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8/3/2019 New Hope for Malnourished Mothers and Children
1/12
www.bread.org
Abstract
Bread for the World Institute providespolicy analysis on hunger and strategies
to end it. The Institute educates its ad
vocacy network, opinion leaders, policy
makers and the public about hunger in
the United States and abroad.
Just 36 Countries Account for 90 Percent of the Worlds Stunted Children
Thescopeofmalnutritionisstaggering.Womenandyoungchildrenarethehardesthit.Inmanycountrieschildmalnutritionratesaresteadilyrising.
Forchildrensufferingmalnutritiontheeffectswillbelong-term,eveninter-generational.Malnutritionimpairsphysicalgrowthandcognitivedevelop-ment.
Incountrieswithhighlevelsofchildhoodmalnutrition,theeconomicloss
canbeashighas2-3percentofGDP. Newevidenceshowsthatinterventionstopreventandtreatmalnutritionof
womenandchildrenfromconceptionthroughthersttwoyearsoflifecansavemillionsoflivesandensurethatchildrengrowuptobehealthy,strong,productiveadults.
AstheUnitedStatesembarksonanewglobalfoodsecurityinitiative,nutri-tionmustbeacentralcomponent.Evidence-basednutritioninterventionsmustbescaledupandnutritionmustbeintegratedintoprogramstoim-proveagricultureandfoodsecurity.
Key Points
briefing paperNumber 7, October 2009
Manydevelopingcountrieshavehad success in reducing malnutri-tion. But malnutrition remainspervasive and, in many countries,comesataveryhighcost.Eachyear,millions ofchildren die from mal-nutrition; millions more suffer illhealthand face long-term physicalandcognitive impairment, leading
tolostproductivity.Theperiodbe-tweenconceptionandthersttwo
yearsinachildslifearecritical.TheObama administrations initiativeto ght hunger offers an opportu-nitytoimprovenutritionofmothersandchildrenaroundtheworld.Inadditiontothefocusonincreasingagricultural productivity and rais-ing rural incomes, the administra-
tion should scale up nutrition in-terventionsand integrate nutritionintoitsdevelopmentprogramming.Itshoulduseimprovementsinma-ternalandchildnutritionasakeyindicatorofsuccess.Itshouldsup-port country-led strategies, coordi-natewithotherdonorsandensurethatU.S.actionsandpoliciesdonotunderminenutritionobjectives.
New Hope for MalnourishedMothers and Childrenby Eric Muoz
Eric Muoz is a policy analyst for Bread for the World Institute.
Source:The Lancet.
n No data
n
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Ifthereisonepositiveresultofthespikeinfoodpricesthatoccurredin2008,itistherenewedemphasisonagricultureandruraldevelopmentindevelopingcoun-
tries. President Obama has made ghting hunger in theUnitedStatesandaroundtheworldatoppriorityofhisad-ministration.Hehashelpedtoconvinceotherwealthyna-tionsthattheyhavearoletoplayaswell.AttheG-8summitinJuly2009,leadersagreedtoinvest$20billionoverthe
nextthreeyearstoincreaseagriculturalproductivityinde-velopingcountries,helpfarmersearnmoremoneyforthefoodtheygrow,andimprovefoodsecurity.1
Renewedattentiontoagricultureandfoodsecuritymustalsoincludematernalandchildnutritionasatopdevelopmentpriority. Providinggood nutrition early in childrens livescanhelpthemgrowuptobestronger,healthieradults,betterable to contribute to their households, communities, andcountries.Yetpreventingandtreatingmalnutritioncurrentlyreceiveslittleattention,support,orinvestment.
The scope of malnutrition is staggering. Hundreds of
millions of young children face hunger and malnutritionevery day. Malnourished mothers are more likely to dieduring childbirth or give birth to undernourished babies
who are also at increased risk of death. In 2008, nearly9 million children died before they reached their fthbirthday.2One-thirdofearlychildhooddeathsarethedirectorindirectresultofmalnutrition. 3Childrenwhosurviveearlychildhoodmalnutritionsufferirreversibleharmincludingpoorphysicalgrowth,compromisedimmunefunction,andimpairedcognitiveabilities.4
Whencountriesdofocusonnutrition,however,dramatiimprovements are possible. In the United States, theimportance of child nutrition became clear in the 1940s
when hundreds of thousands of military recruits wereturneddownforservicebecausetheywereundernourishedandinpoorhealth.5Inresponse,thegovernmentintroducedprograms to reduce hunger, including school breakfasand lunch, the Food Stamp Program, and the Specia
SupplementalNutritionProgramforWomen,InfantsandChildren (WIC).6 In 2008,nearlyhalfof all infants bornintheUnitedStatesreceivedWICbenets,whichincludenutritiousfoodandreferralstohealthandsocialservices. 7
Inothercountries,millionsofmothersandchildrenarenowseeingrapidprogressinnutrition.InMexico,overthlastdecadeandahalf,theOportunidadesprogramhasbeenprovidingpregnantwomenandmothersofyoungchildren(uptoagethree)withcashassistanceandselectednutritiousfoods,onconditionthatthechildrenareregularlyseenbyadoctor.Asaresultoftheprogram,malnutritionamong
youngchildrenhasdropped17percent.8
U.S.foreignassistancesupportsmanyactivitiesthatmakeadifferenceforhungrychildren.HumanitarianassistancehelpsfeedchildrenandputthemonapathtogoodhealthFoodaidprogramsareincreasinglyfocusedonpreventingmalnutrition.U.S.-fundedglobalhealthprogramstargetkeymicronutrientdeciencies,providenutritiousfoodtopeople
with HIV, and offer assistance to developing countriesinterestedinexpandingtheirnutritionefforts.
