The Road to Good Nutrition
A global perspective

The Road to Good Nutrition

The Road to Good Nutrition

Editors

Manfred Eggersdorfer
Klaus Kraemer
Marie RuelMarc Van Ameringen
Hans Konrad Biesalski
Martin Bloem
Junshi Chen
Asma Lateef
Venkatesh Mannar
Kaiseraugust

183 figures and 14 tables, 2013

Basel • Freiburg • Paris • London • New York • New Delhi • Bangkok
Beijing • Tokyo • Kuala Lumpur • Singapore • Sydney

Manfred Eggersdorfer
DSM Nutritional Products Ltd
Wurmisweg 576, 4303 Kaiseraugst, Switzerland

Martin BloemWFP (World Food Programme)
Via C.G. Viola 68,Parco dei Medici, 00148 Roma, Italy

Klaus Kraemer
Sight and Life
P.O. Box 2116, Basel, CH-4002, Switzerland

Junshi Chen
National Institute of Nutrition & Food Safety,
Chinese Center for Disease Control & Prevention
155 Changbai Road, Changping District, 102206, P.R. China

Marie Ruel
IFPRI (International Food Policy Research Institute)2033 K St, NW, Washington, DC 20006-1002, USA
Marc Van Ameringen
GAIN (Global Alliance for Improved Nutrition)
P.O. Box 55, 1211 Geneva 20, Switzerland

Asma Lateef
Bread for the World Institute425 3rd Street SW, Suite 1200, Washington, DC 20024, USA
Venkatesh Mannar
Micronutrient Initiative
180 Elgin Street, Suite 1000, Ottawa, Ontario, K2P 2K3, Canada

Hans Konrad Biesalski
Universität Hohenheim
Garbenstrasse 30, Bio I, 70593 Stuttgart, Germany

Library of Congress Cataloging-in-Publication Data
The road to good nutrition / editor, Manfred Eggersdorfer ... [et al.]p. ; cm.
Includes bibliographical references and index.
ISBN 978-3-318-02549-1 (hard cover : alk. paper)ISBN 978-3-318-02550-7 (e-ISBN)I. Eggersdorfer, Manfred.
[DNLM: 1. Nutrition Policy. 2. Malnutrition. 3. World Health. QU 145.72]
RA645.N87
362.1963’9--dc23		
2013031089

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e-ISBN 978-3-318-02550-7

“Globally, 165 million children
under age 5 are stunted as a resultof malnutrition. This is the faceof poverty,”
Jim Yong Kim, President of the World Bank GroupChild stunting is a problem the world can no longer afford to ignore
Sight and Life

ForewordI

Dr David Nabarro

Working Together for Improved Nutrition

Special Representative of the UN SecretaryGeneral for Food Security and Nutrition
SUN Movement Coordinator

Approximately a third of the world’s children face lifelong
economic and social disadvantage because of poor nutrition
during pregnancy and in the first two years of life. A
significant proportion of these children are disadvantaged
because of unbalanced diets that lead to obesity and its
associated health challenges. Malnutrition is a phenomenon
with many aspects, not all of them immediately apparent.
Analysis of efforts to tackle malnutrition conducted by The
Lancet originally in 2008 and again in 2013 indicates that arange of specific interventions exist that can help people
enjoy good nutritional status. Experience shows that they
are most effective if national development strategies are
sensitive to the underlying determinants of people’s
nutritional status.

“A person who has food has many
problems. A person who has no
food has only one problem.”
Chinese saying

Nutrition-sensitive solutions

The imperative to act

Since 2008 many governments, civil society organizations,research groups and intergovernmental agencies (including
those within the United Nations system) have sought ways
to scale up effective actions for better nutrition. The
collective experience to date suggests that such efforts are
successful if all the different groups that seek to enableimprovements in people’s nutrition work together insupport of sound national policies, the implementation ofeffective interventions, and sector programs that are
sensitive to the determinants of malnutrition.

The Road to Good Nutrition is an expression of this new
way of thinking. It brings together the experience andinsights of globally recognized experts in the field of
nutrition to create an in-depth introduction to the subject
for the non-expert. This book is detailed, accurate and as
up to date as possible, given the speed at which nutrition
research on the one hand and nutrition policy on the otherare evolving. The world of nutrition is moving fast, and it
needs to, for the challenges we face are huge, and theimperative to act, overwhelming.

The evidence also indicates that as efforts are made to scale
up success, all the groups that seek to support theimplementation of national policies should work in synergy.
As they do so, they should, at all times, take account of the
day-to-day challenges faced by communities at risk ofmalnutrition, aligning their efforts to promote social justiceand nutritional equity, and monitoring their collective
impact. Their overarching aim should be to enable all
women and children – and their families – to realize theirright to food and good nutrition.

My hope is that The Road to Good Nutrition will help us
all to accelerate our progress along the path to a world
where everyone receives the food and the nutrition to which
they have a self-evident right.

David Nabarro
Special Representative of the UN Secretary-General for
Food Security and Nutrition
SUN Movement Coordinator

A bold new way of collective and harmonized thinking
The Scaling Up Nutrition or ‘SUN’ Movement was
launched in September 2010 in response to the releaseearlier that year, by more than 100 national and internationalorganizations, of the Framework for Scaling Up Nutrition.
The Movement is designed to bring together diverse
stakeholders – central and local governments, civil society
organizations, research groups and intergovernmental
agencies and business enterprises – so that they can jointly
work on improvements in nutrition on a scale that reflects
the urgency and seriousness of the issue.
The SUN Movement embodies a bold new way of collective
and harmonized thinking, action and communication forimproved nutrition. It is specifically a movement, and not a
new program, institution or fund. Through the Movement,
national governments – both individually and jointly – areleading the worldwide effort to yield lasting nutritional
benefits for individuals and societies within their respective
countries. When joining the SUN Movement, they eachcommit to enabling people to access proven and innovative
solutions for better nutrition, and to work in ways that
increase the effectiveness of their investments so as to yieldsustainable and equitable results.

Rome, June 2013

II

Preface
Manfred EggersdorferIII

SVP DSM Nutrition Science & Advocacy“Everyone has the right to a
standard of living adequate for thehealth and well-being of himself andof his family, including food,clothing, housing and medical careand necessary social services, andthe right to security in the event of
unemployment, sickness, disability,
widowhood, old age or other lack of
livelihood in circumstances beyond
his control.”
Universal Declaration of Human Rights: Article 25 (1948)

Nutrition-sensitive agricultural policies are essential to combat the
global scourge of malnutrition
Sno Shuu Photography

The Road to Good Nutrition is about a journey. It is not
the journey of a lone individual, or organization, or
country, or even continent. It is a journey that the world hasembarked on – and which we can only complete if we allwalk the road together. This book is about how to improve
the nutritional status of the world’s population as a whole.
It therefore touches each and every one of us, and we eachhave a role to play in helping the world a step further
towards that goal.
This work is published at a critical moment in our global
understanding of the challenges and opportunities we face.
The need for a concerted approach to the elimination of
malnutrition worldwide has never been greater. Nor has theworld’s desire to confront malnutrition in a concerted
manner. The Scaling Up Nutrition (SUN) Movement
continues to gather momentum even as this book goes topress; the evidential base for action has been strengthened
yet further by the publication of the 2013 Lancet series onMaternal and Child Nutrition; and the interactions between
nutritionists, policy-makers, program managers and donors
have never been so many, so frequent or so productive. Thisis a moment which the world must seize. And to seize thatmoment, we must grasp the fact that, for all the many
challenges we face, the elimination of malnutrition is apossibility. It can be achieved in practical terms, if only wehave the will to work together.
The Road to Good Nutrition presents a collective vision,and it is the product of a collective effort. As Editor-inChief of the volume, it has been my privilege to work withan international Editorial Board that has brought to thetable the expertise of many different disciplines and theexperience of many decades. For the generous provision of
their time, their telling insights and their firm commitment
to the creation of this book I would like to offer my warm
thanks to Marc Van Ameringen, Hans Konrad Biesalski,
Junshi Chen, Klaus Kraemer, Asma Lateef, Marie Ruel and
Venkatesh Mannar. Klaus Kraemer and Marie Ruel worked
tirelessly to ensure that the book’s contents were as accurate
and up-to-the-minute as possible; Hans Konrad Biesalski
provided important new research in the field of hidden
hunger; Asma Lateef gave perspectives on the growing roleof civil society in combating malnutrition, and Marc Van
Ameringen on the part that donor organizations can play;while Junshi Chen and Venkatesh Mannar offered theviewpoints derived from the experience of China and India
respectively, helping to ensure that our perspective was asglobal as possible. I am grateful to all of them.

IV“A hungry man can’t see right orwrong. He just sees food.”
Pearl S. Buck (1892–1973)

I am likewise grateful to the contributors who graciously
provided the content for this book, taking time out of theirpacked agendas and busy traveling schedules to craft theirindividual chapters. My thanks go to Tom Arnold, Hans
Konrad Biesalski, Martin Bloem, Joachim von Braun, Alan
Dangour, Stuart Gillespie, John Hoddinott, Eileen Kennedy,
Alain Labrique, Asma Lateef, Marguerite B. Lucea, Saskia
de Pee, Victoria Quinn, Marie Ruel, Werner Schultink andPatrick Webb. They have each helped to shape this work,
offering world-class thinking in response to a global
challenge. My thanks, and the thanks of the entire Editorial
Board, go to each of them.
Last but by absolutely no means least, I would like to thankDavid Nabarro for his foreword to this volume, whose
sentiments I can only echo. I hope that it will help to spreadthe good news of SUN yet further and encourage yet more
support for the Movement.
The road that leads us towards good nutrition is not a shortone. Nor is it an easy one. But it is one that we cannegotiate if we walk it together.

Manfred Eggersdorfer
SVP Nutrition Science and Advocacy, DSM
Kaiseraugst, June 2013

Nelson Mandela
Simon Dawson / AP

“Hunger is an aberration of thecivilized world. It is the result ofcivil wars, oppressive governments,and famines of biblical proportions.
Families are torn asunder by thequestion of who will eat. As global
citizens, we must free children fromthe nightmare of poverty and abuseand deprivation. We must protect
parents from the horrifying dilemmaof choosing who will live. Hunger isa basic need that must be met before
anyone can escape the depths ofignorance, before any society canstand without aid, but more
importantly, before any child’s
body can survive the onslaught ofdisease such as the scourges ofHIV, TB and malaria.”
Nelson Mandela, 2004

Preface | The Road To Nutrition | Manfred Eggersdorfer

V

A Healthy Diet with Essential Micronutrients is the Basis for a Healthy Life
Poor diet is the 4th biggest global risk factor for disease.
Source: DSM Nutrition Science & Advocacy
B Vitamins –Establishing Healthy Growth

A
C
D
E
K

Nervous system,
muscles

Vitamin A – Creating a Clear View
Vision, growth, development,
skin, fertility, immune system

Metabolism, tissues andorgans, growth, vision

Vitamin C – Strengthening Our Defenses
Healthy tissue, immune system

GrowthVitamin D – Building a Strong Foundation
Bone development, immune system

Metabolism, healing wounds

Vitamin E – Protecting What We‘re Made Of
Healthy tissue, fertility

Metabolism,
brain function, immune system

Blood clotting, bone health,heart healthHair roots, fingernails

Carotenoids

Red and white blood cells,
nerve cells

β-Carotene
Serves as an important source of vitamin A

Red blood cells, metabolism

LuteinVision, Antioxidant

B1
B2
B3
B5
B6
B7
B9
B12

Omega-3 PUFAs

Zeaxanthin
Vision, Antioxidant

Heart health, eye health, brain function

Life Expectancy Increasing (between 1990 and 2010)
Global male life
expectancy
at birth increasedby 11.1 years

56.4

years

67.5

73.3

years

years

Global female life
expectancy
at birth increasedby 12.1 years

61.2

years

After the year 2015 there
will be more people above
age 65 than below age 5
Source: GBD Study 2010, The Lancet, Volume
380, Issue 9859, Pages 2053-2260, DSM Nutrition
Science & Advocacy

VI

Carol Bellamy, UNICEF
Source: www.iisd.ca“Vitamin and mineral deficiency(VMD) touches the lives of perhaps athird of the world’s people. After adecade of dramatic developments, thefacts are known, the solutions areavailable, and the cause is one in which
many individuals and organizations– governments, the private sector, themedical and scientific community, civilsociety – can all become involved. The
challenge is therefore clear. And when
so much could be achieved for so manyand for so little, it would be a matter ofglobal disgrace if vitamin and mineral
deficiency were not brought undercontrol in the years immediately ahead.”
Carol Bellamy“In our world of plenty, no one should
live in hunger. No child should havehis growth stunted by malnutrition.
No child should have her opportunity
for a better life curtailed even before
she is born, because her mother wasundernourished.”
Ban Ki-moon, World Food Prize laureate award ceremony, 2012.

Ban Ki-moon, United Nations Secretary-General, during a press
conference at the 2011 World Economic Forum in Davos,
Switzerland
Source: WEF 2011

How to Use this Book
1

The Road to Good Nutrition presents a snapshot of current
thinking about the world’s contemporary nutrition challenges.
Written with the general reader in mind, it examines the topic
of nutrition from many angles, providing insights and opinionsfrom some of the world’s leading experts in the field andbacking up their arguments with extensive graphicalinformation and up-to-the-minute photographs.
As will be seen from the Executive Summary, this bookpresents a coherent set of arguments which may be read insequential form from cover to cover, starting with ananalysis of the hugely damaging effects of stunting andconcluding with a call to concerted action in the here andnow. Conversely, the book’s chapters may be read individually,
and in non-sequential order, by the reader wishing to focus on
this or that specific aspect of the subject.
Each chapter follows approximately the same format, withkey messages highlighted at the outset, a personalconclusion from the author, and a list of publications andwebsites for further study of the chapter topic. Graphics
have been used from a wide variety of sources to interpretand enrich the flow of the narrative. These have been
recreated in the house style of the book and their source
acknowledged. Case studies, stories and thought pieces have
likewise been quoted from a variety of sources and their
original publication details provided. Where necessary inview of the constraints of space, these have been abridged,
but they have not been otherwise re-edited or re-formulated.
In presenting such a wide variety of graphic and writtenmaterial to complement the main argumentation of thebook, we hope to provide the general reader with animpression of the global nature of nutrition and of the needfor multi-sectoral solutions worldwide. The Editorial Board
gratefully acknowledges the use of all material drawn fromthe public realm and re-presented in this volume.

The book’s individual chapters are supplemented by a list of
key definitions and, in Chapter Thirteen, an overview of key
scientific and policy milestones, plus a list of key
organizations in the world of nutrition. The index will also
help the reader to navigate around what is by any measure
a complex and multi-faceted subject.
Given the global nature of nutrition and the rapid evolutionof current thinking in this field, a book such as The Road toGood Nutrition can never be complete or comprehensive.
It may, however, function as a guidebook for those wishing
to find out more about this topic, and will hopefully
encourage many readers to take an active part in this global
journey themselves.

Contents
Key Definitions

3

Chapter 9

Executive Summary9

Chapter 1

Making Nutrition Good Politics:
The Power of Governance
Stuart Gillespie

13

Chapter 10

Preventing Stunting: Why it Matters, What it Takes
Martin Bloem

Chapter 2

Chapter 11

39

51

64

Taming Volatile Food Prices: A Prerequisite for
Improving Nutrition:
Joachim von Braun

Chapter 13

169

Afterword181

Now is the Time		
Patrick Webb

74

Profiles of Contributors andEditorial Board members

183

Index

195

Colophon

209

88

How to Improve Nutrition via Effective Programming
Werner Schultink

Chapter 8

158

The Evolving World of Nutrition
Saskia de PeeBest Practice in Nutrition
Victoria Quinn

Chapter 7

Chapter 12

Speaking Up for Nutrition: The Role of Civil Society
Asma Lateef

The Economic Cost of Malnutrition
John Hoddinott

Chapter 6

142

The Power of Innovation
Alain Labrique, Marguerite B Lucea, Alan Dangour

The Obesity Crisis
Eileen Kennedy

Chapter 5124

24

Hidden Hunger in the Developed World
Hans Konrad Biesalski

Chapter 4

2

The Power of Advocacy
Tom Arnold

Food Security and Nutrition:
Linkages and Complementarities
Marie Ruel

Chapter 3

111

102

Key Definitions
3

Acute malnutrition (also known as wasting)Reflects a recent and severe process that has led to
substantial weight loss, usually associated with starvation
and/or disease. Acute malnutrition is calculated bycomparing the weight-for-height (WFH) of a child with areference population of well-nourished and healthy
children. Often used to assess the severity of emergencies
because it is strongly related to mortality.1
Birthrate
The proportion of births in a defined population.
Blanket feeding
Feeding of all persons or households in an affected population
without targeting specific individuals or subgroup.
Blanket supplementary feeding program
Nutrition programs that target a food supplement to allmembers of a specified at risk group, regardless of whether
they have moderate acute malnutrition. Blanket supplementary
feeding programs are usually implemented in combination
with a general food distribution. They primarily aim to prevent
deterioration in the nutritional status of at-risk groups.
BMI-for-age
A nutritional index based on anthropometry, used for theassessment of acute malnutrition in adolescents. It relates
BMI (body mass index) to age in order to take into accountchanges in anthropometric measurements during puberty.2
Body mass index (BMI)
A nutritional index based on anthropometry, used for theassessment of acute malnutrition in adults. It is measured
using body mass index or weight/height2 (kg/m2).2
Breast milk substitute (BMS)
Any food marketed or otherwise represented as a partial or
total replacement for breast milk, whether or not suitable
for that purpose.1
Chronic malnutrition
Chronic malnutrition, also known as stunting, is a sign of‘shortness’ and develops over a long period of time. In
children and adults, it is measured through the height-forage nutritional index.2
Common results framework
Government ministries and other stakeholders in SUN
countries are aligning their efforts to scale up nutrition
using Common Results Frameworks (CRFs). Theseframeworks ensure that all share the same goals andimplement effective and aligned actions to achieve these goals.
Country CRFs include both specific nutrition interventions
and nutrition-sensitive approaches to development.1

Community participation
The active involvement of the community in the planning,
management, implementation, monitoring and evaluationof services and projects.2
Complementary feeding
The transition from exclusive breastfeeding to complementary
feeding – typically covers the period from 6 to 24 months ofage. This is a critical period of growth during which
nutrient deficiencies and illnesses contribute globally tohigher rates of undernutrition among children under five
years of age. The SUN Movement aligns with the WHO
recommendation that infants should be exclusively
breastfed for the first six months of life to achieve optimal
growth, development and health. Thereafter, infants should
receive nutritionally adequate and safe complementary foods,
while continuing to breastfeed for up to two years or more.1
Coverage
The proportion of the target population reached by anintervention. Coverage is a key indicator for monitoringand evaluating interventions.2
Crude mortality rate
The proportion of a defined population who die each day
expressed over 10,000. This is the most useful indicator in
determining the severity of an emergency situation.2
Dehydration
Excessive loss of body fluids.2
Diabetes
Type 1 diabetes, also sometimes called juvenile-onset diabetes
or insulin-dependent diabetes is a chronic condition in which
the pancreas produces little or no insulin.
Type 2 diabetes, also sometimes called adult-onset or
non-insulin-dependent diabetes, is a chronic condition that
affects the way the body metabolizes sugars. With type 2
diabetes, the body either resists the effects of insulin or else
does not produce enough insulin.
“Diabesity” is a term coined by Dr Francine Kaufman toindicate a combination of diabetes and obesity.
Diarrhea
The presence of three or more loose or fluid stools over a
24-hour period, accompanied or not by blood, mucous or
fever. Diarrhea is caused by various bacteria or by viruses,
or may be a symptom of other infections. Diarrhea is one of
the major killers of young children in developing countries
and in emergencies.2

Key Definitions

Double burden of malnutrition
The “double burden of malnutrition” is defined as thecoexistence of undernutrition and overweight in the samecommunity or even the same household.
Dry feeding
Food provided in the form of a dry (take-home) ration.2
Early warning system
An information system designed to monitor indicatorsthat may predict or forewarn of impending food shortages
or famine.2

Food access
Income or other resources are adequate to obtain sufficientand appropriate food through home production, buying,barter, gathering, etc. Food may be available but notaccessible to people who do not have adequate land tocultivate or enough money to buy it.2
Food aid
In-kind rations of food, which can be sourced locally,
regionally or internationally.3

Emergency school feeding
Food provided either as a cooked meal or supplement inschool or as a take-home ration to improve school
attendance and performance, and to alleviate hunger.2

Food assistance
The set of interventions designed to provide access to foodto vulnerable and food insecure populations. Generally
included are instruments like food transfers, vouchers andcash transfers to ensure access to food of a given quantity,
quality or value.3

Endemic disease
An infectious disease that occurs throughout the year in a
population, such as malaria, worms or chest infections.2

Food diversity
A diet containing a wide range of different types offoodstuffs, used as a measure of household food access.2

Enrichment
When micronutrients lost or removed during food processing
are added back or restored in the final product (e.g., wheat
flour is enriched with vitamin B1, niacin and iron).2

Food fortification
The process of adding micronutrients to foodstuffs, during
or after processing, to bring micronutrient levels over andabove amounts in the original food product.2

Essential fatty acids (EFAs)
Fatty acids that cannot be constructed within an organism
from other components by any known chemical pathways,
and therefore must be obtained from food sources, such as
flaxseed oil and sunflower oil.2

Food security
Food security exists when all people, at all times, havephysical and economic access to sufficient safe andnutritious food that meets their dietary needs and foodpreferences for an active and healthy life.

Exclusive breastfeeding(adapted from WHO definition) Breast milk contains all thenutrients an infant needs in the first six months of life. It
protects against common childhood diseases such as
diarrhea and pneumonia, and may also have longer-term
benefits such as lowering mean blood pressure andcholesterol, and reducing the prevalence of obesity andtype-2 diabetes. The SUN Movement aligns with the WHO
recommendation on exclusive breastfeeding whereby infantsreceive only breast milk, no other liquids or solids – noteven water – for the first six months of life, to achieve
optimal growth, development and health. Thereafter,
infants should receive nutritionally adequate and safe
complementary foods, while continuing to breastfeed for up
to two years or more.1

Fortificant
The vitamins and minerals added to fortified foods.2
Fortified blended foods (FBFs)
A mixture of cereals and other ingredients (such as soyabeans preferably de-hulled, pulses, oil seeds, dried skimmed
milk, and possibly sugar) that has been milled, blended,pre-cooked by extrusion or roasting, and fortified with apre-mix of adequate amount and with a wide range ofvitamins and minerals. Fortified blended foods include Corn
Soya Blend and Wheat Soy Blend.2
Growth reference
Nutritional indices are compared to expected
anthropometric values for an individual of the same sex andage. A growth reference reflects the expected values in areference population.2

4

Key Definitions

5

Growth standard
Nutritional indices are compared to expected
anthropometric values for an individual of the same sex andage. A growth standard is based on prescriptive criteria andinvolves value or normative judgments.2

Macronutrients
Nutrients that humans consume in the largest quantities
which provide bulk energy and are needed for a wide rangeof body functions and processes. The three macronutrientsare fat, protein and carbohydrate.2

Healthcare system
All organizations and institutions involved in the delivery ofhealth services, including governmental, non-governmental,
private organizations and institutions.2

Malnutrition
A condition resulting when a person’s diet does not provide
adequate nutrients for growth and maintenance or if they
are unable to fully utilize the food they eat due to illness.1

Hidden hunger
Occurs when a population that may be consuming enoughcalories is not receiving enough micronutrients (vitamins
and minerals), negatively impacting the health, cognitive
development and economic development of over 2 billion
people worldwide.1
HungerA weakened condition brought about by prolonged lack offood. Hunger can lead to malnutrition.1
InfantA child less than 12 months old.2
Infant and young child feeding (IYCF)
Term used to describe the feeding of infants (less than 12
months old) and young children (12–23 months old). IYCF
programs focus on the protection, promotion and supportof exclusive breastfeeding for the first six months; timely
introduction of complementary feeding and continued
breastfeeding for two years or beyond.1
Infant formulaA breast milk substitute formulated industrially inaccordance with applicable Codex Alimentarius standards
to satisfy the normal nutritional requirements of infants up
to six months of age.2
Information, education and communication (ICE)
Methods of providing people with an informed base formaking choices. Nutrition information refers to knowledge,
such as information about new foods that are being
introduced in an emergency situation. Nutrition educationrefers to training or orientation for a particular purpose
such as support for breastfeeding. Nutrition communicationrefers to the method by which information is imparted.2
Low birth weight
Weight at birth less than 2,500 grams.1

Micronutrient deficiency
A lack or shortage of a micronutrient, such as a vitamin or
mineral, that is essential in small amounts for the proper
growth and metabolism of a human or other living organism.2
Micronutrients
Essential vitamins and minerals required by the bodythroughout the lifecycle in miniscule amounts.1
Millennium Development Goals (MDGs)
At the Millennium Summit in September 2000 the largest
gathering of world leaders in history adopted the UN
Millennium Declaration, committing their nations to a new
global partnership to reduce extreme poverty and settingout a series of time-bound targets, with a deadline of 2015,that have become known as the Millennium Development
Goals. The Millennium Development Goals (MDGs) arequantified targets for addressing extreme poverty in its
many dimensions – income poverty, hunger, disease, lack ofadequate shelter, and exclusion – while promoting genderequality, education, and environmental sustainability. They
are also basic human rights – the rights of each person on
the planet to health, education, shelter, and security.1
Moderate acute malnutrition (MAM)
Acute malnutrition, also known as wasting, develops as aresult of recent rapid weight loss or a failure to gain weight.
The degree of acute malnutrition is classified as either
moderate or severe. Moderate malnutrition is defined by a
mid-upper arm circumference (MUAC) between 115 mm
and <125 mm or a WFH between -3 z-score and <-2 z-scoreof the median (WHO standards) or WFH as a percentage ofthe median 70% and <80% ((National Center for Health
Statistics [NCHS] references).2
Multi-stakeholder platform
A shared space for cross-sector stakeholders – including
government representatives, civil society, UN agencies,
donors, businesses and the research and technicalcommunity – to come together within a SUN country toalign activities and take joint responsibility for scaling up
nutrition, including setting shared targets and coordinated,costed plans of action.1

Key Definitions

Non-communicable diseases (NCDs)
Non-communicable diseases (NCDs) – also known aschronic diseases – are not transmitted from person toperson. NCDs can progress slowly and persist in the bodyfor decades. The main types of NCDs include cardiovasculardisease, cancers, respiratory diseases and diabetes.
Nutrition security
Achieved when secure access to an appropriately nutritious
diet is coupled with a sanitary environment, adequate
health services and care.2 Nutrition security exists when, in
addition to having access to a healthy and balanced diet,people also have access to adequate caregiving practices andto a safe and healthy environment that allows them to stayhealthy and utilize the foods they eat effectively.
Nutritional status
The internal state of an individual as it relates to theavailability and utilization of nutrients at the cellular level.2
Nutrition-sensitive approaches
Strategies and plans that address the underlying and basic
causes of malnutrition and take into consideration the
cross-sector impact of nutrition.1
Nutrition-specific interventions
Programs and plans that are designed to address the directcauses of malnutrition and to have a specific impact onnutrition outcomes. These include: support for exclusive
breastfeeding; appropriate complementary feeding;micronutrient fortification and supplementation; andtreatment of acute malnutrition.1
Nutrition-specific interventions and programs
Interventions or programs that address the underlying
determinants of fetal and child nutrition and development– food security; adequate caregiving resources at thematernal, household and community levels; and access tohealth services and a safe and hygienic environment – andincorporate specific nutrition goals and actions. Nutritionsensitive programs can serve as delivery platforms fornutrition-specific interventions, potentially increasing theirscale, coverage, and effectiveness. Examples: agriculture andfood security; social safety nets; early child development;maternal mental health; women’s empowerment; childprotection; schooling; water, sanitation, and hygiene; healthand family planning services.4
Obesity
Obesity for adults is a BMI 30 to 39.99.
Morbidly obese for adults is BMI of 40 or greater.

Overweight
Overweight for adults is a BMI between 25 and 29.00.
Ready-to-use foods (RUF)
RUF can be eaten without further preparation or cooking.
Most RUF have very low moisture content and so can be
stored without refrigeration. They are typically energydense, mineral- and vitamin-fortified foods and can be used
for the treatment or prevention of various types ofundernutrition.2
Ready-to-use supplementary foods (RUSF)
Energy-dense, mineral- and vitamin-fortified foods that aredesigned to provide the quantities of macro- andmicronutrients needed for the treatment or prevention ofmoderate acute malnutrition. RUSFs can be eaten without
further preparation or cooking and are given as a supplement
to the ordinary diet. They have very low moisture content andso can be stored without refrigeration.2
Ready-to-use therapeutic foods (RUTF)
Specialized ready-to-eat, portable, shelf-stable products,
available as pastes, spreads or biscuits, that are used in aprescribed manner to treat children with severe acutemalnutrition.1
Recommended daily allowance (RDA)
The average daily dietary intake level that is sufficient tomeet the nutrient requirements of nearly all (approximately
98 percent) healthy individuals.2
School feeding
Provision of meals or snacks to schoolchildren to improve
nutrition and promote education.2
Selective feeding programs
Targeted supplementary feeding or therapeutic careprograms that admit individuals based on anthropometric,
clinical or social criteria for correction of acutemalnutrition.2
Severe acute malnutrition (SAM)
Acute malnutrition, also known as wasting, develops as aresult of recent rapid weight loss or a failure to gain weight.
The degree of acute malnutrition is classified as either
moderate or severe. A child with severe acute malnutritionis highly vulnerable and has a high mortality risk. Severe
acute malnutrition is defined by the presence of bilateralpitting oedema or severe wasting, defined by MUAC <115 mm
or a WFH <-3 z-score (WHO standards) or WFH <70% of
the median (NCHS references)).2

6

Key Definitions

7

Stunting
Low height-for-age measurement used as an indicator ofchronic malnutrition, calculated by comparing the heightfor-age of a child with a reference population of wellnourished and healthy children.1
SUN donor convener
A representative from a donor organization in each SUN
county who is: actively engaged in the country, involved infinancially supporting nutrition-specific and/or nutritionsensitive programs and committed to increasing resources
for nutrition.1

Sustainable development goals
One of the main outcomes of the Rio+20 Conference wasthe agreement by member states to launch a process todevelop a set of sustainable development goals (SDGs),
which will build upon the Millennium Development Goals
and converge with the post-2015 development agenda. It
was decided to establish an “inclusive and transparent
intergovernmental process open to all stakeholders, with aview to developing global sustainable development goals tobe agreed by the General Assembly”.
In the Rio+20 outcome document, member States agreed
that sustainable development goals (SDGs) must:

SUN government Focal Point
A high-level individual appointed in each SUN country toplay a critical role in leading coordination efforts forcatalyzing efforts to advance nutrition in their country.
Focal Points help to establish the multi-stakeholder
platforms that strengthen coordination to improve support
for national plans. They work across sectors and bringministries and government departments together with local
development partners, civil society organizations, businesses
and UN agencies.1

1. Be based on Agenda 21 and the Johannesburg Plan of
Implementation.

SUN Multi-Partner Trust Fund (MPTF)
A fund established in March 2012 by participating UN
agencies and contributing partners to provide catalytic
grants to governments, UN agencies, civil society groups,
other SUN stakeholders to facilitate the development andimplementation of government or stakeholder actions for
scaling up nutrition.1

6. Focus on priority areas for the achievement of sustainable
development, being guided by the outcome document.

Supplementary feeding
The provision of food to the nutritionally or sociallyvulnerable in addition to the general food distribution totreat or prevent malnutrition.2
Supplementary feeding program
Nutrition programs that aim to prevent individuals withmoderate acute malnutrition from developing severe acutemalnutrition, to treat those with moderate acutemalnutrition and to prevent the development of moderatemalnutrition in individuals. Supplementary feeding
programs can be blanket or targeted.2
Supplementation
Provision of nutrients either via a food or as a tablet,
capsule, syrup, or powder to boost the nutritional content
of the diet.

2. Fully respect all the Rio Principles.
3. Be consistent with international law.
4. Build upon commitments already made.
5. Contribute to the full implementation of the outcomes ofall major summits in the economic, social andenvironmental fields.

7. Address and incorporate in a balanced way all three
dimensions of sustainable development and theirinterlinkages.
8. Be coherent with and integrated into the United Nations
development agenda beyond 2015.
9. Not divert focus or effort from the achievement of theMillennium Development Goals.
10. Include active involvement of all relevant stakeholders, as
appropriate, in the process.

It was further agreed that SDGs must be:• Action-oriented• Concise• Easy to communicate• Limited in number• Aspirational• Global in nature• Universally applicable to all countries while taking into
account different national realities, capacities and levels ofdevelopment and respecting national policies and priorities.

Key Definitions

The outcome document further specifies that thedevelopment of SDGs should:

Undernutrition• Be useful for pursuing focused and coherent action onsustainable development

An insufficient intake of energy, protein or micronutrients,that in turn leads to nutritional deficiency. Undernutritionencompasses stunting, wasting and micronutrient
deficiencies.2• Contribute to the achievement of sustainable development• Serve as a driver for implementation and mainstreaming ofsustainable development in the UN system as a whole• Address and be focused on priority areas for theachievement of sustainable development

The Rio+20 outcome document The Future We Want resolved
to establish an inclusive and transparent intergovernmental
process on SDGs that is open to all stakeholders with a view todeveloping global sustainable development goals to be agreed
by the UN General Assembly. The outcome document
mandated the creation of an inter-governmental OpenWorking Group, that will submit a report to the 68th sessionof the General Assembly containing a proposal for sustainable
development goals for consideration and appropriate action.
The outcome document specifies that the process leading to the
SDGs needs to be coordinated and coherent with the processes
considering the post-2015 development agenda and that initial
input to the work of the Open Working Group will be
provided by the UN Secretary-General in consultation withnational governments.5
Targeted supplementary feeding program
Nutrition programs that provide nutritional support toindividuals with moderate acute malnutrition. They
generally target children under five, malnourished pregnant
and breastfeeding mothers, and other nutritionally at-risk
individuals in the presence of a general food distribution.
The objectives are primarily curative and aim to rehabilitate
individuals with moderate acute malnutrition, prevent
individuals with moderate acute malnutrition fromdeveloping severe acute malnutrition, prevent malnutrition
in at-risk individuals and rehabilitate referrals from thetreatment of severe acute malnutrition.2
UN REACH (Renewed Effort Against Child Hunger
and Undernutrition)
Established in 2008 by the Food and Agricultural
Organization (FAO), the United Nations Children’s Fund
(UNICEF), the World Food Program (WFP), and the World
Health Organization (WHO) to assist governments ofcountries with a high burden of child and maternal
undernutrition to accelerate the scale-up of food andnutrition actions. The International Fund for Agricultural
Development (IFAD) joined REACH later on with anadvisory role. REACH operates at country level as a
facilitating mechanism in the coordination of UN and otherpartners’ support to national nutrition scale-up plans.1

Underweight
Wasting or stunting or a combination of both, defined byweight-for-age below the -2 z-score line. 2
Vulnerability
The characteristics of a person or group in terms of theircapacity to anticipate, cope with, resist and recover fromthe impact of a natural (or human-made) hazard.2
Wasting (also known as acute malnutrition)
Reflects a recent and severe process that has led to
substantial weight loss, usually associated with starvation
and/or disease. Wasting is calculated by comparing theweight-for-height of a child with a reference population ofwell-nourished and healthy children. Often used to assess
the severity of emergencies because it is strongly related tomortality.1
Weight-for-length/height or BMI-for-age below the -2
z-score line. Severely wasted is below the -3 z-score line.2
Z-scoreAn indicator of how far a measurement is from the median,also known as a standard deviation (SD) score. The
reference lines on the growth charts (labeled 1, 2, 3, -1, -2,-3) are called z-score lines; they indicate how far points areabove or below the median z-score = 0).2
This glossary draws on a variety of sources. The provenance of individual
definitions is indicated by a reference as follows:
1 UNICEF SUN 2012
2 UNICEF Training on Nutrition in Emergencies, Glossary of Terms
3 Omamo SW, Gentilini U, Sandström S (eds). Revolution: From food aid tofood assistance. Innovations in overcoming hunger. 2010.
WfP, Rome, Italy.
4 The Lancet 2013 Series on Maternal and Child Nutrition, adapted from
Scaling Up Nutrition and Shekar and colleagues, 2013
5 United Nations Sustainable Development Knowledge Platform, June 20138

Executive Summary
9

Since 2008 many governments, civil society organizations,research groups and intergovernmental agencies havesought ways to scale up effective actions for better
nutrition. The collective experience to date suggests thatsuch efforts are successful if all the different groups that
seek to enable improvements in people’s nutrition work
together in support of sound national policies, theimplementation of effective interventions, and sector
programs that are sensitive to the determinants ofmalnutrition. The Road to Good Nutrition brings together
the thinking of many world experts on this subject, each ofwhom addresses from their specialist perspective thequestion of how to improve the nutritional status of theworld’s population as a whole.
Chapter One, by Martin Bloem (Chief Nutrition and HIV/AIDS Policy/Global Coordinator UNAIDS – United Nations
World Food Program; Adjunct Associate Professor, – Johns
Hopkins Bloomberg School of Public Health, Baltimore,USA) explains how stunting is the result of inadequate
nutrition in early life and how it has severe consequencesthat last a lifetime. Stunting prevents individuals fromachieving their potential, physically, intellectually andeconomically. Its consequences are severe and irreparable,both for the individual and for society as a whole. While
the world has seen significant advances in the field of
nutrition since the development of the Millennium
Development Goals (MDGs), which were to be reached by
2015, stunting remains a problem of global dimensions:according to the latest report of UNICEF/WHO/World Bank
(2012), 165 million children under 5 are stunted, and many
school-age children, adolescents and adults today suffer theconsequences of the stunting that they experienced during
their early years of life. Chapter One outlines the problem
of stunting and traces it to inadequate nutrition, especiallyin the first 1,000 days of life. It argues that the right toadequate nutrition (as opposed to simply food) should berecognized as a Human Right.
Chapter Two, by Marie Ruel (Director, Poverty, Health andNutrition Division, International Food Policy ResearchInstitute [IFPRI], Washington DC, USA) explains that foodsecurity and nutrition security are related but distinct
concepts. Infants, young children, pregnant andbreastfeeding women are especially vulnerable toundernutrition. For this reason, nutrition interventions
must focus on the critical ‘first 1,000 days’ window ofopportunity. Marie Ruel explains how achieving food andnutrition security is a multi-faceted challenge which requiresa multi-sectoral approach – a theme which reappears invarious forms throughout this book.

