 Good morning everyone. I must say to the organizers that it's a bit unfair to have me after Dr. Ludin here. I don't know how I can measure up to that. As much as I was enjoying his presentation, my performance anxiety has been increasing as well. So I hope to impress you, but let's see. He says science is, we know enough, and I would conclude my presentation by actually saying we do know enough. But the topic that I was given is action against malnutrition. What is thought to work? As the title shows, this is a topic where we give MSc degrees, right? It takes a year in the UK to get a degree on this topic, and I have 15 minutes. So I'm considering that I work on under nutrition, diet quality, and food systems and agriculture. So I had to focus somewhere knowing that you had quite a lot on food systems and related issues of diet quality and diets yesterday. I thought I would do the more conventional thing on focus on under nutrition, but happy to talk to anyone afterwards on some of our work on food environment and so on and so forth. So my name is Sunita Kadyala and I'm an associate professor at the London School of Hygiene and Tropical Medicine, and my time starts now. So I don't think you need a lot of introduction on the trends in malnutrition, so I won't go on and on. I just want to show that we are making progress in reductions in under nutrition in South Asia and Southeast Asia. The wasting rates still remain alarmingly high, and in child under nutrition, sorry, over-nutrition or overweight and obesity is increasing. Here I have statistics for children, but it is increasing more alarmingly and faster and steeper in adults more than children, but we are not very far for children either. So we need to continue to work on under nutrition, but also on the issues of nutrition related chronic conditions. There are very few statistics. There are some statistics on the concurrent prevalence of wasting and stunting among children. And as you see, South Asia, the Indian subcontinent has a really high rate of concurrent prevalence of stunting and wasting. And we do know that when there is a concurrent prevalence of stunting and wasting among children, the mortality, the hazard ratios are really high over time times, higher than if a child is suffering from only one of these conditions. So this is something that, again, I don't think it receives enough attention, but it deserves quite a lot of attention. We all in this room, I'm preaching to the choir here, know the importance of a well-nourished child. Here is a very old MRI, and I think we should have more of these actually, of a well-nourished infant. If you see these are the neurons in the brain with a lot of branching, as you will see the finer branches in the brain, that's how a brain should be in terms of if a child is well-nourished. But as you will see, in under-nourished infant, you will see clumps of these neurons without extensive branching, which shows that there is an issue, obviously, with the brain development, and this is something why we are all concerned here and are congregated here today. There are any number of studies to show the impacts of stunting of various kinds, including fetal growth restriction and under nutrition on nutrition-related chronic conditions as well. I won't go into all the details here on all those studies, but the evidence is well-established and robust. So, what do we do now? That is the topic of my talk. What do we know about what we have done and what to do? So, most of you must be familiar with this graph, which is a graph of 54 countries from low and middle-income countries around the world by Victoria et al, which basically shows the HSE scores and the decline in HSE scores once the child is born. But as you can see, even at birth, the HSE scores are lower than the WHO standard median or mean. So, it's no surprise that there is now a focus on pregnancy and, therefore, our beloved phrase of the first thousand days. So, pregnancy under two is now the policy focus. What do we know about that? What do we know about the postnatal nutrition-specific interventions to prevent growth faltering, for example, or in terms of improving nutrition outcomes? The most programmatic modalities include some sort of social behavior change. They could be counseling. Sometimes they can be mass media education, so on and so forth. Growth monitoring, whether it is just weighing a child or actually counseling the mother on what the growth chart means and what growth faltering means is, of course, an implementation, a serious implementation issue, and provision of specific nutrient-dense foods. The most common objective of such programs is to improve IVCF, infant-young child-feeding practices, to improve child nutrition outcomes, although I said here stunting, but it's true for other forms of under-nutrition as well. What do we know about how these programs work? When IVCF programs focus on improving IVCF practices, actually, programs do improve those outcomes. So, we do know that these programs work to improve practices. Then what do we know about their impacts on stunting? We do see some impacts on stunting. I know 30 percent reduction is not trivial, and especially when complementary feeding with food provisioning in food