ToddPost
Basic Denitions
Malnutrition is literally Bad Nutrition. It is also referred to
as undernutrition or undernourishment. Malnutrition is not hav-
ing enough nourishing food with adequate amounts of protein,
vitamins, minerals, and calories to support physical and mental
growth and development. Scientically, malnutrition is measured
in four ways:
Micronutrient malnutrition: deciencies of essential micronutri-
ents needed for physical and mental growth, development, and
health.
Weightforage: where the weight of a child or infant is com-
pared with the weight of a well-nourished child of that age andsex. Malnutrition leads to numbers indicating an underweight
status.
Heightforage: where the height of a child or infant is com-
pared with the height of a well-nourished child of the same age
and sex. Malnutrition results in stunting.
Weightforheight: comparison used to reveal acute malnutri-
tion or wasting. Severe Acute Malnutrition or SAM is a weight-
for-height measurement of 70 percent or less.
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A comprehensive approach to preventing and treatingmalnutritionmeansexpandingprogramstothescaleneededandlinkingcurrentU.S.nutritionactivitieswithbroaderin-
vestmentsinrelatedsectors,includingagriculture,foodsecu-rity,andruralinfrastructure.FocusingonnutritionisoneofthebestinvestmentstheUnitedStatesandtheinternationalcommunitycanmaketoreducehungerandpovertyandpro-motedevelopment.
Nutrition is Critical for DevelopmentThe rst two years of life are a critical window of
opportunitytomakesurechildrenlivehealthy,productivelives.Along-termstudyinGuatemalafollowingindividualsfrom infancy into adulthood provides some of the bestevidenceyetoftheeconomicbenetsofgoodnutrition.9
In1969,youngGuatemalanchildrenintwocommunitieswerechosentoparticipateinanutritionsupplementationprogramthatprovidedthemwithanutritiousdrinktwiceaday.OnegroupofchildrenreceivedadrinkcalledFresco,theotheradrinkcalledAtole,whichcontainedmorecaloriesandproteinthanFresco.
The nutrition intervention had a profound impact.Those who receivedAtole grew on average an additional2.4centimeterstallerthan thosewhoreceivedFresco.Thissmall difference resulted in a 20 percent reduction inseverestuntingintheAtolegroup.VirtuallynoreductioninstuntingwasfoundforchildrenwhoreceivedFresco.10Follow-up monitoring of the children in these two communities25 years later showed that individuals who receivedAtolehadagreaterlikelihoodofcompletingprimaryandsomesecondaryschool,higherscoresonreadingcomprehensionandcognitivetests,and,amongwomen,completionofmoregradesinschool.11
TheimpactofgreaterheightandmoreschoolingintheAtolegrouphaseconomicconsequencesaswell.Asadults,childrenwhoreceivedAtoleduringthersttwoyearsoflifeearnedanaverageof$870moreannuallythanindividuals
whoreceivedFresco.Inacountrywhereannualpercapitaincome is just $2,440, this represents a signicant gainforadultswhowereproperlynourishedinchildhood. 12InGuatemalaandothercountrieswheremalnutritionpersists,theeconomiclosscanbeashighas2to3percentofGDP. 13These direct costs are compounded by indirect costsforexample,fromincreasedhealthcareexpensesandlostlaborhoursresultingfromincreasedsusceptibilitytoillness.
Malnutrition Remains PervasiveThedualcrisesofhighfoodpricesandadeepeconomic
recessioninthelastfewyearshavereversedprogressagainsthunger. In many countries, child malnutrition rates are
steadilyrising. Forchildren sufferingmalnutrition, theeffects will be long-term, even intergenerational. A woman
whohasbeenmalnourishedinchildhoodislikelytodeliverasmallerbabywithpoorfetalgrowthandagreaterlikelihoodofsufferingstunting.14
A number of factors, including poverty, contribute tomalnutrition. During the rst six months of life, breasmilkcontainsallofthenutrientsagrowinginfantneedstomaintainhealth,butexclusivebreastfeedingratesremain
verylow.Inasurveyof82developingcountries,lessthan50percentofmothersexclusivelybreastfedtheirchildrenSuboptimalbreastfeedingresultsinthedeathof1.4million
youngchildreneachyear.15
Healthy childrenbecomemalnourished if they donogetenoughtoeatoriftheyeatfoodoflimitednutritional
value,asoftenhappenswhendietsconsistmainlyofastaplgrainsuchascornorrice.Poordietsarethemselvesoftentheresultofpovertyorlackofavailabilityoffood.SavetheChildrenfoundthatataveragewages,aruralfamilyofveinEthiopiawouldhavetoworkforfourmonthssimplytobeabletoaffordonemonthsworthofhealthyfood.16InNigerandothercountries,severemalnutritionincreasesduringthe so-called hunger season before crops are harvested.1
(SeeFig.1onnextpage)Eveniffoodavailabilityisnotabarrier,mothersmaynot
havegoodinformationaboutwhat,howmuchorhowoften
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oftento feed theirchildren.In thesesituations, providingwomen with basic nutrition education is critical for thehealthofyoungchildren.Inotherinstancesfamilyorculturaldynamicsorlabordemandsmaykeepmothersfrombeingabletoprovideadequatecare.InBurkinaFaso,forexample,onestudyshowedthatyoungchildrenwhosemothersalso
workaremorelikelytobemalnourishedthanmotherswhodonotwork.18
Compounding poor diets, the water children drinkmaybeuncleanandlivingconditionsunsanitary.Inthesesettings, exposure to disease is common. Malnutritionimpairs immune function, putting children at increasedriskofbecomingill.Inturn,illnesscanprolonganddeepenmalnutrition as diseases such as diarrhea keep childrenfrombeingabletodigestthefoodtheyeat.