Food security is necessary, but not sufficient, to ensure
nutrition and to prevent childhood malnutrition. Children
also need their caregivers to provide them with appropriate
feeding, caregiving, hygiene, and health-seeking practices inorder to grow, develop and stay healthy. Food systems canplay a critical role in protecting both food security andnutrition if careful attention is paid to targeting the poor,
reducing inequalities, including gender inequalities, andincorporating nutrition goals and action where relevant.
The book’s third chapter is authored by Hans Konrad
Biesalski, Head of Department, Biological Chemistry andNutrition, University of Hohenheim , Managing Director of
the Food Security Center in Stuttgart, Germany. Drawing
on Hans Konrad Biesalski’s recently published work Hidden
Hunger (Springer Verlag 2012) this chapter describes thephenomenon of hidden hunger. This term refers to a chroniclack of vitamins and minerals, which is not immediately
apparent and which can exist for a long time before clinicalsigns of malnutrition become obvious. It affects over 3 billion
people worldwide, contributing to many millions of deaths
especially in children and young females, and also increasing
the risk of non-communicable diseases such as diabetes,
cardiovascular disease, cancer and osteoporosis. Linked to a
general decline in meeting nutritional standards, hidden
hunger is also a problem in the developed world. Solutions
are nevertheless available: many countries have implemented
mandatory or voluntary fortification of folic acid, vitamin Dor iodine. The experience of many countries indicates that thefortification of staple or processed foods may be an efficient
way to provide an adequate intake of micronutrients.
Eileen Kennedy (Professor of Nutrition and Former Dean of
the Friedman School of Nutrition Science and Policy at Tufts
University, Boston, USA) authors Chapter Four, which deals
with the recent phenomenon of obesity. The current increase in
obesity in the global population is unprecedented:
Worldwide, approximately 1.4 billion adults are overweight,
and 500 million are obese. This phenomenon is closely linked
to inadequate nutrition, and is driving a massive increase in
the incidence of nutrition and lifestyle-related noncommunicable diseases (NCDs). This rise in NCDs is placing
an increasing burden on social and healthcare systems. The
challenge is daunting. Eileen Kennedy argues that theinternational community must aggressively implement
multi-pronged strategies to combat overweight and obesity,
while at the same time tackling undernutrition.
John Hoddinott, Deputy Director, Poverty Health andNutrition Division, IFPRI, Washington DC, USA, presents
Chapter Five, whose subject is the economic cost of
malnutrition. In addition to its substantial human costs,

undernutrition has lifelong economic consequences. John
Hoddinott argues, however, that there exist feasible
solutions to many dimensions of undernutrition, and thatfighting undernutrition has considerable economic benefits– most notably in terms of improving schooling, cognitive
skills and economic productivity. Spending that reduces
both chronic undernutrition and micronutrient deficiencies
is an excellent investment in economic terms, and is one of
the smartest ways to spend global aid dollars.
John Hoddinott’s economic analysis of the problem ofmalnutrition is followed by a presentation of best practicein nutrition by Victoria Quinn, who is Senior Vice Presidentof Programs, Helen Keller International, New York, USA,
and Adjunct Associate Professor, Friedman School of
Nutrition Science and Policy, Boston, USA. Explaining that
undernutrition is a complex and multifaceted phenomenon,
and that it does not have a single cause, or a single solution,
Victoria Quinn uses the Conceptual Framework of YoungChild Nutrition to explain the causes of undernutrition andoutline possible modes of intervention. At the national
level, increased government investment in proven nutritionspecific and nutrition-sensitive interventions is essential for
improving nutrition, while at the family level, women havea critical role to play.
Victoria Quinn’s analysis of best practice in nutrition iscomplemented by a contribution from Werner Schultink,
Associate Director, Nutrition Section, Programme Division,
UNICEF, New York, on How to Improve Nutrition
Through Effective Programming. Werner Schultink
concludes that efforts to scale up nutrition programs areworking, benefiting women and children and theircommunities in many countries, and points out that suchprograms all have common elements: political commitment,
national policies and programs based on sound evidence
and analysis, the presence of trained and skilled community
workers collaborating with communities, effective
communication and advocacy, and multisectoral, integrated
service delivery.
Chapter Eight is penned by Joachim von Braun, Director of
the Center for Development Research (ZEF) and Professor
for Economic and Technological Change at the Universityof Bonn, Germany. Food prices today are not only set by
supply and demand but also influenced by financial
markets. Joachim von Braun explains how sudden pricerises, or ‘spikes’, cause big problems for nutrition of thepoor. He argues that healthy diets need to be affordable,
which requires increased productivity in the food system toprevent high prices. Unfortunately poor countries are hit
worst by spikes in food prices, as they cannot afford

adjustment measures. The solution therefore needs to beworked on globally, and the issue taken more seriously.
Joachim von Braun’s price-specific analysis is followed by abroader interrogation of the governance of nutrition by
Stuart Gillespie, Senior Research Fellow, Poverty, Healthand Nutrition Division, IFPRI, and CEO of the Transform
Nutrition Research Program Consortium. Taking the themeof Making Nutrition Good Politics, Stuart Gillespie outlines
the potential of governance for improving the nutritional
status of the world’s poorest and most disadvantaged
populations. Believing that progress in reducing
undernutrition cannot be sustained where governancesystems are weak or absent, he reasons that strong
leadership – in the form of ambassadors championing thepolitical cause, as well as more mid-level, lateral leadershipto facilitate intersectoral action – is fundamental to success.
While Stuart Gillespie focuses on governance as one of thefactors essential for delivering improved nutrition, Tom
Arnold (Member of Lead Group of the Scaling Up
Nutrition [SUN] movement and former CEO of Concern
Worldwide) explains the key role that advocacy has to play.
Noting that it requires a solid evidential base in order tosucceed, Tom Arnold outlines the importance of presenting
arguments in simple and powerful language and of
maintaining commitment and momentum over time inorder to bring about change. An important political andpolicy mechanism for achieving progress is the SUN Movement,
which brings together governments, civil society and theprivate sector to work in a coordinated way to reduce earlychildhood undernutrition. Real progress can be made overthe next decade if we deliver on what we know is possible,
concludes Tom Arnold.
The following chapter of this book, number Eleven, is
unique in being co-written by three authors: Alan Dangour(Senior Lecturer, London School of Hygiene and Tropical
Medicine [LSHTM]; Marguerite B Lucea (Faculty Research
Associate, Johns Hopkins University School of Nursing(JHUSON), Baltimore, MD; and Alain Labrique (Director,
JHU Global mHealth Initiative and Assistant Professor,
Department of International Health & Dept of
Epidemiology (jt) Bloomberg School of Public Health).
Together they present the power of innovation in the battle
against malnutrition. In a chapter packed with topical casestudies of innovation in practice, they argue that
innovations across the entire span of human nutrition have for
centuries targeted aspects of the farm-to-table continuum, andshow how recent transformative innovations targeting
distribution systems, leveraging public-private partnerships,
and utilizing technological advances have the potential to

10

11

catalyze research and improve nutrition in both the developed
and developing world.
Asma Lateef, Director, Bread for the World Institute,
Washington DC, USA, follows with a chapter on the rolethat civil society has to play in improving nutrition.
Describing hunger and malnutrition as an ‘unfinished agenda’,
Asma Lateef argues that food security and nutrition should be
explicitly addressed in the goals for the post-2015
development framework, and that stunting should be apriority indicator. Civil society organizations are uniquely
positioned to advocate for greater attention to hunger andmalnutrition, and can play an important role in elevating
nutrition as a priority for the next set of goals. She concludes
that communicating the fundamental role that good nutrition
has to play during pregnancy and early childhood must be partof advocacy efforts in the near future.
The final chapter of the book is written by Saskia de Pee(Adjunct assistant Professor Friedman School of Nutrition
Science and Policy, Tufts University, Boston, and visiting
assistant Professor, Wageningen University, theNetherlands). Saskia de Pee’s contribution describes how
the world of nutrition has evolved in recent decades.
Throughout the 20th century, knowledge and approaches
for addressing malnutrition developed within specificscientific and professional disciplines, but there was limited
cross-disciplinary coordination, even with other players in

A well-nourished mother and infant: Elizabeth Farma 16, breastfeeds
her two-month-old son Emmanuel at the Bonthe District Hospital,
Sierra Leone
Source: UNICEF/NYHQ 2010-0952/Olivier Asselin

the food and health systems. Understanding the forms andconsequences of undernutrition, being able to cost theeconomic impact of undernutrition, and having examples ofwhat is required and what works to prevent undernutrition,
including good governance, has generated the strong
momentum behind nutrition that exists today. The
involvement of so many is essential, and while everyone
should focus on what they are good at, Saskia de Peeargues, there is a great deal of cross-disciplinary work to bedone in a target-oriented manner. It is important to develop
context-specific solutions based on the global body ofknowledge and expertise, and to monitor, evaluate andshare these experiences using the information andcommunication technology available today.
Finally Patrick Webb, Dean for Academic Affairs, Friedman
School of Nutrition Science and Policy, Tufts University,
Boston, USA, provides an eloquent afterword to thisvolume. “This book,” he writes, “captures the fact that
there has not been a time in recent decades when so many
people agreed on what needs to be done or why. The
momentum has to be maintained. The next decade of the
21st century should be focused squarely on a global effort
to get it done well, while documenting how. Unlesscoherent, cost-effective actions with measurable impacts
quickly emerge from the current cresting wave of goodwill
toward nutrition, the wait for another may be far too long.
Now is the time.”

Malnourished mother breastfeeding her newborn in Kenya: the signs ofmalnourishment are evident in both mother and childSource: Mike Bloem Photography

Case study

The One Thousand Days Mission

Maternal undernutrition – a mother’s
story (Bangladesh)

The 1,000 days between a woman’s pregnancy and herchild’s 2nd birthday offer a unique window ofopportunity to shape healthier and more prosperous
futures. The right nutrition during this 1,000-day
window can have a profound impact on a child’s ability
to grow, learn, and rise out of poverty. It can also shapea society’s long-term health, stability and prosperity.

Farida is a Bangladeshi housewife of 23. She lives in the
Sreepur Upazila, a rural subdistrict close to the capital,
Dhaka. Married at the age of 17, within a year she fell
pregnant. During her pregnancy, Farida had no access to
skilled prenatal care or education. To stay healthy andaid her pregnancy she wore a tabij (a charm amulet) anddrank paani puri (a mint drink). Unfortunately, after
going into premature labor she lost her baby within half
an hour of delivery. Two years later, Farida became
pregnant once more, but received limited medical
attention. Tragically her second child arrived stillborn.
Several months later, Farida met a Community Nutrition
Worker from Plan Bangladesh’s affiliate Prankteek,
called Nurunnahar. She advised Farida to attend Plan’s
notional information sessions. At these sessions shelearnt the importance of prenatal care, a nutritious dietand receiving proper rest during pregnancy. The lessons
learned in the nutrition sessions were complemented byregular household visits from Nurunnahar, during which
Farida could consult with her on questions or concerns.
When Farida became pregnant for a third time, she went tomedical centers near her home for regular prenatal visits.
On this occasion, she gave birth to a healthy baby boy. She
breastfed him after delivery, and continued exclusive
breastfeeding until her son was six months old. Now 17
months old, Farida’s son is happy, healthy and keeps hervery busy! Farida is thankful for her son, and wants others
to be able to have the same opportunities for care that she
did. “I have lost my first two children through ignorance,”
she said. “I don’t want any other mother to have the same
experience. I am grateful to Nurunnahar.”
Source: Thousand Days Partnership, USA
http://thousanddays.org/success-story/material-undernutrition-a-mothersstory June 2011 (abridged)

Today, undernutrition is still a leading cause of death ofyoung children throughout the world. For infants andchildren under the age of two, the consequences ofundernutrition are particularly severe, often irreversible,
and reach far into the future.
During pregnancy, undernutrition can have a devastating
impact on the healthy growth and development of achild. Babies who are malnourished in the womb have ahigher risk of dying in infancy and are more likely toface lifelong cognitive and physical deficits and chronic
health problems.
For children under the age of two, undernutrition can belife threatening. It can weaken a child’s immune system
and make him or her more susceptible to dying from
common illnesses such as pneumonia, diarrhea and malaria.
Source: Thousand Days Partnership, USA
http://thousanddays.org/about/

One Thousand Days Organization
Solutions to prevent and treat undernutrition alreadyexist. Every day, 1,000 Days partners are putting provensolutions into action in communities around the world.
By working in alignment with the Scaling Up Nutrition(SUN) Framework, 1,000 Days partners join a movement
to work across sectors and specialties to achieve better
nutrition results. By prioritizing proven nutrition solutions,progress is being made and lives are being changed for the
better. Strong nutrition programs, sound policies andbetter investments can make a difference in the lives ofmothers and children today in a way that dramatically
improves the health and well-being of future generationsof individuals, families and communities.
Source: Thousand Days Partnership, USA
http://thousanddays.org/resources/success-stories/

12Chapter One

13

Preventing Stunting: Why
it Matters, What it Takes

Martin Bloem
Senior Nutritionist and WFP’s Global Coordinator UNAIDS – United Nations World Food
Program; Adjunct Associate Professor, – Johns Hopkins Bloomberg School of Public
Health, Baltimore, USA; Adjunct Associate Professor, – Friedman School of Nutrition
Science and Policy, Tufts University, Boston, USA

“Hunger is not only a physical condition. It is a drain on economic
development, a threat to global security, a barrier to health andeducation reform, and a trap for the millions of people worldwide
who work from sun-up to sun-down every day to produce a harvestthat often doesn’t meet their needs... We have the resources to giveevery person in the world the tools they need to feed themselves and theirchildren. So the question is not whether we can end hunger. It’s whether we will.”
Hillary Clinton, 2009

Key messages•	Stunting is the result of inadequate nutritionin early life and has severe consequencesthat last a lifetime.
•	Stunting prevents individuals fromachieving their potential, physically,
intellectually and economically.
•	Stunting affects not only individuals but
also the entire societies to which they belong.
•	The right to adequate nutrition should berecognized as a Human Right.

Recent improvements in nutrition
The world has seen significant developments in the field of
nutrition since the development of the Millennium
Development Goals (MDGs), which were to be reached by
2015, and included ending hunger and reducing
underweight as part of MDG number 1.
In 2008, the Lancet published the first landmark series onnutrition, which summarized the magnitude andconsequences of the nutrition problem, as well as a numberof proven and low-cost solutions. In 2013, the follow-up
series on the subject was published. Four critical points
made by these two Lancet series are:i)chronic undernutrition, or stunting, is considered the main
nutrition problem because it is a key obstacle fordevelopment;ii)

the window to prevent stunting is very small: fromconception to two years of age;iii) stunting at two years of age is associated with ill health,poorer school performance, and an increased risk ofobesity, diabetes, and other chronic diseases later in life;andiv) economic analyses indicate the negative effects of poor
nutrition in early life on the overall economic developmentof nations.

A stunted child at the age of two is deprived from achieving its
full potential for the rest of his/her life, which is an enormous
drain on the world’s human resources. Sufficient knowledge
exists about effective strategies for prevention, and thesestrategies should be implemented by all parties concerned.
Prevention of stunting is central to the Scaling Up Nutrition(SUN) movement, and there is wide recognition that theprevention of stunting should also feature prominently inthe post-2015 development agenda.
According to the latest report of UNICEF/WHO/WorldBank (2012), 165 million children under 5 are stunted, andmany school-age children, adolescents and adults today
suffer the consequences of the stunting that theyexperienced during their early years of life.

14

Chapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

15

What ‘stunting’ indicates
Stunting is defined as inadequate linear growth, and this isdue to the fact that nutrient intake does not meet nutrient
needs. Furthermore, nutrient needs may be increased byillness, and illness also reduces appetite and interferes withnutrient utilization, thus increasing the difficulty of meeting
nutrient needs with existing nutrient intakes. Stunting is arelatively easy indicator to measure, and reflects
undernutrition during a critical period of development, inparticular from conception until two years of age (i.e., thefirst 1,000 days of life). Inadequate nutrition during thisperiod has severe consequences for life, because many
developmental processes occur only during certain stages oflife, and cannot (re)occur later in life.
Stunting develops during life in utero and the first two
years after birth. It is a process of suboptimal growth anddevelopment that gradually accumulates to such an extent
that body length is below that of 97.7 percent of children in
the reference population. Children born with a low birthweight (<2500 g) due to restricted intrauterine growth are
at great risk of remaining stunted. Beyond 24 months ofage, stunting prevalence may still increase, but at a muchslower pace.

Malawi president Joyce Banda at the Nutrition for Growth conferencein London, June 8, 2013
Soucre: Marisol Grandon/Department for International Development

Consequences of stunting
Lack of adequate nutrients in the first 1,000 days will, forexample, lead to irreversible gaps in brain development.
The outcome of brain development by the age of two years
determines to a large extent a person’s mental capacity forthe rest of his/her life, including success in schooling andincome earning.
Not only stunted children are affected by undernutrition:
non-stunted children in populations with a considerable
prevalence of stunting are also likely to be affected, i.e., they
have not reached their full potential either, although theirlength is not below the cut-off which classifies them as ‘stunted’.
Girls who grow up stunted are more likely to suffer
complications during childbirth as adolescents or adults,
because they have a smaller pelvis. Breaking theintergenerational cycle of undernutrition thus also requires
good obstetric care, to facilitate the birth of a larger baby, bornto a mother who may have been stunted herself but then had
good nutrition pre-pregnancy and during pregnancy, resulting
in the development of a larger infant in the womb.
United Kingdom Secretary of State for International Development Justine
Greening concludes the successful Nutrition for Growth conference,
where world leaders gathered with businesses, scientific and civil society
groups, committing to a historic reduction in undernutrition.
Soucre: Marisol Grandon/DfID

Stunting typically co-occurs with micronutrient deficiencies,
because foods that are rich in nutrients that are essential for
linear growth are also good sources of other micronutrients.
This also explains why stunting is such an importantChapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

indicator, reflecting a shortage of essential nutrients during
the most critical developmental phase in life.

16

As such, stunting has been linked to increased morbidity
and mortality, delayed mental development, poor school
performance, and reduced intellectual capacity. This in turnaffects income in adult life, as well as economic productivity
at national level. Furthermore, stunting is also related toincreased risk of overweight and non-communicable diseasesuch as diabetes and cardiovascular disease later in life.
The fact that much of this damage cannot be undone laterin life means that it is essential to prevent stunting.

Prevention of stunting requires anutritious diet
The prevention of undernutrition, or stunting, should start earlyin life, with interventions among at-risk populations that ensurethat pregnant and lactating mothers are adequately nourished,that children receive exclusive breastfeeding during the first 6
months of life, and provision of adequate complementary feedingin addition to breastfeeding for children aged 6–23 months.
Ensuring that pregnant women are adequately nourished may
require intervening before pregnancy, i.e., during adolescence andbefore a next pregnancy, also because the impact ofundernutrition already starts at conception.
The ultimate aim of interventions to prevent stunting
should be that nutrient requirements of the individual child,also during life in utero, are met and that illness is prevented.
An individual needs approximately 40 different nutrients, indifferent amounts, in order to grow, develop and remain
healthy. Meeting these requirements requires consumptionof an adequately diverse diet, including breast milk, and avariety of plant-source foods (vegetables, fruits, staples),animal-source foods (dairy, eggs, fish, meat) as well as
fortified foods. Where such a variety of foods is notavailable, or for those who (usually for economic reasons)cannot access such a variety, specially formulated foods may
be required that fill the so-called ‘nutrient gap’. These mayneed to be made available at lower than normal or no cost.
A home-fortification approach, where a small amount of apowder or lipid-based spread (<20 g, <100 kcal/d) is added tohome-prepared foods, which adds vitamins, minerals andsome other essential nutrients that are unlikely to be available
in adequate amounts in the prevailing diet, is a promisingstrategy for preventing stunting, because it hardly changes the
local diet and food practices. Another good option, which may
be more familiar to families, is the introduction of speciallyformulated complementary foods, such as infant porridges thathave a good content of essential nutrients.

Tanzanian campaigner Frank shares his experience of hunger with British
Prime Minister David Cameron at the Nutrition for Growth Summit
Source: Simon Davis/Department for International Development

Sun by the numbers

41
countries
commitedto Scaling Up
Nutrition

Bangladesh
Benin
Burkina Faso
BurundiCameroon
Chad
Cote d’Ivoire
Democratic
Republic of Congo
El Salvador
Ethiopia
GambiaGhana
GuatemalaWhich means thepotential to reach80

millionchildren
There are100+

committed partners
accountable forsupporting national
plans

GuineaHaiti
Indonesia
Kenya
Kyrgyz Republic
Lao PDR
Madagascar
MalawiMali
Mauritania
Mozambique
MyanmarNamibia
Nepal

Niger
Nigeria
Pakistan
Peru
RwandaSenegalSierra Leone
South Sudan
Sri Lanka
Tanzania
UgandaYemen
ZambiaZimbabwe

By focusing
on the critical

1,000

day window ofopportunity to
improve nutrition
All working
together to drive1

globalmovement

and unleash the potential ofmilllionsof healthier, smarter andstronger children

Status: June 2013. Please see the SUN website for more recent updates.

Chapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

17

Starting at stunting’s basic cause,poverty and inequity
Both dietary diversity, which determines nutrient intake, anddisease, which affects nutrient utilization and nutrient needs,
and also food intake, are strongly linked to poverty. Stunting
at the age of two years is therefore a reflection of inequity andalso perpetuates this, due to its long-term negative health,economic, and social consequences for the individual, theiroffspring and the population they live in. Extreme poverty is
the most critical problem the world has to cope with.
The first millennium development goal (MDG), which wasformulated in 2000, set two indicators for reducing hunger:
the number of undernourished people (energy intake notmeeting requirements – based on food availability atnational level and estimates of the population’s energy
needs) and the percentage of underweight children underfive. Underweight, or too low weight-for-age, reflects bothstunting as well as wasting, which are two different forms
of undernutrition, in terms of immediate causes and possible
solutions, and are therefore better recognized separately.
Since the 2008 and 2013 Lancet series identified stunting as
the most critical indicator for malnutrition and the 65th

Paul Polman makes a heartfelt address to the assembled guests at the
Nutrition for Growth conference, held in the Unilever building in central
London, June 8, 2013
Soucre: Marisol Grandon/Department for International Development

World Health Assembly in 2012 set 6 global targets fornutrition, including as its first goal a 40 percent reductionof the global number of children under five who arestunted, there is a strong push among many stakeholders toinclude stunting as a target in the post-2015 development
agenda (successor of the MDGs).

Former UN Secretary-General Kofi Annan and chairman of the Alliance for a Green Revolution in Africa talks to USAID administrator Dr Raj Shahat the conclusion of the Nutrition for Growth conference in London, 8 June, 2013
Soucre: Marisol Grandon/Department for International Development

Chapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

Prevention of stunting should be a human right
Although child undernutriton has long been used as anindicator or proxy for poverty, the world has never united
behind making prevention of undernutrition a goal in itself.
As stunting is now recognized as so detrimental todevelopment, depriving individuals of the possibility of
having equal chances for the rest of their life, the preventionof undernutrition, or stunting, should be recognized as ahuman right. In view of the fact that it has such widespreadconsequences, impacting on so many aspects of life, it
should not be regarded as merely a ‘nutrition problem’ thatnutritionists should solve.
While nutrition has been mentioned as a component of the“right to food”, “right to health” and “Convention on the
Rights of the Child”, the prevention of chronic
undernutrition has not yet been recognized as a right. In
fact, nutrition is mentioned sparsely in the various ‘humanrights’ documents, which is apparently due to the fact thatnutrition is not regarded as a right in itself but as anelement of health or an outcome of lack of access to food.
The Universal Declaration of Human Rights, article 25,
mentions both health and access to food as rights:“Everyone has the right to a standard of living adequate forthe health and well-being of himself and of his family,
including food, clothing, housing and medical care andnecessary social services, and the right to security in theevent of unemployment, sickness, disability, widowhood,
old age or other lack of livelihood in circumstances beyond
his control.”
The International Covenant on Economic, Social andCultural Rights, meanwhile, provides the mostcomprehensive article on the right to health in international
human rights law. Nutrition is mentioned as one of thedeterminants of health:
Article 12 of the Covenant recognizes the right of everyone to“the enjoyment of the highest attainable standard of physicaland mental health.” “Health” is understood not just as a rightto be healthy, but as a right to control one’s own health andbody (including reproduction), and be free from interferencesuch as torture or medical experimentation. States must
protect this right by ensuring that everyone within theirjurisdiction has access to the underlying determinants ofhealth, such as clean water, sanitation, food, nutrition andhousing, and through a comprehensive system of healthcare,which is available to everyone without discrimination, andeconomically accessible to all.

The UN Committee on Economic, Social, and Cultural
Rights defines the “right to food” as follows:“The right to adequate food is realized
when every man, woman and child,alone or in community with others,
has physical and economic access at
all times to adequate food or means
for its procurement. The right toadequate food shall therefore not beinterpreted in a narrow or restrictive
sense, which equates it with aminimum package of calories,
proteins and other specific nutrients.
The right to adequate food will haveto be realized progressively. However,States have a core obligation to takethe necessary action to mitigate andalleviate hunger as provided for inparagraph 2 of article 11, even intimes of natural or other disasters.”
However, as argued above, the prevention of chronic
undernutrition, or stunting, should be a human rightbecause of its widespread and irreversible lifelong
consequences.

Bill Gates pledged $800 million to support the work of the Gates
Foundation on nutrition and agriculture at the Nutrition for Growth conference
Source: The Children’s Investment Fund Foundation

18

Chapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

All stakeholders need to work together to prevent stunting
As thoroughly recognized by the Scaling Up Nutrition
movement, all stakeholders need to work together toprevent stunting, including governments, the United
Nations network, donor networks, civil society, and theprivate sector. These stakeholders must work together atnational, regional and global level, in order to ensure accessto adequate nutrition for all – in particular women andyoung children – and to prevent disease, which for example
requires action by the healthcare sector as well as
implementation of hygiene and sanitation measures. The
call for all stakeholders to work together is easily made, but
requires the laying out of a strong, localized roadmap thatclearly identifies areas and responsibilities for action for thedifferent stakeholder groups. Division of tasks withinstakeholder groups should be done transparently. Trackingof implementation and progress is key to ensuring that thecountry stays on track relative to its roadmap.

the average height of populations in the US, Europe, andparts of East Asia and Latin America in the second half ofthe 20th century coincided with dramatic economic
development, and because access to healthcare, water andsanitation, and primary education was already good anddid not change much during this period in these parts of theworld, the improvement of nutritional status was to a large
extent due to better access on the part of the lower
economic strata of these populations to a more diverse diet,including improved, processed, complementary foods aswell as animal-source foods such as dairy products. A good
example is the average height of the Dutch male population,
which increased from 165 cm in 1935 to 185 cm at the endof the 20th century. Increased height, which reflects better
nutrition, is associated with higher IQ, a lower risk ofcardiovascular diseases, but a slight increase of some kindof cancers, however, overall with a more healthy population.

It is increasingly recognized that the private sector,
particularly the food industry, plays a critical role inachieving adequate nutrition and preventing stunting, andhas to take that role even more seriously. The increase of

The increase since the 1960s of cardiovascular diseases,
obesity, type 2 diabetes, cancers, and other chronic diseases
related to overconsumption of foods with a high content offats and/or sugars but at the same time a low content of

Average annual
reduction rate

The ten countries with the fastest annual reduction of stunting between 1990 and 2010
% Children
Stunted

19

Saudi Arabia

9.3

7.3

Angola

29.2

6.6

China

13.7

6.0

Brazil7.1

5.7

Mexico15.5

4.7

Vietnam

30.5

4.1

Korea DPR

43.1

4.1

Turkey15.6

3.9

Cambodia

39.5

3.0

Bangladesh

43.2

3.0

Average annual reduction rate
7% and over6 - 6.99%

5 - 5.99%

4 - 4.99%

3 - 3.99%
Country

Source: http://scalingupnutrition.org, June 2013
http://scalingupnutrition.org, June 2013

Chapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

20

vitamins, minerals and other essential nutrients, however,has further complicated the nutrition field. This requires
corrective action from the food and beverage manufacturers.
This is also where the collaboration of the private sector
with governments (who have legislative and norm-setting
responsibilities) and civil society, donors and UN (who, forexample, are important partners in healthcare, educationand promoting consumer awareness of health and nutrition)is important, and the only way to ensure adequate nutrition
for all.

Conclusion
There is an urgent need to give every child equal
opportunities at the age of two. To achieve this, theprevention of stunting should be recognized as a humanright. All stakeholders, including the private sector, need tocollaborate to prevent stunting.

Two girls, Juhora Akter (left) and Asma Akter, who are both 12 years
old, stand in front of a wall with a black tape line indicating thenormal projected height for a 12-year-old child, in a rural area near
the town of Shahrasti, Chandpur, Bangladesh
Source: UNICEF/NYHQ1997-0518/Gilles Vauclair

Because when...
Girls and women
are well-nourishedand have healthy
newborn babies

Communities
and nations
are productive
and stable

Children receive
proper nutrition anddevelop strong
bodies and minds

The world isa safer, more
resilient andstronger place

Families andcommunities emergeout of poverty

Adolescents
learn better andachieve higher
grades in school

Young adults are
better able to obtainwork and earn more

http://scalingupnutrition.org, June 2013

MixMe™ micronutrient powder being added to a meal to improve its
nutritional value
Source: Mike Bloem PhotographyChapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

21

A brief history of Human Rights

The General Assembly proclaims this Universal Declaration of Human Rights
as a common standard of achievement for all peoples and all nations, to theend that every individual and every organ of society, keeping this Declaration
constantly in mind, shall strive by teaching and education to promote respect
for these rights and freedoms and by progressive measures, national andinternational, to secure their universal and effective recognition and observance,
both among the peoples of Member States themselves and among the peoples ofterritories under their jurisdiction.
Declaration of Human Rights, 10 December 1948

The first known instance of a human rights agenda can betraced back to 539 BCE, when Cyrus the Great of Persia
conquered the city of Babylon. In the wake of his triumph,
he did something totally unexpected, freeing all the slaves in
the city to return home. Moreover, he declared that thepeople under his rule should choose their own religion. The
Cyrus Cylinder, a clay tablet containing these pronouncements,
is one of the first human rights declarations in history.1

The first draft of the Declaration was proposed in
September 1948 with over 50 Member States participatingin the final drafting. By its Resolution 217 A (III) of 10
December 1948, the General Assembly, meeting in Paris,
adopted the Universal Declaration of Human Rights witheight nations abstaining from the vote but none dissenting.
Hernán Santa Cruz of Chile, member of the drafting
sub-Committee, wrote:

The idea of human rights spread quickly in the ancientworld to India and Greece, and eventually Rome. The mostimportant advances since then have included the 1215
British Magna Carta, which not only gave people newrights but also made the king subject to the law; the British
1628 Petition of Right, which formalized the rights of thepeople; the 1776 United States Declaration of
Independence, which proclaimed the right to life, liberty
and the pursuit of happiness; and the 1789 French
Declaration of the Rights of Man and of the Citizen, adocument stating that all citizens are equal under the law.2“I perceived clearly that I was participating in a truly
significant historic event in which a consensus had beenreached as to the supreme value of the human person, a valuethat did not originate in the decision of a worldly power, butrather in the fact of existing – which gave rise to theinalienable right to live free from want and oppression and to
fully develop one’s personality. In the Great Hall…there wasan atmosphere of genuine solidarity and brotherhood among
men and women from all latitudes, the like of which I havenot seen again in any international setting.”

In response to the crimes against humanity that werecommitted during the Second World War, the human rights
revolution grew rapidly, subsuming claims from minorities,
women, the politically oppressed, and marginalcommunities from around the globe.3
The human rights revolution began with a disarmingly
simple idea: that every individual, whatever his or her
nationality, political beliefs, or ethnic and religious heritage,
possesses an inviolable right to be treated with dignity.
From this basic claim grew many more, and ever since, thecascading effect of these initial rights claims has
dramatically shaped world history.4
The Universal Declaration of Human Rights, the first document
to list the 30 rights to which everyone is entitled, was adopted by
the UN General Assembly on 10 December, 1948.5

The entire text of the Universal Declaration of Human Rights
was composed in less than two years. At a time when theworld was divided into Eastern and Western blocs, finding acommon ground as to what should constitute the essence ofthe document proved a colossal task.6
1. Adapted from A Look at the Background of Human Rights, http://www.
youthforhumanrights.org/what-are-human-rights/background-of-humanrights.html, July 2013
2. Adapted from A Look at the Background of Human Rights, http://www.
youthforhumanrights.org/what-are-human-rights/background-of-humanrights.html, July 2013
3. Adapted from The Human Rights Revolution: Description http://global.
oup.com/academic/product/the-human-rights-revolution-9780195333145?cc=
gb&lang=en&tab=description, July 2013
4. Adapted from The Human Rights Revolution: Description http://global.
oup.com/academic/product/the-human-rights-revolution-9780195333145?cc=
gb&lang=en&tab=description, July 2013
5. Adapted from History of the Document http://www.un.org/en/documents/
udhr/history.shtml, July 2013
6. Adapted from History of the Document http://www.un.org/en/documents/
udhr/history.shtml, July 2013

Chapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

Case study
Household Rice Expenditure and Maternal and Child
Nutritional Status in Bangladesh
Increases in global food prices have raised concerns thatthe prevalence of malnutrition may increase, especially indeveloping countries. Rising food prices may decrease theability of households to purchase food. Because poor
households use a relatively large proportion of income topurchase food, increases in the price of food can directly
affect the amount and type of food their income can buy,
which can be reflected by decreased amounts of fat andvegetables in meals, elimination of some meals, and an
overall reduction in dietary diversity. Because dietary
diversity and animal-source foods are recognized as key
components of high-quality diets, rising food prices canlead to a reduction in the quality of the diet. Reduced
quality of the diet may adversely affect both nutrition andhealth over time. Previous studies have shown that
increases in food prices lead to greater levels of stunting
among children, decreased maternal micronutrient status,
and impaired growth of infants.
In Bangladesh, poor rural families often deal with highfood costs by purchasing primarily rice. The objective of[the current] study was to characterize the relationshipbetween household expenditure on rice and non-rice foods
with maternal and child malnutrition.
A recent study of data collected in the Nutritional
Surveillance Project (NSP) in Bangladesh between 1992 and2000 evaluated how changes in rice price affected childunderweight. The percentage of underweight children

Further reading2013 Lancet Series on Maternal and Child Nutrition
Scaling Up Nutrition website: scalingupnutrition.org.
Copenhagen Consensus 2008/2012.