insecure populations, you will see much higher impact on stunting. So, these programs are important, should be continued and scaled up. What, again, these reviews do not include are the more recent ones, the ones I'm showing are slightly older, 2013, 2014, and they do not include some of the recent studies that have come up in terms of such as arrive and thrive and carrying trials in these reviews. What do we know about nutrition supplementation during pregnancy? Again, what you see here is that protein energy supplementation improves, has significant impact on small for gestational age. It has variable, but overall small, sometimes small, but sometimes over 85 grams improvements in birth weight, so approximately around 70 grams overall. Again, it is good, but could we do more is the question. I'm the same with multiple micronutrient supplements to pregnant women. So, why are we not seeing larger effects of these nutrition interventions during pregnancy and postnatal and during infancy? Are we intervening too late? Are we, as Marie Ruel would say, are we pressing all these buttons all at the same time for adequate duration? Perhaps not, right? So, should we, is therefore, a thousand-day approach, somewhat myopic or even too narrow, should we be going back to the more conventional traditional way of looking at nutrition as a life cycle approach? And perhaps I would like to conclude that perhaps that should be the case. So, the focus on adolescent nutrition on the international development agenda could not have come sooner, and it is better late than never. So, the focus of adolescent nutrition really going back towards pregnancy preconception and adolescence is very important. The latest in some of the very important studies on epigenetics, which is basically how genes switch on and off with cues in the environment, the studies from Andrew Prentice and Group in the Gambia basically show that the imprint of how a child's growth can happen at the time of conception. So, when we are starting interventions, when we know the mother is pregnant, and that could be any time after first trimester to last trimester, perhaps it's too late. So, we really do need adolescent girls, not because they're just the mothers, I think they're just more than a crucible. I would like to add, you know, just for their own health, but also for healthier population, we do need to focus on adolescent nutrition. About 40 percent globally are underweight, adolescents are underweight, 10 to 19-year-olds, and anemia is the second leading cause of disability. And 11 percent of adolescent girls globally are mothers, and this is much higher, up to 20 to 25 percent in South Asia. So, this is really quite important for an issue for us to focus on. Catch-up growth, this is although not of adolescent catch-up growth, this is a catch-up growth from the cohort studies of young children, catch-up growth is possible, and we should be able to make it possible for adolescent girls, because, sorry, for all adolescents, not just adolescent girls, but because a lot happens during adolescence, right? All the organs are developing at this stage, reproductive organs, lymphatic system, brain, liver, so on and so forth. So, there's a lot happening, and we need to provide an environment where this can happen. But the challenge, then, is how do we not exacerbate some of the adverse consequences that might happen because of our enthusiasm to prevent under nutrition? So, what more can we do, right? I mean, clearly, we need to do a lot more. And what would that be? So, that is where my fortunate or unfortunate title of nutrition, you know, Associate Professor in Nutrition Sensitive Development comes, another jargon. But what does that mean? How do we unpack that? What that means is basically as defined in the Lancet series for maternal and child under nutrition in 2013 is that these are the processes, approaches, programs, policies that address the underlying determinants of fetal and child under nutrition and development, which incorporates specific nutrition goals. That is the key, right? We've been doing lots of different things since human evolution, but the key is here is to really think about nutrition goals and having an objective of nutrition in this. There are several sectors that come into play, and these need to be made nutrition sensitive. Why should we do that? What do we know about that? Will the normal development not get us there? Let's look at that for a bit. So, here is a graph from the Lancet. Again, I'm sorry, I don't have the source here, but I should have put it there. It's from the Lancet series, Ruel and Alderman paper from 2013, where this graph is basically on the y-axis is the stunting prevalence rate and the x-axis is the GDP per capita. And what we see here is that a 10% increase in GDP per capita leads to a 6% reduction in stunting. This is great. So, poverty reduction efforts and economic growth are clearly super important and should remain on the agenda. But income growth, devoid of nutrition objectives, can have some unintended consequences. So, if you look at this graph on the y-axis here is the female overweight prevalence. What you see is that a 10% increase in GDP per capita leads to a 7% increase in overweight and