Deciencies of essential micronutrients represent themost common form of malnutrition, affecting roughly2 billion people, with especially severe consequences forpregnantwomenandyoungchildren.18VitaminAdeciency
can cause blindness. Zinc deciency impairs immunefunction.Iodinedeciencyhindersbraindevelopmentandlowerscognitivecapacity.Irondeciencyimpairschildrensmotordevelopmentandincreasestheriskwomenfaceingivingbirth.Anemiaresultingfrominadequateironintake
isassociated with approximately 130,000 maternal deathannually.19Together,decienciesofthesenutrientsVitamin
A,iron,iodine,andzincareresponsiblefor10percentofaldeathsofchildrenunderveaswellasmuchofthephysicalandcognitiveimpairmentofchildrenlivingindevelopingcountries.20
Around theworld, 178 millionchildren under ve arestunted.21Ofallstuntedchildren,90percentliveinjust36
countries,mostoftheminsub-SaharanAfricaandSouthandCentralAsia.22 The remaining10 percent of stuntedchildren live in countries where 20 to 30 percent of theunder-vepopulationisstunted.
Today, 55 million children are wastedthey weigh lesthantheyshouldgiventheirheightwithatleast19millionofthemexhibitingseverewasting,meaningtheyareonthe
vergeofdeath.23Oftenassociatedwithwarorfamine,thprevalence of wasting is nevertheless high even in somestablecountriessuchasIndia.
Rapid Progress is PossibleTheextentofmalnutritionandthehugetollittakeson
thehealthofmothersandchildrenandtheeconomicdevel-opmentofcommunities and countriescan bedepressing
Butthereisstrongevidencethaaconcertedeffortcouldeliminatthis terrible condition. Thailandhasreducedchildmalnutritionby75percentovertwodecades.24TheThaigovernmenthasundertaken
aprogramofnutritioneducationand growth monitoring, vitaminand mineral supplementationpromotion of nutritious foodssuchasshandlegumes,andfooddistribution to severely malnourishedchildren.Communityhealth
workers,nurses,anddoctorshavebeentrainedtodeliverthesekeyinterventions.Theseactivitiesarcoordinated with other efforts toreducepovertyandimprovelivingconditionsfor example, increasingfoodproduction and improvingaccesstocleanwaterandsani-tation.25
There are many lessons to belearned from Thailands effortsbuttwoareespeciallyworthnoting. First, the country designeda comprehensive strategy tha
25
20
15
10
5
0
January March May July September November
2002
2003
2004
2005
Mean
Dry Season
Food-recession harvest
Land preparation Weeding, hoeing, plowing
Rainy Season
Hunger season
Havest cereals and rice
Figure 1: Seasonal Hunger Takes a Toll on Nutrition
In Niger, the aid group Medicins Sans Frontieres documented the seasonal nature of
hunger. Annual admissions to therapeutic feeding centers accelerates between June and
October when crops have been planted and are awaiting harvest.
Source: Adapted from Medecins Sans Frontieres and FEWS.
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made nutrition a top development pri-ority. The strategy was supported atthe highest levels of government. TheDeputy Prime Minister, given overallresponsibility for leading theprogram,encouraged cooperation and coordina-tionacross manydifferentgovernmentdepartments,includingtheMinistriesof
PublicHealth,Education,andAgricul-ture.26 Despite the ministries different
waysofoperating,areasofexpertise,andpoliticalandlegalmandates,thegovern-mentmanagedtopromoteawholeofgovernmentapproachtoimprovingnu-trition.
Second, the Thai government com-mitted substantial nancial resourcesto the program but welcomed contri-butions from other donors, including
UNICEFandtheUnitedStates.Outsidecontributions increased the technicalcapacity of the Thai government andencouragedtheintegrationofnutritioninprogramsspanningmultiplegovern-mentministries.27
ArecentreviewintheBritishmedicaljournalThe Lancetprovides strong evidence that the nutrition interventionsundertakeninThailandcanworkinothercountrieswithhighratesofmalnutritionaswell.28Theseinterventionsare:
Providing micronutrients, including iodine and ironfolateforpregnantwomenandiodine,zinc,andvitamin
Aforinfantsandyoungchildren;
Promoting exclusive breastfeeding for infants 0-6monthsofage;
Empoweringwomenandcaregiverstoimprovefeedingpracticesandworkingwithcommunitiestoadoptthesepractices;
Providing nutritionallyappropriatefood in food in-securesettingstoensuremothersandchildrenhaveaccesstohealthyfood;
Improving sanitation and hygiene practices andfacilities,includingaccesstocleanwater;
Providing treatment for illnesses, including diarrhea,malaria,andrespiratoryinfections;
Treatingsevereacutemalnutrition.
The Lancetstudyshowsthattheseinterventionscanmakeatremendousdifferenceinthelivesofmothersandchildrenaroundtheworld.Theyshouldbeadoptedandcombined
witheffortstoaddresstheunderlyingfactorsthatallowmal-nutritiontopersist.Povertyandfoodinsecurityareprimary
factorsthatcausemalnutrition,butotherimportantfactorsinclude overstretched, understaffed health care servicespervasive discrimination and gender inequality; and lackofeducation.(Seegure2.)Toaddressthesefactors,nutritionshouldbeintegratedintothedevelopmentplansofev
erycountry,andgovernmentsshouldensurethatnutritionworkiscoordinatedacrossministriesandsectors.
Tensions between different approachesfor examplewhether to scale up onenutrition intervention versus another,orwhethertoimproveagricultureinsteadoffocusingdirectlyonnutritioncannotcontinuetogetinthewayofeffortstomakeprogress.Infact,thesearefalsechoices;improving nutritionwill requireefforts toraiseincomesandreducehungerandpovertyaswellastoinvestinspecicnutritioninterventions.Giventhelong-termconsequencesofmalnutrition,thereisanurgentneedtoactquicklyand
comprehensively.Ultimately,thegoalofnutritionprogramsshouldbeto
empowerfamilieswiththeresourcesandknowledgeneededto prevent malnutrition and raise healthy well-nourishedchildren.Thiswillnot happen overnight,but countriesadisparate as Mexico and Thailand are showing that it ipossible.