22

declined in the situation where rice expenditures fell andhouseholds were able to spend more on non-rice foods. We
sought to expand these investigations to evaluate therelationship between rice expenditure, non-rice expenditure,and household food expenditure and child stunting andmaternal underweight between 2000 and 2005.
The results of [our] study show that households withhigher expenditure on rice have increased odds of childstunting. Conversely, households with a higher
expenditure on non-rice foods have decreased odds ofchild stunting. A similar relationship was observed
between rice and non-rice food expenditures and maternal
underweight. Previous studies have shown that changes inweekly expenditure on rice reflect changes in rice prices …
Previous studies have shown that the percentage of childunderweight increases as rice expenditures rise. The
present study extends these findings and suggests thathigher expenditure on rice (reflecting higher food prices)increases the likelihood of developing child stunting.
Households with highest expenditures on rice and lower
expenditures on non-rice foods have greater childmalnutrition across all age categories up to 59 mo andgreater maternal underweight. In a situation of global foodprices, these findings suggest that there will be considerable
impact upon the prevalence of child malnutrition andmaternal underweight in developing countries.
Source: First published November 25, 2009, doi: 10.3945/jn.109.110718 J.
Nutr. January 2010 vol. 140 no. 1 189S-194S [adapted and abridged]

Baldi G, Martini E, Catharina M et al. Cost of the Diet
(CoD) tool: First results from Indonesia and applications
for policy discussion on food and nutrition security.
Food Nutr Bull 2013;34:35S–42S.
de Pee S. Food Security. In: Caballero B. (ed.)
Encyclopedia of Human Nutrition (3rd ed), vol. 2, pp.
353-360. Waltham, MA: Academic Press, 2013.

Chapter One | Preventing Stunting: Why it Matters, What it Takes | Martin Bloem

23

Case study
Malnutrition is treatable: access to nutrition services
saves the life of a child (Uganda)
When 7-month-old Frank arrived at the Rubaga Hospitalin Uganda in 2010, he was severely malnourished. He
weighed only 7.5 pounds. Frank’s aunt had less than $1
per week to feed and clothe him and his four othersiblings. One of NuLife’s 1,200 volunteers referred Frankto the hospital. (There are 54 NuLife-supported healthfacilities. NuLife is managed by University Research Co.,
LLC (URC) in partnership with the Uganda Ministry of
Health (MOH). They are tasked with engaging multiple
stakeholders to ensure nutrition care for people livingwith HIV/AIDS, pregnant and lactating women, andorphans and vulnerable children.
Frank was diagnosed with severe acute malnutrition. Staff
prescribed and provided Frank with ready-to-use
therapeutic food (RUTF) to treat his condition andenrolled him in an outpatient therapeutic care program.

My personal view
Martin Bloem

Senior Nutritionist and WFP’s Global Coordinator UNAIDS– United Nations World Food Program; Adjunct Associate
Professor, – Johns Hopkins Bloomberg School of Public
Health, Baltimore, USA; Adjunct Associate Professor, –Friedman School of Nutrition Science and Policy, Tufts
University, Boston, USA

While the prevention of chronic
undernutrition, or stunting, should beeveryone’s concern, because of thewidespread consequences forschooling, economic development,
long-term health etc, its prevention
should ultimately result from better
meeting children’s nutrient requirements, and preventing
an increase thereof, during the critical window of

His aunt also received nutrition counseling.
Frank’s recovery was remarkable. After two months of
RUTF he had exceeded his target weight by 20%.
“Everybody gave Frank just two days to live when I firstbrought him, but now everybody wants to hold him andplay with him,” his aunt said. Frank would need to betaken back to hospital for regular follow-ups and more
RUTF to ensure continued recovery.
Frank is just one of 16,000 individuals that have received
treatment via NuLife. Project-supported healthcare
facilities now assess close to 85% of HIV-positive
individuals for malnutrition at admission, and sustainable
processes are now in place allowing facilities to continue
to address malnutrition. These NuLife achievements allow
Ugandan health facilities to continue to treat children likeFrank even after the project’s completion in August 2011.
Source: Thousand Days Partnership, USA
http://www.thousanddays.org/success-story/malnutrition-is-treatable-accessto-nutrition-services-saves-the-life-of-a-ugandan-child/ Dec 2011 (abridged)

opportunity (conception to two years of age). Therefore,
nutrition-specific actions, complemented with nutritionsensitive approaches, are key. In the human rights
documents, nutrition is only considered as a determinant
to health, and the right to food only mentins access to“nutritious food” but none of the “human rights”
documents recognizes the importance of nutrients in thesense that all required nutrients should be provided inadequate amounts. The particular need of children 6-24
months for nutrient-dense foods is very specific and thefact that these needs are difficult to meet from local foods
for large segments of the world population urges for a
discussion on the right to nutrients to prevent chronic
undernutrition. Furthermore, meeting nutrient
requirements of adolescent girls and women, particularly
during pregnancy and lactation, should be prioritized aswell, in order to protect their health and give theirchildren the right start in life.

Chapter Two

Food Security andNutrition: Linkages andComplementarities

Marie Ruel
Division Director of Food Consumption and
Nutrition Division, International Food Policy
Research Institute (IFPRI) Washington DC, USA24

“If we can conquer space, we can conquer childhood hunger.”Buzz Aldrin

25

Key messages• Food security and nutrition security are
related but distinct concepts.
• Food security refers to having enough of
the right foods at all times, and depends
on the availability of food globally andlocally, and on the household’s andindividual’s access and proper utilization.
• Good nutrition (or nutrition security) also
requires having enough of the right foods,
but in addition, it requires having accessto adequate feeding, caregiving andhygiene practices, as well as access tohealth, water and sanitation services.
Nutrition security thus depends on having
access to a healthy diet which provides
all nutrients required for a healthy life, andbeing healthy so that the body can make
optimal use of these nutrients for its
different functions.

• Food security is necessary, but not
sufficient, to ensure nutrition and toprevent childhood malnutrition. Children
also need their caregivers to provide
them with appropriate feeding,caregiving, hygiene, and health-seeking
practices in order to grow, develop andstay healthy.
• Infants, young children, pregnant andbreastfeeding women are especiallyvulnerable to malnutrition; nutritioninterventions must focus on the critical‘First 1,000 Days’ window of opportunity.
• Achieving food and nutrition security is amulti-faceted challenge which requires amulti-sectoral approach; food systems
can play a critical role in protecting bothfood security and nutrition if carefulattention is paid to targeting the poor,
reducing inequalities, - including genderinequalities -, and incorporating nutrition
goals and action where relevant.

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

Food and nutrition security: concepts and definitions
In the past half-century, the world has become increasingly
aware of the challenges and threats to food security. This
heightened awareness has been prompted by a range of well
publicized humanitarian disasters and food price crises on
the one hand and the burgeoning growth of the world’s
population and the changes in its dietary patterns on theother. Development organizations are increasingly
concerned about food security and have focused theirefforts on helping those who are not able to feed themselves
sufficiently and adequately. Over the course of decades,
these bodies have received the support of governments,
private foundations and United Nations organizations.
Many of their efforts have focused on provisioning food insituations of crisis or emergency, and increasingly on
providing cash or food for development. Securing anadequate supply of food, however, is by no means the samething as securing adequate nutrition. Investments inagricultural productivity and yields, for example, are notguaranteed to improve nutrition or health if they do not
improve the poor’s access both to enough calories and to26

high-quality diets rich in essential nutrients. Even improving
access to more and better food may be insufficient toprevent or reduce the persistently high rates of malnutrition
found in the developing world if children are suffering fromrepeated episodes of diarrhea or other infections.
The distinction between food security and nutrition security
is critically important because it affects what can be
expected from the large, and in some cases growing,
investments in boosting agriculture productivity andpromoting global food security worldwide. For example,
investments to stimulate agriculture production, especiallythose focused on staple cereals, although necessary, may not
automatically result in better nutrition if they are notaccompanied by complementary investments to improveaccess to health services for the poor.
Food security has been defined by the Food and Agriculture
Organization of the United Nations (FAO) as existing“when all people, at all times, [have] physical, social andeconomic access to sufficient, safe and nutritious food to

The causes of malnutrition are interconnected

Lack of goodCARE
for mothers & children &support for mothers
on appropriate childfeeding practices
Insufficient access toaffordable, nutritious

Inadequate access to

HEALTH

FOOD

sanitation & cleanwater services

throughout the year

ROOTED IN
Political & Cultural
Environment
Source: TBC

Poverty

Disempowermentof WomenChapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruelmeet their dietary needs and food preferences for an active
and healthy life” (FAO 1996, par. 1). Importantly, thisdefinition stipulates that food should be available insufficient quantity as well as in sufficient quality, should be
culturally acceptable, and should be available at all times
throughout the year.
Nutrition security, by contrast, exists when, in addition tohaving access to a healthy and balanced diet, people also
have access to adequate caregiving practices and to a safe
and clean environment that allows them to stay healthy andutilize the foods they eat effectively. For young children, forexample, this means that they have enough of the rightfoods, and this includes breast milk for up to two years ofage, along with appropriate quantity and quality ofcomplementary foods starting at six months of age because
breast milk can no longer fulfill all of the infant’s nutrient
needs after that age. In addition, young children also needcaregivers who have the time, education, knowledge,
physical and mental health, and nutritional well-being tocare for them adequately. Adequate caregiving means thatcaregivers are able to attend to all their children’s multiple
needs, including adequate feeding, hygiene, health-seeking
practices and supportive parenting. Finally, to be nutrition
secure, young children must also be free of repeated (chronic)or acute infections, which interfere with absorption andutilization of food and nutrients for body functions.
Thus borrowing from both definitions, “food and nutrition
security”can be defined as a situation that exists when all
people at all times have physical, social and economic
access to food, which is consumed in sufficient quantity andquality to meet their dietary needs, requirements for growthand food preferences, and is supported by an environmentof adequate sanitation, health services and caregiving(United Nations Food and Agriculture Committee on World
Food Security). This allows for appropriate utilization offood and nutrients by the body and therefore creates theconditions for a healthy and active life. Nutrition security
therefore implies an optimal nutritional status.
To put this in more concrete terms, a person who has access toeven the healthiest diet would not be able to benefit fully fromthat diet if he or she were ill or were living in the unsanitaryconditions that foster illness. Poverty is often associated withinsufficient food or foods of poor quality, in addition to
suboptimal (or lack of) water and sanitation facilities, andcompounded by an absence of knowledge of how to prevent
contamination in the handling and preparation of food –which further compromises adequate nutrition, even if diets
are adequate. People living in such circumstances are therefore
drawn into a vicious cycle of infection which manifests itself

Linkages between food and nutrition security

Nutrition status /mortality

Exposure to shocks and hazards

27

Individual
level

Individual
foodintakeContext/
framework
Food
availability
markets
Basic
servicesandinfrastructure
Political,
economical,
institutional,
security,social,cultural,gender,environment
Agroecologicalconditions/climateHouseholdfoodaccessHealthstatus/diseaseCare/healthpractices

Health andhygieneconditions

Livelihood
outcomes

Household
Level

Household foodproduction, gifts,
exchange, cash
earnings, loan, savings
transfers

Natural, physical,
human, economical,
social capital / assets

Livelihood
assetsCommunity/
Household Level
Livelihood
assetsWFP Food and Nutrition Security Conceptual Framework (based on UNICEF conceptual
framework for causes of malnutrition and DfID sustainable livelihoods framework).
Reprinted with permission from WFP (2009) Comprehensive Food and Security
Vulnerability Analysis Guidelines, Rome, Italy: WFP Available from www.wfp.org

by repeated bouts of illnesses, leading to poor nutrition, which
in turn exacerbates poor health and susceptibility to infections,and perpetuates poverty.
Many global, national and local factors compromise thechoices that poor populations have regarding their foodconsumption and diets. These include global changes in thefood systems such as food and oil price volatility, climatechange and resulting water shortages, and natural disasters
affecting agriculture productivity, as well as conflicts andemergencies. At the local level, bad harvests, poor agriculturaland husbandry practices, inappropriate procedures for the
packaging and storage of food, and inadequate distribution
mechanisms affect poor farmers’ food production and income,as well as their purchasing power. Food and nutrition
insecurity are the result of inequity.
Most vulnerable of all are infants and young children
during their first two years of life, and women when they
are pregnant or breastfeeding. The vulnerability of these
two groups comes from the fact that they have very highrequirements for essential nutrients (e.g. vitamin A, iron,Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruelzinc, iodine, etc.) during these periods. For children, thesenutrients are necessary for them to grow and for their brain
to develop; for pregnant women, they are necessary because
they have to provide extra calories and nutrients to theirgrowing fetus; and for lactating mothers, they are necessary
because the mothers are producing breast milk, and thisrequires consuming extra calories and micronutrients sothat they can produce enough milk and for the milk to be ofadequate quality.
The critical importance of this period (pregnancy, lactationand first two years of a child’s life), which is now referred
to as the “First 1,000 Days” from conception to the twoyears of age, was made clear in a groundbreaking piece of
research published by The Lancet Journal in 2008 andfurther emphasized in a new Series on Maternal and Child

Nutrition published in the same journal in 2013. Both series 28
highlight that not only is this 1,000-day period the time
when mothers and children are most at risk of malnutrition,
but that it is also the period when they can most benefit
from interventions to prevent the negative consequences ofmalnutrition. In fact, what happens during the first 1,000
days determines the future of an individual, and nutritional
damage that happens during this period is largely
irreversible. Children undernourished during this period areshown to have delays in mental development, are less likely
to perform well and to stay in school, have less skilled jobs
and lower income in adulthood, and are at increased risk ofdeveloping problems of overweight and obesity and otherchronic diseases such as heart diseases, diabetes and some
types of cancers in adulthood.

“Food security exists when all people, at all times, have physical andeconomic access to sufficient safe and nutritious food that meets their dietaryneeds and food preferences for an active and healthy life.”-1996 World Food Summit

Mother working in agriculture (with child)
Source: One Acre Fund

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

29

The four dimensions of food security
The definition of food security highlights the fact that foodsecurity is a multi-faceted problem, which includes four key

dimensions: availability, access, utilization and stability.
The four dimensions of food security are defined as:

Physical AVAILABILITY of food		Food availability addresses the “supply side” of food security and is determined by the level of		food production, stock levels and net trade.
Economic and physical ACCESS to food		An adequate supply of food at the national or international level does not in itself guarantee
household level food security. Concerns about insufficient food access have resulted in a		greater policy focus on incomes, expenditure, markets and prices in achieving food security objectives.
Food UTILIZATION 		Utilization is commonly understood as the way the body makes the most of various nutrients in the
food. Sufficient energy and nutrient intake by individuals is the result of good care and feeding		practices, food preparation, diversity of the diet and intra-household distribution of food. 		
		Combined with good biological utilization of food consumed, this determines the nutritional status
		of individuals.
STABILITY of the other three dimensions		Even if your food intake is adequate today, you are still considered to be food insecure if you haveover time		inadequate access to food on a periodic basis, risking a deterioration of your nutritional status.
		Adverse weather conditions, political instability, or economic factors (unemployment, rising food		prices) may have an impact on your food security status.
Source: United Nations Food and Agriculture Organization (FAO)

For food security objectives to be realized, all four dimensions must be fulfilled simultaneously.

The four dimensions of food security and their determinants
Availability

Access• Domestic production• Import capacity• Food stocks• Food aid• Income, purchasing
power, own
production• Transport and market
infrastructure• Food distribution

Utilization• Food safety andqualtiy• Clean water• Health and sanitation• Care, feeding andhealth-seeking
practices

Stability• Weather variability,
seasonality• Price fluctuations• Political factors• Economic factors

Source: Adapted from FAO

Food security analysts have also defined two general typesof food insecurity: chronic and transitory food insecurity.

These are defined on the basis of their temporality, severity
and rate of recurrence.

CHRONIC FOOD INSECURITY

TRANSITORY FOOD INSECURITY

Is...

long-term or persistent.

short-term and temporary.

Occurs when...

people are unable to meet their minimum foodrequirements over a sustained period of time.

there is a sudden drop in the ability to produce or accessenough food to maintain a good nutritional status.

Results from...

extended periods of poverty, lack of assets andinadequate access to productive or financial resources.
			

short-term shocks and fluctuations in food availability andaccess, including year-to-year variations in domestic foodproduction, food prices and household incomes.

Can be overcome with... typical long-term development measures also used toaddress poverty, such as education or access to
productive resources, such as credit. People may alsoneed more direct access to food to enable them to raise
their productive capacity.

transitory food insecurity is relatively unpredictable and canemerge suddenly. This makes planning and programming moredifficult and requires different capacities and types ofintervention, including early warning capacity and safety net
programs (see Box 1).

Seasonal food insecurity is yet another term. This is used torefer to food insecurity of limited duration linked to cyclicalpatterns of inadequate availability and access to food. Seasonal

food insecurity is usually associated with seasonal fluctuationsin climate, cropping patterns, work opportunities (labordemand), income, and patterns of diseases.

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

The causes and consequences of food insecurity
Food insecurity is not a new phenomenon. The effects ofnatural and man-made disasters have always placed a severeburden on food systems, and there have been few societies thathave existed without the fear of famine, or the memory of it.
Famine is also a highly topical subject – as witnessed in the2011 drought in the Horn of Africa. Figures compiled by
the UK Department for International Development (DfID)
suggest that between 50,000 and 100,000 people, morethan half of them children under five, died as a result of thedrought. A total of 13 million are believed to have been
affected by the disaster, with livelihoods, livestock and local
market systems all caught up in a complex chain ofinterdependency and suffering. According to a reportpublished by Save the Children and Oxfam, and entitled A
Dangerous Delay, many of the deaths could have been
prevented had governments and humanitarian agencies beenquicker to read the warning signs. “Waiting for a situation
to reach crisis point before responding is the wrong way toaddress chronic vulnerability and recurrent drought inplaces like the Horn of Africa,” the report concluded. “Theinternational community must change the way it operates tomeet the challenge of recurrent crises … Long-term
development work is best placed to respond to drought.”
Even in situations in which natural and man-made disasters
are not placing intolerable strain on food systems, however,challenges to food security remain in many parts of theworld. Lack of water for irrigation, poor soil, inadequate
agricultural practices and lack of appropriate tools andseeds can make it difficult to improve yields and efficiency
in the production of nutritious foods. Lack of land itself isanother major factor, as is, of course, lack of capital.
Unsuitable transport systems and inappropriate storagepractices can further compromise food stocks whose
nutritional value and quality may already be questionable.
In addition to these factors, which affect the availability offood globally, there are cultural practices and beliefs that
determine how food is allocated to different individuals within
the household – for example the practice of men eating before
women and children in some parts of the world (andconsuming the choicest and most nutritious elements in a meal
because they are the family breadwinner and perceived to needmore food, and more of the high-quality foods, than otherfamily members); or the cultural beliefs that some foods (suchas eggs in Ghana) should not be given to young children
because this may make them thieves when they grow up; ormangoes, which could be an excellent source of vitamin A for
young children, but are not given to them in some cultures
because these fruits are thought to cause diarrhea.

30

Another critical factor that determines whether households
are food secure or not is women – their social status, theiraccess to resources, and their ability to make key decisions
regarding allocation of income and other resources, such as
food, within the household. It has been shown over andover again that men and women use resources differently,
and that when women have more resources under theircontrol (e.g. income), they are more likely than men toprotect the food security of their family and to invest in thehealth, education and nutrition of their children. For
decades now, women have been referred to as being “thekey to food security”; they are also critically important forprotecting the health and nutrition of their children.
Women’s education, their physical and mental health, andnutritional well-being, as well as the time they haveavailable, are all essential ingredients for ensuring theirfamily’s food security. These factors are equally important
determinants of how women can take care of their young
children’s needs, protect them from infectious diseases, andhelp them grow and develop into healthy adults, which inturn will equip them to more successfully achieve foodsecurity for their own family in the future.
It would be incorrect, however, to assume that foodinsecurity problems are limited exclusively to the developing

Food insecurity, malnutrition and poverty are
deeply interrelated phenomena

PovertyFoodinsecurity
hunger andmalnutrition

Low
productivity

Poor physicaland cognitive
development
Food insecurity, malnutrition and poverty are deeply interrelated
phonemena

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel31

world. Food insecurity and deficiencies of essential nutrientssuch as iron are widespread among the poorest segments ofthe population in many affluent countries. As described in
the chapter on obesity in this book, in developed countries,
food insecurity often leads resource-constrained households
to feed their families cheap, calorie-dense fast foods insteadof fresh fruits and vegetables, meat and dairy, which are
typically much more expensive. As a result, food insecurehouseholds in the developed world often have poor quality
diets containing high levels of saturated fat, refined sugar
and salt, which lead to severe problems of overweight andobesity not only in adults but also in children. Obesity andoverweight lead to stigma and social problems, and more
importantly, they are the most significant risk factors for aseries of health problems including cardiovasculardiseases, diabetes and some forms of cancer. Food
insecurity and malnutrition are not just problems of poor
countries; governments throughout the world need tofind appropriate solutions to protect the food security
and nutrition of their population.

How households cope with food insecurity, and the consequences
for health and nutrition
Deterioration of household food security
Livelihood

Foodrelated

Diversification /change inlivelihood
activities

Reducedexpenditure on
non-essential or
luxury items.
Beginning to sell
non-productive/ disposable
assetsChildren dropout of school.
Emigration (fromrural to urban
areas)

Increased use ofchild labor.
Begin to borrow/ purchase on
credit. Become
indebted

Selling ofproductive
assetsSelling of all
assetsReduceexpenditures on
essential items(e.g. food, wateretc.)

Change tocheaper,lower-quality
andless-preferred
foods

Reduceddiversity offood. Poor
nutrient intake.
Favor certain
HH members
over others for
consumption

Reduced size /number ofmeals

Consume wild
foods /
immature crops/ seeds. Send
HH members
elsewhere to eat(e.g., neigbors)

Begging for
food

Skip entire days
without eating

Eat items noteaten in thepast / not partof normal diet(e.g. plants,
insects etc.)

Engage in illegal/ healththreatening
activities as lastresort coping

Consequences for health and nutrition
Health outcome

Depletion of body nutrient
stores and lowered immunity

Appearance of clinicalsymptoms such as wasting,night blindness, anemia,
increased morbidity and failure
to grow

Increased early childhood
mortality

Increased overall mortality

Changes in livelihood, food selection and consumption, and nutritional status and health outcome when households descend into stress and distress.
Reprinted with permission from Klotz C, de Pee S, Thorne-Lyman A, Kraemer K and Bloem MW. Nutrition in a perfect storm: Why micronutrient malnutrition will be a widespread
health consequence of high food prices. Sight and Life Magazine(2008) 2: 6–13. Adapted from D. Maxwell, R. Caldwell. The Coping Strategies Index: Field Methods Manual,
Nairobi: CARE Eastern and Central Africa Regional Management and World Food Programme, 2nd ed, Jan 2008.

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

Hunger1 statistics

Malnutrition statistics

1) 870 million people in the world do not have enough to eat.
This number has fallen by 130 million since 1990, but
progress slowed after 2008.

1) Undernutrition (including fetal growth restriction, stunting,
wasting, and deficiencies of vitamin A and zinc along with
sub-optimal breastfeeding) contributes to more than 		
3 million deaths of children per year – up to 45% of the
global total.

(Source: State of Food Insecurity in the World, FAO, 2012)

2) The vast majority of hungry people (98 percent) live indeveloping countries, where almost 15% of the populationis undernourished.
(Source: State of Food Insecurity in the World, FAO, 2012)

3) Asia and the Pacific have the largest share of the world’s
hungry people (some 563 million) but the trend is downward.
(Source: State of Food Insecurity in the World, FAO, 2012)

4) Women make up a little over half of the world’s population,
but they account for over 60 percent of the world’s hungry.
(Source: Strengthening efforts to eradicate hunger..., ECOSOC, 2007)

5) 66 million primary-school-age children attend classes
hungry across the developing world, with 23 million in
Africa alone.
(Source: Two Minutes to Learn About School Meals, WFP, 2012)

The term “hunger” is commonly used to refer to “foodinsecurity”
1(Source: Lancet Paper 1 (Black et al 2013)

2) Roughly 100 million children under 5 years of age areunderweight (16%)(Source: Lancet Paper 1 (Black et al 2013)

3) There are still 165 million children stunted in the world(26% or 1 in 4 children) and at least 52 million wasted (8%)(Source: Lancet Paper 1 (Black et al 2013)

4) In 2011, 43 million children younger than 5 years, or 7%,
were overweight – a 54% increase from an estimated
28 million in 1990.
(Source: Lancet Paper 1 (Black et al 2013)

Maternal and child undernutrition isthe cause of more than 3 million
deaths annually(Black et al, Lancet Series 2013)

A girl happy to learn in a classroom in Kenya in 2009Girl learning in an orphanage classroom in Port-au-Prince, Haiti

Source: Mike Bloem Photography

Source: Mike Bloem Photography

32

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

33

UNICEF Conceptual Framework
The UNICEF framework, which the nutrition community has been using for programming for the past 25 years, identifies threelevels of causes of undernutrition
Maternal and childundernutrition

DiseaseImmediate
causesImmediate causes
operating at
the individual level

Unhealthy household
environment and lackof health services

Underlying
causesUnderlying causes
influencing households
and communities

Basic
causesBasic causes aroundthe structure andprocesses of societies

Inadequate dietaryintakeHousehold foodinsecurity

Underlying
causesInadequate care

Income poverty:
employment, self-employment
dwelling, assets, remittances,pensions, transfers etc

Lack of capital: financial, human,
physical, social and natural

Social, economic,
and political context
Source: TBC

The UNICEF conceptual framework
More than two decades ago, UNICEF developed aconceptual framework that identifies the causes ofundernutrition. The nutrition community has used it
extensively ever since because it provides a usefulvisualization of the multiple factors that affect maternal andchild undernutrition. The framework is particularly usefulto illustrate the different levels of factors that affectnutrition – for example factors at the national, community,
household and individual levels – and refers to basic,
underlying and direct determinants of undernutrition. Somevariations of the models also show examples ofinterventions that can be used to address some of thedeterminants of undernutrition at these different levels.
The UNICEF conceptual framework is as relevant today as
it was then, but it is now influenced by recent shifts andexciting developments in the field of nutrition.
Strengthened by new evidence, an understanding of theshort- and long-term consequences of undernutrition has
evolved. There is even stronger confirmation that
undernutrition can trap children, families, communities andnations in an intergenerational cycle of poor nutrition,

illness and poverty. More is known about the mechanismsthat link inadequate growth due to nutritional deficiencies
before the age of 2 with impaired brain development andsubsequent reduced performance in school. And there isclearer, more comprehensive evidence of the need to promote
optimal growth during this critical period to avoid an elevatedrisk of non-communicable diseases, such as cardiovasculardisease, in adulthood and even in the next generation.
The UNICEF conceptual framework defines nutrition andcaptures the multifactorial causality of undernutrition(Figure 1). Nutritional status is influenced by three broad
factors: food, health and care. Optimal nutritional statusresults when children have access to affordable, diverse,
nutrient-rich food; appropriate maternal and child-carepractices; adequate health services; and a healthy environment
including safe water, sanitation and good hygiene practices.
These factors directly influence nutrient intake and thepresence of disease. The interaction between undernutrition
and infection creates a potentially lethal cycle of worsening
illness and deteriorating nutritional status.

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie RuelFood, health and care are affected by social, economic andpolitical factors. The combination and relative importanceof these factors differ from country to country.
Understanding the immediate and underlying causes ofundernutrition in a given context is critical to delivering
appropriate, effective and sustainable solutions andadequately meeting the needs of the most vulnerable people.
Immediate causes of undernutrition
At the immediate level, the two main causes ofundernutrition are a lack of appropriate food and nutrient
intake, and disease. Undernutrition can result fromconsuming too few nutrients or from having repeated
infections, which increase nutrient requirements andprevent the body from absorbing those consumed, or both.
The infection-undernutrition cycle
An estimated one third of deaths among children underage 5 are attributed to undernutrition. Undernutrition puts
children at far greater risk of death and severe illness due tocommon childhood infections, such as pneumonia,
diarrhea, malaria, HIV and AIDS and measles. A child who
is severely underweight is 9.5 times more likely to die ofdiarrhea than a child who is not, and for a stunted child therisk of death is 4.6 times higher.
Undernutrition weakens the immune system, putting
children at higher risk of more severe, frequent andprolonged bouts of illness. Undernutrition is also a
consequence of repeated infections, which may further
worsen the child’s nutritional status at a time of greater
nutritional needs. This interaction between undernutrition
and infection creates a potentially lethal cycle of worsening
illness and deteriorating nutritional status.
Critical nutrition interventions that break this cycle include
promoting optimal breastfeeding practices, encouraging
micronutrient supplementation and reducing the incidenceof low birth weight. For example, infants not breastfed are
15 times more likely to die from pneumonia and 11 times
more likely to die from diarrhea than children who are
exclusively breastfed. Similarly, all-cause mortality is
14 times higher for infants not breastfeeding than for
exclusively breastfed children.
Today’s concerted focus on reducing stunting reflects an
improved understanding of the importance ofundernutrition during the most critical period ofdevelopment in early life and of the long-term consequences
extending into adulthood. Evidence from 54 low- andmiddle-income countries indicates that growth faltering on
average begins during pregnancy and continues to about

24 months of age. This loss in linear growth is not recovered,and catch-up growth later on in childhood is minimal.
While the original UNICEF conceptual framework reflecteda focus on children of preschool age, there is now moreemphasis on policies and programs that support action
before the age of 2 years, especially on maternal nutritionand health and appropriate infant and young child feeding
and care practices.
Adequate maternal nutrition, health and physical status are
crucial to prevent child undernutrition. Pregnancy increases
nutrient needs, and protein, energy, vitamin and mineral
deficiencies are common during pregnancy. Deficiencies are
not solely the result of inadequate dietary intake: Disease can
impair absorption of nutrients and reduce appetite, andenvironmental and psychosocial stress affecting the mothercan contribute to child undernutrition. Poor maternal nutrition
impairs fetal development and contributes to low birth weight,
subsequent stunting and other forms of undernutrition.
Undernourished girls have a greater likelihood of becoming
undernourished mothers who in turn have a greater chanceof giving birth to low birth weight babies, perpetuating anintergenerational cycle. This cycle can be compounded
further in young mothers, especially adolescent girls who
begin childbearing before attaining adequate growth anddevelopment. Short intervals between pregnancies and having
several children may accumulate or exacerbate nutrition
deficits, passing these deficiencies on to the children.
Low birth weight is associated with increased morbidity
and mortality: An estimated 60 to 80 percent of neonatal
deaths occur among low birth weight babies (2005
estimate). In South Asia, an estimated 28 percent of infants
are born with low birth weight.
(Source: Improving Child Nutrition, The achievable imperative for global
progress. UNICEF 2013)34

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

Food system interventions for better nutrition
Policy environment and development priorities
FOOD SYSTEM ELEMENTS

NUTRITION OPPORTUNITIESPOLICY TOOLS

Production “up to
the farm gate” (R&D,
inputs, production, farmmanagement)• Sustainable intensification of production• Nutrition-promoting farming systems,
agronomic practices and crops- Micronutrient fertilizers- Biofortified crops- Integrated farming systems, including
fisheries and forestry- Crop and livestock diversification• Stability for food security and nutrition- Grain reserves and storage- Crop and livestock insurance• Nutrition education- School and home gardens• Nutrient preserving on-farm storage• Food and agricultural
policies to promoteavailability,
affordability, diversity
and quality• Nutrition-oriented
agricultural researchon crops, livestock andproduction systems• Promotion of school andhome gardens

Post-harvest supply chain“from the farm gate toretailer” (marketing,storage, trade, processing,retailing)• Nutrient-preserving processing, packaging,transport and storage• Reduced waste and increased technicaland economic efficiency• Food fortification• Reformulation for better nutrition (e.g.
elimination of trans fats)• Food safety• Regulation and taxation
to promote efficiency,
safety, quality, diversity• Research and promotionof innovation in productformulation, processing
and transport

Consumers (advertizing,labelling, education, safety
nets)• Nutrition information and health claims• Product labelling• Consumer education• Social protection for food security andnutrition- General food assistance programs
and subsidies- Targeted food assistance (prenatal,children, elderly, etc.)• Food assistanceprograms• Food price incentives• Nutrition regulations• Nutrition education andinformation campaigns

AVAILABLE, ACCESSIBLE, DIVERSE , NUTRITIOUS FOODS

Health, food safety, education, sanitation and infrastructure
Source: FAO

Gender roles and environmental sustainability

Economic, social, cultural and physical environment

35

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

What can food systems do to enhance food security and nutrition?
Food systems produce, market, store, trade, process, retail,and promote food for consumers to acquire and use to feed
their families. Food systems also provide livelihood andincome to large amounts of the population around theglobe, including many of the world’s poorest. The latest
Food and Agriculture Organization (FAO)’s State of Foodand Agriculture report, published in 2013, argues that“food systems – from agricultural inputs and production,
through processing, marketing and retailing, toconsumption – can promote more nutritious and sustainable
diets for everyone” (p. 3). The report also highlights thatwhile the nature and causes of food insecurity andmalnutrition are complex and diverse, a common
denominator for both conditions is a nutritionally deficientdiet. For this reason, the food system provides anopportunity to address both food insecurity andmalnutrition, but in order to do so, the food system needs
to be re-shaped to be more nutrition-sensitive. The diagram

below presents the framework adopted by FAO, whichhighlights opportunities for incorporating nutrition
considerations into different elements of the food system.
More specific guidance has also been developed on how to
improve nutrition through agriculture programs and policies.

“Of course, addressing malnutrition
requires interventions not only inthe food system, but also in thehealth, sanitation, education andother sectors. Integrated actions areneeded across the health, education
and agriculture sectors”
FAO, 2013, p. 3

Key recommendations for Improving Nutrition through Agriculture
Food systems provide for all people’s nutritional needs,
while at the same time contributing to economic growth.
The food and agriculture sector has the primary role infeeding people well by increasing availability, affordability,
and consumption of diverse, safe, nutritious foods and diets,aligned with dietary recommendations and environmental
sustainability. Applying these principles helps strengthen
resilience and contributes to sustainable development.
Agricultural programs and investments can strengthen
impact on nutrition if they:
1. Incorporate explicit nutrition objectives and indicators
into their design, and track and mitigate potential harms,
while seeking synergies with economic, social andenvironmental objectives.
2. Assess the context at the local level, to design
appropriate activities to address the types and causes ofmalnutrition, including chronic or acute undernutrition,
vitamin and mineral deficiencies, and obesity and chronic
disease. Context assessment can include potential foodresources, agro-ecology, seasonality of production andincome, access to productive resources such as land,market opportunities and infrastructure, gender dynamics
and roles, opportunities for collaboration with othersectors or programs, and local priorities.

3. Target the vulnerable and improve equity throughparticipation, access to resources, and decent employment.
Vulnerable groups include smallholders, women, youth, thelandless, urban dwellers, the unemployed.
4. Collaborate and coordinate with other sectors (health,environment, social protection, labor, water andsanitation, education, energy) and programs, through joint
strategies with common goals, to address concurrently
the multiple underlying causes of malnutrition.
5. Maintain or improve the natural resource base (water, soil,
air, climate, biodiversity), critical to the livelihoods andresilience of vulnerable farmers and to sustainable foodand nutrition security for all. Manage water resources inparticular to reduce vector-borne illness and to ensuresustainable, safe household water sources.
6. Empower women by ensuring access to productive
resources, income opportunities, extension services andinformation, credit, labor and time-saving technologies(including energy and water services), and supporting
their voice in household and farming decisions. Equitable
opportunities to earn and learn should be compatible withsafe pregnancy and young child feeding.

