the authors of the group authorship of the of the sequence and then there are additional comments in the same issue or the the secure matter as well as online so so these are the four articles to come and you’ll hear from the result scribes for each of those in a few moments what I’m going to talk about though as I say is paper one of the serial which is something we we described the the prevalence of the conditions the the nutritional modes and their consequences one thing we did and it it’s presented in paper one but it’s really an overarching framework for the the part series is to redo somewhat a awfully traditional structure that had been used for a long time firstly developed by UNICEF and then we abused it actually modified somewhat in the previous line which was really the determinants of undernutrition or the determinants of stunting if you will we saw for a variety rationales we should turn that around and say what are what are the determinants of optimum fetal and child swelling but is not simply physical expansion but occurrence as well so very purposefully we combined in this series both the physical and the mental feeling aspects of development and that was drawing on study that came out in two previous Lancet series on child development very important series in their own right and this was our attempt to to marry if you are able to the the nutrition and developmental literature and and involvements because there there is a great need and synergy if one does that so the the central part the central part of this this framework is in a way the familiar determinants where we have at this stage what we’re trying to achieve we have at this grade the the immediate determinants so breastfeeding nutrient peril rich menus feeding and caregiving low-grade revelation to infect infection so these are these are the most immediate determinants is attributable to optimal rise and occurrence and then we have a organize of what we call nutrition specific interventions to address that elevation and you’ll hear from so if we go to the nutrition specific interventions that are listed here we have in this row in the determinants the underlying determinants so this is where you would participate food certificate caregiving environment access to resources of various kinds health services for example and and this is where we say that the nutrition confidential approachings from other sectors can come in particularly strongly to have an effect so this is where agriculture may affect food security and and we must be considered those programs or approaches altering chiefly these the underlying determinants of raise and growth but then importantly we have here the the environment in which all of this takes arrange different contexts political context social political leaders governance issues and and that leads to the paper 4 which talks about the enabling environment to address nutrition and and what are the the approaches that that might be put in place both at national and global level so as I say this is our framework for the for the for the paper another aspect though is is we we framed this a little more now in regard to the life course and we look in the papers across the life course in relationship to the effects of nutritional requirements on morbidity fatality and infancy cognitive motor and social socio-economic service sorry socio-emotional development school performance and learning capacity adult prominence and obesity and and non communicable diseases as well as work capacity and productivity so a life course is very important in the way we conceptualize this as well and in fact one aspect that we’ll deal with now which we didn’t is adolescent nutrition an important aspect that we had not addressed very well in the previous series so I’ll begin to now show you some data that come from paper one of the serial this is in regard to adolescent nutrition important for both girls and for their infant as this shows there’s a very high rate of stunting in in many of these countries and the the rate of of low-pitched BMI are much lower but stunting is quite high and the the rates of high BMI or overweight or obesity not so high either although come through here in Brazil Guatemala but overall as numerous as half of all teen girlfriends in some countries actually in many countries are stunted this rise the hazards of complications in pregnancy and in give with obstructed labour and and increases the problems of poor fetal swelling which will compensate a lot of attention to in this series so to go on to maternal nutrition this shows that trends in the various UN regions of the world trends and thinness so the mount of tables here is low BMI and then the trends in overweight and obesity in maids aged 20 to 29 times so I envisage first you can see that if you take world-wide which is here there’s been perhaps a slight decline initially than a plateauing of of the reduction in thinness or low BMI but overall in in the world and certainly in some regions a very strong increase in high-priced BMI or overweight and obesity in dames this is even true in in in some of the developing areas such as Africa where you construe hear a rise so the prevalence of low-pitched BMI and adult gals has decreased in Asia and Africa since 1980 but remains higher than 10% and maternal overweight and obesity has increased steadily in virtually all regions ensuing in increased maternal morbidity and death regard to the maternal overweight we I don’t have time to present all the details I’ll simply establish a few foregrounds of some of the micronutrient provinces the findings and conclusions iron and calcium scarcities particularly contributes to maternal extinctions are we’ve redone some analysis related to anemia in pregnancy and the risk of maternal demise it’s a very strong risk factor for maternal fatality we think this most likely toils through the risk of dying from hemorrhage and bleeding is the most important cause of maternal fatalities accounting for 23% of all demises calcium scarcity increases the likelihood of preeclampsia which now the second leading campaign of maternal fatalities 19% of total demises and so we consider collectively to deal with those two minerals and their deficiencies could result in a substantial reduction of maternal extinctions the evidence also that we