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      Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data

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      a , * , b , * , d , e , c , b , f , * , on behalf of Nutrition Impact Model Study Group (Child Growth)
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          Summary

          Background

          There is little information on country trends in the complete distributions of children's anthropometric status, which are needed to assess all levels of mild to severe undernutrition. We aimed to estimate trends in the distributions of children's anthropometric status and assess progress towards the Millennium Development Goal 1 (MDG 1) target of halving the prevalence of weight-for-age Z score (WAZ) below −2 between 1990 and 2015 or reaching a prevalence of 2·3% or lower.

          Methods

          We collated population-representative data on height-for-age Z score (HAZ) and WAZ calculated with the 2006 WHO child growth standards. Our data sources were health and nutrition surveys, summary statistics from the WHO Global Database on Child Growth and Malnutrition, and summary statistics from reports of other national and international agencies. We used a Bayesian hierarchical mixture model to estimate Z-score distributions. We quantified the uncertainty of our estimates, assessed their validity, compared their performance to alternative models, and assessed sensitivity to key modelling choices.

          Findings

          In developing countries, mean HAZ improved from −1·86 (95% uncertainty interval −2·01 to −1·72) in 1985 to −1·16 (–1·29 to −1·04) in 2011; mean WAZ improved from −1·31 (–1·41 to −1·20) to −0·84 (–0·93 to −0·74). Over this period, prevalences of moderate-and-severe stunting declined from 47·2% (44·0 to 50·3) to 29·9% (27·1 to 32·9) and underweight from 30·1% (26·7 to 33·3) to 19·4% (16·5 to 22·2). The largest absolute improvements were in Asia and the largest relative reductions in prevalence in southern and tropical Latin America. Anthropometric status worsened in sub-Saharan Africa until the late 1990s and improved thereafter. In 2011, 314 (296 to 331) million children younger than 5 years were mildly, moderately, or severely stunted and 258 (240 to 274) million were mildly, moderately, or severely underweight. Developing countries as a whole have less than a 5% chance of meeting the MDG 1 target; but 61 of these 141 countries have a 50–100% chance.

          Interpretation

          Macroeconomic shocks, structural adjustment, and trade policy reforms in the 1980s and 1990s might have been responsible for worsening child nutritional status in sub-Saharan Africa. Further progress in the improvement of children's growth and nutrition needs equitable economic growth and investment in pro-poor food and primary care programmes, especially relevant in the context of the global economic crisis.

          Funding

          The Bill & Melinda Gates Foundation and the UK Medical Research Council.

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          Most cited references35

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          National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants.

          Data for trends in blood pressure are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. However, few worldwide analyses of trends in blood pressure have been done. We estimated worldwide trends in population mean systolic blood pressure (SBP). We estimated trends and their uncertainties in mean SBP for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (786 country-years and 5·4 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean SBP by age, country, and year, accounting for whether a study was nationally representative. In 2008, age-standardised mean SBP worldwide was 128·1 mm Hg (95% uncertainty interval 126·7-129·4) in men and 124·4 mm Hg (123·0-125·9) in women. Globally, between 1980 and 2008, SBP decreased by 0·8 mm Hg per decade (-0·4 to 2·2, posterior probability of being a true decline=0·90) in men and 1·0 mm Hg per decade (-0·3 to 2·3, posterior probability=0·93) in women. Female SBP decreased by 3·5 mm Hg or more per decade in western Europe and Australasia (posterior probabilities ≥0·999). Male SBP fell most in high-income North America, by 2·8 mm Hg per decade (1·3-4·5, posterior probability >0·999), followed by Australasia and western Europe where it decreased by more than 2·0 mm Hg per decade (posterior probabilities >0·98). SBP rose in Oceania, east Africa, and south and southeast Asia for both sexes, and in west Africa for women, with the increases ranging 0·8-1·6 mm Hg per decade in men (posterior probabilities 0·72-0·91) and 1·0-2·7 mm Hg per decade for women (posterior probabilities 0·75-0·98). Female SBP was highest in some east and west African countries, with means of 135 mm Hg or greater. Male SBP was highest in Baltic and east and west African countries, where mean SBP reached 138 mm Hg or more. Men and women in western Europe had the highest SBP in high-income regions. On average, global population SBP decreased slightly since 1980, but trends varied significantly across regions and countries. SBP is currently highest in low-income and middle-income countries. Effective population-based and personal interventions should be targeted towards low-income and middle-income countries. Funding Bill & Melinda Gates Foundation and WHO. Copyright © 2011 Elsevier Ltd. All rights reserved.
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            Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4.