36

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel37

7. Facilitate production diversification, and increase
production of nutrient-dense crops and small-scale
livestock (for example, horticultural products, legumes,
livestock and fish at a small scale, under-utilized crops,
and biofortified crops). Diversified production systems areimportant to vulnerable producers to enable resilience toclimate and price shocks, more diverse foodconsumption, reduction of seasonal food and income
fluctuations, and greater and more gender-equitable
income generation.
8. Improve processing, storage and preservation to retain
nutritional value, shelf-life, and food safety, to reduceseasonality of food insecurity and post-harvest losses,
and to make healthy foods convenient to prepare.
9. Expand markets and market access for vulnerable groups,
particularly for marketing nutritious foods or products
vulnerable groups have a comparative advantage inproducing. This can include innovative promotion (such as
marketing based on nutrient content), value addition, accessto price information, and farmer associations.
10. Incorporate nutrition promotion and education aroundfood and sustainable food systems that builds on existing
local knowledge, attitudes and practices. Nutrition
knowledge can enhance the impact of production andincome in rural households, especially important for
women and young children, and can increase demand for
nutritious foods in the general population.
These recommendations have been formulated following an extensive review
of available guidance on agriculture programming for nutrition, conducted by
FAO (see: http://www.fao.org/docrep/017/aq194e/aq194e00.htm), andthrough consultation with a broad range of partners (CSOs, NGOs,
government staff, donors, UN agencies) in particular through the Ag2NutCommunity of Practice. They are also referred to as “guiding principles” bysome partners.

Agriculture programs and investments need to be supported
by an enabling policy environment if they are to contributeto improving nutrition. Governments can encourage
improvements in nutrition through agriculture by taking
into consideration the five policy actions below.
Food and agriculture policies can have a better impact onnutrition if they:
1. Increase incentives (and decrease disincentives) foravailability, access, and consumption of diverse,
nutritious and safe foods through environmentally
sustainable production, trade, and distribution. The focus
needs to be on horticulture, legumes, and small-scale
livestock and fish – foods which are relatively unavailable
and expensive, but nutrient-rich – and vastly 		
under-utilized as sources of both food and income.
2. Monitor dietary consumption and access to safe, diverse,
and nutritious foods. The data could include food pricesof diverse foods, and dietary consumption indicators forvulnerable groups.
3. Include measures that protect and empower the poor andwomen. Safety nets that allow people to access nutritious
food during shocks or seasonal times when income islow; land tenure rights; equitable access to productive
resources; market access for vulnerable producers(including information and infrastructure). Recognizingthat a majority of the poor are women, ensure equitable
access to all of the above for women.
4. Develop capacity in human resources and institutions toimprove nutrition through the food and agriculture sector,
supported with adequate financing.
5. Support multi-sectoral strategies to improve nutrition
within national, regional, and local government structures.
The present key recommendations for Improving Nutrition through
Agriculture target policy-makers and program planners. These
recommendations are based on the current global context, and may be
updated over time as challenges and opportunities to improve nutrition
present themselves.

Chapter Two | Food Security and Nutrition: Linkages and Complementarities | Marie Ruel

My personal view
Marie Ruel

Division Director of Food Consumption and Nutrition
Division, IFPRI. Washington DC, USA

Food security and nutrition security
are two complex, interrelated
phenomena that result from a series offactors – some that are common to bothconditions and others that are not.
In spite of the commonalities and close
linkages between the two phenomena,
however, in my view, it is unwise to combine the twoconcepts into one named “food and nutrition security”.
I would prefer to see food security and nutrition (ornutrition security) remain as two distinct, yet clearly
related phenomena.
The first reason is that the combined concept of food andnutrition security (as defined in this chapter) is very broad
and may be difficult to operationalize. It may beparticularly difficult, for instance, to define policies andprograms that would encompass all the factors that need
to be addressed to support both food and nutrition
security, let alone identifying the right set of indicators toproperly measure the impact of these actions on relevant
food security and nutrition outcomes.

Secondly, not all food security and agriculture-focusedpolicies and programs necessarily need to be accountablefor improving nutrition. In some cases, it may be morecost-effective to co-locate programs aimed at tacklingpoverty and food insecurity with programs specificallyfocused on improving nutrition and to target the same
households and individuals for maximum impact.
Even more importantly, by combining nutrition with foodsecurity, we run the risk of seeing nutrition lose its
momentum and become absorbed by (and lost within) the
broader umbrella of food security. We need to move awayfrom food security being perceived as synonymous tonutrition, and for this, we need to keep the concepts
distinct from each other. We also need to correct thewrong perception that if more food could be produced
and food security ensured, malnutrition would
automatically disappear.
As highlighted in this chapter, more food and more of theright quality foods are necessary, but not enough, toimprove nutrition: investments aimed at boosting
agriculture production and productivity and at ensuring
food security of all people need to be accompanied byrenewed efforts to reduce the burden of infectious diseases
and increase poor people’s access to health, water,
sanitation and education services. Most importantly,
progress in nutrition will be made if we can tackle
inequality in all its forms, starting with gender inequalities.

Further reading
Quisumbing AR, Brown LR, Sims Feldstein H et al.
Women: the key to food security. Food Policy Report.
Washington, DC: International Food Policy ResearchInstitute, 1995. And: Women, still the key to foodsecurity. IFPRI Issue Brief 33, 2005.

Food and Agriculture Organization. The state of foodinsecurity in the world 2012. Economic growth isnecessary but not sufficient to accelerate reduction ofhunger and malnutrition. Rome: Food and Agriculture
Organization, 2012.
Food and Agriculture Organization. The state of foodand agriculture 2013. Food systems for better nutrition.
Rome: Food and Agriculture Organization, 2013.

Pinstrup-Andersen P. Food security: Definition andmeasurement. Food Security 2009;1(1): 5–7.
Pinstrup-Andersen P. The food system and its interaction
with human health nutrition. Leveraging agriculture for
improved nutrition and health. 2020 Conference brief
13. Washington, DC: International Food Policy
Research Institute, 2011.
Ruel M T, Alderman H and the Maternal and Child
Nutrition Study Group. Nutrition-sensitive interventions
and programs: How can they help accelerate progress in
improving maternal and child nutrition? Published
online, The Lancet, 6 June 2013.

38

Chapter Three39

Hidden Hunger in theDeveloped World

Hans Konrad Biesalski
Department of Biological Chemistry and Nutrition,
University of Hohenheim, Stuttgart, Germany

“The food you eat can be either the safest and most powerful formof medicine or the slowest form of poison.”Ann Wigmore, Lithuanian holistic health practitioner, nutritionist and health educator.

40

Key messages
Solutions are available: Many countries have
implemented mandatory or voluntary
fortification of folic acid, vitamin D or iodine.
The experience of many countries indicatesthat the fortification of staple or processed
foods may be an efficient way to provide anadequate intake of micronutrients.

The term “hidden hunger” has gained significant currency
among nutrition scientists and policy-makers in recent
years. In its broadest sense, it denotes a chronic lack of
micronutrients – vitamins and minerals – whose effects may
not be immediately apparent and whose consequences may
be long-term and profound.
While much groundbreaking research into the subject ofhidden hunger has been conducted in the last two decades,
many questions remain regarding the extent andimplications of this phenomenon and the best means oftackling it. From today’s perspective, however, it is clearthat hidden hunger is a growing threat to public health,both in the developing and the developed worlds.
The following chapter provides a short introduction andexamples to this topic, which is complex, ramified, and thesubject of considerable scientific attention and controversy
as this book goes to press.

A child with rickets in India in 2006. This non-communicable disease isassociated with vitamin D deficiency and results in irreversible
malformation of the skeleton
Source: Dr Tobias Vogt

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

41

A 1960 photo of a Kings checkout worker is among the items at the New Jersey Supermarket Archives at Rutgers University. Allen Bildner,
whose parents founded Kings in the 1930s, donated memorabilia from the chain’s early days.
Source: Special Collections and University Archives, Rutgers University Libraries

Hidden hunger in the developed world
Hidden hunger, also known as chronic micronutrient
malnutrition, is experienced by more than one in three ofthe world’s total population. This term refers to a chroniclack of vitamins and minerals, which is not immediately
apparent and which can exist for a long time before clinicalsigns of malnutrition become obvious.

intake surveys in Western countries such as the USA,
Canada, Germany, France, Great Britain and many others
indicates that a sufficient intake is not being achieved in thecase of some micronutrients, according to recommendations
using RDAs as reference. This is especially the case for folicacid, vitamin D, vitamin E, iron and iodine.

It is a popular perception that most people who live in thedeveloped countries of the world enjoy a nutritionallysound diet and are not prey to hidden hunger. The reality is,however, different. Micronutrient inadequacies are to befound in the developed world as well as in the developingworld, and their current rate of growth in the developed
world gives cause for concern. Growing evidence fromAccording to the United Nations Food and Agriculture
Organization (FAO), micronutrient inadequacies may, in thelong term, lead to a wide number of health problems,
including impaired cognitive development, lower resistance todisease, and increased risks during childbirth for both mothers
and children. A particular issue in the developed world is theinadequate folic acid intake and vitamin D status.

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

42

Food bank in Hérault, France: The growth of food banks in the developed world is a sign that nutrition insecurity is by no means confined to thedeveloping world.
Source: Anne-Catherine Frey

Global map presenting hidden hunger index based on the prevalence estimates (HHI-PD) in 149 countries and prevalence of low urinary
iodine concentration in 90 countries with 2007 Human Development Index <0.9.
The hidden hunger index HHI-PD was estimated based on national estimates of the prevalence of stunting, anemia due to iron deficiency, andlow serum retinol concentration.
Source: doi:10.1371/journal.pone.0067860.g002

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

43

Key definitions
Macronutrient deficiency

Dimensions of hidden hunger

This type of malnutrition, known as Protein Energy
Malnutrition (PEM), involves a lack of protein and foodcontaining enough calories. This term is applied when hunger
is defined in terms of an insufficient intake of calories.

The human body extracts 51 different essential compounds
from food which it cannot produce itself throughmetabolism. Among these, as far as we currently know, areamino acids, as well as so-called micronutrients (vitamins,
trace elements and minerals), which exert a direct influenceon physical and mental development and the immune
system, and are vital to the body’s metabolic processes. To
date, it is only known what effects the lack of a certain few
micronutrients have on the body in the form of clinicalsymptoms, such as scurvy (due to a lack of vitamin C),
rickets (caused by a vitamin D deficiency), beriberi(triggered by too little vitamin B) and pellagra (resulting
from niacin deficiency). This naturally does not exclude thepossibility that the micronutrients which have hitherto been
the object of less analysis also have an impact on our
susceptibility to certain illnesses or the onset of such
ailments later in life.

Micronutrient deficiency
Unlike PEM, persons suffering from this type of deficiency
may display no outward signs or symptoms. As long as no
significant clinical symptoms appear, no consideration is
given to the possibility of a micronutrient deficiency. Thisbegs the question of whether a shortfall of the recommended
dietary allowances (RDA) is pathologically significant and,if so, how a diagnosis can be made.
Common micronutrient deficiencies
The most common micronutrient deficiencies among
women and children are lack of iodine, which is essential
for bodily and mental development; iron, a lack of whichcauses anemia and hampers the cognitive development ofchildren; and vitamin A, which is needed for healthyeyesight and a healthy immune system.
It is often overlooked that behind each of the deficiencies
attributed by UNICEF to an unbalanced diet there exist
further deficiencies that are not yet visible, yet which exert anegative impact on a child’s development. Likewise, a lackof other micronutrients than the above-mentioned three canhamper development long before symptoms are apparent.
The fact that both the FAO and the WHO define hunger inpurely quantitative terms – i.e., the result of too few calories– misses the mark. Even if the subjective aspect of hunger,
the empty feeling in one’s stomach, is addressed by thisdefinition, there is another aspect of hunger which is left
out: the body’s craving for essential nutritional components.
This is what is meant by ‘hidden hunger’.

The consequences of a micronutrient deficiency
Both sides of the coin – the causes and adverse effects of theabove-mentioned micronutrient deficiencies – are nothing
new and have been researched at length. It is therefore quite
astounding that they are not considered when assessing thefood situation in the world. Moreover, the ‘hidden’ deficits
of micronutrient deficiencies are known, and recommendations
are given to avoid a deficiency, for instance by means ofsupplements or food fortification. However, it is often
overlooked that the underlying cause of such deficiencies isa diet which does not meet the nutritional needs of mostpeople, not to mention children and pregnant women. It isalso not enough to push for a diet which contains all
micronutrients, except in cases of acute, life-saving
intervention. Hidden hunger must first and foremost be
uncovered and then avoided by all means. The negative, infact devastating, effects of hidden hunger, cannot bereversed once the damage is done.
Source: Hans Konrad Biesalski, Hidden Hunger, Springer-Verlag, Berlin
Heidelberg 2013

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

The return of rickets
Leading doctors [in the UK] are calling for vitamin D
supplements to be made more widely available tochildren to beat the returning scourge of rickets.
Cases of rickets have gone up four-fold in the past 15
years because many pregnant women and young
children are not getting enough of the sunshine vitamin.
Says Professor Mitch Blair of the Royal College of
Pediatrics and Child Health (RCPCH): “We know
vitamin D deficiency is a growing problem, andlocalized research reveals startlingly high levels ofvitamin deficiency among certain groups includingchildren. People can only get a fraction – just 10
percent – of their recommended daily amount ofvitamin D through food, and very little from sunlight.
So getting out in the sun more or eating more oily fish
isn’t going to solve the problem.”
Lack of vitamin D is related to a plethora of serious
illnesses in children and adults that could be
prevented through relatively simple steps such as
taking supplements.
Diabetes, asthma, multiple sclerosis, tuberculosis, andlife-threatening heart disease have been linked to lowlevels of vitamin D in early life. The RCPCH
estimates at least half of the UK’s white population,
up to 90 percent of the multi-ethnic population and aquarter of children have vitamin D deficiency.
Many people thought rickets had virtually been
eliminated after the war, but there has been a recent
rise in numbers of children with the disease. Cases
went up from 183 in 1995/96 to 762 last year.
Source: Abridged from Return of rickets: Cases up four-fold in thelast 15 years as pregnant women and children fail to get enoughVitamin D. Jenny Hope, Mail Online, December 14 2012.

An increase in poverty and poor nutritionin the developed world
An increase in poverty in industrialized countries, withchildren primarily affected, is an issue that is often
overlooked. Being poor means having a poor diet and little
dietary diversity in many cases, which means that children
who live in the land of plenty may also suffer frommalnutrition. Sadly, this fact seems to interest only a very
few people.
In a recent article in the Financial Times magazine, Where
austerity really hits home, Gillian Tett raises the issue ofhunger in the United Kingdom, with an example from a
deprived area of Liverpool:“There’s a lot of little kids going hungry round here,”
explained one friend, who works in a local community
center. Indeed, just the other day she had spoken to a family
where the child had been chewing wallpaper at night. “Hedidn’t want to tell his mum because he knew she didn’t havethe money for supper,” she explained. “We hear more andmore stories like this.”Gillian Tett’s anecdotal evidence of poverty and hunger as a
growing problem is backed by figures from the Trussell
Trust, providers of a network of food banks around the UK,
who state:“In 2011–12 food banks fed 128,687 people nationwide, in
2012–13 we anticipate this number will rise to over 290,000.
Rising costs of food and fuel combined with static income,high unemployment and changes to benefits are causing
more and more people to come to food banks for help.”
The UK is not alone. In Germany, Nanette StröbeleBenschop and Peter Tinnemann in their paper HealthInequalities in Berlin, Germany – analysis of local efforts to
support socio-economically disadvantaged people cite aproject supported by the Berliner Tafel e.V. to distribute
fresh produce on a weekly basis to the mostsocioeconomically disadvantaged people, which found thatthe daily number of people served increased by 9% fromMay 2006 to May 2010.
Source: The Financial Times, March 8, 2013; http://www.ft.com/
cms/s/2/7de158e8-86bd-11e2-b907-00144feabdc0.html#axzz2Z7CZFGe8

44

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

45Child poverty and malnutritionin the US
Child poverty in the US has reached record levels, withalmost 17 million children now affected. A growing
number are also going hungry on a daily basis.
Currently, 47 million Americans are thought to depend
on food banks. One in five children receives food aid.
For some families, cheap and easy to prepare food canmean unhealthy choices like pizza – increasing the
likelihood of obesity and health problems later in life.
In many areas schools take part in a “backpack”
program, set up to deliver food parcels to the mostvulnerable on a Friday – so that they have enough to
eat over the weekend. In eastern Iowa and western
Illinois, the River Bend Foodbank now helps 1,500
children in 30 schools through one such scheme. It
has seen the numbers needing help rise sharply.
“It’s changed dramatically since the recession. We’reup about 30% to 40% in terms of the number ofpeople coming forward,” says Caren Laughlin, who
has worked with food banks for 30 years. “That’s not
only because so many people have lost their jobs, it’salso because the jobs that are replacing them are low
paying. You cannot feed a family.”The problems are reflected across America, says thenationwide charity Feeding America, which operates
200 food banks and feeds 37 million people eachyear, including 14 million children.
It says that, in total, nearly 17 million US children
live in homes where getting enough healthy food is
not something they can count on.
Source: Abridged from The children going hungry in America,
Duncan Walker, BBC News, March 6, 2013

The history of the balanced diet
The pioneering biochemists of the first half of the 20th
century revolutionized our understanding of the role thatnutrients play in our health. Founders of the new science ofnutrition such as Casimir Funk and Tadeusz Reichstein
identified and isolated individual vitamins for the first time,and began to map out their complex functioning in themetabolism. A growing appreciation of the essential
health-giving properties of these micronutrients led to theconcept of the ‘balanced diet’ which provided adequatelevels of proteins, fats and carbohydrates as well as
sufficient amounts of vitamins and minerals. Public healthpolicy – intensified by wartime food rationing andunderpinned by educational propaganda – promoted theconcept of the balanced diet. Despite the privations of war,
the population of the United Kingdom, for instance, ate ahealthier diet than at any time in history during World War II
and the years immediately following. This generation has
shown remarkable health and longevity, which are to agreat extent traceable to good dietary habits over a long
period of time.

The decline of the balanced diet
There is a polarization in dietary lifestyles in the developed
world. While the more affluent and educated have theresources to support a healthier lifestyle and diet, those whoare economically poor, who live in ‘food deserts’ and who
do not possess a good knowledge of nutrition often do nothave access to or cannot afford a healthy, balanced diet or
do not have the means to make the right choices. Ironically,
the polarization of diets in the developed world has beenaccompanied by a massive rise in the popularity of cultrestaurants and TV chefs.

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

Sir Jack Cecil Drummond: A pioneerof nutrition science
Sir Jack Cecil Drummond was a Professor of
Biochemistry who isolated pure vitamin A in the
1930s, but perhaps his greatest achievements were intranslating original science into practical dietary
programs. His obituary in the British Journal of
Nutrition in 1954 praised these efforts:“Perhaps Drummond’s name is most closely
associated with the provision of special foods formothers and children. From the outset he pressed theclaims of nutritionally vulnerable groups. The successof his efforts in this direction is seen in the schemesthat were gradually evolved for the cheap supply andpriority rationing of liquid milk, in the earlyexperiments with blackcurrant syrup and rosehip
syrup as sources of vitamins for expectant mothers
and young children, in the subsequent provision ofconcentrated orange juice and cod-liver oil to these
two groups, and in the generous allocation ofrationed foods for school meals and the provision ofnational milk cocoa for adolescents.”
Drummond developed a system of national rationing
to ensure that everyone, whether rich or poor, had an
adequate nutritional intake. As James Fergusson
writes in his 2007 publication The Vitamin Murders:“The health of the British nation, schoolchildren
included, was not just maintained during the Second
World War but improved...[T]he incidence of almost
every diet-related illness was lower than it had everbeen. Drummond was a genuine home-front hero.”
As Tom Jaine writes in his introduction to the 1991
edition of Drummond’s The Englishman’s Food: Five
Centuries of English Diet:
Drummond was working during the heroic period ofnutritional science when the constituents of foodnecessary to maintain, and then improve, the qualityof life were finally defined. This... was the era when
deficiency diseases received their full investigation.
For centuries rickets, scurvy, pellagra, beri-beri, night
blindness and hunger-oedema had been the scourge ofvarious societies...but it needed the new nutrition to
fully explain the treatment and to rapidly extend thebenefits of cure to as many populations as possible.”
Source: Abridged from Sir Jack Cecil Drummond DSc, FRIC, FRS: A
hero of nutrition science and advocacy by Jonathan Steffen, Sight andLife 2/2012‘Food deserts’ and the problem of limitedaccess to balanced nutrition
The more varied one’s diet is, the healthier it is. Normal
body weight and growth can only be achieved if children
take their food from several different sources.
Dietary diversity depends upon certain factors, for instancethat different foods are available and also affordable. It is
this lack of diversity that is responsible for malnutrition andall of its harmful consequences.
There are districts in both urban environments and rural
settings, where shops do not stock the range of fresh andnutritious foods necessary for a balanced diet. These areas
are usually characterized by convenience stores that stock
only processed foods and by fast-food restaurants.
Residents who are unable, for whatever reason, to travel
further afield in search of a better diet therefore findthemselves in a situation where there is food to buy but thenutritional value of that food is inadequate.
In 2010 the United States Department of Agriculture
defined what’s considered a ‘food desert’ as follows: “Toqualify as a ‘low-access community,’ at least 500 people
and/or at least 33 percent of the census tract’s populationmust reside more than one mile from a supermarket or large
grocery store (for rural census tracts, the distance is morethan 10 miles).”

Food deserts in the US and other barriers
to a balanced diet
The United States Department of Agriculture (USDA) has
replaced their original Food Desert Locator with the moredetailed Food Access Research Atlas. This sophisticatedmapping tool allows users to investigate multiple indicatorsof food store access, and highlights the areas of the US
which can be classified as ‘food deserts’
It should be pointed out that, in all cultural andgeographical settings, the question of access to food has
many dimensions, and that a variety of factors may
combine to prevent an individual, or a group of individuals,
from enjoying a balanced diet. These may include, forinstance, lack of mobility (lack of transport or lack ofphysical mobility due to illness or infirmity), lack ofpurchasing power, and also a lack of understanding of basic
nutritional principles. Within the world’s most affluent
societies, there are individuals – whether in hospitals, carehomes or hospices, whether in substandard housing or
sleeping rough in the street, who do not have access to that
‘simplest’ thing, a healthy, balanced diet.

46

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

47

Screenshot from the USDA’s ‘Food Access Research Atlas’, showing food deserts in the US
Source: http://www.ers.usda.gov/data-products/food-access-research-atlas.aspx#.UVBiGELd7dk

The long-term consequences of inadequate nutrition
The long-term consequences of malnutrition and hidden
hunger in the developed world are significant. For example
inadequate and suboptimal vitamin D status alone is known
to be a risk factor for some cancers such as breast cancer,
prostate cancer, and several autoimmune diseases such as
multiple sclerosis, rheumatoid arthritis and type-1 diabetes.
An unhealthy, unbalanced diet rich in unsaturated fats,sugars and salts may contribute to a wide range of noncommunicable diseases such as cardiovascular diseases,
cancers, chronic respiratory diseases and diabetes.
In September 2011 the United Nations launched an effort to
tackle non-communicable diseases (NCDs) such as cancer
and diabetes with a summit meeting devoted to curbing thefactors, such as tobacco and alcohol use behind theoften-preventable scourge that causes 63 percent of alldeaths. The two-day high-level General Assembly meeting
adopted a declaration calling for a multi-pronged campaign
by governments, industry and civil society to set up by 2013
the plans needed to curb the risk factors behind the fourgroups of NCDs – cardiovascular diseases, cancers, chronic
respiratory diseases and diabetes.
As well as steps to curb the use of tobacco and alcohol, the UN
advocated steps to curb “the extensive marketing to children,
particularly on television, of foods and beverages that are highin saturated fats, trans-fatty acids, sugars, or salt.”
Vitamin D has important benefits in lowering the risk offractures, improving muscle strength, and reducing the risk ofa number of conditions and diseases. The benefit regarding the
reduction of fractures and the contribution to muscle strengthis well reported, while other benefits are still emerging,covering areas such as type 2 diabetes, cardiovascular disease,some types of cancers, strengthening of the immune system,
and autoimmune diseases such as multiple sclerosis.1,2Many people have a low level of serum vitamin D(measured as 25-hydroxy-vitamin D) owing to poor accessto natural sources of vitamin D. This may be attributable,
for instance, to factors such as an absence of cold-waterChapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

ocean fish from the diet, living largely indoors and therefore
getting insufficient exposure to sunlight, and inhabiting thehigh latitudes of the world. The reduction of the direct andindirect costs associated with the above-mentioned diseases
is based on randomized controlled trials using an intake of
200–800 IU vitamin D, which results in an adequate
vitamin D status.

developed world could be in the range of billions of euros.3
Economics aside it is, above all, a question of humanity. If
we took the rights of every individual to an adequate diet as
seriously as we take the issue of human rights, and if we
proclaimed these as loudly and often as we rightly do withregard to human rights, then the first big step towardmaking a change would be taken.

Assessments by various research groups indicate that thefinancial burden on direct and indirect healthcare costs
arising from inadequate micronutrient status in the

Hidden hunger across the life cycle
Newborns• Low birthweight• High mortality• Reduced mental
development• Often ill

Seniors• Often chronically ill• Lower life expectancy

ChildrenPoor Micronutrient Status
Adults• Stunting• Often ill• Small stature• High mortality• Lower resilience

Pregnant• Poor• High mortality• Malnourished • Frequent
perinatal• Limited
complications
productivity• Lower
performance

Adolescents• Stunted• Reduced mental andphysical performance• Often ill

UNICEF 2009

The economic impact of vitamin D deficiency
In developed countries, at least 10% of people in thegeneral population and up to 70% and more of individuals
in specific patient groups have blood vitamin D levels lying
in the deficiency range (e.g. 25- hydroxy vitamin D levels<30 nmol/L). Vitamin D deficiency is probably the mostfrequent micronutrient deficiency in developed countries. In
westernized societies, the economic burden of thehealthcare system is high and will further increase in future
due to demographic changes and the increasing proportionof elderly people.
In Europe, total expenditure on health varies between
6% (Eastern Europe) and more than 11% (Western
Europe) of gross domestic product. Thus, an estimatedannual amount of one trillion euros is spent on thehealthcare system in Europe. A recent meta-analysis ofpooled patient-level data from randomized controlled

trials provided convincing evidence that between 14%
and 30% of nonvertebral fractures can be prevented byadequate vitamin D supply. Based on these data it can becalculated that in Europe alone, fracture prevention by
supplementary vitamin D would result in cost savings ofapproximately five billion euros. There is some evidence
from genetic studies, prospective cohort studies andrandomized controlled trials that vitamin D may play arole in the prevention of type 1 diabetes, infections andcardiovascular-related deaths. Vitamin D may also
reduce the risk of exacerbations in patients with chronic
obstructive pulmonary disease and multiple sclerosis.
Although there is much uncertainty about the costsavings potential of adequate vitamin D supply, theamount may reach the binary billions range.
Source: Abridged from Economic impact of undernutrition: Vitamin D by
A. Zittermann, University Bochum and Bad Oeynhausen

48Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

Annual income and diet cost comparison

300

Undernourished persons (in millions)
1000

350
Cost for a healthy diet

800
250

Per million / people

Francs (in thousands)

49

200

150

100

600

400

200

Cost for a diet rich in energy

5000Very poor
near toKabindaVery poor
far awayfrom Kabinda

Poor

Mean
incomeWealthy

1969-71 1979-81 1990-92 1995-97 2003-05

2007

2010

Near East and North Africa

Latin America and Caribean

Rest of Africa

Asia

Fischer et al. 2008; input from FAOSTAT.fao.org 2011, 2012

Save the Children 2010

Trapped in the cycle of hunger, generation after generation
MalnourishedFemales

MalnourishedPregnancies

Highermaternal
mortality

Suboptimal
nutrition of
the child

Malnourished
Elderly

Reduced power
for childcare

Low Birth Weight
Malnourished
Newborns

ImpairedDevelopment
ChildrenHigher mortality

Higher mortality

Reduced physicaland mental
development

Reduced physicaland mental
development

Higher risk forchronic diseasein later life

Higher risk forchronic diseasein later life

ImpairedDevelopment
AdultsReduced physicalcapacity for labor

Stunting

Poor conditions
for education
Reduced economic
potential,
Reduced life
expectancy

Modified from: ACC/SCN 2000

Chapter Three | Hidden Hunger in the Developed World | Hans Konrad Biesalski

My personal view
Hans Konrad Biesalski

Head of the Department of Biological Chemistry andNutrition, University of Hohenheim, Stuttgart, Germany

We have clear evidence that income isrelated to food security, and we havea range of data showing that abalanced diet is related to higher
income and higher education.
We need to evaluate food security, inparticular in females and young
children living in poverty, because inadequacy of
micronutrient supply during the short time period of the
1,000-day window may also in developed countries havean impact on further development and consequently on
the economic and health future of the child.
It may be that the magnitude of this problem isoverestimated in the developed world. Nevertheless, aslong as we lack data of sufficient quality on this subject,
this problem should concern us. Nutrition science isbased on molecular biology on the one hand and on
research related to obesity on the other. Both have an
excellent economically driven lobby. Malnutrition,
however, is not in the focus of nutrition scientists, eventhough its impact is as serious as is that of overnutrition.

Further reading
Biesalski, HK. Hidden Hunger. Berlin/Heidelberg,
Germany: Springer-Verlag, 2013.
Roman Vinas B, Ribas Barba L, Ngo J. Projectedprevalence of inadequate nutrient intakes in Europe.
Ann Nutr Metab 2011;59:84-95.
Wahl DA, Cooper C, Ebeling PR et al. A global
representation of vitamin D status in healthy
populations. Arch Osteoporos, 2012;7(1–2):155-172.
Bailey RL, Dodd KW, Gahche JJ et al. Total folate
and folic acid intake from foods and dietary
supplements in the United States: 2003–2006. Am J
Clin Nutr 2010;91:231–237.
Bischoff-Ferrari HA, Willet WC, Orav EJ et al. A
pooled analysis of vitamin D dose requirements for
fracture prevention. NEJM 2012;367:40–49.
Flynn A, Hirvonen T, Mensink GB et al. Intake of
selected nutrients from foods, from fortification andfrom supplements in various European countries.
Food Nutr Res 2009;53:1–51.
Bischoff-Ferrari H. Health effects of vitamin D.
Dermatol Ther 2010;23(1):23–30.
Fulgoni VL, Keast DR, Bailey RL et al. Foods,
fortificants, and supplements: where do Americans
get their nutrients? J Nutr 2011;141:1847–1854.
Grant WB, Cross HS, Garland CF et al. Estimatedbenefit of increased vitamin D status in reducing the
economic burden of disease in Europe. Prog Biophys
Mol Biol 2009;99:104–113.
Zittermann A, Kuhn J, Dreier J. Vitamin D status andthe risk of major adverse cardiac and cerebrovascular
events in cardiac surgery. Eur Heart J
2013;34(18):1358–64.
Zittermann A. The estimated benefits of vitamin D for
Germany. Mol Nutr Food Res 2010;54(8):1164–71.

50

Chapter Four

The Obesity Crisis
51

Eileen Kennedy
Professor of Nutrition,
Former Dean of the Friedman School of Nutrition Science and Policy,
Tufts University, Boston, USA

“The rise of childhood obesity has placed the health of an entire
generation at risk.”
Tom Vilsack, United States Secretary of Agriculture52

Key messages•		The current increase in obesity in the
global population is unprecedented.
•		Worldwide, approximately 1.4 billion
adults are overweight, and 500 million
are obese.
•		As the most common cause of death,
infectious diseases have now been
overtaken by non-communicablediseases (NCDs).
•		In many low-income countries wealthy
and well-educated people are more likely
to be overweight than the poor.
•		In higher-income countries lower-income
populations tend to be more at risk ofobesity and its long-term consequences.
policy-makers in developing countries
need to pay greater attention to the obesity
crisis and its linkages to undernutrition.

The problem of obesity has assumed epidemic proportions in recent years
Source: Sight and Life

The world continues to experience malnutrition andundernutrition on an unprecedented scale. So huge andcomplex is this problem that it sometimes diverts attention
from another rapidly growing issue which has vast
ramifications and will have severe long-term consequences:
the rise of obesity.
According to the United Nations World HealthOrganization (WHO), 1.4 billion adults worldwide are
overweight, and of these, approximately 300 million
women and 200 million men are obese. Worldwide obesity
has doubled since 1980, in fact, and 65% of the world’s
population now lives in countries where overweight andobesity related diseases kill more people than undernutrition.
This is a dramatic reversal of the traditional paradigm
whereby poor diet is associated exclusively with
undernutrition. What makes it especially concerning is thefact that overweight and obesity can lead to healthproblems such as diabetes, hypertension, heart disease andcancer. The significant increase in the prevalence of these
non-communicable diseases (NCDs) in recent years isdirectly attributable to the rise in obesity in the world’s
population. The traditional focus of governments andNGOs on eliminating starvation and hunger, however, tends
to divert attention from this growing public health problem.
It is hard to imagine that a person can overeat their way tomalnutrition. But this is precisely what is happening.

Chapter Four | The Obesity Crisis | Eileen Kennedy

53

The nutrition transition
In poorer regions of the world and poorer sections ofsociety in general, the staple diet has traditionally been low
in fat, generally taking the form of cereals and pulses andbeing supplemented as and when possible by nutrient-richanimal protein. The past few decades have witnessed a‘nutrition transition’ to a more Western-influenced diet inmany parts of the globe, however. This diet offers morediversity, but contains considerably more saturated fats,
total fats, sugars, starches and animal proteins.
A striking example of this phenomenon is to be found in
Micronesia in the Pacific Ocean. According to the Bulletinof the World Health Organization (Volume 88, Number 7,
July 2010, 481–560), “Replacing traditional foods with
imported, processed food has contributed to the highprevalence of obesity and related health problems in the
Pacific Islands … Beyond the image of white sandy beaches
and carefree lifestyles, the Pacific Islands are facing serious
health problems, the prime culprit being imported foods. In
at least 10 Pacific Islands more than 50% (and in some, up
to 90%) of the population is overweight … Obesity
prevalence ranges from more than 30% in Fiji to a
staggering 80% among women in American Samoa, aterritory of the United States of America (USA). WHO
defines overweight as having a body mass index (BMI)
equal to or more than 25, and obesity as a BMI equal to or
more than 30. Diabetes prevalence among adults in the
Pacific region is among the highest in the world; 47% in
American Samoa compared with 13% in mainland USA,and it ranges from 14% to 44% elsewhere in the region.”

Stranger than paradise
Micronutrient deficiencies are common in the PacificIslands. In 15 of 16 countries surveyed, more than one fifthof children and pregnant women were anemic. In Fiji,
Papua New Guinea and Vanuatu, iodine deficiency andrelated goiter are endemic. Vitamin A deficiency is also asignificant public health risk in Kiribati, the MarshallIslands, the Federated States of Micronesia and Papua
New Guinea.
About 40% of the Pacific Island region’s population of
9.7 million has been diagnosed with a NCD, notably
cardiovascular disease, diabetes and hypertension. Thesediseases account for three quarters of all deaths across the
Pacific archipelago and 40–60% of total healthcare
expenditure, according to a meeting on obesity prevention
and control strategies in the Pacific held in Samoa in
September 2000.
Dr Temo K Waqanivalu, technical officer for nutrition andphysical activity at the Office of the WHO Representative
for the South Pacific in Suva, Fiji, partly blames poor dietfor the region’s health problems. “Promotion of traditional
foods has fallen by the wayside. They are unable tocompete with the glamour and flashiness of imported
foods,” he says.
People in the Pacific Islands may know what constitutes
healthy eating but, as in many parts of the world,
governments struggle to change people’s behavior. In eight
countries, less than 20% of people surveyed reported
eating the recommended five or more portions of fruit andvegetables a day. The often calorie-rich and nutrient-poor
imported foods have a stronger appeal.
Life expectancy data make clear the urgent need for action.
The average age at which people develop diabetes andcardiovascular disease is getting lower. In Fiji, only 16% of
the population is aged more than 55 years due to premature
deaths primarily caused by non-communicable diseases.

The double burden of malnutrition: parental obesity and child malnutrition
often exist side by side
Source: Sight and Life

Source: Bulletin of the World Health Organization (Volume 88, Number
7, July 2010, 481–560)

Chapter Four | The Obesity Crisis | Eileen Kennedy

The extremes witnessed among the populations of the
Pacific Islands are part of a trend that is leaving no cornerof the globe unaffected. Certain populations – inhabitantsof the Indian subcontinent, for instance, or the Pima Indiansin the United States – are especially susceptible to weightgain in the face of exposure to a Western diet rich in fats,sugars and starches. But the whole world is affected by thegeneral trend towards a more sedentary lifestyle. Whereas
before World War II, the majority of the world’s population
worked in agriculture, manufacturing or some other area
requiring physical effort, the proliferation of labor-saving
devices, automotive transportation and computerization has
vastly and rapidly reduced the need to expend physicaleffort during the course of a normal day. People are burning
off fewer calories during their day-to-day lives and at thesame time consuming more calories. This inevitably resultsin weight gain. The combination of a change in dietary
patterns plus a change in lifestyle has brought about thesimple formula for obesity: ‘energy in’ exceeds ‘energy out’.
According to the Morbidity and Mortality Report publishedin 2004 by the Centers for Disease Control and Prevention,in 1971, women in the US consumed an average of 1,542
calories per day compared with 1,877 in 2004. Men
consumed an average of 2,450 calories in 1971, but
consumed an average of 2,616 calories in 2004. So in a timeframe of just over 30 years, average calorie intake increased
by 22% for women, and 10% for men. It is not surprising
then, that obesity has become a major problem in the US.