looked at shows that short-lived maternal prestige may have contributed to prevented labour and to both maternal and fetal complications leading to either stillbirth or early neonatal extinction from clogged labor peculiarly if services are limited and cesarean section not available maternal stunting and low form mass index increases the risk of fetal swelling control and we use in this series being small-for-gestational-age as the indicator and maternal obesity on the other hand also has has bad upshots leading to gestational diabetes preeclampsia hemorrhage likelihood of added danger of neonatal and infant death so problems on both ends of the nutrition spectrum there there is in this series a mount of brand-new dissections done by join Katz who’s here in the public on the risk of being born small-for-gestational-age the prevalence of small-for-gestational-age burst and by others of other colleagues of ours and and this was put together to get the the deaths attributed to being tiny for gestational senility so in in the various regions of the world you attend a quite high proportion more than 25% let’s say in in Asia of the erupts being small-for-gestational-age and overall 27% of bursts all burst in low and middle-income countries are small-for-gestational-age that’s 32 million newborns stand per year when we look at the risk of mortality in a child born small-minded for gestational senility or preterm or both what we see here is that if the baby is full-term but small-minded for gestational senility there’s a two or threefold increase in the risk of death babies who are preterm but appropriate for gestational age have a five or so crease increase in the risk of death having both greatly increases perhaps in an additive way the risk of death so the worst is being both preterm and small-for-gestational-age now the prevalence of these conditions though would be this is a small fraction and a call and small-for-gestational-age is a large fraction of births so the attributable responsibility would be vary vastly in this category so the reductions in child mortality might be expected if we can target interventions to reach babies who are born too small as well as too soon or premature but in addition to the risk of mortality for the subsisting newborns who are born with small who are small for gestational senility we also see that they’re at risk of stunting so stunting at 24 months stunted linear expansion actually has a much higher frequency in newborns who are born small for gestational age so if you take now small-time for gestational age but full-term they have more than double the rate of being stunted at 24 months of age and high but with wide confidence intervals likewise for the combination of preterm and SGA so in our attributable likelihood planning what we’re able to say blending the prevalence of the condition and the risk is that 20% of stunting by 24 months of age could be attributed to being born small-for-gestational-age again emphasizing the need for interventions at the at the time of pregnancy or even before going on to child nutrition we see that the rate of stunting the prevalence of stunting has resulted in a reduction gradually in from all parts of the world the world-wide lessen is here about 2 % a year and these are projections out so we’re about we’re about here these are also estimations out to 2025 and so you realise where we might be I’ll precisely has pointed out while I’m on the global figure that the the current World Health Assembly targets for 40 percentage reduction in stunting would have the number of e about a hundred million at at this time point but in fact our current trends would project out to 127 million so so we we have a ways to go to to accelerate that that that decreased in stunting I think you can also attend though the the rates of decline in the in the prevalence have been highest in Asia than in Latin America but actually fairly slow in sub-saharan Africa so not only are the rates slowly declining of the prevalence frequency gradually waning we really have an increase in the number because the population increase so this is the only part of the world where the number of children who are stunted is actually increasing so overall for the world we say that there’s 165 million children under under five who were stunted 26% of all children and as I am talking about a 2% annual pace of reduction which is not fast enough to reach reach the World Health Assembly target we too look at the prevalence of wasting and the prevalence is still too high for squandering shown in the light bars or serious wasting shown in darker blue and and this in fact is not declining either as much as we would like so 52 million children under 5 currently with consuming 19 million gravely wasted now looking at the at the flip side of this we likewise look at child obesity and and where is this going so the uncertainty Mars are quite massive because it’s harder to predict the future with some of these but if you look at the world chassis you can certainly meet an upswing in the predicted prevalence of obesity in in children and going up to prevalence of around 10% but we’re less certain about Africa but certainly an expression of an increase in obesity and and truly no question about sorry Africa is here no question about about a trend going up in obesity and on two micronutrient scarcities deficiencies of the essential points vitamins and minerals continue to be very widespread they have adverse effects on child survival and development and they have bad upshots on maternal health as well we single out vitamin A and zinc absences because they adversely affect child health morbidity and mortality and shortages of iodine in iron together with stunting we think they contribute to children not contacting their developmental potential we have in the world significant progress in regard to vitamin A and so our assessment of the attributable onu are much lower than they might be without the program so the current coverage levels of vitamin A supplementation are rather high not Universal yet and still some ways to go with that but clearly we can’t afforded backsliding in this because the dietary intake of vitamin A in many countries is still inadequate and the supplementation is still needed when we we talked about the deaths attributed to nutrition