Women’s, Children’s, and Adolescents’ Health

open access

Nutrition and health in women, children, and

adolescent girls

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Urgent action is needed to tackle malnutrition in all forms and to help nutrition unlock
the potential of investment in the health of women, children, and adolescents, say
Francesco Branca and colleagues

E
very year the lives of around 50 mil- Methods mal breast feeding, stunting, wasting, and
lion children are put at risk because This paper highlights nutrition related prior- deficiencies of vitamin A and zinc). In 2013
they are dangerously thin from ity actions to improve the health of women, the growth of around 161 million children
acute undernutrition, while the children, and adolescent girls. It is based on aged under 5 was stunted by chronic under-
long term health of more than 40 existing policy guidance issued by the World nutrition, leading to hampered cognitive and
million children is threatened because they Health Assembly in the form of resolutions physical development, poor health, and an
are overweight. Two billion people suffer or targets; guidelines from the World Health increased risk of degenerative diseases.3  In
from vitamin and mineral deficiencies, but Organization; or the outcome documents of the same year 51 million children were
overweight and obesity are key contributors the Second International Conference on wasted (having low weight for height)
to the non-communicable diseases that Nutrition (ICN2). because of acute undernutrition; severe
account for almost two thirds (63%) of adult The vast majority of the recommended wasting increases the risk of morbidity, par-
deaths globally. These different forms of mal- actions proposed in this paper were agreed ticularly from infectious diseases such as
nutrition—undernutrition, overweight and by the 162 member states attending the ICN2 diarrhoea, pneumonia, and measles, and is
obesity, and micronutrient deficiencies— in Rome in November 2014.1  These recom- responsible for as many as two million
now affect people across the same communi- mendations were developed by the secretar- deaths a year.4
ties and harm people of all ages. (Unless iats of the Food and Agriculture Organization Meanwhile, deficiencies of vitamin A and
otherwise cited, the figures given are WHO of the United Nations and WHO on the basis zinc cause many deaths (157 000 and 116 000
estimates.) of current ­evidence and were subject to child deaths, respectively, in 2011),5  and
Improving nutrition therefore presents a extensive consultation. An information note iodine and iron deficiencies, along with
key opportunity to improve health. As the on the ICN2 provides more background infor- stunting, contribute to children not achiev-
UN secretary general launches his second mation on the recommended actions.2 ing their full potential. Iron and calcium
Global Strategy for Women’s, Children’s and Some additional recommendations, spe- deficiencies increase the risks associated
Adolescents’ Health in September 2015 a cific to women’s, children’s, or adolescents’ with pregnancy, particularly maternal mor-
strengthened focus on nutrition is war- nutrition, are based on WHO guidance. tality.5
ranted, with special attention to the first Where such a recommendation does not At the same time overweight and obesity
1000 days of life (from pregnancy to the exist, emerging evidence reviewed by the in children and adults have been increasing
child’s second birthday), pregnant and lac- authors is cited. rapidly in all regions of the world, and half a
tating women, women of reproductive age, billion adults were affected by obesity in
and adolescent girls. Problems associated with poor nutrition 2010. Dietary risk factors, together with
Good nutrition is fundamental for optimal ­inadequate physical activity, were responsi-
health and growth. Through its effect on ble for 10% of the global burden of disease
health and cognitive development it is also and disability in 2010.6
vital for academic performance and produc-
Key messages
tivity, and therefore for healthy economies Socioeconomic impact of malnutrition
Investment in nutrition is crucial to future and socioeconomic development. Malnutrition contributes to an estimated 200
efforts to improve the health of women, million children failing to attain their full
children, and adolescents; the potential Health effects of malnutrition development potential. Stunting is esti-
human, societal, and economic gains from The consequences of malnutrition could mated to reduce a country’s gross domestic
such investment are substantial. hardly be more serious: around 45% of child product by as much as 3%,7  and eliminating
Clear global commitments to action are deaths in 2011 were due to malnutrition anaemia could increase adult productivity
in place, backed by targets to measure (including fetal growth restriction, subopti- by 5-17%.8
progress. All contributors, across
government and society, must come Box : Nutrition in recent global initiatives and commitments
together to turn these commitments into
• Global Strategy for Women’s and Children’s Health: the UN secretary general’s strategy, put into action
action.
by the global Every Woman Every Child movement, clearly set out the need to tackle nutrition in young
Specific actions are needed to improve the children.11
quality of the diet; to protect, promote, • Global nutrition targets for 2025: countries are working towards six global targets agreed at the 65th
and support breast feeding; to ensure that World Health Assembly in 2012 (table 1).
everyone has access to essential nutrition • Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-20: includes
actions; to provide adequate water and targets to reduce salt intake by a third and to halt the increase in obesity among adolescents and adults.
sanitation; and to provide information and • Second International Conference on Nutrition: in November 2014 the world’s leaders committed to
education. eradicating hunger and preventing all forms of malnutrition worldwide.12