            Previous assessments have highlighted that less than a quarter of countries are on track to achieve Millennium Development Goal 4 (MDG 4), which calls for a two-thirds reduction in mortality in children younger than 5 years between 1990 and 2015. In view of policy initiatives and investments made since 2000, it is important to see if there is acceleration towards the MDG 4 target. We assessed levels and trends in child mortality for 187 countries from 1970 to 2010. We compiled a database of 16 174 measurements of mortality in children younger than 5 years for 187 countries from 1970 to 2009, by use of data from all available sources, including vital registration systems, summary birth histories in censuses and surveys, and complete birth histories. We used Gaussian process regression to generate estimates of the probability of death between birth and age 5 years. This is the first study that uses Gaussian process regression to estimate child mortality, and this technique has better out-of-sample predictive validity than do previous methods and captures uncertainty caused by sampling and non-sampling error across data types. Neonatal, postneonatal, and childhood mortality was estimated from mortality in children younger than 5 years by use of the 1760 measurements from vital registration systems and complete birth histories that contained specific information about neonatal and postneonatal mortality. Worldwide mortality in children younger than 5 years has dropped from 11.9 million deaths in 1990 to 7.7 million deaths in 2010, consisting of 3.1 million neonatal deaths, 2.3 million postneonatal deaths, and 2.3 million childhood deaths (deaths in children aged 1-4 years). 33.0% of deaths in children younger than 5 years occur in south Asia and 49.6% occur in sub-Saharan Africa, with less than 1% of deaths occurring in high-income countries. Across 21 regions of the world, rates of neonatal, postneonatal, and childhood mortality are declining. The global decline from 1990 to 2010 is 2.1% per year for neonatal mortality, 2.3% for postneonatal mortality, and 2.2% for childhood mortality. In 13 regions of the world, including all regions in sub-Saharan Africa, there is evidence of accelerating declines from 2000 to 2010 compared with 1990 to 2000. Within sub-Saharan Africa, rates of decline have increased by more than 1% in Angola, Botswana, Cameroon, Congo, Democratic Republic of the Congo, Kenya, Lesotho, Liberia, Rwanda, Senegal, Sierra Leone, Swaziland, and The Gambia. Robust measurement of mortality in children younger than 5 years shows that accelerating declines are occurring in several low-income countries. These positive developments deserve attention and might need enhanced policy attention and resources. Bill & Melinda Gates Foundation. Copyright 2010 Elsevier Ltd. All rights reserved.
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              World Development Report 2008

              (2007)
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                Author and article information

                Contributors
                Journal
                Lancet
                Lancet
                Lancet
                Lancet Publishing Group
                0140-6736
                1474-547X
                01 September 2012
                01 September 2012
                : 380
                : 9840
                : 824-834
                Affiliations
                [a ]Department of Health Statistics and Information Systems, WHO, Geneva, Switzerland
                [b ]Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
                [c ]Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
                [d ]Department of Statistics, University of California, Berkeley, CA, USA
                [e ]School of Computer Science and Heinz College, Carnegie Mellon University, Pittsburgh, PA, USA
                [f ]MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College London, London, UK
                Author notes
                [* ]Correspondence to: Prof Majid Ezzati, MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Medical Faculty Building, Norfolk Place, London W2 1PG, UK majid.ezzati@ 123456imperial.ac.uk
                [*]

                Contributed equally to the research and preparation of the report

                [†]

                Members listed at the end of the report

                Article
                LANCET60647
                10.1016/S0140-6736(12)60647-3
                3443900
                22770478
                c443d4f7-eb57-4677-80e4-50f6dc26999a
                © 2012 Elsevier Ltd. All rights reserved.

                This document may be redistributed and reused, subject to certain conditions.

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