Malnutrition/Death
InsufficientHousehold Food
InadequateMaternal/Childcare
Insufficient HealthServices/Unhealthy
Environment
Manifestations
ImmediateCauses
UnderlyingCauses
BasicCauses
Inadequate Dietary Intake Disease
Resources and Control:
Human, Economic and Organizational
Political and Ideological Superstructure
Potential Resources
Economic Structures
Figure 2: Framework for Understanding the Causes of Malnutrition
Source: UNICEF.
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Bringing Interventions to ScaleReaching mothers and young children with critical
health and nutrition interventions will require sustainedcommitmentsandcooperationamongthemanyinternationalpartnerswhohavearoleinpromotingdevelopment.Itwillalsorequirenewnancialcommitments.TheWorldBankestimates that the cost of scaling up essential nutritioninterventions, including expanding upon those identiedin The Lancet, is $11.8 billionannually.29 Of thisamount,it is expected that $1.5 billion would be covered throughhousehold expenditureson improved food products (suchasiodizedsalt).Theremainder,$10.3billion,wouldneedtocomefrompublicsources.
Over the past decade, international developmentassistancehasmorethandoubled,butfundingtoaddressmalnutritionremainsmodest.Basedondatareportedbymajor aid donors and excluding multilateral assistancefrom the World Bank and others, spending on basicnutritionactivitiestotaledjust$439millionoverthefour
years between 2002 and 2007. This was less than onepercentofallbilateraldevelopmentassistance.30
IntheUnitedStates,fundingforinternationalnutritionprograms is scattered across a number of agencies andprograms.Mostnutritionprogrammingoccursthroughthematernal child health program within the Global HealthBureauattheU.S.AgencyforInternationalDevelopment(USAID).Initiativesincludemicronutrientsupplementation,foodfortication,andprogramstotreatinfectiousdiseasesthat contribute to malnutrition. The agship nutritionprogram, the Infant and Young Child Nutrition Project(IYCN), provides technical and nancial assistance forprogramsdesignedtodeliveressentialnutritionmessages,such as the importanceof exclusive breastfeeding, timelyintroductionofcomplementaryfoodtomaintaintheweightgainofgrowingchildren,andappropriatecarepracticesforchildrenwhoareill.31
SomenutritionactivitiesaresupportedthroughU.S.foodaid.Themajorityoffoodaidisusedinemergencies,butrecent changes to food aid programs have sharpened thefocus on addressing malnutrition in non-disaster-affectedcommunitiesghtingchronicmalnutrition.ThePreventingMalnutrition for ChildrenUnder2 Approach(PM2A)forfoodaidwasrecentlytestedinHaitiandisbeingimplementedinseveralothercountries.32Programsbasedonthismodelseektopreventmalnutritionbyprovidingfoodassistancetoallyoungchildrenlivingintargetedcommunities.
TheU.S.foodaidbudgetin2008totaledapproximately$2.9 billion, the majority of which was distributed inemergencies although not necessarily targeted for thetreatment of malnutrition.33 Non-emergency food aidamounted to approximately $354 million (excluding the
U.S. FOOD AID: An Asset for Improved Nutrition?
Over the past decade, the United States has provided about
half of all the food aid delivered to hungry and poor people
around the world.39 Much of this aid alleviates immediate
suffering, but it comes at a high cost. Current regulations
require U.S. food aid to be purchased in the United States
and shipped on U.S.-agged ships. These requirements add
signicant expense to food aid programs. For every dollar
allocated to food aid, up to 60 cents goes to pay for packing
and shipping costs.40
An additional concern about U.S. food aid is that current
food aid commodities do not meet the nutritional needs of
women and young children. In 2007, wheat and sorghum
accounted for more than half of all U.S. food aid donations.41
Unfortied and unprocessed, these and other basic grains do
not contain the nutrients, vitamins, and minerals needed by
mothers and young children.
Two other commonly provided commoditiesCorn SoyBlend and Wheat Soy Blendare little better. These fortied
blended foods were developed in the 1960s, when much less
was known about the unique nutritional needs of expectant
and new mothers and their children.42 The World Food Pro-
gram (WFP) recognizes that, as currently formulated, these
fortied blended foods are the least preferred option for use
in programs targeting young children.
As efforts are made to better target food aid programs
to address maternal and child malnutrition, it is critical to
ensure that much more of each food aid dollar reaches
intended beneciaries and that food aid commodities meetthe unique nutritional needs of women and young children.43
Expanding the local and regional purchase (LRP) of food
aid presents new opportunities for using food aid in nutrition
programs while also stimulating agricultural production. The
current focus of LRP programs is on supporting local farmers,
fostering agriculture markets, and improving the efciency of
U.S. food aid by avoiding shipping costs. Current programs
do not emphasize sourcing nutritionally appropriate foods
that avoid the problems associated with bulk commodities
shipped from the United States. More work is needed to align
LRP programs with positive nutritional outcomes.