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Women’s, Children’s, and Adolescents’ Health

Box : What do we mean by malnutrition?

• Malnutrition: nutritional disorders in all of their forms (including imbalances in energy intake, macronutrient and micronutrient deficiencies, and unhealthy
dietary patterns). Conventionally, the emphasis has been on inadequacy, but malnutrition also applies to excess and imbalanced intakes.

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• Overweight: a situation caused by an excessive, unbalanced intake of energy or nutritional substances (and often combined with a sedentary lifestyle).
• Stunting: low height for age (more than two standard deviations below the WHO child growth standard median for children under 5). Stunting is defined by
WHO as a public health problem when 20% or more of the population are affected.
• Undernutrition: a situation in which the body’s energy and nutrient requirements are not met because of under-consumption or the impaired absorption and
use of nutrients. Undernutrition commonly refers to a deficit in energy intake, but it can also refer to deficiencies of macronutrients and micronutrients, and it
can be either acute or chronic.
• Wasting: low weight for height (more than two standard deviations below the WHO child growth standard median for children under 5). Wasting becomes a
public health problem when 5% or more of the population are affected.

Every $1 (£0.64; €0.91) invested in tackling along with unsustainable production and stunted and to have a higher risk of morbid-
undernutrition is estimated to yield around consumption patterns, food losses and ity and mortality and of developing
$18 in return—the median benefit:cost ratio waste, and unequal distribution and access. non-communicable diseases later in life.
from a study modelling the effect of prevent- Malnutrition is often aggravated by poor Conversely, if the mother is obese when she
ing one third of stunting in children up to feeding and care practices for infants and starts her pregnancy she is also at increased
age 3 in 17 high burden countries. 9  More spe- young children, as well as poor sanitation risk of complications during pregnancy or
cifically, a recent study of the benefit:cost and hygiene. A lack of access to education, delivery, which could result in premature
ratio of a package of nutrition interventions quality health systems, and safe drinking delivery—and, therefore, a low birth weight
aimed at averting stunting in 15 countries water can also have a negative effect, along for her baby. Alternatively, if she carries the
found that benefits outweighed costs by as with infectious disease and the ingestion of baby to full term, her baby is more likely to
much as 42:1, depending on the existing eco- harmful contaminants. have a higher birth weight and a higher risk
nomic and nutritional situation.10 In recent years progress has been made in of child and adolescent obesity.
developing knowledge and understanding The past two decades have also seen a
What progress has been made in tackling of the magnitude and scope of nutritional major shift in understanding of the policy
malnutrition? challenges, the increasing contribution of responses required to improve nutrition and
Better understanding of the challenges non-communicable diseases, and the promote healthy diets. It is now clear that an
and solutions ­complex web of factors that can influence enabling environment plays a key role and
The root causes of malnutrition and the fac- ­nutrition. that policies that change aspects of the food
tors leading to it are complex and multidi- A greater understanding has developed environment are required (such as what foods
mensional. Poverty, underdevelopment, and regarding the importance of nutrition at dif- are available, what levels of fat, sugar, or salt
low socioeconomic status are major contrib- ferent stages of the life course and the effect they contain, or how much they cost), as well
