10. Transición de la nutrición a nivel global

The Nutrition Transition Globally:

Alternative Solutions

15 May 2015

Martin Bloem

2

The need for both nutrition specific and nutrition

sensitive interventions is well recognized…

Interventions or programmes that address

the immediate determinants

1. adequate food and nutrient intake,

feeding,

2. infectious diseases

Interventions or programmes that address

the underlying determinants

1. food security;

2. adequate care-giving resources

3. access to health services and a safe

and hygienic environment

Nutrition specific interventions Nutrition sensitive interventions

Ruel et al. 2013

3

Lancet Series in 2013 framework, including nutrition

specific and sensitive interventions & approaches

4

Multisectoral, multistakeholder efforts required to

address malnutrition G

lob

al

pro

cess

es Regional/global processes supporting national nutrition efforts

Go

v’t

effo

rts

National governments prioritizing nutrition efforts

Health Agriculture &

fisheries Social

development Finance

Oth

er s

take

ho

lder

s

Donors UN* NGOs / CSOs Private sector Academia

Education

* UN Nutrition Network comprised of FAO, UNICEF, WFP, WHO and IFAD; other agencies engaged in nutrition include UNHCR, UNFPA, UN Women, and UNDP

Stakeholder landscape for nutrition – not exhaustive

5

SGA, Mortality and Undernutrition

6

WFP’s focus

(1) Micronutrient powders (2) Provides kcal, protein, essential fatty acids and micronutrients (3) Micronutrient deficiencies (4) Sexual reproductive health (5) Folic acid, multiple micro-nutrients, Calcium, Iron / iron + folate, Iodine (6) multiple micro-nutrients

Adolescents Pregnancy Lactation /

Neonates

Infants and

Children

Meeting micronutrient

requirements

• Fortified foods

• Supplements or school

meal fortification

(MNPs1)

Food support (e.g.

school feeding)


requirements

• Specialized nutritious

foods2

• Treatment of MAM

Food support in the

last trimester


requirements


foods2

Food support during

lactation (first 6

months)

Prevention of under-

nutrition

• Complementary

foods2 (6-23 months)

Treatment of MAM

• Supplementary


Addressing MNDs3

Ro

le o

f W

FP

Inte

rve

nti

on

s b

as

ed

on

La

nc

et

evid

en

ce

& S

UN

Raise awareness about the importance of health and nutrition

7

…but implementation is complex and requires broad

stakeholder involvement

(1) Micronutrient powders (2) Provides kcal, protein, essential fatty acids and micronutrients (3) Micronutrient deficiencies (4) Sexual reproductive health (5) Folic acid, multiple micro-nutrients, Calcium, Iron / iron + folate, Iodine (6) multiple micro-nutrients

Adolescents Pregnancy Lactation /

Neonates

Infants and

Children

• Supplements

• Preconception

health and nutrition

• Family planning

• SRH4 awareness

• Delayed age at

marriage & first

pregnancy

• Prolonging inter-

pregnancy interval

• Abortion care

• Early enrollment in

prenatal care

• Disease prevention

(malaria, obesity,

deworming)

• Family planning /

birth spacing

• Tobacco cessation

• Bfding counseling

• Psychosocial care

• Supplementation5

• Delayed cord

clamping

• Early initiation &

continued bfding

feeding (exl 6 mos)

• Vitamins A & K for

newborns


• Early enrollment in

post-natal care

• Skin-to-skin contact

• Exclusive

breastfeeding

• Management of

SAM

• Water, Sanitation

and Hygiene

(WASH)

• Disease prevention

(malaria, obesity)

• Deworming



requirements

• Fortified foods

• Supplements or school

meal fortification

(MNPs1)

Food support (e.g.

school feeding)


requirements


foods2


Food support in the

last trimester


requirements


foods2

Food support during

lactation (first 6

months)

Prevention of under-

nutrition

• Complementary


Treatment of MAM

• Supplementary


Addressing MNDs3

Ro

le o

f o

ther

part

ne

rs/s

tak

eh

old

ers

R

ole

of

WF

P

Inte

rve

nti

on

s b

as

ed

on

La

nc

et

evid

en

ce

& S

UN

Raise awareness about the importance of health and nutrition

8


stakeholder involvement - nutrition sensitive interventions

Health WASH Education Agriculture Social Dev’t

• Food assistance

to enable uptake

of services

(maternal health,

MAM treatment,

HIV treatment)