USAID
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McGovern-DoleSchoolFeedingProgram).Ofthisamount,approximately66percentwassoldonmarketstogeneratecash for development activities.34 Little information isavailable abouthow much ofthe non-emergencyfoodaid
wasusedfornutritionprograms.The Presidents Emergency Program for AIDS Relief
(PEPFAR) also addresses nutrition concerns to improvetheeffectivenessofanti-retroviralmedicationsamongsome
program participants. Nutrition counseling and food byprescriptionareprovidedtomalnourishedpeoplelivingwithHIV. Additionally, PEPFAR provides nutritional support(assessment,counseling,andfoodwhenneeded)aspartofthecontinuumofcarefororphansandvulnerablechildren.35OfPEPFARslargeannualbudget(approximately$5billionin2008)about10percentisdirectedtowardcarefororphansandvulnerablechildren,andonlyaportionofthisbudgetisusedtoaddressmalnutrition.36
Ifspendingwithinmaternalandchildhealthprograms(which includes funding for IYCN) is any indication,
totalcommitmentsfornutritionaresmall.In2008,$447million was directed at achieving maternal and childhealth objectives, ofwhichreducing malnutrition is justone component.37 Clearly, this is a modest investment,particularly considering that U.S. poverty-focuseddevelopmentassistanceamountedto$15.4billionin2008.38
Linking Agriculture, Food Security,
and Nutrition
In2008,foodriotsfocusedmediaattentiononincreasedhungeramongurbanpopulations.Still,thevastmajorityofpeoplesufferingfromhungerandmalnutritionliveinruralareasandearnalivingthroughfarming.Improvementsinagriculturecan help enhance foodsecurity and nutrition.For example, higher yields and better storage capacitycan increase the amount of food available tohouseholds,endingcyclesofseasonalhungerwherefoodshortagesleadtomalnutrition.Plantingcropshighinmicronutrientscanleadtodiversieddiets,ensuringthatchildrengetessentialmicronutrients. Increasing the capacity to process foodslocallyandtofortifycommonlyconsumedfoods (salt,soysauce,wheat,corn)canensurethatbasicfoodscontainthe
vitamins and minerals young children need to grow uphealthyandstrong.
InBangladesh,aUSAID-supportedprogramencouragedwomentogrowsmallhomegardensinordertoincreasefam-ilyfruitandvegetableproductionandconsumption.Along
withseedsandotherinputs,theprogramprovidedpracticalinformationaboutfarmingandnutritioneducation.House-holdconsumptionoffoodsrichinvitaminAincreased,andin turn, the incidence of night blindnessan indicator of
vitamin A deciencydecreased. In addition to increaseddietary diversity, women earned on average $4 more permonthfromthesaleoffruitsandvegetables.Thisadditionaincomewasusedtofurtherimprovedietsandhouseholdlivingconditions.44
AstheBangladeshexampledemonstrates,strengtheningthelinkagesamongagriculture,foodsecurity,andnutritionwillnotcomewithoutspecicallyfocusingattentiononthroles ofwomenascaregivers and as farmers. Agricultureprograms designed to raise incomes, for example, musalsoaddressbarrierstowomenscontrolovernancialandproductiveresources.Projectstoexpandthekindsofcropbeing grownmust also provide mothers with informationabouthowtofeedchildrenadiversieddietandwhyitisimportant.Recentpledgestoincreaseinternationalfundingforagricultureafteryearsofneglectpresentanopportunity
tofurtherexplorethelinkbetweenagricultureandnutritionandtotrynewapproaches.
It isalso critical toensurethat new efforts topromoteagriculture do no harm. Efforts to increase income bypromoting the cultivation of cash crops such as coffeeorcotton may actually lead to a worseningof householdnutrition, especially if it leads to a greater demand fofemalelaborwithoutreturningincomewomencanusetobuyfoodorotherimportanthouseholditems.Incorporatingnutrition analysis into agriculture programs can help to
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avoid such inadvertent negative consequences. Genderand environmentalanalyseshave become a standardpartof program design and evaluation and perhaps provideusefulmodelsforincorporatingnutritionanalysisintoothersectoralinvestments.
Astrongerfocusonnutritioncanhavesubstantialpositiveresultsinotherareasaswell,includingeducation,especiallyforgirls,andprogramstostrengthenandprotecttherights
of women. The point is that sustained improvementsin nutrition over time will require addressing both theimmediateandunderlyingcausesofmalnutrition.
Coordinating Action Around a Shared AgendaFewdevelopingcountrygovernmentshavemadeghting
malnutrition a development priority. The connections be-tweengoodnutritionforchildrenandimprovedeconomicgrowthanddevelopmentarenotwellunderstood.Maternalandchildmalnutritionisalsooftenaproblemofthepoliti-callypowerless.Bilateralandmultilateraldonorshaventgiv-entheissuemuchattentioneither.Themanyinternationalagencies,researchinstitutions,aidorganizations,andothers
withastake innutritionhave beenvariouslydescribedasweakanddysfunctionalandthecollaborationandintegra-tionamongthemasbroken.46
Country-ownedand-ledstrategiestoaddressmalnutritionarecriticallyneeded.Acountry-ledstrategyismorelikelytohavethepoliticalwillneededtoensurecooperationamongdifferentministriesandsustainednancialcommitmentovertime.Country-drivenstrategiesalsoprovideacoordinatingmechanism around which donors can collaborateanimprovement over the fragmentationand project-oriented
approach that characterize many aid donors, the UnitedStatesincluded.InBurkinaFaso,thegovernmenthascreatedaNationalNutritionPlantoguidepoliciesandprograms.
AccompanyingthePlanisaNationalCoordinationGroupforNutritionwhichservesasaplatformforcoordinatingthactivitiesofgovernmentministries,reliefanddevelopmenorganization,anddonors.
ThesuccessofBrazilsanti-hungercampaignistheresult
ofbothhigh-levelgovernmentleadershipandstrongcivilsocietyparticipation.Upontakingofce,PresidentLulamadeghtinghungerandmalnutritionatoppriorityofhisadministration.ThecreationofaNationalFoodandNutritionalSecurity Policy was made possible through participatoryfoodandnutritional securitypolicymakingwithastrongroleforcivilsocietygroups.47ImplementationofthestrategyistheresponsibilityoftheMinistryofSocialDevelopmentandHungerEradication,anagencycreatedduringtheLulaadministration.