utors, along with other social determinants. of poor nutrition across generations (fig 1). as nutrition education and information.
Current food systems struggle to provide An intergenerational cycle of malnutrition Similarly, there is now much greater
adequate, safe, and diversified foods. The exists whereby a woman who has anaemia, awareness that effective responses need to
reasons include constraints on access to for example, is likely to have a baby with a come from beyond the health sector and that
land, water, and other resources—often reduced birth weight. Low birthweight this must involve other sectors, such as those
aggravated by environmental damage— babies are more likely to be wasted or related to water and sanitation, education,
trade, and social protection. Crucially, a rad-
Low birth weight and ical transformation is needed so that food
compromised body systems can ensure that everyone has access
composition
Impaired mental to a sustainable, balanced, and healthy diet.
development
Higher mortality rate
Inappropriate feeding practices
Progress towards global nutrition targets
Frequent infections
Reduced Fetal and infant Significant progress has been made in reduc-
capacity for care malnutrition Inappropriate food,
Societal and ing hunger and undernutrition in the past
environmental Inadequate health and care (including
untimely/inappropriate
factors Rapid catch-up
growth complementary feeding) two decades: the percentage of people in
Elderly growth developing regions experiencing hunger fell
malnutrition Child
malnutrition from 24% in 1990-92 to 14% in 2011-13.14 The
Obesity, Reduced intellectual
abdominal obesity, potential and reduced 2014 Global Nutrition Report showed, how-
Inadequate diabetes,
fetal cardiovascular school performance ever, that the world is not on track to meet
nutrition disease
Inappropriate food, Inappropriate food, any of the six World Health Assembly nutri-
health and care health and care tion targets (table 1).
Adult
malnutrition Adolescent
malnutrition
Pregnancy What are the priorities for improving
low weight Reduced intellectual
gain nutrition?
potential and reduced
Inappropriate food, school performance Improving women’s, children’s, and adoles-
health and care
Higher maternal cents’ nutrition requires a range of policies,
mortality
programmes, and interventions at different
Fig 1 | Nutrition through the life course—proposed causal links13
stages of life. And, since we know that mal-
Reproduced from WHO childhood overweight policy brief, based on figure from Darnton-Hill I, nourished women give birth to malnour-
Nishida C, James WPT. A life course approach to diet, nutrition and the prevention of chronic ished children, it is possible to take action to
diseases. Public Health Nutr 2004;7:101-21. improve nutrition across generations (fig 2 ).

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 Women’s, Children’s, and Adolescents’ Health

Table 1 | Findings of the 2014 Global Nutrition Report17

Baseline Baseline Globally
Category WHA target years status Target for 2025 on course? Comments

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Stunting 40% reduction in number of children under 5 2012 162 million ~100 million No Current pace projects 130 million by
who are stunted* (~15% prevalence) 2025 (20% reduction)
Anaemia 50% reduction of anaemia in women of 2011 29% 15% No Very little movement (was 32% in 2000)
reproductive age
Low birth weight 30% reduction in low birth weight 2008-12 15% 10% No Little progress to date
Under 5 overweight No increase in childhood overweight 2012 7% 7% No Upward trajectory is unchecked
Under 5 overweight Increase the rate of exclusive breast feeding in 2008-12 38% 50% No Rate was 37% in 2000, 41% in 2012
first six months to at least 50%
Wasting Reduce and maintain childhood wasting to 2012 8% <5% No No progress (was 8% globally in 2013)
under 5%