• Incorporating

nutrition and SRH

into School

Feeding prgms

• Innovative

distribution

modalities (e.g.,

Cash and

Vouchers)

MAM: Moderate acute malnutrition; WASH: Water, sanitation and hygiene; CHAI: Clinton Health Access Initiative; P4P: Purchase for Progress; FFW/A: Food for Work/Assets

WFP

lead

ing

Partn

ers le

adin

g

Nutrition sensitive: incorporating nutrition into other sector approaches to achieve improved nutrition outcomes

9




• Food assistance

to enable uptake

of services

(maternal health,

MAM treatment,

HIV treatment)

• Incorporating

nutrition and SRH

into School

Feeding prgms

• Innovative

distribution

modalities (e.g.,

Cash and

Vouchers)

• Behaviour

change

communication

• Staff trainings on

WASH essentials

• Asset creation

• Incorporating

nutrition and SRH

into adolescent

girls groups

• Behaviour

change

communication

• Ag. and market dev’t (P4P)

• Maximizing nutritional

benefits of ag. value chains

• Livelihoods, economic

empowerment of

smallholders and women

(FFW/A, P4P)

• Processing (fortification,

safety)

• Advocating for and

designing explicit

nutrition

objectives and

outcomes within

social protection

programmes


WFP

lead

ing

Partn

ers le

adin

g


10




• Food assistance

to enable uptake

of services

(maternal health,

MAM treatment,

HIV treatment)

• Incorporating

nutrition and SRH

into School

Feeding prgms

• Innovative

distribution

modalities (e.g.,

Cash and

Vouchers)

• Behaviour

change

communication

• Staff trainings on

WASH essentials

• Asset creation

• Incorporating

nutrition and SRH

into adolescent

girls groups

• Behaviour

change

communication

• Ag. and market dev’t (P4P)

• Maximizing nutritional

benefits of ag. value chains

• Livelihoods, economic

empowerment of

smallholders and women

(FFW/A, P4P)

• Processing (fortification,

safety)

• Advocating for and

designing explicit

nutrition

objectives and

outcomes within

social protection

programmes

• Family planning

and reproductive

health services

• Improving access

to water,

sanitation and

hygiene

• Including nutrition

in educational

policies

• Introducing

nutrition courses

in universities

• Increasing and

diversifying production

• Delivering

complementary

nutrition-

sensitive

package


WFP

lead

ing

Partn

ers le

adin

g


11

Nutrition activities focused

on vulnerable groups1,

including people living

with HIV and TB

Treatment of acute

malnutrition

WFP Nutrition Strategy

1 Prevention of

undernutrition 2

Enabling environment:

Technical Assistance and Advocacy with governments and other stakeholders

WASH Social

protection Agriculture

Ensure relevant sectors contribute to improved nutrition outcomes

Health

3

WFP’s Nutrition Policy supports improved nutrition

outcomes among vulnerable groups

Moderate acute

malnutrition Acute malnutrition*

Stunting*

Micronutrient deficiencies

*Prevention of acute malnutrition and stunting are not mutually exclusive, as ensuring adequate nutrition during the first 1000 days contributes to prevention of stunting,

acute malnutrition and micronutrient deficiencies. 1. Includes adolescent girls, PLW, 6-23 mo old children, chronically ill and other vulnerable individuals such as

disadvantaged school children, general population affected by emergencies; SRH: Sexual and reproductive health WASH: Water, Sanitation and Hygiene

Education

Food assistance as enabler for uptake

Behaviour change, staff trainings

Explicit nutrition objectives and

outcomes

Diversification, livelihoods, processing: fortification,

food safety

Behaviour change, school feeding, SRH

12

WFP has an important role to play in overcoming global

bottlenecks to improved nutrition outcomes w/ partners

Adolescent girls

Pregnant and lactating

women

Children 6-23 mo

• Meeting micronutrient requirements

• Food support (i.e., school feeding as an enabler for uptake of services)

• Meeting micro nutrient requirements

• Food support in last trimester and first six months of lactation


• Prevention of undernutrition and stunting

Difficulty of reaching most at-risk girls (e.g., married, not in school) with nutrition and SRH education

Programming gap in providing food support to PLWs in food insecure areas

• Lack of access to safe, high quality, nutritious complementary foods to fill the ‘nutrient gap’ for young children