we have to be very clear where we’re talking about an interaction between nutrition under nutrition and infectious diseases and so what we call the synergy of synergies between these two truly outcomes in the attributable deaths this is just showing some some brand-new separations we redo reasonings related to the risk of of extinction that the hazard fractions I’m only demo stunting here similar multitudes for for underweight or wasting in fact the wasting numbers the risk are even higher but if you take for example the children who are – 3 – 2 – 2 z-score length or meridian for senility they’re their elevated probability of demise is more than double if you take – 3 for all campaigns it’s more than five times risk of extinction and you can see it here for private individuals cases let’s say pneumonia where there’s substantial hill diarrhea measles so these major causes of death are the ones in particularly in these infectious crusades where the synergy of nutrition and desire upshots in the excess demises so this is where we do the estimates related to the attributable demises to under nutrition I wanted to show this quickly because it shows the great disparity in equity in stunting in regard to wealth quintiles so on the x-axis our countries if you have a telescope you can read them there in the paper I think they’re readable but it basically says that the the poorest quintile have much higher rates of stunting than the wealthiest quintile within each country there are notably few countries but one I would single out way down at the bottom now that is a remarkable narrative that is Brazil which has not only achieved in in recent years a very large reduction in stunting but has essentially eliminated its unfairnes it used to have a very large gap between rich and poverty-stricken and the prevalence of stunting and through very concerted very wide wide national platforms it has essentially eliminated both stunting and the gap in stunting hitherto many other countries continue to have that inconsistency the top panel is an interesting one because this is overweight and what you can see is virtually no pattern in some countries the wealthiest quintile has a little more overweight as you might expect but in some countries it’s the lowest quintile so not very much gap in the in the specific characteristics of overweight at this stage breastfeeding rehearses we’ve look back again analyzing survey data still inadequate suboptimal in regard to the recommendations of exclusive breastfeeding for the first six months and then continued breastfeeding for at least the next 18 months so you can see the the specific characteristics here by you know by by sphere there’s another aspect we we do look at in terms of the prevalence early initiation of breastfeeding within one hour which is recommended so not as high-pitched as it should be only fifty percent or so so the there’s enormous significance to the breastfeeding practices and what we would have to say though is they’re still inadequate and need more attention exclusive breastfeeding is merely at about thirty percent for the first six months of soul in in all of the major UN neighborhoods we we have done this calculation of the deaths attributed to each of these nutritional modes and this is for the individual ones so fetal rise regulation pointed out by small-scale for gestational senility more than 800,000 demises stunting a million deaths per year I’m talking about and then you can go down now but really it’s it’s important not only to look at these separately because you do get some impression of their importance but we likewise since they are they do overlap have to look at the Joint Distribution so by some statistical wizardry we are capable of look at all of these at the same time that will enable us to not over count a double count the conditions and and what that does is it allows us to say that if you if you do look at all of these together that includes fetal rise restriction suboptimal breastfeeding something squandering and vitamin A and zinc insufficiencies because those two mineral vitamin and mineral shortcomings are the ones that are associated with excess demises we we then come up with about three million deaths per year attributed to these nutritional requirements about forty five percentage of all under five extinctions at this detail importantly a large fraction of those “wouldve been” precisely in the the related to the two interventions specially that affect the neonatal period fetal proliferation control and suboptimal breastfeeding so overall as I say you know 45% of all under five extinctions attributed to two undernutrition three of the six point nine million demises for 2011 and fetal proliferation rule suboptimal breastfeeding together are responsible for more than a million deaths inadequacies of vitamin A in zinc for about 300,000 fatalities between them so ultimately to end on the key contents I would say short stature low BMI vitamin mineral defects in maternity contribute to maternal morbidity and fatality lend also to fetal proliferation restriction child mortality and stunted rise and development of the child stunting of proliferation in the first two years of life feigns 25 ms frequency affects 165 million children who have an heightened hazard of death they have cognitive deficits at increased risk of adult obesity and non communicable diseases I don’t have time to go into the details on that however do talk about the common sources of of the consequences of undernutrition but likewise the longer term influences on overweight obesity and NCDs and there is a companion paper with the with the serials from Linda Adair that stowed from the cohorts group that that talks about long term outcomes that that fit with this this conceptualization and and finally this new evidence strengthens the subject for the focus on the critical thousand dates the window of maternity and the first two years of life foreground even more the importance of early involvements in maternity and also adolescent nutrition because at the time of conception and early pregnancy even before gestation is recognized nutrition is important and one can only address that by having better nutrition for adolescent girls and I would end with that thank you very much you

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