Table 2 | Recommended actions to improve adolescents’ nutrition

Recommendations and actions Who needs to take action?
Improve maternal nutrition and health
Establish policies and strengthen interventions to ensure that pregnant and National policy makers, health service providers
lactating adolescent mothers are adequately nourished
Introduce measures to prevent adolescent pregnancy and to encourage pregnancy National policy makers, health service providers, education sector
spacing
Prevent and control anaemia
Promote healthy and diversified diets containing adequate amounts of bioavailable National policy makers, food and agriculture sectors, health and education sectors
iron
Promote consumption of nutrient dense foods, especially foods rich in iron National policy makers, health and education, food and agriculture sectors
Where necessary, implement supplementation strategies and consider fortification National policy makers, food and agriculture sectors
of wheat and maize flours with iron, folic acid, and other micronutrients in settings
where these foods are major staples
Prevent and treat malaria in pregnant women as part of strategies to prevent and control anaemia
Ensure universal access to and use of insecticide treated nets National policy makers, health service providers, development partners
Provide preventive malaria treatment for pregnant women in areas with moderate to National policy makers, health service providers
high malaria transmission
Offer a healthy diet to all populations
Create coherence in national policies and investment plans, including trade, food, Regional and national policy makers, food and beverage industries, creative and
and agricultural policies, to promote a healthy diet and protect public health18* media industries
Encourage consumer demand for healthy foods and meals*
Promote physical activity in adolescents
Create a conducive environment that promotes physical activity to tackle sedentary Regional, national, and local policy makers, urban planners, early years education,
lifestyle19† health services
Promote optimal nutrition in adolescents with HIV/AIDS
Provide nutrition counselling to improve health outcomes in adolescents with HIV20‡ Health service providers, development partners
All recommended actions are based on those proposed in the Framework for Action issued by the Second International Conference on Nutrition in November 2014 except (*), which is based
on a WHO healthy diet fact sheet; (†), which is based on WHO guidelines on physical activity; and (‡), for which evidence is available but no formal WHO recommendation.

Specific recommendations and actions to

help put them into practice are shown in
Immediate initiation of breast feeding tables 2 to 4.  
Exclusive breast feeding to 6 months
Diet and micronutrients
during pregnancy Actions to improve adolescent girls’
Adequate complementary nutrition
Diet and micronutrients feeding from 6 months Adolescent girls should be at the heart of a
during ageing
Birth
life course approach—a young adolescent
7 days girl is still a child, but often she will soon
Pre-pregnancy dietary 28 days
become a mother. Adolescent pregnancy is
advice for adolescent associated with higher risk of maternal mor-
girls and women
1 year Continued breast feeding tality and morbidity, stillbirths, neonatal
deaths, preterm births, and low birth weight.
20 years In addition to actions to prevent adolescent
10 years
5 years pregnancy and encourage pregnancy spac-
Adolescent dietary Energy and nutrient
advice adequate diet ing, efforts are required to ensure that preg-
nant and lactating teenage mothers are
Micronutrient adequately nourished.
supplementation
as necessary
School meals Actions to improve child nutrition
The first 1000 days of life (from pregnancy to
Fig 2 | Improving nutrition throughout the life course15 the child’s second birthday) present an

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Women’s, Children’s, and Adolescents’ Health

Table 3 | Recommended actions to improve child nutrition

Recommendations and recommended concrete actions Who needs to take action?
Promote optimal infant and young child feeding*