Unless people compensate for increased calorie intake bymeans of increased energy expenditure, they will put on
unnecessary weight.
The United States and Western Europe were the first regionsof the world to go through the nutrition transition. In the
1920s and 1930s, during the Great Depression, theseregions contained many food-insecure people andhouseholds. By the 1950s and 1960s, greater affluence led
to richer diets, with an evening meal usually comprising
meat, potatoes and vegetables for even the poorer sectionsof society. This did not lead to obesity on a wide scale,
however, for the fast-food culture of today was still in its
infancy and lifestyles were still comparatively active for mostpeople. The situation has changed radically in recent years
in the US, however, with a knock-on effect that extends
beyond the shores of the United States and to the furthest
corners of the globe.
The poorest countries of the world are now going throughthe nutrition transition first charted by America, and they
too have seen an increase in the proportion of the
population that is overweight and obese. This increase has
been followed by a dramatic increase in non-communicablediseases, particularly type 2 diabetes. Recent statistics fromthe World Health Organization show that 44% of theworld diabetes burden, 23% of the ischemic heart disease
burden and between 7% and 41% of certain cancer
burdens are attributable to overweight and obesity.

Definitions of key terms

does not produce enough insulin.

Overweight for adults is a BMI between 25 and 29.99“Diabesity” is a term coined by Dr Francine Kaufman toindicate a combination of diabetes and obesity.

Obesity for adults is a BMI 30 to 39.99
Morbidly obese for adults is BMI 40 or greater
Note: BMI is weight (kg)/height squared (meters)
For children, overweight is 85th to 95th percentile on
child growth chart, and obesity is more than the 95%
Type 1 diabetes, also sometimes called juvenile-onset diabetes
or insulin-dependent diabetes is a chronic condition in which
the pancreas produces little or no insulin.
Type 2 diabetes, also sometimes called adult-onset or
non-insulin-dependent diabetes, is a chronic condition that
affects the way the body metabolizes sugars. With type 2
diabetes, the body either resists the effects of insulin or else

Non-communicable diseases (NCDs) – also known aschronic diseases – are not transmitted from person to person.
NCDs can progress slowly and persist in the body for
decades. The main types of NCDs include cardiovasculardisease, cancers, respiratory diseases and diabetes.
“Hidden hunger” is another name for micronutrient
malnutrition. This term is used since the specific deficiency is
typically not visible.
The “double burden of malnutrition” is defined as thecoexistence of undernutrition and overweight in the samecommunity or even the same household.

54

Chapter Four | The Obesity Crisis | Eileen Kennedy

55

Case study
The Pima Indians: A case study of therelationship between obesity and diabetes
The National Institute of Diabetes and Digestive andKidney Diseases (NIDDK)
Research conducted on the Pima Indians for the past 30
years has helped scientists prove that obesity is a majorrisk factor in the development of diabetes. One half ofadult Pima Indians have diabetes and 95% of those withdiabetes are overweight.
These studies, carried out with the help of the Pima
Indians, have shown that before gaining weight,
overweight people have a slower metabolic rate comparedto people of the same weight. This slower metabolic rate,
combined with a high-fat diet and a genetic tendency toretain fat may cause the epidemic overweight seen in thePima Indians, scientists believe.
Along with genetic make-up, diet is a key factor to healthy
lifestyle. The influence of traditional desert crops on themetabolism of the Pima Indians is being studied to determine
how to prevent the onset of diabetes and obesity.
Scientists use the “thrifty gene” theory proposed in 1962
by geneticist James Neel to help explain why many Pima
Indians are overweight. Neel’s theory is based on the factthat for thousands of years populations who relied on
farming, hunting and fishing for food, such as the Pima
Indians, experienced alternating periods of feast andfamine. Neel said that to adapt to these extreme changes
in caloric needs, these people developed a thrifty gene thatallowed them to store fat during times of plenty so thatthey would not starve during times of famine.
This gene was helpful as long as there were periods offamine. But once these populations adopted the typicalWestern lifestyle, with less physical activity, a high-fat diet,and access to a constant supply of calories, this gene began
to work against them, continuing to store calories in
preparation for famine. Scientists think that the thrifty genethat once protected people from starvation might also
contribute to their retaining unhealthy amounts of fat.
There are approximately 100,000 genes packed into 23
pairs of chromosomes in every cell of a person’s body.
Within a gene, chemicals form individual codes, likewords, which tell the cells of the body what to do. It is thecode within a gene that directs the body to grow skin, anddetermines whether the skin is brown, yellow, black orwhite; to form hair and bone; to circulate blood andhormones such as adrenalin and insulin; and to perform
every other biological process in the body.
Some diseases are caused by bacteria or viruses that infectthe body and make it sick. Others, such as diabetes, occur
because a gene’s code causes it to function differently
under some circumstances. For instance, if a person has agene that makes that person likely to get diabetes, eating a
lot of high-fat food over time may increase that person’s
chance of getting sick. On the other hand, eating lower fat
foods such as fruits and vegetables and exercising each
day may help to prevent the disease. A person can’t
choose his or her genes, but can choose what to eat andwhether or not to exercise.
Finding the gene or genes that may increase a person’s risk
for getting diabetes and obesity is the most effective way
scientists have to learn what’s wrong in a diabetic person.
With the help of the Pima Indians, National Institutes of
Health (NIH) scientists have already learned that diabetes
develops when a person’s body doesn’t use insulin
effectively. They know that other genes probably influencesome people’s bodies to burn energy at a slow rate, and/or
to want to eat more, making it more likely that they will
become overweight. Being overweight, in turn, puts aperson at even higher risk for diabetes. Because they havelearned this over 30 years of working with the Pima
Indians, NIH scientists now are able to test ways toprevent the disease with low-fat diets and regular exercise.
Source: http://diabetes.niddk.nih.gov/dm/pubs/pima/obesity/obesity.htm,
March 2013

Chapter Four | The Obesity Crisis | Eileen Kennedy

56

An inhabitant of Pohnpei in Micronesia, where diet-related obesity is a problem of epidemic proportions
Source: Sight and LifeThe critical first one thousand days

The time bomb of obesity

The Scaling Up Nutrition (SUN) Movement was launchedin September 2010. The SUN Movement stresses direct
nutrition interventions of known efficacy targeted topregnant women and children up to age two. The direct
nutrition interventions are complemented by nutritionsensitive policies and programs. SUN addresses
undernutrition; ironically, by improving nutritional status in
the first 1,000 days, health and nutrition in adulthood canbe enhanced. The developmental origins of health anddisease (DOHaD), also called the Barker Hypothesis,
uncovered a relationship between birth weight and chronic
disease. Infants born small have a higher risk of obesity,
hypertension, coronary heart disease and diabetes.
Environmental stresses, primarily in utero, alter structures oforgans and change regulatory gene expression, resulting in an
increased risk of chronic disease later in life. Thus, poormaternal diet has a double, negative effect of contributing to alower birth weight, an increased risk of developmental
disorders and higher risk of chronic disease later in life.
Effective nutrition interventions aimed at the 1,000 days have
immediate as well as long-term health consequences.

In the past few years, non-communicable diseases such asheart disease, diabetes and cancer have overtaken infectious
diseases as the major cause of death globally. However,health policy in developing countries still tends to focus on
combating undernutrition and infectious diseases only,
rather than tackling the obesity epidemic and its
consequences at the same time. There is a generalperception that if people are overweight, then they havemore than enough food and are not in need of help. The
time bomb of NCDs linked to obesity is all too frequently
overlooked. The Millennium Development Goals, forexample, do not include a goal related to NCDs.
According to WHO, many low- and middle-income
countries are now facing a “double burden” of disease.
While they continue to deal with the problems of infectious
disease and undernutrition, they are experiencing a rapid
upsurge in non-communicable disease risk factors such as
obesity and overweight, particularly in urban settings. It is
not uncommon to find undernutrition and obesity existingside by side within the same country, the same communityand even the same household.

Chapter Four | The Obesity Crisis | Eileen Kennedy

57

The double burden of malnutrition
Many developing countries now face the double burden of
malnutrition, defined as the coexistence of undernutritionand overweight in the same community or even in thesame household.
This study sought to estimate the prevalence of the double
burden of malnutrition and to identify associatedmaternal, child, and household characteristics in rural
Indonesia and Bangladesh.
A total of 247,126 rural households that participated in
the Indonesia Nutrition Surveillance System (2000–2003)
and 168,317 rural households in the Bangladesh
Nutritional Surveillance Project (2003–2006) were
included in the analysis. Maternal and child double
burden (MCDB) and its association with individual andhousehold characteristics were determined by using
logistic regression models.

MCDB was observed in 11% and 4% of the households
in rural Indonesia and Bangladesh, respectively. Maternal
short stature, and older age of mothers were strong
predictors of MCDB. Child characteristics such as older
age and being female were associated with an increased
risk of MCDB, whereas currently being breastfed wasprotective against MCDB. A large family size and higher
weekly per capita household expenditure was a strong
predictor of MCDB.
This study showed for the first time that even in
Bangladesh the double burden is not exclusive to urban
areas. Therefore, future policies and interventions should
address under- and overweight simultaneously in bothrural and urban developing country settings.
Source: Oddo VM, Rah JH, Semba RD, Sun K, Akhter N, Sari M, de Pee S,
Moench-Pfanner R, Bloem M, Kraemer K. Predictors of maternal and childdouble burden of malnutrition in rural Indonesia and Bangladesh. Am J
Clin Nutr. 2012; 95(4):951–8.

A healthy, balanced diet, accompanied by regular exercise, is the best way to avoid the risk of obesity
Source: Sight and Life

Chapter Four | The Obesity Crisis | Eileen Kennedy

Double Burden of Malnutrition: Time to Drop “Double”?
One of the things that is apparent from the recent Lancet
Nutrition Series is that it is becoming more and more difficult
to keep the under- and overnutrition agendas separate.

has not been much thinking in the past 10 years on how
to bring them together in the policy, program, training,communication and advocacy spaces.

It is really tempting to keep them separate.

Perhaps the time is only now right to do this.

First, dealing with undernutrition is difficult enoughwithout having to deal with overnutrition … And ofcourse, dealing with undernutrition is one great way tohelp prevent overnutrition later in life. In addition, dealing
with overnutrition means having to grapple with the foodindustry and a whole range of factors outside ofnutrition’s comfort zone: urban development, education,
trade, taxes and agriculture for example. Also, there aren’t
exactly a range of interventions and policies that havebeen shown to be effective to inspire us to ramp up action
on the overnutrition front. Finally, it is not easy to get
research funding to address the two in an integrated fashion.

A paper in the Lancet from December 2012 by Moodle etal. (“Profits and Pandemics”) draws the parallels between
the practices of the tobacco, alcohol and “ultra-processedfood and drink” industries. They conclude that “despite
the common reliance on industry self-regulation andpublic-private partnerships, there is no evidence of theireffectiveness or safety”. I think the evidence base uponwhich they draw is weak (not their fault), but theirconclusions are in accord with my own sense of thesituation and indeed I made the same parallels in a
Development Policy Review paper from 2003 where I go
through the various triggers for successful government
regulation of tobacco and see how they apply to obesity.

But I think the separation … is no longer sustainable.
First, overnutrition does not operate in a different space: it
is not just a later in life phenomenon – it is happening tounder fives; it is not just in urban areas and it is not just in
middle- and upper- income countries – it is everywhere.
Second, the undernutrition community can’t avoid
engaging with the private sector – not having to deal withthe private sector is no longer a reason for not getting
involved in overnutrition. Third, we now know that thefight against undernutrition has to go way beyond health,and into the wider development space. This is somethingeven more obvious in dealing with overnutriton.

I think policy-makers are about to get a wakeup call fromadvocacy groups, consumers, the health community, andeven some industry leaders, to do something.
The Double Burden is here to stay. Perhaps it is time todrop the Double (on the double).
Source: Lawrence Haddad, Institute of Development Studies (http://www.
developmenthorizons.com/2013/06/double-burden-of-malnutrition-time-to.html?
utm_source= feedburner&utm_medium=email&utm_ campaign=Feed %3A+
DevelopmentHorizons+%28Development+Horizons%29) 23 June 2013

All the reasons for separating the two are dissolving.
So, seemingly, something that is difficult (undernutrition
reduction) just got much harder (dealing with under- andovernutrition). But is that really so? Can an integrated
approach help us address both issues better? I think that
may be the case.
Making development more nutrition-sensitive and making
nutrition more politically aware surely brings the worldsof over- and undernutrition together, indeed, shows they
were never that far apart in the first place. They should nolonger be separated at birth.
In this context, a new review of Global Evidence on the
Double Burden of Malnutrition from the World Bank (byRoger Shrimpton and Claudia Rokx) is comprehensive
and well done, but depressing … It is depressing because itshows how divided the two camps are and how that is toeither’s advantage. Beyond the physiological linkages there

Snack bar in Micronesia with overweight manager
Source: Sight and Life58

Chapter Four | The Obesity Crisis | Eileen Kennedy

59Childhood obesity
Once considered a high-income country problem,
overweight and obesity are now on the rise in low- andmiddle-income countries, particularly in urban settings.
More than 30 million overweight children are living indeveloping countries and 10 million in developed countries.
Children in low- and middle-income countries are more
vulnerable to inadequate prenatal, infant and young childnutrition. At the same time, they are exposed to high-fat,high-sugar, high-salt, energy-dense, micronutrient-poor
foods, which tend to be lower in cost but also lower innutrient quantity and quality. These dietary patterns inconjunction with lower levels of physical activity, result in
sharp increases in childhood obesity while undernutrition
issues remain unsolved.
Childhood obesity is associated with a higher chance ofobesity, premature death and disability in adulthood. But
in addition to increased future risks, obese children
experience breathing difficulties, increased risk offractures, hypertension, early markers of cardiovasculardisease, insulin resistance and psychological effects.
Source: WHO Fact Sheet 311, March 2013

Protecting children from the negative impact of marketing on dietary behavior
The marketing of food and beverage products high in fat,sugar and salt to children is recognized in Europe as animportant element in the etiology of child obesity and in
the development of diet-related non-communicable diseases.
Overweight is one of the biggest public health challenges ofthe 21st century: all countries are affected to varying extents,
particularly in the lower socioeconomic groups.
The picture is not improving in most countries of the
WHO European Region. The figures for children from the
WHO Childhood Obesity Surveillance Initiative show
that, on average, one child in every three aged 6–9 years isoverweight or obese.
The WHO Regional Office for Europe has been working
in recent years with Member States to devise policy
options that could protect children better from thenegative impact of marketing on dietary behavior. This
process has been developed by working together in theimplementation of the set of recommendations endorsedat the Sixty-third World Health Assembly in 2010 on themarketing of food and non-alcoholic beverages tochildren, as well as within the context of the WHO
European Network on reducing food marketing pressure
on children.
The bases of policies to address unacceptable marketing
practices to children depend on appropriate intersectoral
action and dialogue, sound governance and accountability
mechanisms, as well as a focus on equity and a child’s
rights approach. These are all elements at the heart of the
new health policy framework for the WHO European

Region, Health 2020, which supports action acrossgovernment and society for health.
I strongly believe that the trends in childhood obesity canbe reversed. This report [Marketing of foods high in fat,salt and sugar to children: update 2012–2013],
although a small step in providing evidence on thetrends and policy processes in tackling one of thedeterminants of childhood obesity, illustrates theenormous progress that has been made in recent years.
At the same time, it highlights how collaboration
among Member States can trigger decisive action.
To be effective, the initiative to reduce the exposure ofchildren to the marketing of foods and non-alcoholic
beverages should be part of a broader package that needs
to include: scaling up and adopting the WHO Childhood
Obesity Surveillance Initiative; introducing appropriate
governance mechanisms with an intersectoral perspective
to streamline action and implement a best buys approachto tackling childhood obesity; and ensuring that childhood
obesity strategies and non-communicable disease policies
are connected and interact appropriately with strategies toreduce inequality.
Zsuzsanna Jakab
WHO Regional Director for Europe
Source: Marketing of foods high in fat, salt and sugar to children: update
2012–2013, http://www.euro.who.int/en/what-we-publish/ abstracts/
marketing-of-foods-high-in-fat,-salt-and-sugar-to-children-update-20122013

Chapter Four | The Obesity Crisis | Eileen Kennedy

		

Men

Women

Urban

49%

45%

Rural

25%

43%

60

BrazilIndia
Urban		 19.9%

Bangladesh
Urban

5.4%

5.4%

Rural

3.7%

3.6%

Russia

30.3%

50.3%

USA

61%*

Rates of overweight and obesity in selected networkcountries in men and women 30–59 years old
Source: Asia Pacific J Clin Nutr 2002;11:S738-S739

The world is getting wider
It is lunchtime at Eastside Elementary School in Clinton,
Mississippi, the fattest state in the fattest country in theWestern world. Uniformed lunch ladies stand at the ready.
Nine-year-olds line up dutifully, trays in hand. Yes tochocolate milk, yes to breaded chicken sandwiches, yes tobaked beans, yes to orange jelly, no to salad. Bowls of
iceberg lettuce and tomatoes sit rim to rim, rejected.
Regina Ducksworth, in charge of Clinton’s lunch menu,
sighs. “Broccoli is very popular,” she says, reassuringly.
Persuading children to eat vegetables is hardly a new
struggle, nor would it seem to rank high on the list of
global priorities. In an age of plenty, individuals have theluxury of eating what they like. Yet America, for all its
libertarian ethos, is now worrying about how its citizens
eat and how much exercise they take. It has become anissue of national concern.
Two thirds of American adults are overweight. This isdefined as having a body mass index (BMI, a common
measure of obesity) of 25 or more, which for a man
standing 175 cm (5 feet 9 inches) tall means a weight of
77 kg (170 pounds) or more. Alarmingly, 36% of adults
and 17% of children are not just overweight but obese,with a BMI of at least 30, meaning they weigh 92 kg or
more at the same height. If current trends continue, by
2030 nearly half of American adults could be obese.
Americans may be shocked by these numbers, but for the
rest of the world they fit a stereotype. Hamburgers, sodas

and sundaes are considered as American as the Stars andStripes. Food at state fairs is American cuisine at its mostexuberantly sickening. At the Mississippi fair, a deep-fried
Oreo biscuit’s crispy exterior gives way to soft dough,sweet cream and chocolate goo. It is irresistible.
The rest of the world should not scoff at Americans,because belts in many other places are stretched too, asshown by new data from Majid Ezzati of Imperial College,
London, and Gretchen Stevens of the World HealthOrganization (WHO). Some continental Europeans remain
relatively slender. Swiss women are the slimmest, and most
French women don’t get fat, as they like to brag (thoughnearly 15% do). But in Britain 25% of all women are obese,with men following close behind at 24%. Czech men takethe European biscuit: 30% are obese.
And it is not just the rich world that is too big for its own
good. The world’s two main hubs for blub are the PacificIslands and the Gulf region. Mexican adults are as fat astheir northern neighbors. In Brazil the tall and slender are
being superseded by the pudgy, with 53% of adults
overweight in 2008. Even in China, which has seen
devastating famine within living memory, one adult infour is overweight or obese, with higher rates amongcity-dwellers. In all, according to Dr Ezzati, in 2008 about
1.5 billion adults, or roughly one third of the world’s
adult population, were overweight or obese. Obesity rates
were nearly double those in 1980.

Chapter Four | The Obesity Crisis | Eileen Kennedy

61

Fat of the land
Not long ago the world’s main worry was that people had
too little to eat. Malnourishment remains a serious
concern in some regions: some 16% of the world’s
children, mainly in sub-Saharan Africa and South Asia,
were underweight in 2010. But 20 years earlier the figure
was 24%. In a study of 36 developing countries, based ondata from 1992 to 2000, Barry Popkin of the Universityof North Carolina found that most of them had more
overweight than underweight women.

availability of food have made the car the new dining
room. In the Middle East, Bedouin traditions of hosting
and feasting have combined with wealth to makeovereating a nightly habit. Any inclination to exercise is
discouraged by heat and cultural restrictions. In Beijing
teenagers and office workers cram the fast-food restaurants
along Wangfujing. Even home-cooked Chinese meals containmore meat and oil than they used to. Doting grandparents
shower edible treats on scarce grandchildren.

The clearest explanation of this extraordinary modern
phenomenon comes from a doctor who lived in the 5th
century BCE. “As a general rule,” Hippocrates wrote,“the constitutions and the habits of a people follow thenature of the land where they live.” Men and women of
all ages and many cultures did not choose gluttony andsloth over abstemiousness and hard work in the space ofjust a few decades. Rather, their surroundings changed
dramatically, and with them their behavior.

Together, these disparate changes have caused more andmore people to become fat. Many cultures used to view alarge girth with approval, as a sign of prosperity. But
obesity has costs. It lowers workers’ productivity and in
the longer term raises the risk of myriad ailments,
including diabetes, heart disease, strokes and somecancers; it also affects mental health. In America,
obesity-related illness accounted for one fifth of total
healthcare spending in 2005, according to one paper.

Much of the shift is due to economic growth. BMI rises inline with GDP up to $5,000 per person per year, then thecorrelation ends. Greater wealth means that bicycles areabandoned for motorbikes and cars, and work in thefields is swapped for sitting at a desk. In rich countries theshare of the population that gets insufficient exercise ismore than twice as high as in poor ones.

A new global health study, led by Christopher Murray of
the University of Washington, shows that since 1990
obesity has grown faster than any other cause of disease.
For women a high BMI is now the third-largest driver ofillness. At the same time childhood mortality has dropped
and the average age of the world’s population has risen
rapidly. In combination these trends may mark a shift inpublic-health priorities. Increasingly, early death is less ofa worry than decades spent alive and sick.

Very importantly, argues Boyd Swinburn of Deakin
University in Melbourne, diets change. Families can afford
to eat more food of all kinds, and particularly those highin fat and sugar. Mothers spend more time at work andless time cooking. Food companies push their products
harder. Richard Wrangham of Harvard University saysthat heavily processed food may have helped increaseobesity rates. Softer foods take less energy to break down
and finely milled grains can be digested more completely,
so the body absorbs more calories.
These global changes react with local factors to create
different problems in different regions. Counter-intuitively, insome countries malnutrition is leading to higher obesity
rates. Undernourished mothers produce babies who are
predisposed to gaining weight easily, which makes children
in fast-developing countries particularly prone to getting fat.
In Mexico unreliable tap water and savvy marketing havehelped make the country the world’s leading guzzler ofCoca-Cola: the average adult consumed 728 servings lastyear. In America junk-food calories are often cheaper thanhealthy ones. Suburban sprawl and the universal

It is plain that obesity has become a huge problem, thatthe factors influencing it are fiendishly hard to untangle
and that reversing it will involve difficult choices. Radical
moves such as banning junk food would infringe
individuals’ freedom to eat what they like. Instead, somegovernments are cautiously prodding their citizens to eat
less and exercise more, and food companies are offering atleast some healthier foods.
In a few places obesity rates seem to be leveling, but for
now waistlines in most countries continue to widen
unabated. Jiang He and his colleagues at Tulane
University have estimated that by 2030 the global numberof overweight and obese people may double to 3.3 billion.
That would have huge implications for individuals,
governments, employers, food companies and makersof pharmaceuticals.
Source: Charlotte Howard, Special Report: The world is getting wider,
www.theeconomist.com, December 2012

Chapter Four | The Obesity Crisis | Eileen Kennedy

Why lower-income households suffer the most
In many low-income countries, the populations affectedmost by the problem of obesity and NCDs are the wealthy
and well-educated people that have changed theirtraditional dietary patterns. One reason for this shift is theincreased capability that comes with rising incomes topurchase a more diverse diet, including more protein andfat, combined with changing tastes. In developed countries,
however another reason for the change in diet is that poor
households lack access to more nutritious foods, either
because they are not readily available (cf. the section onfood deserts in Chapter Three) or they cannot afford them.
The more inexpensive foods tend to be high in fats andsugars, so they may be energy-dense but are typicallynutrient-sparse.

62

It is not unusual to find households containing overweightpeople who are also anemic, or who have significant
deficiencies in zinc, vitamin A, and other micronutrients. It
can be difficult to acknowledge such dietary inadequacies,
as anemia is not immediately apparent to the eye. Calorierich but nutrient-poor fast food is one obvious culprit, butthere are other factors too. Snacking, for instance, isanother major problem and it has become, in developed
countries, the ‘fourth full meal’ of the day – a meal that is
surplus to requirements.

The long road to behavior change
In the United States and Europe, much attention was given
to the topic of nutrition at the end of World War II. Thiswas partly on account of the lessons learned about therelationship between nutrition and health in the extreme
conditions of wartime, and partly on account of a general
concern about how to feed a rapidly growing global
population during a time of general peace. In the UnitedStates, as elsewhere in the West, the people who had
experienced the war wanted a better life – less work, more
food, more leisure, more consumer goods. The creation andsatisfaction of consumer desire became a key driver of theeconomy in the boom years of post-war peace and plenty.
While cheap food was made readily available, however, thelong-term consequences of the new fast-food culture were
not understood. We now have a situation whereby theUnited States feeds itself too well – and at the same time notwell enough. In the United States, around two thirds ofadults are either overweight or obese. Non-Hispanic,
African-Americans and Mexican-Americans in the US tend
to have higher rates of obesity linked to low incomes. And

the rest of the world is following the American model, withalarming consequences: the UN reports a worldwide figureof $190 billion (US) worth of workdays lost and healthcare
costs as a direct result of obesity and its related noncommunicable diseases.
Treating people who are already obese is not easy, however.
Studies show that only 5–8% of people who go on weight
reduction diets keep the weight off long-term (defined as
5–10 years or more). There is a long-running study called the‘Weight Maintainers Study’ in the United States which sets
participants the goal of losing 50lb and keeping this weight off
for five years or more. The weight maintainers have succeededin keeping the weight off by following a combination ofclosely monitoring their food intake, routinely eating breakfast
and having, on average, one hour of exercise per day. This
specific set of behaviors is proven to work. Nevertheless, formany people, adoption of these behaviors is difficult due tomoney and time limitations. Thus gaining weight is easy but
alas losing it is a very different matter.

Further reading
World Health Organization. Obesity: Preventing andmanaging the global epidemic. Report of a WHO
consultation. WHO Tech Rep Ser 2000;894:1-252.
Geneva: WHO, 2000.
Birch LL, Parker L, Burns A (eds). Early Childhood
Obesity Prevention Policies. Washington, DC:
Institute of Medicine, 2011.

Chapter Four | The Obesity Crisis | Eileen Kennedy

63WHO’s recommendations
Overweight and obesity, as well as their related noncommunicable diseases, are largely preventable.
Supportive environments and communities arefundamental in shaping people’s choices, making healthierfoods and regular physical activity the easiest choice(accessible, available and affordable), and therefore
preventing obesity.
At the individual level, people can: limit energy intake
from total fats and sugars; increase consumption of fruitand vegetables, as well as legumes, whole grains and nuts;
engage in regular physical activity (60 minutes a day forchildren and 150 minutes per week for adults).
Individual responsibility can only have its full effect where

people have access to a healthy lifestyle. Therefore, at thesocietal level it is important to: support individuals in
following the recommendations above, through sustained
political commitment and the collaboration of many
public and private stakeholders; make regular physicalactivity and healthier dietary choices available, affordable
and easily accessible to all - especially the poorest individuals.
The food industry can play a significant role in promoting
healthy diets by: reducing the fat, sugar and salt content ofprocessed foods; ensuring that healthy and nutritious
choices are available and affordable to all consumers;
practicing responsible marketing especially those aimed atchildren and teenagers; ensuring the availability of healthy
food choices and supporting regular physical activity
practice in the workplace.

The WHO Global Strategy on Diet,
Physical Activity and HealthMy personal view

Adopted by the World Health Assembly in 2004, the
WHO Global Strategy on Diet, Physical Activity and
Health describes the actions needed to support healthy
diets and regular physical activity. The Strategy calls
upon all stakeholders to take action at global, regional
and local levels to improve diets and physical activity
patterns at the population level.

Professor of Nutrition, Former Dean of the Friedman
School of Nutrition Science and Policy, Tufts University,
Boston, USA

WHO has developed the 2008–2013 Action Plan for the
Global Strategy for the Prevention and Control of
Noncommunicable Diseases to help the millions who are
already affected cope with these lifelong illnesses andprevent secondary complications. This action plan aims
to build on the WHO Framework Convention on
Tobacco Control and the WHO Global Strategy on Diet,
Physical Activity and Health. The action plan provides aroadmap to establish and strengthen initiatives for thesurveillance, prevention and management of NCDs.
The Political Declaration of the High Level Meeting of
the United Nations General Assembly on the Prevention
and Control of Non-communicable Diseases of
September 2011 recognizes the critical importance of
reducing the level of exposure of individuals andpopulations to unhealthy diet and physical inactivity.
Source: WHO Fact Sheet 311, March 2013

Eileen Kennedy

Globally we are facing an obesity
epidemic of alarming proportions.
Diet-related chronic diseases now
account for more deaths thanundernutrition. This is seen in someof the poorest countries of the world.
In the past few decades traditional
grain-based diets have been replacedby diets higher in total fats, saturated fats and sugars.
The changing consumption patterns are occurring
simultaneously with lifestyles that include less physicalactivity. Yet, despite the magnitude of the problem, themessage has not reached policy-makers in many
low-income countries. The challenge is daunting. Theinternational community must aggressively implement
multi-pronged strategies to combat overweight andobesity, while at the same time tackling undernutrition.

Chapter FiveThe Economic Costof Malnutrition

John Hoddinott
Deputy Director,
Poverty Health and Nutrition Division, International Food Policy Research Institute(IFPRI) Washington DC, USA

64

“Money is a needful and precious thing, and when well used, anoble thing, but I never want you to think it is the first or only
prize to strive for.”Louisa May Alcott, American novelist (1832–1888)
65

Key messages•	Chronic undernutrition and micronutrient
deficiencies are prevalent across thedeveloping world.
•	In addition to its substantial human costs,
undernutrition has lifelong economic
consequences.
•	There exist feasible solutions to many
dimensions of undernutrition.
•	Fighting undernutrition has considerable
economic benefits, most notably in termsof improving schooling, cognitive skills
and economic productivity.
•	Spending that reduces both chronic
undernutrition and micronutrient
deficiencies is an excellent investment ineconomic terms; it is one of the smartest
ways to spend global aid dollars.

The problem of widespread undernutrition
Around 165 million preschoolchildren suffer from chronic
undernutrition. Because of inadequate food intake, repeated
infection or both they fail to grow at the same rate as
healthy, well-fed children. Millions more suffer fromdeficiencies in micronutrients such as vitamin A, iron,
iodine and zinc – a phenomenon sometimes called ‘hidden
hunger’. Deprivation in a world of plenty is reason enoughfor investments that reduce undernutrition. Attacking these
problems is also good economics.

Hunger, food insecurity and undernutrition
Hunger, food insecurity and undernutrition are related but
not synonymous. Hunger is “A condition, in which people
lack the basic food intake to provide them with the energy
and nutrients for fully productive lives” (Hunger Task
Force, 2003). Food security exists when all people, at all
times, have physical, social and economic access to
sufficient, safe and nutritious food which meets their dietaryneeds and food preferences for an active and healthy life
(United Nations, Food and Agriculture Organization). As
discussed here and elsewhere in this book, nutrientsprovided by food combine with other factors, including the

Malnourished children eating rice in Kakuma Refugee Camp, Kenya
Source: Mike Bloem PhotographyChapter Five | The Economic Cost of Malnutrition | John Hoddinott

health state of the person consuming the food, to produce“nutritional status.” Undernutrition reflects an absence ofmacro- or micronutrients which may be exacerbated bydebilitating health stresses such as parasites.

Both macro- and micronutrient deficiencies have insidiouseffects on neurological development. Iodine deficiency
adversely affects development of the central nervous system
leading to loss of IQ and mental retardation. Iron is needed
to make brain chemicals (neurotransmitters) that aid in
A powerful investment to reduce hunger and food insecurity
concentration; iron deficiency constrains cognitiveis increased spending on agricultural research anddevelopment in children. Chronic undernutrition has
development. This includes research that enhances drought,
neurological consequences that lead to cognitive
heat and salt tolerance, identifying and disseminating
impairments. The prefrontal cortex is especially vulnerable
varieties with enhanced yield potential, increasing milk yields
to undernutrition with the result that undernourishedand soil diagnostics that would permit optimal combinations
children can suffer from attention deficits and reducedof organic and inorganic fertilizers. This investment has fiveworking memory. Other neurological insults resulting from
benefit streams: i) increases in welfare gains resulting fromchronic undernutrition include damage to the parts of thelower prices faced by consumers; ii) welfare gains frombrain responsible for spatial navigation and motor skills,
reduced yield volatility; iii) the option value of reduced yield
The parts of the brain (axons) responsible for transmitting
volatility resulting from climate change; iv) productivity gains
signals from one neuron (brain cell) to another are damaged
derived from the impact of increased caloric consumption on
by chronic undernutrition with the result that these signals
worker productivity; and v) the income gains in adulthood
are passed more slowly and inefficiently.
resulting from reduced undernutrition in early life. An
additional $8 billion dollars per year would, by 2050, reduce These malign effects can be exacerbated by the interactions
the number of hungry people in the world by 210 million.
that occur, or do not occur, between children and theircaregivers. For example, delayed development of motor
skills such as crawling and walking, together with lethargy
and increased incidence of illness in undernourished
Undernutrition and its consequences –infants, reduces their interactions with adults and withphysical and neurologicaltheir environment.
The first thousand days, in utero and the first two years after
birth, are critical for a child’s physical and neurologicaldevelopment. During this period, children’s nutritional statusis affected by the quantity and quality of food they consume.
Exclusive breastfeeding in the first six months conveys criticalbenefits and it is vitally important that complementary foods
introduced after this contain the right quantities of macronutrients – calories and protein – as well as micronutrients.
What happens when these are lacking? As discussed
elsewhere in this book, children need energy to grow. Where
this energy is absent, or where a child is repeatedly ill with
infections that divert energy from growth while suppressing
appetite, children fail to grow at a healthy rate. Studies thathave followed children from infancy through to adulthoodfind that this lost growth is never fully regained and so these
individuals end up shorter in height than they would havebeen if their diets had been adequate and they had not been
subject to repeat infection. Vitamin A deficiencies kill.
Current estimates suggest that more than 145,000 deaths inchildren under five occur each year because children lackvitamin A. This number has significantly declined in recent
years due to the improved reach of vitamin A capsule
distribution programs. Zinc deficiency affects children’s
physical growth and leads to increased susceptibility to anumber of infections including diarrhea and pneumonia.

Girls in a classroom in Kakuma Refugee Camp, Kenya
Source: Mike Bloem Photography

66

Chapter Five | The Economic Cost of Malnutrition | John Hoddinott

67

Undernutrition and its consequences– economic
The persistently malign effects of undernutrition in early life havesignificant economic consequences in adulthood. A number ofstudies show that shorter individuals have lower earnings inadulthood although the precise reason for this – the direct
effect of height on physical productivity; the social benefits
associated with height – vary from place to place. There isevidence that undernutrition in early life, manifested as low
birth weight, increases susceptibility to coronary heart disease,non-insulin dependent diabetes, and high blood pressure – theBarker hypothesis. However, the biggest economic
consequences are those resulting from neurological damage.
Studies that have followed undernourished preschoolchildren
find that they attain fewer grades of schooling and develop poorer
cognitive skills such as those relating to problem solving. By
contrast, there is strong evidence that interventions that combat
undernutrition in early life convey lifelong benefits.
Everywhere in the world, schooling and cognitive skills arevital for success in the labor market. A useful rule of thumbis that every additional grade of schooling raises wages by
eight to 12 percent. So individuals without such skills andwith less schooling earn lower wages, which makes it more
likely that they will be poor.