Amongthesafetynetprogramsadministeredbythenew
ministry is a conditional cash transfer programaimed aimproving the health and nutrition of pregnant and newmothersandyoungchildren.WiththeWorldBankandotherdonors support, the maternal and child health programhas helpedto improvedietarydiversityandfoodsecurityinthepoorernorthernregionofthecountry.Nutritionandgrowthindicatorssuggestthatchildrenintheprogramarebeneting.48
Evenwhennationalgovernmentsarecommitted,design-ingand implementingcountry-led programs iseasiersaidthandone.Manygovernmentslackthecapacityneededto
designrobust cross-sectoral programs that place nutritionwithinabroaderdevelopmentplan.Buildingupacadreotechnicalexperts,asinthecaseofThailand,iscriticaltoreachingconsensusanddevelopingandimplementingasetofpoliciesandinterventionsthatwillhavethegreatestimpactinreducingmalnutrition.49
The need for consensus, collaboration, and capacityextendstodonorsaswell.Inordertobettersupportcountryled initiatives, major development institutions such atheWorldBank,theWorldFoodProgram,theFoodand
AgriculturalOrganization,theWorldHealthOrganization,
and UNICEF need to reach agreement on major policymessagesfornutrition,buildtechnicalcapacitywithintheirrespectiveorganizations, establish an agenda forresearchand coordinate activities at the international level and
within developing countries.50 The World Bank, USAIDandpartnersareintheprocessofdevelopingaglobalactionplanfornutrition,arststepinthisdirection.51
Coordinationofstrategiesandactionisalsoneededwith-inandamongthedepartmentsandagenciesthatdeliverU.Sassistance.Ina2008reporttoCongress,USAIDsetanam
The Millennium Challenge Corporations
Investments in Agriculture: A Missed Opportunity
for Nutrition?
The Millennium Challenge Corporation (MCC), with its
substantial investments in agriculture and food security,
could play a role in supporting nutrition outcomes, but to date
it has not. Currently, maternal and child malnutrition ratesare not used in the selection criteria to determine eligibility
for MCC programming, nor have nutrition interventions or
objectives been incorporated into the country compacts that
guide investment decisions or into the evaluations that gauge
program success.45 While the MCC is focused on poverty
reduction through economic growth, its operations currently
do not seem to recognize the impact of nutrition as both a
cause and outcome of chronic poverty. It is also not clear that
MCC is coordinating with other aid agencies on nutrition issues
to improve the effectiveness of its investments.
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bitiousgoalin itsMaternalandChildHealth (MCH)Pro-gram:toreducechildmalnutritionbyanaverageof15per-centinatleast10countriesby2013.Ifthisgoalisreached,itcouldimprovethelivesofapproximately14millionchil-dren.52Achievingthisgoalwillrequiresubstantialresourcesbutalsocoordinatedaction.However,theMCHnutritiongoalsarenot sharedbyotherUSAIDprogramsthatworkonnutrition.Thisislessbecauseotheragenciesandofces
donotsupportthegoalthanbecausethereisnooverarchingstrategythatidentieshownutritionprogrammingcanbeintegratedintootherprogramsandwhatarethepriorityin-terventions,targetcountries,andcommunity-baseddeliverymechanisms.Withoutsuchastrategy,eachagencyorofceislefttodesignitsownprogramwithlittleassurancethatprogramsareworkinginacomplementaryfashion.
TheObamaadministrationscallforarenewedfocusonfood security is promoting precisely such a strategy. Theinitiativeaimstobuildabroad-basedstrategyagreeduponbythedifferentagenciesinvolvedinfoodandnutritionsecurity.
Goingonestepfurther,theadministrationcoulddesignatea singleofce,pointperson, and staff tocoordinate foodsecurityactivities.TworecentinitiativesadvancedbyNGOcoalitions,theRoadmap to End Global HungerandtheEmergency
Presidential Initiative for the Worlds Children,havebothcalledforahigh-levelcoordinatortooverseechildnutritionamongotheractivities.53
Among U.S. aid programs, the lack of strategic visionisnotuniquetonutritionorevenfoodsecurity.Infact,anoverarchingdevelopmentstrategytoguideallU.S.foreignassistanceissorelyneeded.Reducinghungerandpoverty,
andimprovingnutritionandhealth,shouldbeatthecenterofanewU.S.developmentstrategy.
A Way Forward on NutritionFor too long, malnutrition has been overlooked in
internationaleffortstopromotedevelopment.Thisistrueofdonorsthathavefailedtoinvestmoney,time,andenergyineffectivenutritionprograms and ofdeveloping countrygovernments that have not made ghting malnutrition apriority.Giventheimpactofmalnutritiononeconomicand
humandevelopment,thishasbeenacostlyoversight.AstheUnitedStatesembarksonanewglobalfoodsecurity
initiative,nutritionmustbeacentralcomponent.TheUnitedStateshastheopportunitytoleadaninternationalagendaforactiononnutrition.Thisshould:
Focus on what works: Evidence-based interventionsidentiedinTheLancetshouldbescaledupinallcoun-trieswheremalnutritionpersists.Deliverystrategiesfortheseinterventionsneedtobedesignedtomeetcountryconditions.Scalingupthesekeyinterventionsinthe36
countrieswhere90percentofstuntedchildrenlivecouldreducedeathsofchildrenunderagetwobynearly25percent.54
Invest resources to bring interventions to scale:BringingThLancetinterventionstoscalewillrequiresubstantialnewinvestmentssincetheresourcesdedicatedtonutritionarecurrentlysmall.Fundingfordirectnutritioninterventionmustbeincreased.Theannouncementofsubstantialnew
commitmentsforagricultureandfoodsecurity,madeatheG-8summitinLAquila,Italy,inJune2009,presentsan important opportunity to increase spending on keynutritionprograms.
Link investments in agriculture and food security withnutrition:Recentcommitmentstoincreaseagriculturalproductivity are important. The ultimate goal of thiseffortshouldbe improved foodsecurity and nutritionIncreasingagriculturalproductivitywillmeanlittleifitdoesnotleadtoimprovednutritionforthemillionsochildrenaroundtheworldwhocannotgetenoughcalories,protein,vitamins,andmineralsforhealthygrowthanddevelopment.