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Adapt and implement the International Code of Marketing of Breast Milk Substitutes National policy makers
and subsequent relevant World Health Assembly resolutions
Ensure that health services and employment policies promote, protect, and support National policy makers, employers, health facilities
breast feeding, including WHO’s Baby-Friendly Hospital Initiative
Encourage and promote active participation of men in sharing care for infants and National policy makers, educational institutions, employers, health facilities
young children
Empower women and enhance their health and nutritional status throughout the life National policy makers, educational institutions, employers, health facilities
course
Ensure that policies and practices in emergency situations and humanitarian crises International organisations, national policy makers, humanitarian actors
promote, protect, and support breast feeding
Tackle maternal exposure to the availability and marketing of complementary foods International organisations, national policy makers, humanitarian actors
Improve supplementary feeding programmes for infants and young children International organisations, national policy makers, humanitarian actors
Improve coverage of treatment for wasting
Adopt policies and actions and mobilise funding to improve coverage using the National policy makers, development partners, humanitarian actors, health services
community based management of acute malnutrition approach
Improve the integrated management of childhood illnesses National policy makers, health services
Reduce the risk of anaemia in children
Provide iron supplementation for pre-school children National policy makers, health services
Reduce prevalence and severity of infectious disease in children
Provide zinc supplementation to reduce the duration and severity of diarrhoea and National policy makers, health services
to prevent subsequent episodes in children
Implement policies and programmes to ensure universal access to and use of National policy makers, health services
insecticide treated nets
Provide periodic deworming for all school age children in endemic areas National policy makers, health services, schools
Improve the management of moderate acute malnutrition in children
Provide supplementary foods for the management of moderate acute malnutrition National policy makers, health services, development partners, humanitarian actors
in children†
Reduce children’s intakes of free sugars and sodium
Regulate the marketing of food and non-alcoholic beverages to children in National policy makers, food industry, advertising and media sector
accordance with WHO recommendations
Provide adequate food in school settings
Promote physical activity in children
Create a conducive environment that promotes physical activity and tackles National and local policy makers, urban planners, early years education services,
sedentary lifestyle health services
*Exclusive breast feeding up to age 6 months, followed by adequate complementary feeding (from 6 to 24 months) and continued breast feeding up to 2 years of age or beyond.
All recommended actions are based on those proposed in the Framework for Action issued by the Second International Conference on Nutrition in November 2014 except (†), which is based
on a WHO Technical Note (www.who.int/nutrition/publications/moderate_malnutrition/9789241504423/en/).

important window of opportunity to improve and control over, social protection and nutrition is needed now. We know what
child nutrition. The key pillar of any strategy resources such as income, land, water, and needs to be done—as explained by the rec-
to improve this—in addition to good mater- technology. Direct multisectoral actions to ommended actions in tables 2 to 4  —and the
nal nutrition and health—is optimal feeding tackle critical women’s nutritional chal- clear global commitments to action.
and care for infants and young children. lenges, such as iron deficiency anaemia, We now need to implement these commit-
Exclusive breast feeding (defined as the need to be rolled out on a larger scale to ments and ensure the resources to do so (the
practice of giving an infant only breast milk achieve universal coverage. Addis Ababa Action Agenda refers to the need
for the first six months of life, with no other to scale up efforts to end hunger and malnu-
food or water), in particular, has the single Improving nutrition across the life course trition at paragraph 13 and the need to
largest potential effect on child mortality of These targeted recommendations must be strengthen national health systems at para-
any preventive intervention. Timely and ade- supported by a raft of nutrition interventions graph 77).16 In a nutshell, actions are needed
quate complementary feeding, with particu- throughout the life course (see the ICN2 to improve the quality of diets; protect, pro-
lar attention to vitamin and mineral content Framework for Action for the full range of mote, and support breast feeding; ensure that
and the nutrient density of foods, is urgently recommended actions). Policies are needed, everyone has access to essential nutrition
needed. for example, to transform food systems and actions; provide adequate water and sanita-
strengthen health systems. Universal access tion; and provide information and education.
Actions to improve women’s nutrition to functioning and resilient health systems To achieve these aims governments and
The health and nutrition statuses of women and the scaled-up delivery of interventions society must join forces and make nutrition a
and children are intimately linked. Improv- can improve nutrition. Governments and priority. Governments, health services, the
ing the health of women and children, there- international organisations also have a role food and agriculture industries, schools and
fore, begins with ensuring the health and in developing clear guidelines on healthy universities, and community leaders—along
nutritional status of women throughout all diets. with many others—must work together in a
stages of life, and it continues with women coordinated and coherent way.
being providers for their children and fami- What needs to happen now? The potential human, societal, and eco-
lies. Thus, a key priority is female empower- If we want to improve the health of women, nomic gains from turning these commitments
ment and women’s full and equal access to, children, and adolescents, action to invest in into action are substantial, and the costs of

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 Women’s, Children’s, and Adolescents’ Health