The fetal programming concept“A consequence that is also emerging more clearly is the impact
of stunting and subsequent disproportionate and rapid weightgain on health later in life. These long-term effects are referred toas the fetal programming concept: Poor fetal growth, small size atbirth and continued poor growth in early life followed by rapid
weight gain later in childhood raises the risk of coronary heartdisease, stroke, hypertension and type 2 diabetes. Attaining
optimal growth before 24 months of age is desirable; becoming
stunted but then gaining weight disproportionately after 24months is likely to increase the risk of becoming overweight anddeveloping other health problems.
“As stunted children enter adulthood with a greater
propensity for developing obesity and other chronic
diseases, the possibility of a burgeoning epidemic of poor
health opens up, especially in transitional countries
experiencing increasing urbanization and shifts in diet andlifestyle. This epidemiological transition could create new
economic and social challenges in many low- and middleincome countries where stunting is prevalent, especiallyamong poorer population groups.”
Source: UNICEF Improving Child Nutrition 2013

Case study
A series of studies led by Professor Reynaldo Martorell at
Emory University, have shed light on the long-term
benefits of improving nutritional status in young children.

of additional information that was collected, it is possible
to draw causal inferences of the effect of the high-proteinenergy drink.

More than four decades ago, between 1969 and 1977,
two nutritional supplements - a high-protein-energy drink
called Atole and a low-energy drink devoid of protein
called Fresco – were provided to preschoolchildren in four
villages in eastern Guatemala. Between 2002 and 2004,individuals who had been exposed to this intervention
were traced throughout Guatemala and interviewed about
their schooling, marital histories, living conditions andparticipation in the labor market. They took reading,
vocabulary and problem-solving tests. Their heights andweights were measured as were the heights and weights of
their children. Because these supplements were randomly
assigned across villages, and because of the care withwhich the intervention was implemented and the wealthFor both men and women, access to atole significantly
raised scores on reading, vocabulary tests and on tests ofproblem-solving ability more than twenty-five years after theintervention had concluded. For men, access to atole
increased wages by more than 40 percent. (There was no
impact on women’s wages largely because relatively few
women participated in work outside the home.) The benefitsof atole were intergenerational. Offspring of women exposed
to atole had higher birth weights and were taller comparedwith offspring of women exposed to fresco.
The Guatemala study provides powerful evidence of thelong-term investments that reduce chronic undernutrition.

Chapter Five | The Economic Cost of Malnutrition | John Hoddinott

The economics of reducing undernutrition
The human and economic costs of undernutrition would
seem to make a compelling case for investments – purposive
actions by governments, non-governmental organizations
and the private sector – to reduce undernutrition. Some ofthese investments – such as increasing girls’ schooling,
improving the health and status of women (“healthy mothersfor healthy children”) and improved water and sanitation – areimportant development objectives in their own right. But what
about direct interventions to reduce macro- and micronutrient
deficiencies? Are these good investments?
A number of studies have looked at the costs of theseinvestments relative to the economic benefits that theywould provide. There is an element of uncertainty
surrounding these calculations – as there is with any
benefit: cost analysis – because they rely on estimating thecosts of these interventions today and calculating the streamof economic benefits that accrue over the decades that follow.
With that caution in mind, a good economic investment is
an investment where the benefit:cost ratio exceeds one; thatis to say that for every dollar spent today on investments to
reduce undernutrition, the future stream of economic
benefits valued in today’s terms exceeds one dollar.
Measured in this way, there is overwhelming evidence thatinvestments to reduce micronutrient deficiencies andchronic undernutrition have high benefit:cost ratios:• Every dollar spent iodizing salt generates $30 in
economic benefits;• Every dollar spent on iron supplements for mothers
and children aged six to 24 months generates $24 ineconomic benefits• Every dollar spent on vitamin A generates economic
benefits estimated to be $40 or more
• Reducing chronic undernutrition requires bundlingmicronutrient interventions such as those that reduce
vitamin A, iodine and iron deficiencies with the provision ofother micronutrients (such as zinc powders needed toreduce the duration and severity of diarrhea), andenergy-dense foods. Also important is communication withmothers and other caregivers about the importance of
these for healthy child growth. The costs associated withdoing so vary across countries as do the benefits but in a
typical developing country, every dollar spent on thisbundle generates around $18 in economic benefits

By the standards of economics, these are impressively highbenefit:cost ratios. Not only that, the costs of theseinvestments are trivially low. In addition to current
expenditures spent combatting undernutrition, an
additional annual investment of about $650 million dollars
a year – less than two dollars from every North Americanand western European – would be enough to eliminate
vitamin A deficiency in the 95 million preschoolchildren
who are vitamin A deficient, iodine deficiencies affecting
nearly two billion people and anemia affecting 80 million
pregnant women. A larger investment is needed for thebundle of interventions needed to reduce chronic
undernutrition – current estimates suggest that around nineand half billion dollars per year would reach 90% ofchildren in the 34 countries that account for 90% of theburden of undernutrition in the developing world.

The Copenhagen Consensus
The origin of the Copenhagen Consensus dates back to
2002, and a small team of people headed by Bjorn
Lomborg, then Director of the Danish Environmental
Assessment Institute. Funded for a period of time by theDanish government, the Copenhagen Consensus Centre is athink tank which “commissions and conducts new research
and analysis into competing spending priorities. In particular
we focus on the international community’s effort to solve
the world’s biggest challenges and on how to do this in themost cost-efficient manner.”
In 2004, 2008 and 2012, the Copenhagen Consensus Centre
held a series of global conferences. At each, an expert panel,including four Nobel Laureates, looked at twelve major global
challenges, deliberating the question: “If you had $75 billion
for worthwhile causes, where should you start?” The experts
were informed by 30 economic research papers by eminent
scholars which provided cost-benefit analyses for a range ofpotential interventions. In each round, the panel foundinvestments to reduce micronutrient deficiencies and chronic
hunger to be among the best investments that could be madewith these funds. In 2012 the panel ranked ‘Interventions to
Reduce Chronic Undernutrition in Preschoolers’ to be thehighest-ranking solution.

68

#2

Copenhagen
Consensus 2012

Best Investment
Copenhagen Consensus 2004:–> Providing micronutrientsTOP INVESTMENT PRIORITIESSolving the69#1

Best Investment
Copenhagen Consensus 2008:–> M
 icronutrient supplements
for children (vitamin A, zinc)#1

World’s Challenges

Best Investment

What are the best ways of advancing global welfare(especially in developing countries)? Should
US$75 billion be available over a 4-year period?
HUNGER & MALNUTRITION

Amount allocatedper year in
US $ Bill. Dollars

BUNDLED MICRONUTRIENT INTERVENTION
TO FIGHT HUNGER & IMPROVE EDUCATION

3.0

MALARIA COMBINATION TREATMENT

0.3

CHILDHOOD IMMUNIZATION

1.0

DEWORMING

0.3

TB TREATMENT

1.5

R&D TO INCREASE YIELD ENHANCEMENTS

2.0

EFFECTIVE EARLY WARNING SYSTEMS

1.0

ARMED CONFLICTSURGICAL CAPACITY

3.0

CHRONIC DISEASEHEPATITIS B IMMUNIZATION

0.12“One of the most

EDUCATION
INFECTIOUS DISEASE

CLIMATE CHANGE    compelling investments   – to get nutrients to the    world’s undernourished

NATURAL DISASTERS

Vernon Smith, Nobel Laureate Economist

POPULATION GROWTH
BIODIVERSITY”WATER & SANITATIONTOTAL:
US $75 BILLIONOVER FOUR$100 PER CHILDYEARSLOW-COST DRUGS FOR ACUTE HEART ATTACKS

0.2

SALT REDUCTION CAMPAIGN

1.0

SOLAR RADIATION MANAGEMENT

1.0

CONDITIONAL CASH TRANSFERS

1.0

HIV VACCINE R&D

0.1

INFORMATION CAMPAIGN ON SCHOOL BENEFITS

1.34

BOREHOLE AND HAND-PUMP INTERVENTIONS

1.89

$30
PAY-OFF

Micronutrient
provision

Improved Health,
Schooling & Productivity

Complementary
foods

LEADS TO
Treatment forworms | diarrhea

Behaviorchange programs

EQUALS
Chronic undernutrition
in developing countries-36%$1 SPENT

Sight and LifeThe Developmental Course of Human Brain Development
Experience-dependent synapse formation
Neurogenesis in the hippocampus
Synaptogenesis(-3 months to 15–18 years?):

Neurulation(18–24 prenatal days)

Receptive language area/
speech production (angulargyrus/Broca’s area)

Cell migration(6–24 prenatal
weeks)

Seeing/hearing (visual cortex/
auditory cortex)

Prefrontal
cortex

Myelination (-2 months to 5–10 years)

Higher cognitive functions(prefrontal cortex)

Adult levels of synapses- 9 -8 -7 - 6 - 5 - 4 - 3 - 2 - 1 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 30 40 50 60 70
Age (Months)
Age (Years)
Age (Decades)

Conception

BirthThis figure shows that the rapid period of brain development occurs within the 1,000-day window between the start of awoman’s pregnancy and her child’s second birthday.
Source: Thomson, Nelson (2001) Developmental Science and the Media.

Thomson, Nelson (2001) Developmental Science and the Media

Death

Chapter Five | The Economic Cost of Malnutrition | John Hoddinott

Global estimates of undernourishment(hunger) 1969-2010
PeriodRegional estimates of undernourishment
1990-2008

Number ofundernourished(millions)

Prevalence(percentage)

1969-71875

33

1979-81850

25

1990-92848

16

1995-97792

14

2000-02836

2006-08

1990-1992
Africa1995-1997

2000-2002

2006-2008

Northern
AfricaSub-SaharanAfrica170.9m5.0m

165.9m193.6m5.4m

188.2m203.3m5.6m

197.7m223.6m6.1m

217.5mLatin America
and theCaribbean

Asia

Oceana

14

850

13

54.4m

2009

1023*

18

2010

925*

16

607.1m

0.7m

53.4m

526.2m

0.8m

50.8m

565.7m

1.0m

47.0m

567.8m1.0m

Hunger and Malnutrition, Copenhagen Consensus 2012

FAO, State of Food Insecurity in the World, 2012

Projected change in World Commodity Prices presented as a percent change between baseline
2010 and baseline 2050
Beef

Pork

Lamb

Poultry

Milk

20%

55%

3%

47%

8%

Rice

Wheat

Maize

MilletSorghum

34%

40%

56%

12%

32%

Other Grains

SoybeanSoybean Oil

Rapeseed

Rapeseed Oil

14%

24%

51%

47%

92%

HungerHunder andand Malnutrition,
Malnutrition, Copenhagen
Copenhagen Consensus
Consensus 2012
2012

70

Chapter Five | The Economic Cost of Malnutrition | John Hoddinott71

Per child cost of interventions to reduce stunting and mortality at age 36 months
Intervention

Child agerange
(months)

Cost per unit

Total
cost perchild

Community based nutrition programs that provide informationon breastfeeding, complementary feeding, handwashing, anddistribute micronutrient powders and iron-folate supplements

0–59$7.50 per child$7.50

Vitamin A supplementation

6-59$1.20 per year

$4.80

Therapeutic zinc supplementation for
management of diarrhea

6-59$1.00 per year
(assumes two or threetreatments per year)$4.00

Multiple micronutrient powders

6-23$3.60 per course; 3
courses recommended$10.80

Deworming

12-59$0.25 per round; one roundrecommended per year

$1.00

$2.00 per pregnancy$2.00

Iron-folic acid supplementation
for mothers during pregnancy
Iron fortification of staples

12-59$0.20 per year

$0.80

Universal salt iodization

12-59$0.05 per year

$0.20

Providing complementary foods to 80 percent of children in
South Asia, 50 percent in Africa and East Asia, 10 percent
elsewhere

6-23$0.11 per day$0.14 per day in India$56.88Community based managementof severe acute malnutrition

6-59

$8.13

Hunger and Malnutrition, Copenhagen Consensus 2012

Benefit: cost estimages of investments that reduce stunting

Discount rate

23.8% income increase

15% income increase

5%

3%

5%

3%

Bangladesh

Increased income, NPV:
Cost:
Benefit: Cost ratio:

3647
96.1
38.0

7165
96.1
74.6

2303
96.1
24.0

4523
96.1
47.1

Ethiopia

Increased income, NPV:
Cost:
Benefit: Cost ratio:

2289
96.1
23.8

4496
96.1
46.8

1445
96.1
15.0

2838
96.1
29.5

Kenya

Increased income, NPV:
Cost:
Benefit: Cost ratio:

3713
96.1
38.6

7295
96.1
75.9

2344
96.1
24.4

4605
96.1
47.9

India

Increased income, NPV:
Cost:
Benefit: Cost ratio:

7875
111.6270.6

15470
111.62
138.6

4972
111.6244.5

9767
111.62
87.5

Hunger and Malnutrition, Copenhagen Consensus 2012

NPV = net present value

Chapter Five | The Economic Cost of Malnutrition | John Hoddinott

Baseline projections for people
at risk of hunger in 2010, 2025 and 2050

Baseline projections of malnourishedchildren in 2010, 2025 and 2050

72

RegionPeople at
Risk of Hunger(millions)RegionNumber of
MalnourishedChildren (millions)

Projected Year
East Asia and Pacific
Europe and Central Asia
Latin America and the Caribbean
Middle East and North Africa
South Asia
Sub-Saharan Africa
Developing
Developed
World

2010
177
23
60
17
318
240
835
49
884

Projected Year
East Asia and Pacific
Europe and Central Asia
Latin America and the Caribbean
Middle East and North Africa
South Asia
Sub-Saharan Africa
Developing
Developed
World

2010
20
4
8
4
74
41
150
12
163

2025
131
23
61
21
310
275
821
50
870

2050
122
21
45
24
235
268
716
50
766

Hunger and Malnutrition, Copenhagen Consensus 2012

2025
13
3
7
3
65
44
135
12
147

2050
8
3
4
2
50
39
106
12
118

Hunger and Malnutrition, Copenhagen Consensus 2012

Benefit: cost ratios of micronutrient interventions
26 Intervention: Supplements, mothers and

Fe
Iron

children 6-24 months
Previous Estimates

New Estimates

Current Estimates ofcost per beneficiary

-

23.8

$0.96

RAJ

RAJ

26 Intervention: Biofortification

Fe
Iron

26 Intervention: Supplements, pregnant mothers

Fe

Previous Estimates

New Estimates

82-140

8.1

RAJ

-

Iron

HOR

Fe
Iron

7.8
HAR

-

Fe
Iron

New Estimates

9.1

HOR

-

6.7

CASEY 2011

I 15-520

Previous Estimates

Fe
Iron

-

53

HAR

26

-

<$0.01HOR

New Estimates

Current Estimates ofcost per beneficiary

81

$0.05

-

Iodine& IronCurrent Estimates ofcost per beneficiary

$0.17

HOR

-

37

$1.20
HOR

New Estimates

2.5
RAJ

2-5
HOR

HAR

Current Estimates ofcost per beneficiary

$0.25
HOR

Intervention: Supplement

A 4.3-43

Previous Estimates
BAH

Vitamin A

30

Current Estimates ofcost per beneficiary

RAJ

Intervention: Doubly fortified salt

I Fe Previous Estimates

New Estimates

HOR

30

Iodine26 Intervention: Home fortification

Previous Estimates

Current Estimates ofcost per beneficiaryIntervention: Salt Iodization

Current Estimates ofcost per beneficiary

26 Intervention: Fortification of wheat flour

Previous Estimates

New Estimates

BAH

$2.00
HOR 2010

New Estimates

BAH

16.7
HAR

53

Current Estimates ofcost per beneficiary

26 Intervention: Fortification, general

Previous Estimates

Previous Estimates

11.6-19

Zn
Zinc

6.1-250HAR

New Estimates

Current Estimates ofcost per beneficiary

12.5

$0.29

RAJ

RAJ

Intervention: Supplement
Previous Estimates-

New Estimates

Current Estimates ofcost per beneficiary

2.85

$1.26

RAJ

RAJ

Hunger and Malnutrition, Copenhagen Consensus 2012. Casey GJ, Sartori D, Horton SE, Phuc TQ, Phu LB, et al, 2011. Weekly Iron‐Folic Acid supplementation with Regular
Deworming Is Cost‐Effective in Preventing Anaemia in Women of Reproductive Age in Vietnam. PLoS ONE 6(9) 23723. doi:10.1371/journal.pone.0023723. BAH Behrman, J.,
Alderman, H., and Hoddinott, J., 2004. Hunger and Malnutrition, in B. Lomborg (ed.) Global crises, Global solutions, Cambridge University Press, Cambridge UK. HAR Horton,S., H. Alderman and J. Rivera, 2008. Hunger and Malnutrition. Copenhagen Consensus 2008 Challenge Paper, Copenhagen Consensus Center, Copenhagen. HOR Horton,S., A. Wesley and M.G. Venkatesh Mannar, 2011. Double‐fortified salt reduces anemia, benefit: cost ratio is modestly favorable. Food Policy, 36(5): 581‐587. HOR 2010 Horton,S., M. Shekar, C. McDonald, A. Mahal and J. Brooks, 2010. Scaling up nutrition: What will it cost? World Bank, Washington DC. RAJ Rajkumar, A.S., C. Gaukler, and J. Tilahun,
2012. Combating Malnutrition in Ethiopia: An Evidence‐Based Approach for Sustained Results World Bank: Washington DC.

Chapter Five | The Economic Cost of Malnutrition | John Hoddinott

73

Malnutrition and obesity
The word “malnutrition” encompasses undernutrition,
deficiencies in macro- and micronutrients, and what issomewhat inelegantly termed overnutrition, excessive
caloric intake, exacerbated by diseases such as diabetes andlow levels of physical activity. Overweight and obese
individuals are one manifestation of overnutrition.
Overweight and obesity are significant public healthproblems in much of the developed world and increasingly
in middle income countries such as Brazil and Mexico.
Across the developing world, however, undernutrition is the
major form of malnutrition.

My personal view
John Hoddinott

Deputy Director,
Poverty Health and Nutrition Division, International Food
Policy Research Institute (IFPRI) Washington DC, USA

There is intrinsic value in eliminating
undernutrition – it is simply the rightthing to do. But beyond this, it isgood economics too. Investments in
reducing chronic undernutrition andmicronutrient deficiencies haveconsiderable economic benefits.

An astonishing return on investment“Improving nutrition is in fact a precondition to achieving
many of the Millennium Development Goals (MDGs):
eradicating poverty and hunger, reducing child mortality,
improving maternal health, combating disease, empowering
women and achieving universal primary education.
“Research shows that children who are well nourished,especially in the critical 1,000 day window between
conception and the child’s second birthday, receive thestrong start in life they need to grow, fight disease, learn
more in school, and earn more as adults. They also grow up
to help lift their countries out of poverty: a 2010 study
found that investing in nutrition can increase a country’s
GDP by at least 2–3 percent each year. And in May of thisyear, the Copenhagen Consensus panel of experts, which
included no fewer than four Nobel Laureates, found thatproviding micronutrients to children under five is the single
smartest way to spend global aid dollars. Every $1 spentyields $30 – an astonishing return on investment ratio by
any measure. We cannot improve health and promote
development without addressing micronutrient deficiencies.
Micronutrients have a key role to play in nourishing theworld’s people, building strong families and creating vibrantand economically sustainable communities.”
Klaus Kraemer, Sight and Life

Further reading
Behrman J, Alderman H, Hoddinott J. Hunger andmalnutrition. In: Lomborg B (ed) Global crisis,
global solutions. Cambridge: Cambridge University
Press, 2004.
Horton S, Shekar M, McDonald C et al. Scaling up
nutrition: What will it cost? Washington, DC: World
Bank, 2010.
Hoddinott J, Rosegrant M, Torero M. Investments to
reduce hunger and undernutrition. In: Lomborg B(ed) Copenhagen Consensus 2012. Cambridge:
Cambridge University Press, 2013.
Hoddinott J, Maluccio J, Behrman J et al. Effect of anutrition intervention during early childhood on
economic productivity in Guatemalan adults. Lancet
2008;371:411-416.

Chapter Six

Best Practice in Nutrition
74

Victoria Quinn
Senior Vice President of Programs, Helen Keller International, New York, USA
Adjunct Associate Professor, Friedman School of Nutrition Science and Policy, Boston, USA

“The war against hunger is truly mankind’s war of liberation.”John F. Kennedy

75

Key messages• Undernutrition is a complex andmultifaceted phenomenon, and is not
limited to the developing world.
• Undernutrition does not have a single
cause, nor does it have a single solution.
• The Conceptual Framework of YoungChild Nutrition provides a clear andcoherent way of understanding thecauses of undernutrition and where wemight intervene, though to do so requiresthat we carefully assess and analyze thelocal situation to inform any actions thatmight be taken.
• At the national level, increased government
investment in proven nutrition-specificand nutrition-sensitive interventions isessential for improving nutrition.
• At the family level, women have a criticalrole to play in improving nutrition.

The focus of this chapter is on child undernutrition, which
is manifested as growth deficits in children (stunted heightor underweight) or in clinical deficiencies in micronutrients(e.g., vitamin A deficiency, iron deficiencies). Although notdiscussed in detail in this chapter, with changing dietary
practices due to a variety of reasons, childhood overweightin developing regions is becoming an increasingly important
contributor to adult obesity, diabetes, and noncommunicable diseases.1
When children do not grow adequately due toundernutrition they suffer from deficits in linear growth andbecome too short for their age, or in other words “stunted”.
Stunting is defined as a height-for-age ratio that is morethan two standard deviations below the international
standards produced by the World Health Organization.
Once a child becomes stunted due to sub-optimal nutrition
during pregnancy and the first two years of life, there islittle opportunity for catch-up growth later on. Literature
now exists on the immense negative consequences ofstunting, which range from increased under-five mortality
through reduced IQ, poor school performance, and reduced
worker productivity later in life, to increased risk of adultnon-communicable diseases.2
Evidence also exists today that shows the most critical timeto intervene to prevent undernutrition and stunting isduring the first thousand days from conception until achild’s second birthday. During pregnancy, poor maternal
nutrition leads to low birth weight babies who are at higher
risk of stunting. Providing women with support for optimal
nutrition even before they become pregnant when they areadolescents girls, and continuing this support throughgestation and after the baby is born – including optimal
infant and young child feeding until his/her second birthday– is critical to promote good nutrition and healthy growth.

Chapter Six | Best Practice in Nutrition | Victoria Quinn

Confusion before enlightenment: a short history of dealing with undernutrition
For decades, there have been many different schools ofthought as to the nature, causes and consequences ofundernutrition in developing regions of the world, which inturn led to changing views as to what should be done about
it. As one nutrition expert put it: “New paradigms in publichealth nutrition have repeatedly replaced one other [sic] inthe second half of the 20th century. This convulsive
process continues”.3
The discovery of vitamins and minerals in the early part ofthe 1900s focused interest on the micronutrient aspects ofwhat was believed to constitute a healthy diet, with theabsence of these thought to lead to poor health. During
pre-war British colonial times, the causes of undernutritionin the people of the colonies fluctuated from being viewed
as either poverty (putting the colonial powers at blame) or
ignorance (putting mothers themselves at blame).4 In Gold
Coast (pre-independent Ghana), the British medical doctor
Dr Cecily Williams discovered kwashiorkor, which she
believed was the result of a protein deficiency in a child’sdie. Kwashiorkor was later proclaimed to be the mostserious and widespread nutritional disorder in children
known to medical or nutritional science. Therefore formany years, particularly from 1950 to the mid-70s, much ofglobal nutrition attention in developing regions was basedon the belief that protein deficiency was the cause of poor
nutrition. Much effort and many resources were placed onincreasing the production and consumption of protein. Thisobsession with protein deficiency was later de-bunked byProfessor Donald McLaren in his famous 1972 Lancet
article where he referred to this as the ‘great protein fiasco’:“The concept of the much-publicized world protein “gap”,“crisis”, or “problem” arose from the description of
kwashiorkor in Africa in the 1930s and the assumption,
which has turned out to be wrong, that malnutrition inchildren takes this form throughout the world. As a result,measures to detect protein deficiency and treat and prevent
it by dietary means have been pursued until the present
time. The price that has had to be paid for these mistakes isonly beginning to be realized.”5

In later years, following the establishment of the United
Nations, more emphasis was placed on the structural causesof poor nutrition, culminating in the noble but naïve
declaration of the 1974 World Food Conference that hunger
and malnutrition would be eliminated within one decade(World Food Conference 1974, resolution V). An era ofmulti-sectoral nutrition planning followed from this time up
through the early 1980s, with lively and often contentious
debate ensuing among international nutrition experts on
how successful, or not, these attempts were.6 As it
transpired, the multi-sectoral nutrition plans produced were
extremely complicated and impossible to implement. Nor
did they factor in political determinants, including whether
political will from government leadership or planners in
non-health sectors existed or whether resources wereavailable and would be committed to fund the lofty
recommendations made.4
By the mid-1980s, interest in community-based nutrition
planning was gaining momentum. This continued for about
a decade, with some useful lessons learned from UNICEF’s
work with the Government of Tanzania in the Iringa regionof that country.7 From the mid-1990s, the focus on
nutrition in developing regions dramatically shifted tohidden hunger and micronutrient deficiencies.3 Soon
thereafter, global efforts, including resources, aligned toreach vulnerable populations with micronutrient
supplementation.
In summary, the nutrition community has shifted its
position over the decades for a variety of reasons including
evolving scientific knowledge, accumulating field experienceon what has worked, and differing ethical positions.3 One
undercurrent that has existed through the decades has been
the existence of two schools of thought – one that viewed
poor nutrition as a structural issue related to poverty, andthe other that viewed it as a technical issue, for example,
resulting from a specific deficiency that could be addressedwith a health-oriented action (e.g. a pill).4 Anotherobservation is that over time, professionals from the healthsector (e.g. nutritionists and medical doctors) and foodscientists have dominated the dialogue. In other words,
there has been a relative absence of voices from otherdisciplines important for nutrition, particularly
agriculturalists and economists, whose actions could have amassive impact on not just food availability but also theeconomic access of families to adequate food (in terms ofboth quality and quantity) through their own production,purchases or trade.

76

Chapter Six | Best Practice in Nutrition | Victoria Quinn

77

Coming to consensus
By the late 1980s and early 1990s, a consensus began to form on
the nature of child undernutrition. This consensus was informedby the field experiences of UNICEF and the Government of
Tanzania in Iringa, who implemented a large-scale community
nutrition program, and is embodied in the UNICEF Conceptual
Framework of Young Child Nutrition published in 1990.8 As
shown in Figure 1 opposite, the Conceptual Framework brought
together in an easily understood manner a practical model that
identifies the many key factors causing undernutrition at eachlevel (from the child upwards) across different sectors relevant
for nutrition. It also inherently encompasses different
viewpoints, including structural and technical dimensions.
Taking the complex problem of undernutrition, theConceptual Framework clearly communicates how all actors
in the nutrition space need to work together to address key
causes of undernutrition at each level. The Conceptual
Framework’s validity today is as great as when it was firstpublished in 1990. It can also be argued that the Conceptual
Framework was a quantum leap forward in the way the
problem of nutrition has been understood and addressed by
the nutrition community. Over time, it has been adapted toinclude new insights from the growing evidence base of what
we need to do and how and when we need to do it.9,10
As shown in Figure1, the immediate causes of childundernutrition stem from inadequate dietary intake (e.g.
quality and quantity) combined with disease. These areaffected in turn by three spheres of underlying causes:
household food insecurity, inadequate care and feedingpractices, and unhealthy environment and inadequate
health services, which operate at the family and community
level. These three underlying causes are in turn again
directly influenced by the basic causes of undernutrition,
which include the inadequate financial, human, physicaland social capital found in each country. These basic factors
are rooted in the overarching sociocultural, economic andpolitical circumstances, and are also often affected byexternal global factors. Across all dimensions of theConceptual Framework, it is important to note that thestatus and access of women to such resources is critical, as
women are the nutrition gatekeepers for their children andtheir families. This is discussed further below.
In summary, undernutrition does not exist in isolation, andit cannot be solved by one sole intervention, as a mix ofinterventions in different sectors and at different levels is required.

Figure 1: Causes of malnutrition and death.
The original UNICEF Conceptual Framework of Young Child Nutrition
Source: UNICEF Policy Paper (E/ICEF/1990/L.6). Strategy for Improved Nutrition of Children
and Women in Developing Countries. ISSN: 1013-3194. Page 22. 9 March 1990.

The need for assessment and analysis before action
Another important consideration is that nutrition problems –and therefore interventions – are highly context-specific. Whatworks in one setting may well not have the desired effects if
used without adaptation to a different context. The tendency
until the 1990s was to introduce nutrition interventions “lock,
stock and barrel,” which led to ineffective programs orsometimes to results opposite to those intended.4 For example,
when it was believed that the main cause of malnutrition wasprotein, some donors spent their resources digging andstocking fish ponds even in areas where fish was in abundant
supply. Often no research was carried out to understand the
local nutrition circumstances before interventions were
designed and rolled out. In fact, it has only been relatively
recently that we have had a robust evidence base concerning‘what’ nutrition interventions work though we still have muchto learn on what can be done to improve nutrition in sectors
outside of health. Even in light of these advances, much more
attention and investment is still needed to identify cost-effective
ways to deliver these proven interventions at scale (e.g. delivery
science and the ‘how’) especially under differing circumstances.
Therefore before any actions are put into place, an assessment
and analysis of the local situation needs to be carried out toinform the design of the actions and ensure their relevance interms of addressing the actual nutrition problems found in thatparticular community. This cycle of Assessment-AnalysisAction, coined by UNICEF as the Triple A Cycle, is important
if we are to understand the immediate factors that affectdietary intake and health status vis-à-vis the underlying
determinants of household food security, care and feedingpractices, and health services including environmental
sanitation, as well as higher-level basic factors. Whilequantitative approaches have their part to play in any processof assessment and analysis, qualitative data are also essential
when assessing the nutritional status of a given individual orgroup, analyzing the findings, and determining the best courseof action for improving it. This is in part because many aspects
of undernutrition are behavioral, and are better elucidated bymeans of qualitative rather than quantitative research.
Number of undernourished children today
According to UNICEF (2013), globally more than one
quarter (26 percent) of children under 5 years of age werestunted in 2011. This corresponds to roughly 165 million
children worldwide. The burden is not evenly distributed
around the world, with sub-Saharan Africa and South Asia
being home to three fourths of the world’s stunted children.
Levels of stunting among children under 5 years of age in
sub-Saharan Africa are at 40 percent and in South Asia areat 39 percent. Stunting prevalence is slowly decreasing globally,
but in some regions, such as Africa, the absolute number ofstunted children is increasing due to high population growth
figures. Clearly there is much more work to do.
Latest thinking and the Conceptual Framework
Figure 2 below shows a modified version of the Conceptual
Framework which includes the most recent state-of-the-art
knowledge from the 2013 Lancet Nutrition Series on whatworks to improve fetal and child nutrition. Two categories
of nutrition actions are shown, nutrition-specificinterventions and nutrition-sensitive interventions.1

Figure 2: Framework for actions to achieve optimum fetal and child nutrition and development
Source: Black RE, Victora CG, Walker SP, and the Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middleincome countries. Figure 1, page 16. The Lancet. 2013.

The definitions of nutrition-specific and nutrition-sensitive are shown in the table, and are discussed further overleaf.

78Chapter Six | Best Practice in Nutrition | Victoria Quinn

79

Mozambican mothers and babies
Nutrition-speciﬁc interventions and programs: Interventions
or programs that address the immediate determinants of fetal
and child nutrition and development— adequate food andnutrient intake, feeding, caregiving and parenting practices, andlow burden of infectious diseases. Examples include:• adolescent, preconception, and maternal health and nutrition;• maternal dietary or micronutrient supplementation;• promotion of optimum breastfeeding;• promotion of complementary feeding and responsive feedingpractices and stimulation;• dietary supplementation;• dietary diversification and micronutrient supplementation or
fortification for children;• treatment of severe acute malnutrition;• disease prevention and management; and• nutrition in emergencies.
Nutrition-sensitive interventions and programs: Interventions
or programs that address the underlying determinants of fetal andchild nutrition and development—food security; adequate
caregiving resources at the maternal, household and community
levels; and access to health services and a safe and hygienic
environment—and incorporate specific nutrition goals and actions.
Nutrition-sensitive programs can serve as delivery platforms fornutrition-specific interventions, potentially increasing their scale,coverage and effectiveness: Examples include:
•
•
•
•
•
•
•
•
•

Photo © HKI / Victoria Quinn

Nutrition-specific interventions – proven actions
Nutrition-specific interventions are fairly well-defined dueto the solid evidence base that now exists on what actions
are proven to make an impact on reducing undernutrition.
These nutrition-specific interventions are similar to the setof nutrition actions identified in the original Lancet Maternaland Child Nutrition series published in 2008, and very
similar to other approaches including the Essential Nutrition
Actions endorsed by other development organizations.11,12,13
Apart from needing to know exactly ‘what’ to do toimprove nutrition at the level of the child or women, it isimportant to know ‘when’ to do it, as the nutrition needsvary throughout their life cycles. Figure 3 below (UNICEF
2013) provides useful programmatic guidance on what
actions should be promoted when during the life cycle ofinfants, young children and women.

agriculture and food security;social safety nets;
early child development;maternal mental health;women’s empowerment;child protection;schooling;water, sanitation, and hygiene; andhealth and family planning services.

Source: Adapted from Ruel MT, Alderman H, and the Maternal and Child Nutrition Study
Group. Nutrition-sensitive interventions and programmes: how can they help to accelerate
progress in improving maternal and child nutrition? Page 66. The Lancet. 2013.

Health worker counseling pregnant woman on early initiation ofbreastfeeding in Ethiopia
Photo ©: Victoria Quinn

Chapter Six | Best Practice in Nutrition | Victoria Quinn

ADOLESCENCE> PREGNANCY• Improved use of
locally available
foods• Food fortification,
including salt
iodization• Micronutrient
supplementationand deworming• Fortified foodsupplements forundernourishedmothers• Antenatal care,including HIV
testing

BIRTH

0 – 5 MONTHS• Early initiation ofbreastfeeding
within one hour ofdelivery (including
colostrum)• Exclusive breastfeeding• Appropriate infant
feeding practices
for HIV-exposed
infants, andantivirals (ARV)

6 – 23 MONTHS• Timely introduction of adequate, safe and appropriate
complementary feeding• Appropriate infant feedingpractices for HIV-exposed • Continued breastfeeding
infants, and ARV• Appropriate infant feeding practices for HIV-exposed• Vitamin A supplementation infants, and ARV
in first eight weeks after• Micronutrient supplementation, including vitamin A,
deliverymultimicronutrients; zinc treatment for diarrhea;• Multimicronutrient
deworming
supplementation• Community-based management of severe acute• Improved use of locallymalnutrition; management of moderate acuteavailable foods, fortified
malnutrition
foods, micronutrient• Food fortification, including salt iodization
supplementation/home
fortification for• Prevention and treatment of infectious disease; handundernourished women
washing with soap and improved water andsanitation practices• Improved use of locally available foods, fortified
foods, micronutrient supplementation/home
fortification for undernourished women, handwashing with soap

Figure 3: Key proven practices, services and policy interventions for the prevention and treatment of stunting and other forms of undernutrition
throughout the life cycle
Pink refers to interventions for women of reproductive age and mothers. Black refers to interventions for young children.�
Source: UNICEF Report “Improving Child Nutrition: The Achievable Imperative for Global Progress. ISBN: 978-92-806-4686-3. Adapted from Figure 2, page 18. 2013. Original
sources include: Policy and guideline recommendations based on UNICEF, WHO and other United Nations agencies, Bhutta, Zulfiqar A., et al., ‘Maternal and Child
Undernutrition 3: What works? Interventions for maternal and child undernutrition and survival’, Lancet, vol.371, no.9610, February 2008, pp.417–440.

This nutrition support will sometimes be delivered in theform of counseling (e.g. health worker to mother) to
encourage the adoption of optimal nutrition practices (e.g.
to give only breast milk during the first six months of her
baby’s life) or in the form of nutrition supplies (e.g. a healthworker providing vitamin A capsules to children starting at
six months of age up to 59 months). Behavior change
communication, including interpersonal communication, is
an important element that needs to be built into the deliveryof such nutrition support so that it reaches the right personat the right point in time in the right way. As mentioned
earlier, much more attention is needed on ‘how’ to deliver
this nutrition support to vulnerable infants, young children
and women at high coverage to have a public health impact.

