4 ways to reduce malnutrition

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Tackling undernutrition is, as the full extent of malnutrition and micronutrient deficiencies becomes apparent, critical for human wellbeing and development. In the past we have tended to focus, with limited success, on ensuring people have enough to eat, on making the world “food secure” and on fighting hunger but now we are beginning to understand that if we are to lead healthy, productive lives, it is also about having enough to eat of the right mix of nutrients. And unlike hunger, often viewed as a more common problem in developing countries, poor nutrition, whether through famine or feasting, can be universal.

In 2008, when The Lancet published their Series on Maternal and Child Undernutrition, global policymakers began to take notice and the Scaling-Up Nutrition movement was born. Today this momentum is continuing and the new Sustainable Development Goals focus more on nutrition and non-communicable diseases than the Millennium Development Goals did. We are also learning more and more about what can be done to lessen the burden of malnutrition. Here we discuss four approaches, all of which will be needed for malnutrition to significantly decline: the scaling up of successful and cost-effective direct interventions; prioritisation of the first 1,000 day window in a child’s existence; the development of food systems that deliver enough healthy food and prioritise human health; and coordination and collaboration across government sectors to put nutrition at the heart of relevant policies and programmes.

Scale-up direct interventions where they work

Nutrition, while impacted by agricultural productivity, poverty and income, is unlikely to be improved through more general programmes aimed at bringing about economic and social development. Income growth alone will not reduce rates of malnutrition, and so we need direct interventions to tackle malnutrition. Things such as vitamin, mineral and micronutrient supplementation; delayed cord clamping after birth, kangaroo mother care, early initiation of breastfeeding, promotion of dietary diversity, fortifying staple foods, cash transfer programmes, community-based nutrition education, and school feeding programmes.

Although many cost-effective nutrition interventions have been tried and tested, and shown to reduce the physical signs of malnutrition such as stunting and wasting in children, knowing which interventions will work where and should be scaled up is complex. Different factors matter in different countries, for example when investigating childhood nutrition outcomes in East Africa maternal health was found to be the most important factor in reducing malnutrition in Uganda and Rwanda but not for other countries. In a World Bank review of 46 nutrition impact evaluations published since 2000, each assessing the effect of a range of nutrition interventions, many interventions were found to have a positive effect but not consistently across all programmes and indicators. One intervention may have worked well in one place but not in another. Local context such as the age of the target group, length of intervention and methodologies used caused significant disparity in the results. As the review states “we should not be asking simply ‘What works?’ but rather ‘Under what conditions does it work, for whom, what part of the intervention works, and for how much?’” We now need to go beyond the idea of one-size-fits-all nutrition interventions while learning from successful nutrition interventions.

Prioritise the 1000 day window

In early age, malnutrition can have largely irreversible negative impacts on physical and cognitive development, education, future earning and mortality. Some 165 million children who survive early malnutrition experience stunted growth and impaired metal capacity. Maternal undernutrition is estimated to contribute to some 800,000 neonatal deaths each year and stunting, wasting and micronutrient deficiencies are believed to contribute to almost 3.1 million deaths annually. As such it is critical that interventions are directed to the first 1,000 days of a child’s existence, from conception to 2 years old, if the long-term problems associated with childhood malnutrition are to be addressed. Without tackling undernutrition in these 1,000 days the cycle of undernourished mothers birthing undernourished children will be difficult to break.

Medical studies have found that interventions during gestation and in the first two years of life can prevent child malnutrition and its effects, and investments during this period are likely to have the greatest value in reducing malnutrition. Bhutta et al (2013) modelled the effects a range of interventions in the 34 countries that contain 90% of the world’s children with stunted growth. They found that current total deaths in children under five can be reduced by 15% if 10 evidence-based nutrition interventions are implemented at 90% coverage. The cost of doing so in these 34 countries is calculated as $9.6 billion per year. But the study also stresses the importance of nutrition-sensitive approaches in such areas as education, agriculture, female empowerment and social protection.

Develop healthier food systems

Food systems began changing in the mid-20th century but modern systems no longer meet the needs of nutritious, healthy and sustainable diets. The modern food system emerged from government policies addressing the need to increase calories and protein in diets by focusing on intensifying production of key commodities (e.g. maize, soy, and livestock) after World War II. What followed from this were policies to encourage globalisation, increased control of the food system by private businesses, and vertical integration in food chains. Although designed to enhance global food security and availability, it developed without consideration for its impact on providing healthy diets. As such a system well-equipped to transport large amounts of highly-processed and treated foods around the world is also well suited to supporting the excessive intake of refined carbohydrates, sodium, sugar and saturated fat.

The modernisation of food systems, which is occurring rapidly in many low- and middle-income countries, is facilitating the consumption of more packaged, processed foods with added sugar and salt, greater consumption of meat, increase incidence of snacking and reduced consumption of whole foods. Although countries differ in the characteristics of their “nutrition transition”, in general there is a trade-off between being able to access more food but that food being less nutritious. Indeed it was found that increased food supplies globally have resulted in significant reductions in malnutrition since the 1970s.

But what would a healthy and sustainable food system look like? Being made up of the environment, people, institutions and processes by which agricultural products are produced, processed and brought to consumers. As well as food prices, consumer knowledge and markets, there are a lot of factors which all need to be working towards delivering healthy, nutritious and safe foods. Unfortunately a single model will not work everywhere but building in socioeconomic and environmental feedbacks, making the processes transparent and the actors accountable, and utilising a diversity of food systems to support resilience, should one fail, are some of the principles to apply.

Coordinate across governmental sectors

Direct nutrition interventions are undoubtedly important but so too are agricultural production, diversity and sustainability as well as non-food factors such as health services, women’s education and access to water. A vast number of factors contribute to a population’s nutrition status, although their relative importance may differ by geographic area and food availability. As such government sectors such as agriculture, health, environment, education and the economy in general must be on the same page and committed when it comes to tackling nutrition. Reductions in childhood stunting in Peru, from a rate of 29.8% in 2005 to 18.1% in 2011, have been attributed to improved policy and institutional coordination, pooled funding for nutrition and binding nutrition targets, as well as the creation of a civil society platform, the Child Malnutrition Initiative. Policy change after 2006, which saw a reduction in the number of nutrition stakeholders and the creation of common policy goals and agreements, as well as a firm and public commitment from the Peruvian government to reduce chronic malnutrition in children under five by 5 percent in 5 years, along with direct nutrition interventions and efforts to reduce poverty enable Peru to reach this goal.

The Hunger and Nutrition Commitment Index (HANCI) ranks governments on their political commitment to tackling hunger and undernutrition. Latest results sees 11 of the last 15 (those countries whose governments are the least committed to tackling hunger and undernutrition) are in Africa. Peru has overtaken Guatemala and tops the rankings and is in fact making a clear effort in the fight against hunger and undernutrition, although the country still has high stunting rates in rural areas. The 2014 HANCI report, released in September 2015, finds that commitment to addressing undernutrition falls short of the commitment to ending hunger and that despite a greater focus on nutrition in the SDGs, it is still insufficient to tackle undernutrition.

So we know that we need better access to nutritious foods, safe water and sanitation, quality healthcare, poverty reduction, social protection and women’s education and empowerment. We know that there are a variety of direct, indirect, systemic and political changes that can improve nutrition. But knowing broadly what is needed is only a very small part of the battle. Nutrition is multi-scale, multi-sector, and location-specific. We really need for global objectives and policy such as the SDGs to promote the goal of ending malnutrition effectively and then we need countries to follow Peru’s lead in committing to this goal. What is clear is that significantly reducing rates of malnutrition in developing countries is both achievable and scalable.

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