Table 4 | Recommended actions to improve women’s nutrition

Recommended actions and evidence Who needs to take action?
Prevent and control anaemia

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Promote consumption of nutrient dense foods, especially foods rich in iron National policy makers, food and agriculture sectors
Implement actions to ensure that pregnant and lactating adolescent mothers are National policy makers, development partners, food and agriculture sectors
adequately nourished
Introduce measures to prevent adolescent pregnancy and to encourage pregnancy National policy makers, health service providers
spacing
Reduce the risk of low birth weight, maternal anaemia, and iron deficiency
Provide daily iron and folic acid and other micronutrient supplementation to National policy makers, health service providers
pregnant women as part of antenatal care
Provide intermittent iron and folic acid supplementation to menstruating women National policy makers, health service providers
where prevalence of anaemia is 20% or higher
Provide periodic treatment with anthelminthic (deworming) medicines for all National policy makers, health service providers, development partners
women of childbearing age living in endemic areas
Promote healthy weight gain and adequate nutrition during pregnancy
Provide dietary counselling to women during pregnancy National policy makers, health service providers
Prevent and treat malaria as part of anaemia prevention and control
Ensure universal access to and use of insecticide treated nets National policy makers, health service providers, development partners
Provide preventive malaria treatment for pregnant women in areas with moderate to National policy makers, health service providers, development partners
high malaria transmission
Ensure access to reproductive healthcare
Ensure that women have comprehensive information about safe pregnancy and National policy makers, health service providers, development partners
delivery
Ensure that women have access to integral healthcare services that ensure National policy makers, health service providers, development partners
adequate support for safe pregnancy and delivery
Promote protection of working mothers to support or sustain breast feeding
Implement policies and practices to promote protection of working mothers (eg, National or regional policy makers, employers
longer maternity leave, breaks to feed or express breast milk)
Improve pregnancy outcomes for undernourished pregnant women
To prevent pre-eclampsia, provide calcium supplementation for pregnant women in National policy makers, health service providers, development partners
areas where dietary calcium intake is low and for higher risk women21*
All recommended actions are based on those proposed in the Framework for Action issued by the Second International Conference on Nutrition in November 2014 except (*),which is based
on a WHO recommendation.