• Governments are reluctant to import good quality comp. foods

• Partnership with UNICEF, UNFPA – adolescent girls and pregnant women

• Nutrition for MNCH in emergencies – PLW, children 6-23 mo

• Increasing access to complementary foods – children 6-23 mo (partnership with CHAI)

Nutrition interventions Global bottlenecks WFP’s contribution

13

Adolescent girls are a critical population in efforts to

reduce maternal and newborn mortality and stunting

P R E G N A N C Y

1st Trimester

2st Trimester 3rd Trimester DEL

IVER

Y

A D O L E S C E N C E

HEALTH FACILITY

FAMILY / COMMUNITY

SCHOOLS

FO

CU

S TI

ME

PER

IOD

S

TH

EOR

Y O

F C

HA

NG

E

Improved nutrition for all adolescent girls

MATERNITY WAITING HOMES

INDIVIDUAL & HOUSEHOLD LEVEL INTERVENTIONS

Beyond good health and nutrition for the next generation, nutrition for adolescents is also important for their own health and potential and for being a good parent

14



P R E G N A N C Y

1st Trimester


IVER

Y


HEALTH FACILITY

FAMILY / COMMUNITY

SCHOOLS

FO

CU

S TI

ME

PER

IOD

S

TH

EOR

Y O

F C

HA

NG

E


Improved nutrition during pregnancy




15



P R E G N A N C Y

1st Trimester


IVER

Y


HEALTH FACILITY

FAMILY / COMMUNITY

SCHOOLS

FO

CU

S TI

ME

PER

IOD

S

TH

EOR

Y O

F C

HA

NG

E


Improved nutrition during pregnancy

• Reduced stunting & SGA • Reduced maternal &

newborn mortality




16

Health 4+ / H4+

WFP’s contribution similar to the UNAIDS model

− Nutrition services integrated into RMNCH programs and platforms that reach

adolescent girls

− Delivery channels leveraged depending on country context and needs

Existing platforms with partners need to be leveraged

for WFP to add a nutrition component

Harnesses the collective power of each of the

six agencies and 53 countries to improve the

health of women and children

Global movement by UNSG to improve the

health of women and children

Launched by UNFPA to reach the most

marginalized adolescent girls

(1) IHP+ is a group of partners committed to improving the health of citizens in developing countries. International organizations, bilateral agencies and country

governments all sign the IHP+ Global Compact. They commit to putting internationally agreed principles for effective aid and development co-operation into practice in

the health sector.

Maternal new

born and child

health platforms

using IHP+

principles1

Efforts to fulfil

human rights

adolescent girls

Every

woman every child

Action for

Adolescent Girls (AAG)

17

Nutrition sensitive approaches for adolescents impact

behavioural outcomes and improve nutrition

Health Education Food chain actors Social Development

• Nutrition counselling

• Micronutrient supplementation

• Sexual and reprod-uctive health ed.

• Contraceptive access

• Compulsory school attendance

• School feeding

• Food fortification

• Diversification of food production

• Improving processing, storage, preservation

• Impr. market access

• Child support grants

• Youth programmes

• Provision of (conditional) food / nutrition support

Sect

ors

B

eha

vio

ura

l ou

tco

mes

Adolescent girl, age 14, food insecure, living in area with high prevalence of HIV and teenage pregnancy

Co

nte

xt

Nu

trse

ns.

po

licie

s

Healthy, well-nourished adolescent girl

Imp

act

18

Nutrition sensitive approaches for adolescents impact

behavioural outcomes and improve nutrition

Health Education Food chain actors Social Development

• Nutrition counselling

• Micronutrient supplementation

• Sexual and reprod-uctive health ed.

• Contraceptive access

• Compulsory school attendance

• School feeding

• Food fortification

• Diversification of food production

• Improving processing, storage, preservation

• Impr. market access

• Child support grants

• Youth programmes

• Provision of (conditional) food / nutrition support

Sect

ors

B

eha

vio

ura

l ou

tco

mes

Sexual behaviours

Uptake of health services

School attendance

Dietary intake

• Delayed sexual debut

• Contraceptive use

• Decreased risk of transactional sex

• ART adherence (if HIV positive)

• Attendance at ante/postnatal care (if pregnant)

• Delayed age of sexual debut

• Engagement in workforce (improved financial prospects)

• Increased dietary diversity

• Consumption of nutrient-rich foods

Adolescent girl, age 14, food insecure, living in area with high prevalence of HIV and teenage pregnancy

Co

nte

xt

Nu

trse

ns.

