The Investment Case for Nutrition:

What Works?

Harold Alderman

International Food Policy Research Institute

April 28, 2015

Evidence Based Interventions for Improving

Maternal and Child Nutrition:

What Can be Done and at What Cost?

A team of international nutrition experts reviewed the

global evidence for a 2013 Lancet Nutrition Series and

estimated the impact and cost of scaling up 10 proven

effective nutrition specific interventions to cover 90% of

the at-risk population.

These core interventions are across the life-cycle, assisting

women of reproductive age, neonates and young

children.

They also use a range of delivery platforms including

community programs for nutrition education, integrated

management of child illnesses and food fortification.

Potential Impact of Scaling Up

10 Proven Interventions

Continued investment in nutrition-specific interventions and delivery strategies to reach the population at greatest risk can make a significant difference

If these 10 proven nutrition-specific interventions were scaled-up from current population coverage to 90%, we could:

• Save an estimated 900,000 lives in 34 high burden countries (where 90% of the world’s stunted children live)

• Reduce the number of children with stunted growth and development by 33 million

Added to existing trends, the World Health Assembly targets for 2025 are reachable

3

Effect of Scaled-up Interventions on Deaths in

Children Younger than 5 Years

4

Total Additional Annual Cost of Achieving 90%

Coverage with Nutrition Interventions

Nutrition interventions Cost

Salt iodisation $68

Multiple micronutrient supplementation in pregnancy (includes

iron-folate)

$472

Calcium supplementation in pregnancy $1914

Energy-protein supplementation in pregnancy $972

Vitamin A supplementation in childhood $106

Zinc supplementation in childhood $1182

Breastfeeding promotion $653

Complementary feeding education $269

Complementary feeding supplementation $1359

SAM management $2563

Total $9559

Data are 2010 international dollars, millions.

5

Intervention based on Bhutta et al (2008) and

Horton et al (2010)

Cost per

child

Intervention based on Bhutta et

al 2013

Universal salt iodization $0.05 Universal salt iodization

Iron fortification of staples $0.80

Iron-folic acid supplementation for mothers

during pregnancy

$2.00 Multiple micro-nutrient

supplements

Community based nutrition programs

providing information on breastfeeding,

complementary feeding, handwashing;

distribution of micronutrient powders, iron-

folate supplements

$15.00 Community based nutrition

programs that provide

information on breastfeeding

($14.32); complementary

feeding education ($5.27)

Providing complementary foods $50.001 Provision of complementary

foods

Community based management of severe

acute malnutrition

$8.13 Community based management

of severe acute malnutrition

Vitamin A supplementation $4.80 Vitamin A supplementation

Multiple micronutrient powders $10.80 Multiple micronutrients

Therapeutic zinc supplementation for

management of diarrhea

$4.00 Zinc supplementation

Deworming $1.00

TOTAL $96.58 TOTAL

Per child costs of interventions to reduce stunting in children under 24 months

Intervention d=3%

DALY=

$1000

d=6%

DALY=

$1000

d=3%

DALY=

$5000

D=6%

DALY=

$5000

1. Micronutrient supp. 17.3 10:1 86.5 52.1

2. Micronutrient fortif.

-Iron

-Iodine

8.0

30.0

7.0

12.1

8.0

30.0

7.0

12.0

3. Biofortification 16.7 10.0 33.5 50.0

4. Deworming (preschool) 6.0 2.4 6.0 2.4

5. Nutrition education 12.5 7.5 62.5 37.5

These interventions have individually high

Benefit:Cost Ratios, under a wide range of

assumptions

Why does improved nutrition of children

affect adult earnings?