Nepali mother breastfeeding her baby
Photo © HKI / Victoria Quinn

80Chapter Six | Best Practice in Nutrition | Victoria Quinn

81

Nutrition-sensitive interventions – still building the evidence base
While undernutrition has a profoundly negative effect on
health and well-being, it is not merely a health issue, nor can it
be solved only by nutrition-specific interventions confined tothe health sector. This is because a range of non-healthprograms and higher-level policies in other key sectors can also
influence nutrition outcomes at broad scale through pathways
affecting the underlying and basic causes of undernutrition,
especially food, care and health dimensions.

in the review above, are poorly designed with weak
monitoring and evaluation systems.15 Better designed
programs, including their monitoring and evaluation
dimensions, are needed. This will allow us to assess the‘process’ aspect of programs, for example, in terms ofwhether programs are being delivered as originally planned
or if other unexpected factors have emerged that haveadverse effects on implementation.

The tendency through the years has been to view
undernutrition first and foremost as a health issue, which islikely due to the fact the early work was undertaken bycolonial medical doctors as well as nutrition and foodscientists studying the effects of deficiencies in protein,vitamins and minerals. However, the fact is that a range of
non-health nutrition-sensitive determinants can have a
profound effect on nutritional status if they influence thewell-being of women, the ability of families to produce orpurchase food, maternal and child care and feedingpractices or the access of families to adequate health,hygiene and sanitation support. For example, government
programs can exert a major impact on nutrition outcomesthrough such channels as agricultural extension services,
consumer and producer food price policies, income andwage policies, and government investments in primary
health care and basic education, to name just a few. The
status and situation of women throughout is also a critical
determinant, especially in terms of how programs may or
may not affect their access to essential resources. Even theimpact that these programs have on women’s use of time
can affect nutrition outcomes if they take time away fromessential child care, for instance.

Work to this end, especially research, is imperative. As
stated in the recent 2013 Lancet series, the “acceleration ofprogress in nutrition will require effective, large-scale
nutrition-sensitive programmers that address key underlying
determinants of nutrition and enhance the coverage andeffectiveness of nutrition-specific interventions”.15 Lastly,
the reach of nutrition-sensitive programs could be immense
as they “…can have a pivotal role in prevention of theexcess stunting, wasting, and impaired child developmentthat the scale-up of nutrition-specific interventions cannot
resolve on its own”.15

Unlike nutrition-specific interventions, nutrition-sensitive
development is still being actively debated by global
experts, thus a commonly accepted definition has yet to bereached. There is also insufficient evidence on what
nutrition-sensitive interventions actually work under whatcircumstances. Collecting this evidence is a recognizedresearch priority, and would help align our efforts acrosssectors and at different levels.14
More research and documentation regarding what works interms of agriculture, education, social safety nets, educationand programs to reach adolescent girls is needed to build
this evidence base.15 A recent systematic review ofagricultural interventions concluded that these did not
improve the nutritional status of the children they weretargeting. However, the problem is not that agriculture does
not have an important effect on nutrition and child growth,
but that many of these programs, including the ones studied

Women are central to the solution
As touched upon above, the role of women in improving
child undernutrition and stunting is critical. Not only aremothers key providers for the family, producing much of
the food and generating income, but they are also thegatekeepers of their children’s nutritional status in their roleas caretakers overseeing the feeding, health and hygiene
care of their infants and young children. Often the healthand nutritional status of women is compromised for avariety of reasons due to past constraints (e.g. long-term
results of childhood stunting) and current constraints (e.g.
too little food also low in micronutrients, malaria, too
many closely spaced pregnancies).
Undernutrition in pregnant women puts newborns at highrisk of being born with low birth weight. This in turn leads
to an intergenerational cycle where malnourished girls growto be malnourished women who are at greater risk of giving
birth to malnourished babies.16
Recent evidence also shows that undernutrition during
pregnancy, affecting fetal growth and the first two years oflife, is a major determinant not only of stunting, but also of
subsequent obesity and non-communicable diseases inadulthood.1,17,18 Thus undernutrition, overnutrition andnon-communicable diseases later in adult life all appear to
be interwoven with the sub-optimal development of the
fetus in the womb if the pregnant woman herself is sufferingfrom undernutrition.

Chapter Six | Best Practice in Nutrition | Victoria Quinn

The long road to food, care and healthIn recent years, progress in nutrition has been made on anumber of fronts, for example the high coverage of young
children with twice yearly supplementation with vitamin A(UNICEF 2013). Unfortunately on many other fronts,
including the adoption of optimal breastfeeding andcomplementary feeding practices, the reduction in acutemalnutrition, and the continuing high levels of maternaland child anemia, much more progress is necessary, so there
is still much more work to do.
The notion of food, care and health is now widely used
today, as is evidenced by global nutrition documents using
the Conceptual Framework as the basis on which todevelop their nutrition strategies and recommendations.19 It
has also been embraced by the global Scaling Up Nutrition(SUN) Movement, launched in 2010, which comprises
many international, regional and national groups
committed to taking evidence-based nutrition actions toscale and is discussed extensively elsewhere in this volume.
The SUN Movement has made significant progress in recent
times, and by mid-2013, the leadership of forty countries
from Africa, Asia and Latin America had madecommitments to address undernutrition. Half of thesecountries have also released costed nutrition plans which
they intend to roll out to reduce levels of undernutrition.
More countries are expected to engage in a similar mannerin the coming months. Also, very importantly, in 2012 theWorld Health Organization (WHO) set global targets to
reduce stunting by 40 percent (along with other indicatorsand targets).20 With these WHO global targets, our end goal
to reduce undernutrition has been clearly spelt out.
Achieving this will necessitate continued investment, focus
and resolve in the years ahead.
It should be underscored that under the national
governments within the SUN Movement are in the driver’s
seat and are fundamentally responsible for bringing aboutchange via their relevant ministries and departments (theministries of agriculture, health, and education). Today weknow that successfully addressing undernutrition and its
various determinants will require strong political will,
especially on the part of national governments and leadership.
Strong commitment and follow-up by national leaders
creates the ‘enabling environment’ which is necessary forsuccess. Under the SUN Movement this means a ‘whole-ofsociety’ approach must be employed to improve nutrition,
based on policies which encourage equity, social justice andthe empowerment of women.

In addition, close liaison and the sharing of proven bestpractices between national governments is vital, supportedby the agencies of the United Nations. These – UNICEF,
WHO, WFP, FAO, IFAD and so on – can play a decisiverole in delivering insights, expertise, and tried and tested
approaches along with other development partners
including civil society, but all must work more closely
together, as well as with the national governments they
advise. It is to be hoped that the SUN Movement willencourage improved sharing of best practice between
governmental and civil society in the service of better
nutrition. The private sector and academia – both of which
are key players within the SUN Movement – also have an
important contribution to make in delivering the nutritionsensitive actions that will bring about positive change.
None of this, however, is achievable without thenecessary human resources and national capacity
development in nutrition. In both the health and therelevant non-health sectors, a significant investment must
be made in developing a cadre of skilled professionals in
key sectors who have improvements in nutrition as
explicitly parts of their job descriptions.21
Above and beyond this, the world of nutrition has had torespond to a range of developments which lie far beyond its
original remit. These include, for instance, the humanitariancrises triggered by natural and man-made disasters(famines, earthquakes, tsunamis, wars), the phenomenon of
HIV/AIDS, the spread of non-communicable diseases suchas type 2 diabetes and cardiovascular disease,
unprecedented population growth, and climate change.
Fortunately, the world of nutrition is now united in the first
decade of the 21st century through the SUN Movement topromote national action through a global agenda
addressing these issues.
The reality, however, is that it will still take time for major
inroads to be made to ensure that high enough coverage ofvulnerable women and children under two years is achieved
with quality nutrition support at critical points in the life
cycle so as to make a public health impact. The feeling, andhope, is that we are now on the right path and that thepolitical will needed at all levels but most especially fromnational leadership and the donor community remains
strong and unwavering.

82

Chapter Six | Best Practice in Nutrition | Victoria Quinn

83

Enhanced homestead food production: The view of Helen Keller International (HKI)The Problem• Despite significant progress achieved since 1990,
according to the Food and Agriculture Organization, today
in 2013 one in eight people around the globe still goes
hungry every day. The diets of more than one in four arecomprised predominantly of staple crops, which, evenwhen they fill the stomach, lack essential vitamins andminerals for health, vitality and survival.
• This global food crisis is worsening the problem ofundernutrition across developing regions of the world
leading to stunted physical growth and mental
development in young children as well as contributing tonearly half of all child deaths worldwide.
• Conditions in various developing nations are particularly
severe, and food price volatility is making matters worse formany families, striking rural and urban areas alike.

What HKI Is Doing• With its partners in government and civil society, since1988 Helen Keller International (HKI) has been honing anutrition-sensitive agricultural approach to address these
problems. The goal of HKI’s Enhanced Homestead Food
Production (EHFP) program is to put crops in the ground,nutrients in the diet, and food in the mouths of the mostvulnerable family members in communities affected byprolonged undernutrition and food insecurity.
• To date, nearly one million families in Asia (Bangladesh,
Cambodia, Indonesia, Nepal and the Philippines) havebeen reached. The EHFP approach is now being tested
and adapted in sub-Saharan Africa in the countries of
Burkina Faso, Cote d’Ivoire, Senegal and Tanzania.
• EHFP targets women from poor households with young
children as the primary beneficiaries, placing farming
inputs, knowledge and skills directly in their hands.
• HKI works in collaboration with local government
agriculture and health teams and the staff of nongovernmental organizations (NGOs) to develop theircapacity to provide long-term support to sustain theactivities after three years of external assistance.
• The program helps communities establish technically
improved local food production yielding micronutrient-richfruits and vegetables complemented with poultry and small
livestock. This diversified production ensures the yearround availability of vitamins and minerals essential for
proper immune system function and full physical,
intellectual and cognitive development and which are often
lacking in traditional diets.
• EHFP also contains a strong nutrition behavior change
component targeting the mothers and other family andcommunity members to ensure not only is more diverse
and nutritious food produced but that that food benefits
those who need it the most, namely infants and children
under two years and pregnant and lacating women.
Evidenced-based Essential Nutrition Actions are promoted
at each point of the life cycle-from conception to thesecond year of life-and span the promotion of optimalbreastfeeding and complementary feeding, micronutrient
consumption, and women’s nutrition.
• In Asia where the model was conceived, EHFP has used
Village Model Farms (VMF) as a site for community
demonstration and training and for the production of inputs
to allow households to establish vegetable, pulse and fruit
gardens and small animal husbandry (mainly poultry)
adjacent to their homesteads. More recently in both Asiaand in adaptations for sub-Saharan Africa, HKI has been
exploring new approaches to ensure better equity by using
a farmer field school model, wherein the demonstration
plot is a shared enterprise and female Village Farm Leaders(VFL) are selected for leadership and mentoring skills rather
than for having greater resources needed to establish andmaintain a private VMF.
• Data collected from EHFP programs across four countries
in Asia, where HKI has promoted EHFP the longest, showthat households with improved gardens produced on
average 45 varieties of vegetables compared to 10 inhouseholds with traditional gardens.
• EHFP contributed to significant increases in householdincome, which was largely invested in improved family
well-being, such as education, higher quality foods andproductive enterprises. In addition, consumption ofdark-green leafy vegetables, orange vegetables and fruits,children’s consumption of eggs, and overall household dietary
diversity scores increased significantly more in intervention
households from baseline to endline compared to controls.
• The prevalence of night blindness (due to vitamin A
deficiency) and of anemia has also been shown to be lower
in households practicing EHFP.
• In 2009, HKI’s Homestead Food Production program in
Bangladesh was selected as a case study of a provennutrition-agriculture model for the International Food Policy
Research Institute’s “Millions Fed: Proven Successes inAgricultural Development”, funded by the Gates Foundation.
Sources: Iannotti, L. et. al. Diversifying into Healthy Diets - Homestead foodproduction in Bangladesh. IFPRI Paper 928. 2009. Campbell, A. et al.
Relationship of homestead food production with night blindness amongchildren below 5 years of age in Bangladesh. Public Health Nutr. 2011
Sep;14(9):1627-31. doi: 10.1017/S1368980011000693. Epub May 4 2011.
Talukder A, et. al. Homestead food production model contributes to improved
household food security and nutrition status of young children and women inpoor populations - lessons learned from scaling-up programs in Asia
(Bangladesh, Cambodia, Nepal and Philippines). The Journal of Field Actions:Field Actions Science Reports (FACTS Report); Special Issue 2010.

Chapter Six | Best Practice in Nutrition | Victoria Quinn

Case study
Scaling up Essential Nutrient Actions in Madagascar
From 1997 to 2006 the Essential Nutrition Actions (ENA)
were adapted in Madagascar, through the USAID funded
LINKAGES project. ENA provides a framework throughwhich evidenced based nutrition support on infant andyoung child feeding, micronutrients and women’s nutrition
can be targeted to children under two years and theirmothers at critical life cycle points using existing programsin the health sector.
In 1997 an inter-sectoral nutrition coalition called theGroupe d’Actions Inter-Sectoriel en Nutrition was formed
with support from USAID, UNICEF and the World Bank.
Chaired by the Nutrition Division of the Ministry of Health,the Groupe d’Actions Inter-Sectoriel en Nutrition comprised
more than 75 representatives from 50 organizations,
including government ministries (health, finance, education,
agriculture, trade, population) and representatives from thedonor community and nongovernmental organizations. Key
aspects of this group’s work to implement the ENA
framework at scale included:• Vision: A shared vision to achieve scale with ENA wasestablished from the very beginning.
• Wide coverage: Many partners, especially those with big
field programs with wide reach were encouraged toparticipate, and multiple programs served as opportunities
for entry points to implement support for ENA.
• Specificity: Initial focus was placed on promoting
optimal breastfeeding practices within the overall context
of the integrated package of ENAs which also included
support to complementary feeding, micronutrients as well
as women’s nutrition.

84• Behavior change: A behavior change strategy, based onformative research on local nutrition practices including
barriers and obstacles mothers faced, was used todesign and promote key ENA messages on small,do-able actions known to make a difference.
• Community volunteers: Members of women’s groups
were trained in ENA promotion and subsequently wereable to support health workers stationed at primary
facilities in the promotion of optimal nutrition practices.
• Monitoring and evaluation: Key ENA indicators andresults were collected annually and shared with allpartners to celebrate results and encourage successbreeding more success.

Through the LINKAGES project, ENA support reached atotal of 6.3 million people (out of a total national
population of 19 million) in selected program sites. Over a
five-year period in these areas, timely initiation ofbreastfeeding increased from 34 percent to 68 percent,and exclusive breastfeeding increased from 46 percent to
70 percent. The ENA field approach may have spilled overto improve infant and young child feeding practices in
non-program sites since at the national level between 1997
and 2003, early initiation of breastfeeding rose from
34 percent to 62 percent, and exclusive breastfeeding
increased from 47 percent to 67 percent (2003 Madagascar
Demographic Health Survey).
Sources: Quinn VJ, Guyon AB, Schubert JW, Stone-Jimenez MA,
Hainsworth M, and Martin L. Improving breastfeeding practices at broad
scale at the community level: Success stories from Africa and Latin America.
J Hum Lact 21: 345-354. 2005. http://www.linkagesproject.org/
publications/index.php?detail=29 (26 July 2013). Guyon, AB, Quinn, VJ,
Hainsworth, M, Ravonimanantsoa, P, Ravelojoana V., Rambeloson, Z, andMartin, L. Implementing an integrated nutrition package at large scale in
Madagascar: The Essential Nutrition Actions Framework Food andNutrition Bulletin, vol. 30, no. 3, The United Nations University. 2009.

• Harmonization: Partners reached consensus on ENA
messages and field approaches so that everyone was“singing the same nutrition song to the same tune”.
• Support to all levels: Groups at the national level, regional/
district levels, and community level received support.
• Short-term, skills-based training: Training modules forhealth workers and community members included
counseling and negotiation skills to encourage mothers
and other child caretakers to adopt optimal nutrition
behaviors promoted by the ENA framework; thesetraining modules were integrated into existing childsurvival, reproductive health, and nutrition programs.

Community mobilization being used in Madagascar to promote
optimal breastfeeding practices
Photo © Victoria Quinn

Chapter Six | Best Practice in Nutrition | Victoria Quinn

85

Case study
Why malnutrition persists in many food-securehouseholds• Caregivers feed children under age two years too little
food, or foods that are not energy dense.

• Mothers have too little time to take care of their young
children or themselves during pregnancy.

• Though food is available, because of inappropriate
household food allocation, women and young children’s
needs are not met and their diets often do not containenough of the right micronutrients or protein.

• Mothers of newborns discard colostrum, the first milk,
which strengthens the child’s immune system.
• Mothers often feed children under age six months foods
other than breast milk even though exclusive
breastfeeding is the best source of nutrients and the bestprotection against many infectious and chronic diseases.

• Caregivers do not know how to feed children during andfollowing diarrhea or fever.
• Caregivers’ poor hygiene contaminates food with bacteria
or parasites.

• Caregivers start introducing complementary solid foods
too late.

Source: Directions in Development: Repositioning Nutrition as Central toDevelopment – A Strategy for Large-Scale Action, The International Bankfor Reconstruction and Development/The World Bank, 2006.

Three myths about nutrition

health and public services, especially water and sanitation.
Thailand has shown that moderate and severe
malnutrition can be reduced by 75 percent or more in a
decade by such means.

Poor nutrition is implicated in more than half of all childdeaths worldwide – a proportion unmatched by any
infectious disease since the Black Death. It is intimately
linked with poor health and environmental factors. But
planners, politicians, and economists often fail torecognize these connections.
Serious misapprehensions include the following myths:
Myth 1
Malnutrition is primarily a matter of inadequate foodintake. Not so. Food is of course important. But mostserious malnutrition is caused by bad sanitation anddisease, leading to diarrhea, especially among young
children. Women’s status and women’s education play big
parts in improving nutrition. Improving care of young
children is vital.
Myth 2
Improved nutrition is a by-product of other measures ofpoverty reduction and economic advance. It is not possible
to jump-start the process. Again, untrue. Improving
nutrition requires focused action by parents andcommunities, backed by local and national action inMyth 3Given scarce resources, broad-based action on nutrition ishardly feasible on a mass scale, especially in poor
countries. Wrong again. In spite of severe economic
setbacks, many developing countries have made impressive
progress. More than two thirds of the people indeveloping countries now eat iodized salt, combating theiodine deficiency and anemia that affect about 3.5 billion
people, especially women and children in some 100
nations. About 450 million children a year now receive
vitamin A capsules, tackling the deficiency that causes
blindness and increases child mortality. New ways havebeen found to promote and support breastfeeding, andbreastfeeding rates are being maintained in many
countries and increased in some. Mass immunization andpromotion of oral rehydration to reduce deaths fromdiarrhea have also done much to improve nutrition.
Source: Directions in Development: Repositioning Nutrition as Central toDevelopment – A Strategy for Large-Scale Action, The International Bankfor Reconstruction and Development/The World Bank, 2006 (extracted
from Jolly [1996]).

Chapter Six | Best Practice in Nutrition | Victoria Quinn

The window ofopportunity for addressing
undernutrition
The window of opportunity for
improving nutrition is small – frombefore pregnancy through the firsttwo years of life. There is consensus
that the damage to physical growth,brain development, and humancapital formation that occurs
during this one thousand day
period is extensive and largely
irreversible. Therefore interventions
must focus on this window ofopportunity. Any investments after
this critical period are much lesslikely to improve nutrition.

The vicious cycle of poverty and malnutrition
Income Poverty

Low food
intakeFrequent
infections

HardphysicallaborFrequent
pregnancies

Largefamilies

Manutrition

Direct loss in
productivity frompoor physical status

Indirect loss in
productivity from poorcognitive development
and schooling

Loss in resourcesfrom increased healthcare costs ofill health

Source: Modified from World Bank (2002a(; Bhagwati and others (2004)

My personal view

Victoria Quinn

Senior Vice President of Programs, Helen Keller
International, New York, USA
Adjunct Associate Professor, Friedman School of Nutrition
Science and Policy, Boston, USA

How do we know when we’ve beensuccessful?
Care must be taken in applying thecorrect metrics for measuring progress
made in reducing undernutrition andhunger. National food balance reports,
which have frequently been used in thepast to assess these problems, provide
a theoretical picture of the food available per capita in agiven population and do not necessarily reflect the realityof what goes into people’s mouths. The presence of food(especially increasing production levels) is centrally
important but does not necessarily ensure the presence of
optimal nutrition, as factors such as the quality of food andaccess of vulnerable groups to purchase or grow it must be
considered, along with other factors related to care andhealth.
Only when children are well nourished and developing in the
direction of achieving their full growth potential can we saythat our efforts have been successful. Too often, policymakers focus on economic indicators or national agricultural
production yields to determine how well a nation is faring. In
fact, investments in national and economic development
should use the growth of children, particularly stunting, as
the best and most accurate yardstick – a human yardstick –to measure success. Indicators of child undernutrition, suchas height, reflect much more accurately than gross domestic
product whether development and human welfare has truly
progressed in a country.

86Chapter Six | Best Practice in Nutrition | Victoria Quinn

87

References

Further reading
UNICEF Policy Paper (E/ICEF/1990/L.6). Strategy
for Improved Nutrition of Children and Women in
Developing Countries8
World Bank. Repositioning nutrition as central todevelopment: A strategy for large-scale action19
UNICEF. Tracking Progress on Child and Maternal
Nutrition: A survival and development priority. New
York, NY, USA: UNICEF, 2009
Jonsson, U. Commentary: The Rise and Fall of
Paradigms in World Food and Nutrition Policy.3
Horton S, Shekar M, McDonald C et al. Scaling Up
Nutrition: What will it Cost? Washington DC, USA:World Bank 2010.
2008 Lancet Series on Maternal and Child
Undernutrition
UNICEF Report “Improving Child Nutrition: The
Achievable Imperative for Global Progress.”92013 Lancet Series on Maternal and Child Nutrition

1Black RE, Victora CG, Walker SP, and the Maternal and Child Nutrition Study
Group. Maternal and child undernutrition and overweight in low-income andmiddle-income countries. Lancet 2013;382:427–451.

2. Prado E, Dewey K. Nutrition and brain development in early life. Alive andThrive Technical Brief 2012; Issue 4.
3. Jonsson U. The rise and fall of paradigms in world food and nutrition policy.
(Commentary). World Nutrition 2010;1(3):128–158.
4. Quinn V. Nutrition and National Development: An evaluation of nutrition
planning in Malawi from 1936 to 1990. The Hague, The Netherlands:
Wageningen Agricultural University Press 1994.
5. McLaren D. The Great Protein Fiasco. Lancet 1974;7872:93–96.
6. Berg A. (1987). Nutrition Planning is Alive and Well, Thank You. Food Policy
1987; 12(4):365–375. Rejoinder to: Field JO. (1987). Multisectoral Nutrition
Planning: A Post-Mortem. Food Policy 1987;12(1):15–28.
7. UNICEF 1993, “We Shall Never Go Back”
8. UNICEF Policy Paper (E/ICEF/1990/L.6). Strategy for Improved Nutrition ofChildren and Women in Developing Countries. New York, NY, USA: UNICEF,
1990 p.22.
9. UNICEF. Improving Child Nutrition: The Achievable Imperative for Global
Progress. New York, NY, USA: UNICEF, 2013, p.18.
10. Bhutta, ZA, Ahmed T, Black RE et al. What works? Interventions for maternaland child undernutrition and survival. Lancet 2008;371(9610):417–440.
11. USAID. Child Survival Programs – Technical Reference Materials: Nutrition
2006
12. WHO. Essential nutrition actions: improving maternal, newborn, infant andyoung child health and nutrition. Geneva, Switzerland: World HealthOrganization, 2013.
13. Core Group. Essential Nutrition Actions Training Materials. 2011 http://www.
coregroup.org
14. Mucha N. Implementing Nutrition-Sensitive Development: Reaching Consensus.
Briefing Paper. Washington DC, USA: Bread for the World, 2012
15. Ruel MT, Alderman H, and the Maternal and Child Nutrition Study Group.
Nutrition-sensitive interventions and programmes: how can they help toaccelerate progress in improving maternal and child nutrition? Lancet
2013;382(9891):536–551
16. Özaltin E, Hill K, Subramanian SV. Association of maternal stature with
offspring mortality, underweight, and stunting in low- to middle-income
countries. JAMA 2010;303(15):1507–1516;
17. Barker DJP. Maternal Nutrition, Fetal Nutrition, and Disease in Later Life.
Nutrition 1997;13(9):807–813
18. Uauy R, Kain J, Corvalan C. How Can the Developmental Origin of Health andDisease [DOHaD] Hypothesis Contribute to Improving Health in Developing
Countries? Am J Clin Nutr 2011;94(6):1759S.
19. World Bank. Repositioning Nutrition as Central to Development: A Strategy forLarge-Scale Action. Washington, DC, USA: World Bank, 2006.
20. WHO Comprehensive Implementation Plan on Maternal, Infant and YoungChild Nutrition, endorsed by the 65th World Health Assembly, May 2012
21. Mucha N, Tharaney M. Strengthening Human Capacity to Scale Up Nutrition.
Report by Bread for the World and Helen Keller International, June 2013

Chapter Seven

How to Improve Nutrition
via Effective Programming

Werner Schultink
Associate Director,
UNICEF88

“What we think or what we know or what we believe is, in theend, of little consequence. The only consequence is what we do.”John Ruskin, English artist, art critic and philosopher (1819 –1900)
John Ruskin
http://www.chrisiliff.co.uk/blog/?p=807

89

Key messages•	Reductions in stunting and other forms ofundernutrition can be achieved throughproven interventions. These include
improving women’s nutrition, especiallybefore, during and after pregnancy; earlyand exclusive breastfeeding; timely, safe,
appropriate and high-quality
complementary food; and appropriate
micronutrient interventions.
• Timing is important – interventions should
focus on the critical 1,000-day window
including pregnancy and before a childturns two. After that window closes,
disproportionate weight gain may
increase the child’s risk of becoming
overweight and developing healthproblems such as non-communicablediseases in adult life.
• Efforts to scale up nutrition programs areworking, benefiting women and children
and their communities in many countries.
Such programs all have common
elements: political commitment, national
policies and programs based on soundevidence and analysis, the presence of
trained and skilled community workers
collaborating with communities, effective
communication and advocacy, and multisectoral, integrated service delivery.

UNICEF’s 2009 report Tracking Progress on Child andMaternal Nutrition drew attention to the impact of highlevels of undernutrition on child survival, growth anddevelopment and their social and economic toll on nations.
It described the state of nutrition programs worldwide andargued for improving and expanding delivery of key
nutrition interventions during the critical 1,000-day
window covering a woman’s pregnancy and the first two
years of her child’s life, when rapid physical and mental
development occurs. This chapter builds on those earlier
findings by highlighting new developments anddemonstrating that efforts to scale up nutrition programs
are working, benefiting children in many countries. It isbased on the 2013 UNICEF publication Improving Child
Nutrition: The achievable imperative for global progress.

Nutrition-specific interventions
Nutrition-specific interventions are actions that have a
direct impact on the prevention and treatment ofundernutrition, in particular during the 1,000 days covering
pregnancy and the child’s first two years. These
interventions should be complemented by broader,nutrition-sensitive approaches that have an indirect impact
on nutrition status. Equity considerations in nutrition
programming are particularly important, as stunting andother forms of undernutrition usually afflict the mostvulnerable populations.
Promoting optimal nutrition practices, meeting
micronutrient requirements and preventing and treating
severe acute malnutrition are key goals for nutrition
programming. The 2009 Tracking Progress on Child andMaternal Nutrition report summarized the evidence basefor nutrition-specific interventions.

Chapter Seven | How to Improve Nutrition via Effective Programming | Werner Schultink

Key proven practices, services and policy interventions for the prevention
and treatment of stunting and other forms of undernutrition throughout the life cycle
Adolescenceto Pregnancy+ Improved use of locally available
foods+ Food fortification, including salt

0 to 5MonthsBirth+ Early initiation of breastfeeding
within one hour of delivery(including colostrum)+ Exclusive breastfeeding+ Appropriate infant feeding
Imagepractices for HIV-exposed infants,
and ARV

6 to 23Months+ Timely introduction of adequate,
safe and appropriate
complementary feeding+ Vitamin A supplementation in first+ Continued breastfeeding+ Appropriate infant feeding+ Fortified food supplements for+ Multi-micronutrient+ Micronutrient supplementation,+ Antenatal care, including HIV+ Improved use of locally available

iodization+ Micronutrient supplementation anddeworming+ Appropriate infant feedingpractices for HIV-exposed infants,
and antivirals (ARV)

undernourished mothers
testingeight weeks after delivery
supplementation

foods, fortified foods, micronutrient
supplementation/home fortification
for undernourished womenpractices for HIV-exposed
infants, and ARV
including vitamin A,
multi-micronutrients; zinctreatment for diarrhoea;
deworming+ Community-based managementof severe acute malnutrition;
management of moderate acutemalnutrition+ Food fortification, including salt
iodizationKey:+ interventions for women of reproductive age and mothers.
+ interventions for young children.
Source: Policy and guideline recommendations based on UNICEF, WHO and other United Nations agencies, Bhutta ZA,
Ahmed T, Black RE et al.‘Maternal and Child Undernutrition 3: What works? Interventions for maternal and childundernutrition and survival’, Lancet, vol. 371, no. 9610, February 2008, pp. 417–440, derived from 2013 UNICEF
publication Improving Child Nutrition: The achievable imperative for global progress

Taking a life-cycle approach, the activities fall broadly into
the following categories:• Maternal nutrition and prevention of low birth weight• Infant and young child nutrition (IYCN)– Breastfeeding, with early initiation (within one hour of birth)and continued exclusive breastfeeding for the first six
months followed by continued breastfeeding up to 2 years– Safe, timely, adequate and appropriate complementary
feeding from 6 months onwards• Prevention and treatment of micronutrient deficiencies• Prevention and treatment of severe acute malnutrition• Promotion of good sanitation practices and access to clean
drinking water• Promotion of healthy practices and appropriate use ofhealth services+ Prevention and treatment of

infectious disease; hand washingwith soap and improved water andsanitation practices+ Improved use of locally available

foods, fortified foods, micronutrient
supplementation/home fortification
for undernourished women, handwashing with soap

Maternal nutrition
Nutritional status before and during pregnancy influencesmaternal and child health. Optimal child development
requires adequate nutrient intake, provision of supplements
as needed, and prevention of disease. It also requires
protection from stress factors such as cigarette smoke,narcotic substances, environmental pollutants andpsychological stress. Maternal malnutrition leads to poor
fetal growth and low birth weight.
Interventions to improve maternal nutrient intake include
supplementation with iron, folic acid, iodine, or multiple
micronutrients and provision of food and other supplements
where necessary. Compared to iron-folic acidsupplementation alone, supplementation with multiple
micronutrients during pregnancy has been found to reduce
low birth weight by about 10 percent in low-income
countries. Adequate intake of folic acid and iodine aroundconception and of iron and iodine during pregnancy areimportant, especially for development of the infant’s brain.

90

Chapter Seven | How to Improve Nutrition via Effective Programming | Werner Schultink

Percentage of children worldwide put to the breast within
one hour of delivery; exclusively breastfed; both breastfed
and receiving complementary foods; and continuing tobreastfeed at specified ages
Early initiation of breastfeeding(within one hour of birth)

Exclusive breastfeeding(0–5 months)

Exclusive breastfeeding
Exclusive breastfeeding in the first six months of life saves
lives. During this period, an infant who is not breastfed ismore than 14 times more likely to die from all causes than an
exclusively breastfed infant. Infants who are exclusively
breastfed are less likely to die from diarrhea and pneumonia,
the two leading killers of children under 5. Moreover, manyother benefits are associated with exclusive breastfeeding forboth mother and infant, including prevention of growth faltering.
Globally 39 percent of infants less than 6 months of age
were exclusively breastfed in 2011 (Figure 20 ##in original– please renumber for this publication##). Some 76 percent
of infants continued to be breastfed at 1 year of age, while
only 58 percent continued through the recommended

60%

Continued breastfeeding(at 1 year old)76%

Continued breastfeeding*(at 2 years old)

80%

100%

58%

60%

Early initiation of breastfeeding

Fewer than half of newborns globally are put to the breast within
the first hour of birth, though early initiation of breastfeeding ishigher in least-developed countries (52 percent in 2011).

39%

Introduction to solid,semi-solidor soft foods (6–8 months)

Beyond such specific interventions, other relevant interventions
include preventing pregnancy during adolescence, delaying ageof marriage, preventing unwanted or unplanned pregnancy,
increased birth spacing and overcoming sociocultural barriers
to healthy practices and healthcare-seeking.

Several studies have demonstrated that early initiation ofbreastfeeding reduces the risk of neonatal mortality.
Colostrum, the rich milk produced by the mother during
the first few days after delivery, provides essential nutrients
as well as antibodies to boost the baby’s immune system,
thus reducing the likelihood of death in the neonatal period.
Beyond saving lives, early initiation of breastfeedingpromotes stronger uterine contractions, reducing the
likelihood of uterine bleeding. It also reduces the risk ofhypothermia, improves bonding between mother and childand promotes early milk production.

42%

40%

Many interventions to promote maternal health and fetal
growth are delivered by the health system and throughcommunity-based programs. Antenatal care visits should be
used to promote optimal nutrition and deliver specificinterventions, such as malaria prophylaxis and treatment
and deworming. Community-based education andcommunication programs can encourage appropriate
behaviors to improve nutrition.

Globally, less than 40 per cent of infants
are exclusively breastfed

20%

Among undernourished women, balanced protein-energy
supplementation has been found effective in reducing theprevalence of low birth weight. The use of lipid-based
supplements for pregnant women in emergency settings is being
studied as a way to improve child growth and development.

0%91* Excludes China.

UNICEF Global Nutrition Database, 2012, based on MICS, DHS and other national
surveys, 2007–2011.

Most regions have increased rates of
exclusive breastfeeding
Percentage of infants exclusively breastfed (0–5 months),
by region, around 1995 and around 2011100%
Around 1995
Around 2011

80%

60%

20%

0%

48

47

40%

41

28 29

22

SubSaharanAfrica

43

41

South
Asia

East Asiaand thePacific*

34

Least
developed
countries

34

World** Excludes China.

Note: Estimates based on a subset of 50 countries with available trend data. Regional estimates
are presented only where adequate population coverage is met. Rates around 2011 may differ
from current rates, as trend analysis is based on a subset of countries.

UNICEF Global Nutrition Database, 2012, based on MICS, DHS and othernational surveys.

Chapter Seven | How to Improve Nutrition via Effective Programming | Werner Schultink

duration of up to two years. The regions with the highest
exclusive breastfeeding rates of infants under 6 months old
were Eastern and Southern Africa (52 percent) and South
Asia (47 percent), with similar rates in least-developed
countries as a whole. However, coverage is lowest in
sub-Saharan Africa, with 37 percent of infants less than 		
6 months of age exclusively breastfed in 2011. This is due
largely to the low rate in West and Central Africa (25percent) compared to Eastern and Southern Africa (52 percent).

Rates of exclusive breastfeeding have increased by morethan 20 percent, from 34 percent around 1995 to 43
percent around 2011. It is particularly encouraging to notethe nearly 50 percent increase in exclusive breastfeeding
rates in sub-Saharan Africa, from 22 percent to 41 percent
during this period. Progress has also been made in least
developed countries, where exclusive breastfeeding rates
increased by nearly one third, from 34 percent to 48 percent.

Complementary feeding
Studies have shown that feeding with appropriate, adequate
and safe complementary foods from the age of 6 months
onwards leads to better health and growth of children.
Breast milk remains an important source of nutrients, and it
is recommended that breastfeeding continue until children
reach 2 years of age. In vulnerable populations especially,
good complementary feeding practices have been shown to
reduce stunting markedly and rapidly.
Key principles guide programming for complementary
feeding. They include education to improve caregiver practices;increasing energy density and/ or nutrient bioavailability ofcomplementary foods; providing complementary foods, withor without added micronutrients; and fortifying
complementary foods, either centrally or through homefortification including use of multiple micronutrient powder(MNP), in each case paying greater attention to foodinsecure populations.
Globally, only 60 percent of children aged 6 to 8 months
receive solid, semi-solid or soft foods, highlighting
deficiencies in the timely introduction of complementary
foods. Of the 24 countries profiled in this report, only 8 hadrecent data reflecting both the frequency and quality ofcomplementary feeding for children aged 6 to 23 months.