po

licie

s

Healthy, well-nourished adolescent girl

Imp

act

19

WFP has an important role to play in overcoming global

bottlenecks to improved nutrition outcomes w/ partners

Adolescent girls

Pregnant and lactating

women

Children 6-23 mo

• Meeting micronutrient requirements

• Food support (i.e., school feeding as an enabler for uptake of services)

• Meeting micro nutrient requirements

• Food support in last trimester and first six months of lactation


• Prevention of undernutrition and stunting

• Difficulty of reaching most at-risk girls (e.g., married, not in school) with nutrition and SRH education

• Programming gap in providing food support to PLWs in food insecure areas

• Lack of access to safe, high quality, nutritious complementary foods to fill the ‘nutrient gap’ for young children

• Governments are reluctant to import good quality comp. foods

• Partnership with UNICEF, UNFPA – adolescent girls and pregnant women

• Nutrition for MNCH in emergencies – PLW, children 6-23 mo

• Increasing access to complementary foods – children 6-23 mo (partnership with CHAI)

Nutrition interventions Global bottlenecks WFP’s contribution

20

SC+, more appropriate from a nutritional perspective, is

not being widely used due to several bottlenecks

Quality & safety of

local products

Perceived Sustainability

Knowledge of

nutrient needs

• Locally produced nutritious foods are often of an inferior quality in terms of nutrient content

• Products can be non adherent to international safety standards

• Lack of knowledge about what constitutes a healthy nutritious diet for children 6-23 months

o Nutrient needs of infant and young children require a diverse diet: breast milk, plant & animal source foods and fortified foods

• High quality products are imported from Europe (Italy and Belgium) and USA

• Governments are hesitant to import SC+ since it is not a sustainable solution for them (in contrast with ARVs?!)

Affordability

• Using natural foods to meet the nutrient requirements can be expensive (buy different fresh foods, avoid spoilage, prepare few times a day)

• Top-end imported complementary foods are costly De

man

d s

ide

bar

rie

rs

Sup

ply

sid

e b

arri

ers

21

SC+, more appropriate from a nutritional perspective, is

not being widely used due to several bottlenecks

Quality & safety of

local products

Perceived Sustainability

Knowledge of

nutrient needs

• Locally produced nutritious foods are often of an inferior quality in terms of nutrient content

• Products can be non adherent to international safety standards

• Lack of knowledge about what constitutes a healthy nutritious diet for children 6-23 months

o Nutrient needs of infant and young children require a diverse diet: breast milk, plant & animal source foods and fortified foods

• High quality products are imported from Europe (Italy and Belgium) and USA

• Governments are hesitant to import SC+ since it is not a sustainable solution for them (in contrast with ARVs?!)

Affordability

• Using natural foods to meet the nutrient requirements can be expensive (buy different fresh foods, avoid spoilage, prepare few times a day)

• Top-end imported complementary foods are costly De

man

d s

ide

bar

rie

rs

Sup

ply

sid

e b

arri

ers

22

Need for developing profitable, sustainable and

innovative business models to scale up nutrition

Partnership

with

Government

• Weak engagement and alignment between private and public sectors

• Weak enforcement of regulation and standards, reducing incentives to invest

• SUN Country strategies inadequately detail the role of business

• Food security and ag national plans and partnerships are well developed but need to address malnutrition

• Importance of partnerships with business acknowledged, but what it means in practice should be outlined

• Costed plans only include public resources

Advocacy

required for

Businesses

• Business is not ‘sensitised’ to its role and impact on nutrition

• Investment in the ‘Bottom of the Pyramid’ not attractive to business (particularly small/medium enterprises)

• Role of business is included for food fortification, agriculture, media, workplace

• WFP’s partnership with CHAI is a good example of a private-public sector business model

Creating

Demand

• Weak evidence for partnerships with businesses

• Institutional demand under-utilised (e.g fortification of food aid, vouchers for nutritious food)

• Models and business cases are growing - evidence base will increase

• Opportunity to incorporate food/nutrition related vouchers in social safety nets

Challenges Opportunities

23

Need for developing profitable, sustainable and

innovative business models to scale up nutrition

Partnership

with

Government

• Weak engagement and alignment between private and public sectors

• Weak enforcement of regulation and standards, reducing incentives to invest

• SUN Country strategies inadequately detail the role of business

• Food security and ag national plans and partnerships are well developed but need to address malnutrition