Use improvements in maternal and child nutrition as a keyindicator of progress:Addressingtheimmediatecauseandconsequencesofmalnutritionmustbemadepartobroadereffortstotackletheunderlyingfactorsthatallowmalnutritiontopersist.Giventhecomplexlinksamonghealth, environment, social protection, education, agriculture, and nutrition, thenutritional statusofmothersandchildrenisanexcellentindicatorformeasuringprogressorlackofprogressindevelopmentefforts.Th
weightandheightofchildrenunderveyearsoldare
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widelyaccepted,standardized,andpowerfulmeasuresofnutritionimpact.
Coordinate action around country-led strategies: FromBurkinaFasotoGuatemala,manycountriesaredesign-ingcomprehensivefoodandnutritionsecurityplanstoguideinvestmentsand interventions.Developingcoun-triesshouldbesupportedintheireffortstodesignna-tionalstrategieswithassurancethatinternationaldonors
willprovidesustainedsupport.Thesestrategiesshouldbaseactiononevidenceandincludespaceandexibil-itytoadjustpoliciesandprogramdesignsbasedonnewinformationgainedfromresearchandexperimentation.Fortheirpart,internationaldonors,theUnitedStatesin-cluded,mustcoordinatetheiraidactivitiestoensurethatlong-termandappropriateaidresourcesareavailable.
Build capacity and consensus for action:Improvingthetechnicaland institutionalcapacity ofnationalgovern-ments will ensure that countries have the informationandabilityneeded.Withouttrainedprofessionalstode-sign and implement nutrition interventions, programs
will not besustainable.A network of experts can alsohelp communicatebestpracticesandsuccess storiesinnutritionandcontributetobuildingapolicyframeworkatthenationalandinternationallevels.Assistinginthedesign of training curricula, supporting postsecondaryeducationalopportunities,andfacilitatinginternationacooperation and communication among nutrition expertsiscriticaltobuildingcapacityandachievinggreater
consistencyamongeffortstoimprovenutrition.Ensure coherence across development activities and othedeveloped country policies.TherearemanyU.S.policiesoutsidedevelopmentthatcanimpactnutrition.Tradeandagriculturepoliciesthathurtsmallholderfarmersinde-
velopingcountries,forexample,canincreaseorperpetuatepoverty.Intellectualpropertyrightsthatrestrictaccestoneededtechnologiescanmakeitmoredifculttopursuekeyhealthinterventions.TheUnitedStatesmusttakeawholeofgovernmentapproachtoitsglobalnutritionfoodsecurity,andagriculturedevelopmentobjectives.
Newevidenceaboutwhatworksmakesitclearthatwcan substantially reduce malnutrition, especially duringpregnancyandintheearlyyearsoflife.Notonlywouldmorechildrensurviveinfancy,butbypreventingoraggressivelytreatingmalnutritionduringthersttwoyearsoflife,thesechildren wouldgrow up tobe healthier, more productiveadults. What is needed is concerted global attention andactionalongwithsustainedcommitmentofresources.
Asthe world struggles to recover from thedevastatingimpactofthefoodandnancialcrisis,renewedcommitmentsto investment inagricultureandfoodsecurity present anopportunitytotacklematernalandchildmalnutrition.Thisopportunityshouldnotbewasted.Bothfromamoralandaneconomicstandpoint,thismaybe thebesttimeforthe
worldtofocusontheenormouspricethattheinternationacommunitypaysbyfailingtoaddressmalnutrition.
Endnotes
1G8(2009)LAquila Joint Statement on Global Food Security.2You,D.,et.al.(2009)LevelsandTrendsinUnder-5Mortality,19902008The Lancet.3 Victora, C.G., et. al. (2008) Maternal and Child UndernutritionConsequencesforAdultHealthandHumanCapitalThe Lancet.4Ibid.5Levenstein,H.(2003)Paradox of Plenty: A Social History of Eating in Modern
America.6 Kennedy, E.(1999)Public Policy inNutrition: The U.S.NutritionSafetyNetPast,Present,andFutureFood Policy.7 USDA. WIC at a Glance. http://www.fns.usda.gov/wic/aboutwic
wicataglance.htm.AccessedSeptember15,2009.
MargaretW.Nea
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8 Levy, S. (2006) Progress Against Poverty: Sustaining Mexicos Progresa-Oportunidades Program.TheprogramwasoriginallycalledProgresa.9Hoddinott,J.,et.al.(2008)EffectsofaNutritionInterventionDuringEarlyChildhoodonEconomicProductivityinGuatemalanAdults. The
Lancet.10Ibid.11Maluccio,J.A.,et.al.(2006)TheImpactofNutritionDuringEarlyChildhoodonEducationAmongGuatemalanAdults.Population StudiesCenter Working Paper.12Op.cite,Hoddinott,J.,et.al.(2008).
13WorldBank(2006)Repositioning Nutrition as Central to Development: AStrategy for Large-Scale Action.14Op.cite,Victoria,C.G,et.al.(2009).15Black,R.et.al.(2008)MaternalandChildUndernutrition:GlobalandRegionalExposuresandHealthConsequences.The Lancet.16SavetheChildrenUK(2007)The Minimum Cost of a Healthy Diet: Findings
from Piloting a New Methodology in Four Study Locations.17Defourny,I.,et.al.(2009)ALarge-ScaleDistributionofMilk-BasedFortiedSpreads:EvidenceforaNewApproachinRegionswithHighBurdenofAcuteMalnutritionPlosOne.AccessedJuly23,2009.18 Oudraogo, H.Z., et. al. (June 2008) Home-Based Practices ofComplementaryFoodsImprovementareAssociatedwithBetterHeight-for-Age Z Scores in Rural Burkina Faso. African Journal of Food and
Agricultural Nutrition and Development.