• Height (curiously) affects wages even in white

collar jobs

• Malnourished children start school later (which

in itself reduces earnings through delayed entry

to labor force)

• Malnourished children attend fewer classes

• And they learn less per year of schooling

Undernutrition is a risk factor for overall

cognitive development

Neglect of undernutrition can cost an

economy millions of dollars

According to ECLAC underweight in 2004 cost

Guatemala $3 Billion (11.4% of GDP)

El Salvador $1Billion (7.4% of GDP)

Honduras $780 Million (10.6% of GDP)

Costa Rica $318 million (1.7% of GDP)

These estimates are based on the lost potential

education of the current labor force. Projections for

cost of undernutrition of today’s children under 5

(fewer and often healthier) range from 0.5% of GDP

for Guatemala to virtually nothing for Costa Rica

There is a need to complement Nutrition

Specific investments with Nutrition

Sensitive Programs

The 2013 Lancet Nutrition Series estimated that

scaling 10 nutrition specific interventions would

reduce stunting globally by 20 percent.

While this would be a major improvement in the

health and development of children, it does not go

far enough.

Thus, there is also a need for programs that address

the core determinants of undernutrition

This is the role of nutrition sensitive interventions

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Definition: Nutrition-sensitive Interventions

These are interventions or programs that address the underlyingdeterminants of fetal and child nutrition — food security; adequatecaregiving resources at the maternal, household and communitylevels; and access to health services and a safe and hygienicenvironment—and incorporate specific nutrition goals andactions.

Nutrition-sensitive programs can serve as delivery platforms fornutrition-specific interventions, potentially increasing their scale,coverage and effectiveness

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Examples:

Agriculture and food security Social safety nets

Early child development Maternal mental health

Women’s empowerment Child protection

Schooling Water, sanitation and hygiene

Health and family planning services

Why Nutrition Sensitive Programs are also

Important Instruments to Reduce

Undernutrition

The potential for nutrition sensitivity in sectors such as

agriculture and social protection comes in part from their

scale; most governments devote substantial resources to

programs in these sectors.

In addition, these programs are generally intrinsically targeted

to the poor

They often contain design features that can empower women

These programs can also serve as delivery platforms for

nutrition-specific interventions, potentially increasing their

scale, coverage and effectiveness

Moreover, by improving nutrition they increase overall

economic growth 13

Nutrition-sensitive programs have enormous potential, yet to be fully

unleashed it is important to strengthen nutrition goals in the design

and to use programs as delivery platforms for health and nutrition

services.

It is also important to focus on women’s time availability and their

physical and mental health and empowerment

Targeted agricultural programs and social safety nets play a key

role in mitigating negative effects of shocks as well as supporting

livelihoods, food security, diet quality, and women’s empowerment.

Safety nets can be linked to nutrition services via conditions and by

social marketing.

Incorporating nutrition in early child development programs and in

school curricula can benefit both nutrition and child development

and have long-lasting impacts into adulthood

Enhancing the Nutrition-sensitivity of

Programs

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Obesity and related non-communicable diseases are a rising

concern in many countries.

Part of the problem is that obesity increases faster with

income growth than stunting declines. Transfers, such a

PROGRESA, help on one front but hurt on another

But the double burden is not only a concern for high income

settings; even low and middle income countries are seeing

rising levels of obesity. Mexico has one of the highest rates of

obesity in the world.

It is not uncommon to find an individual with a high body mass

index in the same household with a stunted child.

The double burden of obesity presents a

challenge for nutrition sensitive programs

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Linking cash support to nutrition education has been shown to

improve the impact on undernutrition; plausibly the linkage can

also address obesity

School meals are being redesigned in much of Latin America

to address obesity among students and to provide an entry

into nutrition education

Mexico introduced taxes on sugary soft drinks. They have also

introduced regulations on advertising such drinks and also

high calorie snacks

However, it is too soon to know whether any of these

approaches work at large scale

Nutrition Sensitive approaches to addressing

obesity are being explored

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Some concluding points for knowledge

generation

The knowledge base on what can work (efficacy) is extensive;

much more is needed to go from this knowledge to a national

scale.

Some questions still to be answered include:

What behavioral change communication can augment food security

measures to encourage diet diversity and improved mother-child

interaction?

How can schools be a vehicle for practical nutrition education?

What are the most feasible means to achieve an institutional

continuity from nutrition in the first 1,000 days through preschool?

Can this institutional framework link health care with social

protection as well as with education ministries?