new hope for malnourished mothers and children

8/3/2019 New Hope for Malnourished Mothers and Children

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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


2/122 BriengPaper,October2009

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.


3/12www.bread.org BreadfortheWorldInstitute 3

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



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.



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.



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


7/12www.bread.org BreadfortheWorldInstitute

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



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.



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



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



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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