19MicronutrientInitiative(2009)Investing in the Future: A United Call toAction on Vitamin and Mineral Deciencies: Global Report 2009.20Ibid.21Op.cite,Black,R.et.al.(2008).22Ibid.23Ibid.Thisguredoesnotincludingchildrensufferingfromoedema,swellingoffromexcessuidwhichisoftenassociatedwithmalnutritionandoftenleadstodeath.24Op.cite,WorldBank(2006).25Heaver,R.(2002)HNPDiscussion Paper: Thailands National Nutrition
Program: Lessons in Management and Capacity Development.26Op.cite,WorldBank(2006).27Op.cite,Heaver,R.(2002).28Bhutta,Z.,et.al.(2008)WhatWorks?InterventionsforMaternalandChildUndernutritionandSurvival.The Lancet.29Horton,S.,et.al.(2009)Scaling Up Nutrition: What Will It Cost?Thirteeninterventionsare included in thecostestimate.Interventions fall intothreebroadcategories:behaviorchangeinterventions;micronutrientanddeworminginterventions;and,complementaryandtherapeuticfeedinginterventions. The estimate acknowledges that absorptive capacity todeliver nutritioninterventions is small,thus,funding shouldcome instages.Intherststage$5.1billioncouldbeusedtodelivermicronutrientand deworming interventions, behavior change interventions, andadditionalfundstobuildcapacityforfoodbasedprograms.Additionalfunding would be used to scale-up food-based approaches includingcomplenentaryandtherapeuticfeeding.30 OECD DAC (2009) International Development Statistics Online.
Accessed July 7,2009.Datais basedon reportedOECDbilateralaiddisbursementstobasicnutrition.Dataisreportedascategorizedbydonorandissubjecttomisreportingorerror.Foodaid($13.4billion)andbasicwaterandbasicsanitation($2.9billion)investmentscanalsoimpactnutrition.Addingthesetobasicnutritionbringstotalspendingonnutritionupto5.2percentofbilateraldonorassistanceover2004-2007.31InfantandYoungChildNutritionProgram(Jan.2008).IYCN Brief.32 Fanta2, PM2A: Preventing Malnutrition in Children Under Two
Approachhttp://www.fantaproject.org/pm2a/index.shtml.AccessedJuly14,200933USAID(2009)U.S. International Food Assistance Report, 2008.34Ibid.
35U.S.GlobalAIDSCoordinator(May2008)Report to Congress by the U.SGlobal AIDS Coordinator on Food Security.36 U.S.Global AIDS Coordinator(May2008) Celebrating Life: The US
Presidents Emergency Plan for AIDS Relief: 2009 Annual Report to Congress.37DepartmentofState USAID (2008) Working Toward the Goal of Reducing
Maternal and Child Mortality: USAID Programming and Response to FY08Appropriations.38CalculatedbyBreadfortheWorldbasedonbudgetnumbersintheUSbudgetandsupplementalspendinglegislation.39WFPFood Aid Reportgenerated8/10/09.
40U.S.GovernmentAccountabilityOfce(2007)Various Challenges Impedthe Efciency and Effectiveness of U.S. Food Aid.41USDAFoodAidReports:Table 4: Commodity Summary, Commodity Valuand Tonnage.Bymetrictonnage.42Asoriginallyformulated,theseproductsalsocontainedpowderedmilk
Asthepriceofpowderedmilkincreased,theingredientwasdroppedfrommostfortiedblendedfoods.SeeMarchione,T.(2002)FoodsProvidedThroughtheU.S.GovernmentEmergencyFoodAidPrograms:PoliciesandCustomsGoverningTheirFormulation,SelectionandDistribution.The Journal of Nutrition.43Arecentlycommissionedstudywillexaminefoodaidqualityandmakerecommendations aboutappropriate formulationsfor use in nutritionprograms.Unfortunately,thisstudyisnotexpectedtobecompletedunt2010.See:USAIDFoodAidResearch:NutrientQualityofFoodAidAScientic Review. http://nutrition.tufts.edu/1174562918285/NutritionPage-nl2w_1238749209680.html44WorldBank(2007)From Agriculture to Nutrition: Pathways, Synergies andOutcomes.Talkuder,A.(2000)IncreasingtheproductionandconsumptionofvitaminArichfruitsandvegetables:LessonsLearnedinTakingtheBangladeshHomesteadGardeningProgrammetoaNationalScale.Foodand Nutrition Bulletin.45 See MCC Selection Criteria. http://www.mcc.gov/mcc/selectionindicators/index.shtml. This may be due in some part to a lack oconsistentnutritiondataprovidedonanannualbasis.46 Levine, R., et. al. (2009) GlobalNutritionInstitutions:is Therean
Appetite forChange?; Morris,S., et.al. (2008) Effective InternationaActionAgainstUndernutrition:WhyHasItProvensoDifcultandWha
CanbeDonetoAccelerateProgress?The Lancet.47Beckmann,D.,et.al.(2004)Building Political Will to Fight Hunger.Papeprepared forthe UnitedNationsMillenniumProject onHungerTaskForce.48Hall,A.(Nov2006) FromFomeZerotoBolsaFamilia:socialpolicieandpovertyalleviationunderLula. Journal of Latin American Studies.49Heaver,R.(2005)Strengthening Country Commitment to Human Development
Lessons from Nutrition.50Op.cite,Levine,R.,et.al(2009)51Moving Towards Consensus: A Global Action Plan for Scaling-Up NutritionDraft:Beta.Xersiononlewithauthor.52USAID(2008)Working Toward the Goal of Reducing Maternal and Child
Mortality: USAID Programming and Response to FY08 Appropriations.53SeeA Roadmap to End Global Hunger,http://www.care.org/getinvolved/
advocacy/pdfs/agenda2009/end-hunger-care.pdf; and EmergencyPresidential Initiative for the Worlds Children, http://wwwglobalactionforchildren.org/page/-/01%2026%2009%20Presidents%20Initiative%20for%20Worlds%20Children%20two%20pager.pdf.54Opcite,Bhutta,Z.,et.al.(2008).
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