obesity. That is very disturbing because if you take these two graphs together, what you see is that income growth, devoid of nutrition objectives, increases overweight and obesity among female adults faster than it reduces under nutrition among children. Now, that is quite disconcerting. So, this is why we need a nutrition-sensitive approach to our development. Research tells us that there are various underlying causes of under nutrition and addressing these can make a difference. They're all here. I won't go into excruciating detail on what all these studies say. But suffice to say that there are several sectors reflected here in terms of asset accumulation, which is basically about economic growth, including fertility, which is really you're talking about family planning perhaps here, decreasing open defecation, agriculture growth. Yesterday you must have heard about equity from Carlos Montero in Brazil. So, we know all these things are important and nicely also we find empirical evidence for these things. Here is another neat study by Laurence Haddad and Lisa Smith where they do show that the contributions of under nutrition by various sectors or what explains child nutrition by various sectors or various factors in terms of under nutrition. If you look at this, what is interesting to me in this pie chart is all the green, the two green pies are about food. The red ones are about wash and the blue ones are about some sort of an indicator of empowerment. And each of them add up to roughly a third of that. So, it really is quite a powerful pie chart, a simple but effective one. So, clearly we need a lot of sectors and here I'm going to choose two sectors for my talk or two types of interventions for my talk here and to take us through what we know about that. Social safety nets is a huge topic by itself. So, I've chosen cash transfers, which is timely for South and Southeast Asia as an intervention policy instrument. So, there is a strong, what do we know about cash transfers and their impact on nutrition? We know that there is a strong evidence of their impact on poverty reduction, food security and service utilization. But we see limited impacts on child nutrition and some studies show that their impacts are higher for younger, poorer children with longer exposure. But remember that none of them actually had nutrition objectives to begin with. So, what happens once you have nutrition objectives? Here is a neat study by Akhtar Ahmad and John Hoddinot and team in Bangladesh and what you see is a forearm plus randomized controlled trial with cash, food, cash plus food and cash plus nutrition BCC. And you can see the results for yourself. When nutrition is included, you can see a steeper reduction and a sharper reduction in stunting rates. So, clearly sole cash transfers and even food and cash plus food depending on the context are continue to be quite important. If made nutrition sensitive, they can be effective tools. So, what do we know about agriculture and nutrition pathways? I have just two slides on this, on a vast topic. And what we know, again, is a study by Patrick Webb and Steve Block from Tufts University and what they show is what actually several ag economists showed in the context of poverty reduction. Is that countries favoring stunting, sorry, countries favoring agriculture led development, have a faster and steeper declines in stunting rates than countries that favor other forms of development, non-agriculture related economic growth path, right? So, clearly agriculture and nutrition sensitive agriculture are clear, are important for reductions in under nutrition. So, over the last, since especially the financial and food price crisis, there has been quite a lot of attention to the agriculture sector and the role of agriculture sector in tackling under nutrition. Where are we with that evidence base? We know that, fortunately, that agriculture interventions, when made nutrition sensitive, and I'm happy to talk about what we mean by nutrition sensitive and how do you make anything nutrition sensitive? During the discussion, if we have time, is that they improve agriculture production, women's empowerment, income and diets. We see some impacts on wasting and wasting and anemia, but again, we do not see that many impacts. The studies do not show an impact on stunting. And is that because the timelines are true short, many of these studies have three months, three years of implementation at best. And perhaps that's too short. Or again, we are starting too late in our interventions. But to me, what I take away from this is the positive news that we are, the pathways to impact are firmly along the right direction. So, in conclusion, thank you, in conclusion, I like to think that, you know, we know enough, I think we have enough to act. And the question again is how do we work more comprehensively to bring resources and actions to bear at the same time and place on the same mother and child at the right time for long enough duration to impact on under nutrition? IE, how do we make all these sectors converge on the mother and child at the same time when they need it the most? I think that is our implementation challenge. With that, I thank everyone for your kind attention. Thank you.