• Importance of partnerships with business acknowledged, but what it means in practice should be outlined

• Costed plans only include public resources

Advocacy

required for

Businesses

• Business is not ‘sensitised’ to its role and impact on nutrition

• Investment in the ‘Bottom of the Pyramid’ not attractive to business (particularly small/medium enterprises)

• Role of business is included for food fortification, agriculture, media, workplace

• WFP’s partnership with CHAI is a good example of a private-public sector business model

Creating

Demand

• Weak evidence for partnerships with businesses

• Institutional demand under-utilised (e.g fortification of food aid, vouchers for nutritious food)

• Models and business cases are growing - evidence base will increase

• Opportunity to incorporate food/nutrition related vouchers in social safety nets

Challenges Opportunities

24

Business efforts in support of the SUN Movement

WFP and GAIN are co-facilitators of the Business Network

SUN Gov’t

Focal Point

SUN

Country

Network

Civil

Society

Network

Donor

Network

UN System

Network

Business

Network

Countr

y L

evel

Glo

bal Level

SUN

Secretariat

SUN Lead

Group Global platform for business

commitments

• Collective effort of business and various

ways business can support SUN

country plans

• 51 companies have made commitments

– aim for 99 companies by the end of

2015

• Tracking business commitments for the

first time in 2014

Support to SUN Countries

• Developing model for business

engagement (Tanzania, Pakistan,

Nigeria)

• Creating policy guidelines and guides

for engaging business

• 80 companies or business associations

in SUN countries engage in national

plans

Civil

Society

Network

Donor

Network

UN System

Network

Business

Network

Visualization of SUN Business Network What is the SUN Business Network?

25

By reaching 4.1 million beneficiaries in East and Central

Africa, WFP will have a significant impact on malnutrition

WFP will reach 4.1 million beneficiaries by

procuring SC+ with high quality specifications &

standards from Ethiopia and Rwanda

WFP is already reaching 2.8 million beneficiaries

through current programming. However,

• 1.2 million are receiving a less suitable product (SC

instead of SC+)

• 1.6 million are receiving SC+, but for a shorter

duration

WFP will reach an additional 1.3 million

beneficiaries for the prevention of undernutrition

• Country-specific proportion of U2s below poverty

line

Programming will be done in the context of the SUN Movement along with other complementary interventions

WFP’s contribution to 11 SUN countries in East and Central Africa

26

Sustainable, market-based solution to undernutrition in

East and Central Africa

Local production of SC+ entails: Local production of SC+ will prevent

undernutrition and support local economies

• Development of a nutritious product for young children that can be produced locally in Eastern Africa (SC+)

• Engagement with the private sector to invest in the development of factories for SC+ in Rwanda and Ethiopia

• Engagement with smallholder farmers through WFP’s Purchase for Progress (P4P) initiative to procure raw ingredients

Governments of Ethiopia and Rwanda are prioritizing increasing access to good quality comp foods (6-23 mos) use of social safety nets

Preventing undernutrition

• WFP will procure SC+ to support national nutrition programming

• Governments will purchase SC+ to reach vulnerable children through social protection platforms

• Mothers will be able to purchase affordable complementary foods in local markets

Supporting sustainable economic

growth

• Factories will provide guaranteed markets for soya and maize, stabilize prices and help 100,000 smallholder farmers increase income

• Large scale, globally competitive food processing companies will create employment opportunities

27

Sustainable, market-based solution to undernutrition in

East and Central Africa

Local production of SC+ entails: Local production of SC+ will prevent

undernutrition and support local economies

• Development of a nutritious product for young children that can be produced locally in Eastern Africa (SC+)

• Engagement with the private sector to invest in the development of factories for SC+ in Rwanda and Ethiopia

• Engagement with smallholder farmers through WFP’s Purchase for Progress (P4P) initiative to procure raw ingredients

Governments of Ethiopia and Rwanda are prioritizing increasing access to good quality comp foods (6-23 mos) use of social safety nets

Preventing undernutrition

• WFP will procure SC+ to support national nutrition programming

• Governments will purchase SC+ to reach vulnerable children through social protection platforms

• Mothers will be able to purchase affordable complementary foods in local markets

Supporting sustainable economic

growth

• Factories will provide guaranteed markets for soya and maize, stabilize prices and help 100,000 smallholder farmers increase income

• Large scale, globally competitive food processing companies will create employment opportunities

28

Conclusion and recommended actions