inaction are high. The time is right to tackle 1 Second International Conference on Nutrition. 12 Second International Conference on Nutrition.
Conference outcome document: framework for Conference outcome document: Rome declaration on
malnutrition in all forms at all ages and to action. Oct 2014. www.fao.org/3/a-mm215e.pdf. nutrition. Oct 2014. www.fao.org/3/a-ml542e.pdf.
break its intergenerational cycle. 2 Second International Conference on Nutrition. 13 World Health Organization. Global nutrition targets
The authors thank Karen McColl, Lina Mahy, Rebecca Olson, Information note on the framework for action. 4 Nov 2025: childhood overweight policy brief (WHO/NMH/
and Shelly Sundberg for their contributions to this paper. 2014. www.fao.org/fileadmin/user_upload/faoweb/ NHD/14.6). 2014. w ­ ww.who.int/nutrition/topics/
ICN2/documents/InfoNote-e.pdf. globaltargets_overweight_policybrief.pdf.
Competing interests: We have read and understood 3 World Health Organization. WHA global nutrition 14 United Nations. The millennium development goals
BMJ’s policy on declaration of interests and have no targets 2025: stunting policy brief. 2014. www.who. report 2014. 2014. www.un.org/
relevant interests to declare. int/nutrition/topics/globaltargets_stunting_ millenniumgoals/2014%20MDG%20report/MDG%20
The authors alone are responsible for the views policybrief.pdf. 2014%20English%20web.pdf.
expressed in this article, which does not necessarily 4 World Health Organization. WHA global nutrition 15 World Health Organization. Essential nutrition actions:
represent the views, decisions, or policies of WHO or the targets 2025: wasting policy brief. 2014. www.who. improving maternal, newborn, infant and young child
institutions with which the authors are affiliated. int/nutrition/topics/globaltargets_wasting_ health and nutrition. 2013. http://apps.who.int/iris/
policybrief.pdf. bitstream/10665/84409/1/9789241505550_eng.pdf.
Provenance and peer review: Not commissioned; 5 Black RE, Victora CG, Walker SP, et al; Maternal and 16 United Nations. The Addis Ababa action agenda of
externally peer reviewed. Child Nutrition Study Group. Maternal and child the Third International Conference on Financing for
Francesco Branca,director1 undernutrition and overweight in low income and Development. July 2015. www.un.org/esa/ffd/ffd3/
Ellen Piwoz, senior program officer 2 middle income countries. Lancet 2013;382:427-51. wp-content/uploads/sites/2/2015/07/Addis-Ababa-
6 Lim SS, Vos T, Flaxman AD, et al. A comparative risk Action-Agenda-Draft-Outcome-Document-7-July-2015.
Werner Schultink, chief of nutrition3 assessment of burden of disease and injury attributable pdf.
Lucy Martinez Sullivan, executive director4 to 67 risk factors and risk factor clusters in 21 regions, 17 International Food Policy Research Institute. Global
1Department of Nutrition for Health and Development, 1990-2010: a systematic analysis for the Global Burden nutrition report 2014: actions and accountability to
World Health Organization, Avenue Appia 20, 1211 of Disease Study 2010. Lancet 2012;380;2224-60. accelerate the world’s progress on nutrition. 2014. http://
Geneva 27, Switzerland 7 International Bank for Reconstruction and cdm15738.contentdm.oclc.org/utils/getfile/collection/
2Bill and Melinda Gates Foundation, USA
Development, World Bank. Repositioning nutrition as p15738coll2/id/128484/filename/128695.pdf.
central to development: a strategy for large scale 18 World Health Organization. Healthy diet. Fact sheet no
3Unicef, New York, USA
action. 2006. https://openknowledge.worldbank.org/ 394. May 2015. www.who.int/mediacentre/factsheets/
41000 Days, Washington, DC, USA handle/10986/7409. fs394/en/.
8 World Health Organization. Comprehensive 19 World Health Organization. Global recommendations
Correspondence to: F Branca brancaf@who.int
implementation plan on maternal, infant and young on physical activity for health. 2010. www.who.int/
© World Health Organization 2015. Licensee BMJ child nutrition. 2014. http://apps.who.int/iris/ dietphysicalactivity/publications/9789241599979/
bitstream/10665/113048/1/WHO_NMH_NHD_14.1_ en/.
This is an open access article distributed under the
eng.pdf?ua=1. 20 World Health Organization. Nutrition counselling for
terms of the Creative Commons Attribution-
9 Hoddinott J, Alderman H, Behrman JR, Haddad L, Horton adolescents and adults with HIV/AIDS. WHO e-Library
Noncommercial IGO License (https://creativecommons. S. The economic rationale for investing in stunting of Evidence for Nutrition Actions (eLENA). July 2015.
org/licenses/by-nc/3.0/igo/), which permits use, reduction. GCC Working Paper Series 2013;13-08. www.who.int/elena/titles/nutrition_hiv/en/.
distribution, and reproduction for non-commercial 10 Hoddinott J, Horton S. Stunting as a sustainable 21 World Health Organization. Guideline: calcium
purposes in any medium, provided the original work is development goal. SCN News 2015;41:59. www.unscn. supplementation in pregnant women. 2013. www.who.
properly cited. In any reproduction of this article there org/files/Publications/SCN_News/SCNNEWS41_web_ int/nutrition/publications/micronutrients/guidelines/
should not be any suggestion that WHO or this article low_res.pdf. calcium_supplementation/en/.
endorse any specific organisation or products. The use 11 United Nations Secretary General. Global strategy for
of the WHO logo is not permitted. This notice should be women’s and children’s health. Sept 2010. www.who.
preserved along with the article’s original URL. int/pmnch/topics/maternal/20100914_gswch_en.pdf. Cite this as: BMJ 2015;351:h4173

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