Complementary feeding in eight countries
Percentage of breastfed and non-breastfed children aged 6–23 months receiving minimum acceptable diet, minimum
dietary diversity, and minimum meal frequency

Minimum dietary diversity

Minimum acceptable diet

Ethiopia

Guinea

4
5
49

7
16
39

RwandaMalawi

%

%

17
26
51

Pakistan

%

%

%

8
4
66

Bangladesh

19
29
54

%

21
25
65

Minimum meal frequency

Burundi

%

9
19
33

Nepal

%

24
29
79

Note: The eight countries selected were those profiled in this report with available data on complementary feeding indicators. Minimum meal frequency refers to the percentage of children aged 6–23 months who
received solid, semi-solid or soft foods the minimum number of times or more (for breastfed children, minimum is defined as two times for infants 6–8 months and three times for children 9–23 months; fornon-breastfed children, minimum is defined as four times for children 6–23 months); minimum dietary diversity refers to the percentage of children aged 6–23 months who received foods from four or more foodgroups; and minimum acceptable diet refers to the percentage of children aged 6–23 months who received a minimum acceptable diet both in terms of frequency and quality, apart from breastmilk.

UNICEF Global Nutrition Database, 2012, based on MICS, DHS and other national surveys, 2010–2012.

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Infant and Young Child Nutrition (IYCN)

Many countries have increased rates of
exclusive breastfeeding
Percentage of infants exclusively breastfed (0–5 months), bycountry, around 1995 and around 2011
0%

20%

40%

60%

80%

44

Malawi(2000, 2010)

62
46

Bangladesh(1994, 2011)

61

Nutrition programming in this area continues to receive
insufficient attention, despite the well-established benefits ofage-appropriate IYCN practices. Valuable lessons fromprogramming experiences have led to changes to IYCN
strategies. A comprehensive, multi-pronged approach isneeded, with both cross-cutting and targeted strategies atcommunity, health system and national levels.

48
51

Madagascar(1997, 2009)29

United Republic of
Tanzania (1996, 2010)

50
46
50

Guatemala(1995, 2009)1148

Key components and interventions ofan infant and young child feeding strategy

44
46

India
(1993, 2006)

30

Mozambique(1997, 2011)16

Pakistan(1995, 2007)

41

Legislation
Marketing of breastmilk substitutes
Maternity protection

37
24

Democratic Republic of
the Congo (1995, 2010)
Central African Republic(1995, 2010)

69

64

19

Zambia(1996, 2007)

Two practices together – ensuring optimal breastfeeding in
the first year and complementary feeding practices – could
prevent almost one fifth of deaths of children under 5 yearsof age. Studies suggest that optimal breastfeeding improves
brain development. Breastfeeding may also protect against
cardiovascular risk factors, although it is not yet clear
whether this is the case in low- and middle-income settings.

72

Burundi(2000, 2010)

Guinea(1999, 2008)

100%

83
85

Rwanda(1992, 2010)

3

Around 1995

37

Around 2011

34
26

Philippines(1993, 2008)
Sierra Leone(2000, 2010)

4

Niger
(1992, 2010)

3

Nigeria(1990, 2008)

134

Skilled support by the health system
Curriculum development for IYCF
IYCF counselling and other support services
Capacity development for health providers
Institutionalization of the Baby-Friendly Hospital Initiative

Community-based counselling and support
Established community-based integrated
IYCF counselling services
Mother support groups

32
27

Communication
13

Communication for behaviour and social change
74
70

Nepal
(1996, 2011)

Additional complementary feeding options
Improving the quality of complementary foods
through locally available ingredients
Increasing agricultural production
Provision of nutrition supplements and foods
Social protection schemes

54
52

Ethiopia(2000, 2011)
Liberia(1999, 2010)35
34

Indonesia(1994, 2007)

32
0%

Optimal IYCN practices include initiating breastfeeding within
one hour of birth, exclusive breastfeeding for the first six
months of life and continued breastfeeding up to the age of 2
and beyond, together with safe, age-appropriate feeding ofsolid, semi-solid and soft food starting at 6 months of age.

20%

IYCF in difficult circumstances

37

40%

60%

80%

UNICEF Global Nutrition Database, 2012, based on MICS, DHS and other national
surveys100%

HIV and infant feeding
IYCF in emergencies
Adapted from Programming Guide: Infant and young child feeding,
UNICEF, 2011.

Chapter Seven | How to Improve Nutrition via Effective Programming | Werner Schultink

Continuing the Discussion on Adequate Nutrient Intakes for Infancy
The following letter by Zulfiqar Ahmed Bhutta, whichappeared in Sight and Life magazine, Vol. 27 (1) 2013, is a
response to David Thurnham’s article on “Adequate Nutrient
Intakes for Infancy, Part 1: From 0 to 6 Months,” publishedin Sight and Life magazine, Vol. 26 (3) 2012 [Ed.]The article by Thurnham1 in Sight and Life 3/2012 reviewsthe evidence around breast milk volumes, nutrient
composition and recommendations for infants under six
months of age. The review covers a vast landscape andsummarizes pertinent information as to volume, energy andmicronutrient needs, and adequacy of intake throughbreastfeeding and breast milk. In addition to useful
information on milk volumes and energy, an important
conclusion made by the authors is the identification ofGroup 2 nutrients whose concentrations are unaffected bymaternal intake, and can lead to maternal depletion. This isa key step in addressing the adequacy of intake in the firstsix months of life.
The review highlights two areas that merit further work.
Firstly, there exists a real need to develop sensitive andreliable methods for estimating breast milk intake in a rangeof settings. The continued reliance on test-weighing and thevariability in measurements in ambulatory settings makes
this a less-than-optimal method for assessing breast milk
volume. Although there are established stable isotope
techniques for measuring breast milk intake2,3 these areonerous and not widely available. Secondly, information onbreast milk intake and quality in malnourished populations
is also outdated, and few studies have been conducted in
populations with high rates of HIV infection or among
wasted women with a body mass index <18.5. Whilestudies do suggest that the volume of breast milk produced
may not be affected during acute infection, milk composition
is known to change during this state.4 Although the effects
of marginal maternal malnutrition on breast milk compositionand quality are well-recognized,5 these effects may be
exaggerated among populations with more severe forms ofmaternal wasting and concomitant infections such as HIV.
Investments must be made in optimizing the healthand nutrition of mothers
As underscored by Thurnham et al,1 the onset of linear
growth failure among young infants varies in different
populations. While the onset of stunting may accompany
the introduction of complementary foods after 4–6 months,
and coincidental infections,6 in many regions the onset of
linear growth retardation may occur earlier7 and reflect the
impact of maternal health factors and micronutrient

deficiencies. The implications of these findings and thelimitations of addressing key micronutrient deficiencies
sufficiently through maternal supplementation duringlactation suggest the need for intervening early during
pregnancy or the pre-pregnancy period. In many
populations with high rates of maternal micronutrient
deficiencies and malnutrition, most women present forantenatal care well into the second trimester, andreplenishing deficits in this limited time window ofpregnancy may not be possible.8 In such circumstances,reaching adolescent girls and women in the pre-pregnancy
period, along with adequate birth-preparedness andnutrition support, is critical in addressing key micronutrient
deficits during pregnancy and early infancy. With theincreased emphasis on lactation support and counseling forbreastfeeding, comparable investments must be made in
optimizing the health and nutrition of mothers prior to, andduring, pregnancy.
Zulfiqar Ahmed Bhutta
The Noodin Noormahomed Sheriff Endowed Professor and Founding Chair,
Division of Women and Child Health, Aga Khan University, Karachi, Pakistan

References
1. Thurnham D. Adquate Micronutrient Intakes for Infancy. Sight and Life
Magazine 2012;3:28–39.
2. Wells JC, Jonsdottir OH, Hibberd PL et al. Randomized controlled trial of
4 compared with 6 months of exclusive breastfeeding in Iceland: differencesin breast milk intake by stable-isotope probe. Am J Clin Nutr 2012;96:73–9.
3. da Costa TH, Haisma H, Wells JC et al. How much human milk do infants
consume? Data from 12 countries using a standardized stable isotope
methodology. J Nutr 2010;140:2227–32.
4. Zavaleta N, Lanata C, Butron B et al. Effect of acute maternal infection onquantity and composition of breast milk. Am J Clin Nutr 1995;62:559–63.
5. Brown KH, Akhtar NA, Robertson AD, Ahmed MG. Lactational capacityof marginally nourished mothers: relationships between maternal
nutritional status and quantity and proximate composition of milk.
Pediatrics 1986;78:909–19.
6. Dewey KG, Peerson JM, Heinig MJ et al. Growth patterns of breast-fed
infants in affluent (United States) and poor (Peru) communities:
implications for timing of complementary feeding. Am J Clin Nutr
1992;56:1012–8.
7. Victora CG, de Onis M, Hallal PC et al. Worldwide timing of growth
faltering: revisiting implications for interventions. Pediatrics.
2010;125:e473–80.
8. Bhutta ZA. Summary on Micronutrient Requirements and Deficiencies inMaternal and Child Nutrition. In Bhutta ZA, Hurrell RF, Rosenberg IH(eds): Meeting Micronutrient Requirements for Health and Development.
Nestlé Nutr Inst Workshop Ser Nestec Ltd, Vevey / Basel, Switzerland: S
Karger AG 2012;70:74–77.

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95

Prevention and treatment of micronutrient deficiencies
Micronutrient deficiencies, including deficiencies of vitamin A,
iron, iodine, zinc and folic acid, are common among womenand children in low- and middle-income countries. Ensuring
adequate micronutrient status in women of reproductive
age, pregnant women and children improves the health of
expectant mothers, the growth and development of unborn
children, and the survival and physical and mental
development of children up to 5 years old.

Globally, three in four children (75 percent) aged 6 to 59
months received two doses of vitamin A in 2011, sufficient
to reduce under-five child mortality. Coverage of vitamin A
supplementation was highest in East Asia and the Pacific(85 percent; excluding China for lack of data) and West andCentral Africa (83 percent). Nearly half of countries
reporting these data in 2011 did not reach the 80 percent
coverage target.

Programs to address micronutrient deficiencies include
delivery of supplements to specific vulnerable groups, homefortification of complementary food for children aged 6 to
23 months and fortification of staple foods and condiments.

Iron supplementation

Vitamin A supplementation
Globally, one in three preschool-aged children and one in six
pregnant women are deficient in vitamin A due to inadequate
dietary intake (1995–2005, WHO: http://whqlibdoc.who.int/
publications/2009/9789241598019_eng.pdf). The highest
prevalence remains in Africa and South-East Asia. Vitamin A isnecessary to support immune system response, and children
who are deficient face a higher risk of dying from infectious
diseases such as measles and diarrhea. Vitamin A
supplementation delivered periodically to children aged 6 to
59 months has been shown to be highly effective in reducing
mortality (on average -24 percent) from all causes in countries
where vitamin A deficiency is a public health problem.

Vitamin A supplementation reaches
more than 80 per cent of young children
in least developed countries
Percentage of children aged 6–59 months who
received two doses of vitamin A in 2011

85%

83%

EasternandSouthern
Africa

82%
75%

73

72

%

%

West
and
CentralAfrica

South
Asia

East
Asia
and thePacific*

Leastdeveloped
countries

World** Excludes China.

Source: UNICEF Global Nutrition Databases, 2012. Regional estimates are presented
only where adequate population coverage is met.

Iron deficiency predominantly affects children, adolescent girls
and menstruating and pregnant women. Globally, the mostsignificant contributor to the onset of anemia is iron deficiency.
Consequences of iron deficiency include reduced school
performance in children and decreased work productivity inadults. Anemia is most prevalent in Africa and Asia, especiallyamong poor populations. Global estimates from the WHO
database suggest that about 42 percent of pregnant womenand 47 percent of preschool-aged children suffer from anemia.
Universal salt iodization
Iodine deficiency is the most common cause of preventablemental impairment. Fortification of salt is widely used toavert consequences associated with this deficiency.
Significant progress has been made in reducing the numberof countries whose populations suffer mild to severe iodine
deficiency, from 54 countries in 2003 to 32 in 2011. During
this period the number of countries reaching adequate iodine
intake increased by more than one third, from 43 to 69.
Globally, 75 percent of households have adequately iodized
salt (15 parts per million or more), but coverage varies
considerably by region. East Asia and the Pacific had thehighest coverage, 87 percent in 2011, and as a region had
nearly reached the universal salt iodization target of 90
percent. Coverage was lowest in sub-Saharan Africa, where
less than half of households have adequately iodized salt.
Coverage is generally higher among richer households thanpoorer households.
One fifth of countries reporting in 2011 had reached the 90
percent target of universal salt iodization. Most had reachedonly 50 to 70 percent coverage. Support of national salt
iodization programs is needed, along with advocacy toincrease awareness among country policy-makers about theneed to eliminate iodine deficiency, private-public
partnerships to assist salt producers with sustained
iodization, and education of civil society to build demandfor iodized salt.

Chapter Seven | How to Improve Nutrition via Effective Programming | Werner Schultink

Iodized salt consumption is more likely among the richest households
than the poorest households
Consumption of adequately iodized salt among the richest households compared to the poorest, in countries
with available data
100%

Richest 20% more than twice as likely as poorest 20% (12 countries)

Richestmore likely

Richest 20% more likely than poorest 20% (13 countries)

Consumption by richest 20 per cent of households

Richest 20% equally as likely as poorest 20% (16 countries)
Richest 20% less likely than poorest 20% (2 countries)

80%

How to read this graph:
Each circle represents data from one country. The size ofa circle is proportional to the size of the country’s
population. The horizontal axis represents the percentageof the poorest 20 per cent of households consuming
adequately iodized salt, while the vertical axis represents
the percentage of the richest 20 per cent of households.
Circles along the green line represent countries in which
the likelihood of consuming adequately iodized salt issimilar among the richest and the poorest households.
Circles above or below the green line suggest disparity.
The closeness of circles to the upper-left corner indicatesgreater advantage for the richest households in thatcountry (greater disadvantage for the poorest households).

60%

40%

20%

Poorestmore likely

0%

0%

20%

40%

60%

80%

Consumption by poorest 20 per cent of households

100%

Note: Based on 43 countries with available disparity data.
Source: UNICEF Global Nutrition Database, 2012, MICS, DHS andother national surveys, with additional analysis by UNICEF, 2006–2011,derived from 2013 UNICEF publication Improving Child Nutrition: The
achievable imperative for global progress.

Fortification of complementary foods, staple foods and condiments
Home fortification

Large-scale fortification

Multiple micronutrient powders (MNPs) offer a low-cost,highly acceptable way to improve the quality ofcomplementary foods. MNPs have been found highly
effective in preventing iron deficiency and iron-deficiency
anemia. Combined with additional supplementary energy,
protein and fats, MNPs have also been shown to improvechild growth and development.

Adding micronutrients to staple foods such as wheat andmaize flour, cooking oil, sugar, salt, complementary foods
and condiments in factories and other production sites is acost-effective way to improve the micronutrient status of
populations. For example, flour is commonly fortified withiron, zinc, folic acid and other B vitamins such as thiamin,
riboflavin, niacin, vitamin B12 and vitamin A in somecountries. As of December 2012, wheat flour fortification is
mandated by law in 75 countries compared with only 33
countries in 2004. The amount of flour currently fortified
represents about 30 percent of the global production ofwheat flour from industrial mills.

Based on a global assessment carried out in 2011, some 22
countries, mostly in Asia and Latin America and the
Caribbean, were implementing MNP interventions toimprove the quality of complementary food. They reachedover 12 million children in 2010, mainly by distributing
MNPs through the public health system. Four countries are
implementing national-scale programs and 17 countries areworking to scale up to a national level. Further expansion istaking place, mainly in Africa and South-East Asia.

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97

Scaling up nutrition
Kenya continues to shine in addressing malnutrition, apublic health problem that also hinders economic
development in many developing countries. This week [inNovember 2012], leaders, professionals, private sector
representatives and other partners gathered in Nairobi for ahigh-level symposium on Scaling Up Nutrition (SUN).
Kenya is one of 31 countries to join the Movement to date.
The SUN event comes on the heels of the launch of an
exciting public-private partnership, expected to reach
27 million Kenyans with a range of foods fortified withessential vitamins and minerals (micronutrients).
Children who are well-nourished – especially in the 1,000
days between pregnancy and the second birthday – grow up
to learn more, earn more and stay healthy. But those whoare malnourished suffer irreversible and lifelong damage,including stunted growth and impaired cognitive development.
Based on this evidence, SUN partners focus on
implementing solutions that improve nutrition, including
support for breastfeeding and ensuring access to essential
vitamins and minerals through supplementation,
micronutrient powders and food fortification. Countries
working to scale up nutrition have established targets
tailored to address their own specific challenges andcapitalize on their greatest opportunities for lasting impact.
In Kenya, 35 percent of children under five are stunted andover 10 million people suffer from poor nutrition andchronic food insecurity.

Lost productivity
Micronutrient deficiencies are widespread, leading tohealth problems including blindness, lost productivity,
pregnancy complications and increased risk of deathfrom diseases like measles and diarrhea. The Governmentof Kenya has developed a comprehensive National Food
Security and Nutrition Policy and Strategy thatrecognizes the need for multi-public and private-sector
involvement in addressing malnutrition.
They also have a long history of supporting foodfortification. The fortification of common foods is a proven,cost-effective way to improve the health and productivity ofwhole populations. The fortification of commercially
produced staple foods continuously delivers nutrients tolarge segments of the population, without requiring thatthey change their eating habits.
The impact is huge. Take the case of fortified flour, now
required by 57 countries. Fortifying flour with folic acid has
reduced cases of brain and spine birth defects (also known
as neural tube defects) by up to 70 percent.
The return on investment from micronutrient provision,
including food fortification, is astounding. According to the2012 Copenhagen Consensus panel of experts, every $1
spent providing essential micronutrients to preschoolers
generates $30 in benefits. Just last month, the Kenya
National Food Fortification Alliance launched the national
fortification logo kuboresha afya (improving health),marking for Kenyan consumers the range of foods now
fortified with vital micronutrients.
If we are going to improve global health and development,
we need to scale up nutrition. Proven, high-impact, low-costinterventions like food fortification exist. We need more
public-private partnerships to implement these interventions.
We need more countries like Kenya to join the SUN, to bothshare what they have learnt and to learn from other
Movement members. Because we can do far more by working
together than any one of us could do alone.

Klaus Kraemer and Gladys Mugambi, www.africareview.com,
9 November 2012 (abridged)
Source: Dr Klaus Kraemer is the Director of Sight and Life, a non-profit humanitarian
nutrition think tank of DSM, which cares about the world’s most vulnerable
populations and exists to help improve their nutritional status.
Gladys Mugambi is Kenya’s deputy head of the Division of Nutrition, Food Fortification
Project Manager for the Ministry of Public Health and Sanitation, and Secretary of the
Kenya National Food Fortification Alliance.

Chapter Seven | How to Improve Nutrition via Effective Programming | Werner Schultink

Community-based interventions

98

Children with severe acute malnutrition (SAM) are ninetimes more likely to die than children who are wellnourished. Children who are wasted, have highly variableweight-for-height or experience negative changes inweight-for-height, are at a higher risk for linear growth
retardation and stunting.

Globally in 2011, an estimated 2 million children under 5were admitted for treatment of SAM – compared with justover 1 million reported during 2009. This increase inreported admissions is not only indicative of improved
access to SAM management, but also reflects improved
national reporting.

While prevention is the first step towards management of
SAM, once it occurs, urgent action is needed to minimize
complications and avoid the risk of death. It is increasingly
recognized that SAM is a problem not only in emergency
contexts but also in non-emergency settings.

Key strategies to expand access to quality treatment of SAM
include creating national policies to help governments
accelerate and sustain scale-up, building national capacities
and strengthening systems to support CMAM scale-up, andintegrating CMAM into other health and nutrition activities.

Community-based management of acute malnutrition(CMAM) has proven to be successful in treating acutemalnutrition and was officially endorsed by the United
Nations in 2007. It decentralizes the management of SAM,
making it easier to reach and treat children in theircommunities. It involves early detection of children with
SAM with treatment in the community, timely referral toinpatient care for those who need it and subsequent
follow-up in the community. Multiple partners havesupported this approach in both emergency and nonemergency settings by guiding policy change, providing
technical support and making commitments to provide
therapeutic supplies. Using this approach, more than 75
percent of treated children are expected to recover. In
addition, more children have access to treatment because
hospitalization is not required for the majority of cases.

Water, sanitation and hygiene and access tohealth services

Five countries account for morethan half of admissions for treatment
of severe acute malnutrition
Number of reported cases admitted for treatmentof SAM in 2011

Total

Ethiopia

302,000

Niger

299,000

Somalia

167,000

Pakistan

157,000

Democratic Republic of the Congo

157,000
1,082,000

Note: Figures are presented to the nearest 1,000. There is no standardized system of national reporting,therefore the mode of each country’s data collection differs (whether based on health facilities withfunctional services for SAM or numbers of implementing partners submitting reports). Also note thatwhile Niger, Somalia and Pakistan received 100 per cent of expected reports for 2011, Ethiopia and the
Democratic Republic of the Congo indicated receiving 80 per cent of expected reports.

Source: UNICEF Global Nutrition Database, based on Global SAM Update, 2012.

Repeated episodes of diarrhea, intestinal infestation withnematode worms and possibly tropical or environmental
enteropathy (in which fecal contamination causes changes
to the intestines affecting permeability and absorption) can
impede nutrient absorption and diminish appetite, resulting
in stunting and other forms of undernutrition.
Improving water, sanitation and hygiene as well as housing
and access to and use of health services can promotehealthy environments and reduce the prevalence of
infectious diseases, and key interventions implemented atscale can reduce undernutrition. These include
immunization, improving sanitation by creating
environments free of open defecation, hand washing withsoap, access to clean drinking water, use of oral rehydration
salts and therapeutic zinc to treat diarrhea, prevention (withinsecticide-treated mosquito nets) and treatment of malaria,
and treatment of pneumonia with antibiotics. Ongoing
research is needed to help quantify the effect and theeffectiveness of interventions in different settings.
Community-based approaches
Scale-up of integrated, community-based nutrition
programs linked with health, water and sanitation, andother relevant interventions is a priority strategy that canbring measurable improvements in children’s nutritional
status, survival and development. Community support can
include providing services such as counseling, support andcommunication on IYCN; screening for acute malnutrition
and follow-up of malnourished children; deworming; anddelivering vitamin A and micronutrient supplements.
Synergizing nutrition-specific interventions with other earlychild development interventions at the community level isalso important for holistically promoting early childdevelopment and reducing inequalities.

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99

Communication for behavior and social change
Based on formative research on the barriers to and thefacilitators of good nutrition, communication for behavior
and social change can promote behavior change incommunities, raise awareness about nutrition services andstimulate shifts in social norms in order to improve theenabling environment for good nutrition in communities.

Maintaining the focus on equity
Maintaining a focus on equity is particularly important,because stunting and other forms of undernutrition areconcentrated among the most disadvantaged in society.
Undernutrition is inextricably linked with poverty. Equityfocused nutrition programming and other development
strategies can effectively address the inequalities caused bypoverty and the forms of exclusion that exist among groups
and individuals.
For biological reasons, women and children are more
vulnerable to nutritional deficiencies; special efforts are
therefore needed to address the biological and social
inequities that affect them. Women’s low education levels,
unequal social status and limited decision-making power
can negatively influence the nutrition status of theirchildren, as well as their own. Improving access to
education and creating opportunities for both girls andboys, and their families, will confer many benefits in termsof nutritional status and child development.
Creating an enabling environment that targets the needs ofvulnerable people is crucial. Since inequalities in nutritional
status have a long-lasting, intergenerational impact on acountry’s physical, social and economic well-being, theresponse by communities and governments has implications
for the nation’s pursuit of equitable development.

The way forward
Over the past few years, national and global interest in
nutrition has increased dramatically. There are a number ofreasons for this new interest.
Recurrent food shortages, rising food prices andhumanitarian crises in some regions have garnered global
attention. The debate on climate change and the focus onbuilding resilience in communities under stress have also
focused attention on nutrition. At the other end of thespectrum, the rising numbers of people who struggle withoverweight and obesity have become more glaring.

More persuasive evidence has become available on theharmful consequences of micronutrient deficiencies and thepositive impact of exclusive breastfeeding and adequate
complementary feeding for adult life and the next
generation. At the same time, evidence has improved on theeffectiveness of program approaches to treat conditions
such as severe acute malnutrition using ready-to-use
therapeutic foods and iron and folic acid deficiency using
supplementation and wheat flour fortification – as well ason the feasibility of implementing these programs at scale.
Scientific knowledge and understanding have also improved
regarding the linkages between stunting and rapid anddisproportionate weight gain in early childhood. This has
resulted in a shift in response. Previously the focus was on
efforts to reduce the prevalence of underweight amongchildren under the age of 5, an indicator of MDG 1. Now it
is shifting towards prevention of stunting during the period
from pregnancy up to 2 years of age.
The improved scientific evidence on the impact ofinterventions has enhanced advocacy to position nutrition
as a sound investment for poverty reduction and social andeconomic development.
A unified international nutrition community has been using
the Scaling Up Nutrition (SUN) Movement to successfully
advocate for reduction of stunting, acute malnutrition andmicronutrient deficiencies. This message has been heard andechoed by other initiatives and channels, including theSecretary-General’s Zero Hunger Challenge, the 1,000 Days
initiative and the Copenhagen Consensus 2012 Expert
Panel’s findings that malnourishment should be the top
priority for policy-makers and philanthropists. The G8 has
also included action to address stunting and other forms ofundernutrition in its agenda.
By mid-2013, the SUN message had led 40 countries inAfrica, Asia and Latin America to scale up their nutrition
programs, supported by a wide range of organizations and,in many cases, by the donor community. This is probably
the clearest indication of the growing interest in tacklingstunting and other forms of undernutrition. It is crucial tomaintain this momentum and to further increase the level ofinterest and motivation.

Chapter Seven | How to Improve Nutrition via Effective Programming | Werner Schultink

Nutrition-sensitive approaches

Social protection

Nutrition-sensitive approaches involve other sectors inindirectly addressing the underlying causes ofundernutrition. There is less evidence for the impact ofnutrition-sensitive approaches than for direct nutritionspecific interventions, in part because they are hard tomeasure. However, policies and programming in
agriculture, education, social protection and poverty
reduction are important for realizing nutrition goals.
Achieving nutrition-sensitive development requires
multi-sectoral coordination and cooperation with many
stakeholders, which has historically been challenging in
nutrition. Agriculture and social protection programs are
discussed in more detail below.

Social protection involves policies and programs that
protect people against vulnerability, mitigate the impacts ofshocks, improve resilience and support people whose
livelihoods are at risk. Safety nets are a type of social
protection that provides or substitutes for income: Targetedcash transfers and food-access-based approaches are thetwo main categories of safety nets intended to avert
starvation and reduce undernutrition among the mostvulnerable populations. Food-based safety nets are designed
to ensure livelihoods (such as public works employment
paid in food), increase purchasing power (through foodstamps, coupons or vouchers) and relieve deprivation (byproviding food directly to households or individuals).

Agriculture

While social safety net programs operate in at least a dozen
countries, evidence indicating that these programs have
improved child nutritional status is still limited. A review of
evaluations of conditional cash transfer programs showed
an impact on stunting in two of five studies, the Familias en
Acción program in Colombia and the Oportunidades
program in Mexico. Of the three unconditional cashtransfer programs, two (South African Child Support
Grants and Ecuador’s Bono Solidario) reduced stunting.
More research and evidence is needed on the long-term
outcomes of these programs and how they can be bettertargeted, how long they are needed and with what
interventions. But social safety net programs may be one
way to ensure more equitable nutrition-sensitive
development if they are aligned with local and national
needs and an understanding of capacity, resources andtimeliness aspects in scaling up.

Recently, attention has increasingly been paid toimproving synergies and linkages between agriculture
and nutrition and health, in both the programmatic andthe research communities.
The global agricultural system is currently producing
enough food to feed the world, but access to adequate,
affordable, nutritious food is more challenging. Improving
dietary diversity by increasing production of nutritious
foods is achievable, particularly in rural populations. It isdone by producing nutrient-dense foods, such as fruits andvegetables, fish, livestock, milk and eggs; increasing thenutritional content of foods through crop biofortificationand post-harvest fortification; improving storage andpreservation of foods to cover ‘lean’ seasons; and educating
people about nutrition and diet. In several settings thesetypes of interventions have been shown to improve dietary
patterns and intake of specific micronutrients, either directly
or by increasing household income. However, the impact on
stunting, wasting and micronutrient deficiencies is less clear.
More effort is needed to align the pursuit of food security
with nutrition security and improved nutritional outcomes.

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101

My personal view

Werner Schultink
Associate Director,
UNICEF

A number of common determinants
are fundamental to successful
implementation. These include thepolitical commitment to reducestunting and other forms ofundernutrition; the design andimplementation of comprehensive
and effective national policy andprograms based on sound situation
analysis; the presence of trained and skilled community
workers collaborating with communities; effective
communication and advocacy; and multi-sectoraldelivery of services.
Now that many countries are scaling up nutrition
programs, it is important to ensure optimal use ofresources and achieve results rapidly. If programs are notmaking the necessary progress, strategies need to beadapted quickly. This requires a monitoring system toassess whether bottlenecks impeding program
effectiveness are effectively addressed and the collectionof information in real time rather than reliance onlarge-scale household survey data, which are normallycollected intermittently.
The evidence demonstrating the impact of stunting andother forms of undernutrition on survival, individual andnational development, and long-term health is irrefutable.
As the world looks to the post-2015 development
agenda, it is clear that prevention and treatment ofundernutrition must be at its core. The evidence outlinedin this chapter, the momentum around tackling the
problem, the successes already achieved and the impact
on equitable and sustainable poverty reduction showthat improving child and maternal nutrition is bothachievable and imperative for global progress.

Further reading
UNICEF. Improving Child Nutrition: The achievable
imperative for global progress. New York, NY, USA:
UNICEF, 2013.
Save the Children. Surviving the first day: State of theworld’s mothers 2013.
World Health Organization. Essential Nutrition
Actions: Improving maternal, newborn, infant andyoung child nutrition. Geneva: WHO 2013.
2013 Lancet Series on Maternal and Child Nutrition.
World Health Organization. Global nutrition policy
review: What does it take to scale up nutrition
action? Geneva: WHO 2013.

Chapter Eight

Taming Volatile Food
Prices: A Prerequisite for
Improving Nutrition

Joachim von Braun
Director of the Center for Development Research (ZEF)
Professor for Economic and Technological Change,
University of Bonn, Germany

102

103

“We have the resources and the knowledge to end hunger. We
know how to protect the poorest from the impact of rising
prices. We know how to tame volatile prices. Every child,woman and man has a right to enough nutritious food for an
active and healthy life. Let us act – now.”Ban Ki-moon, World Food Day Commemoration, 2011

Key messages•	Food prices today are not only set by
supply and demand but also influenced
by financial markets.
•	Sudden price rises, or ‘spikes’, cause big
problems for nutrition of the poor.
•	Healthy diets need to be affordable, andthat requires increased productivity in thefood system to prevent high prices.
•	Poor countries are hit worst as theycannot afford adjustment measures.
•	The solution needs to be worked on
globally, and the issue taken more seriously.

There are more than 800 million people seriously
undernourished in the world today, and two billion
suffering from hidden hunger. The price of food is a key
factor in this situation.
Recent years have witnessed extreme fluctuations in theprices of food commodities. The basic cause is lack ofagricultural productivity; additional factors include
financial market volatility, political instability, and armed
conflict. Others are scarcity of natural resources such as
land and water, and rising energy prices.
The situation becomes even more complex when
agricultural subsidies provided by governments in the Westto their own farmers are considered – a factor that played
an important role in the past – or when exports are
restricted, which in recent years led to further scarcity andsudden price hikes in the global market. And it seems thecountries giving out the subsidies are not without theirproblems either. In the US and Egypt, it has been argued
that the artificially low prices can lead to unhealthy
incentives for consumers. When energy-dense foods such as
grains and sugar become cheaper, it is argued that these
attract low-income families, leading to problems withoverweight and obesity.
All of these factors and the price fluctuations that result
have put pressure not just on individuals but on entire
social groupings and, indeed, societies as a whole. Dramaticincreases – or ‘spikes’ – in the cost of commodity foods
have not only impoverished the diet and constrained thepossibilities of many of the world’s poorest and mostvulnerable populations; they have in some instances actually
led to food riots which have triggered major political andsocietal changes. The ‘Arab Spring’ that commenced on
18 December 2010 had complex causes, but food prices did
play some role in triggering the violent change.
This chapter examines the various factors that influence
food pricing, the repercussions experienced when price rises
are deemed excessive, and solutions that could help alleviate
the problem. Food price volatility is an issue that needs tobe addressed on a global scale, rather than by individual
countries only, for it is the poorer nations that suffer mostin the wake of a food pricing crisis, as they are unable tofund the social and economic mitigation. Furthermore, notChapter Eight | Taming Volatile Food Prices: A Prerequisite for Improving Nutrition | Joachim von Braun

Economic Crisis+
Food Insecurity

Coping strategies

Modification ofhousehold behaviors

Poverty
Access to foodIntakeChange in priorities

Vulnerable groups

Food price

Quantitative
Changes
Micronutrient
deficiencies

Poor cognitive development
Negative growth rate
Reversal of previous gains+

Healthcare utilization
Expenditure on education
Expenditure on psychologicalwell being

Quantitative
Changes
Wasting
StuntingLong term
Morbidity
Mortality

Adaptations

The vicious cycle of the economic crisis
Source: Maternal and Young Child Nutrition Adversely Affected by External Shocks Such as Increasing Global Food Prices, Ian Darnton-Hill and Bruce Cogill, Journal of Nutrition 2010

only do the sudden or short-term crises need to be addressed,
but also the chronic situation that needs a coordinated andlong-term response. One feature of that is the relative priceincrease of pulses, animal products and vegetables
compared to calorie-dense foods, which leads to unhealthy
diets of poor consumers, for instance in South Asia.

The effect of food price increases
Food prices around the globe are tracked by the Food Price
Index, managed by the FAO (Food and Agricultural
Organization). Strange as it may sound, the fact that foodprices are either high or low in absolute terms is not themain destabilizing factor. The most serious problem occurs
when a sudden change or ‘spike’ in prices occurs, forcountries whose nutrition security is already compromisedfind it very hard to cope with these changes. Traditionally,such sudden price increases have been attributable tonatural disasters such as droughts and floods, and to
man-made disasters such as wars. Such occurrences limit
the supply of food available. As supply dwindles but
demand grows due to population and income growth, theresult is inevitably higher prices for such produce.
If this is a phenomenon as old as money itself, there are also
more recent factors that play a significant role in triggering
food price spikes. One is the growing demand for high-end
foods such as meat and dairy products on the part of theburgeoning middle classes of China and India. Another is thehigh price of oil in our oil-based global economy, which drives
up the cost of every type of economic activity. A third was theglobal decline of food stocks in the last decade, for agricultural
productivity growth had been declining worldwide for anumber of years. Perhaps the most important, however, is thenature of the global commodities market.
During the past decade, there have been notable spikes in
the period of 2007–8 and again in 2011. In certain

countries, food prices were found to be three times as highin mid-2008 as the five-year average for that particular timeof year. Prices rose again in mid-2010 because fears regarding
droughts in Russia and parts of Asia affected stock levels.
The relationship between food production and pricing has anumber of important dynamics:
1)When prices rise, the cost of acquiring food poses a
growing problem. This is the most obvious effect. In
order to prioritize the purchase of food within theframework of an unchanged budget, cuts have to bemade elsewhere. On a household level, this can result in a
general lowering of living standards, while governments
may have to reduce funding for certain initiatives not
related directly to the provision of food.
2)If the food in question becomes unobtainable on account of
its increased price, the quality of the diet will deteriorate.
Malnutrition leads to short-term health problems, but it
also lays the foundation for long-term problems such as
stunting and an increased predisposition to noncommunicable diseases such as cardiovascular disease andtype 2 diabetes. The undernutrition rate of the under-fives
also rises, and the increased prevalence of these conditions
has a lasting negative influence not only on the individuals
affected but also upon the entire societies of which they
form a part.

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Chapter Eight | Taming Volatile Food Prices: A Prerequisite for Improving Nutrition | Joachim von Braun

3) Changes in the price of food can also impact the macroeconomy and labor markets, causing wages to rise or fallconcomitantly. The worst-case scenario is when a drop in
job opportunities is accompanied by a rise in food prices, as
was the case in parts of the Arab region in recent years.

social safety net, putting emergency schemes in place for themost economically vulnerable, but poor countries lack theresources for that and the effectiveness and coverage ofsuch measures is often limited. Another response is to tax
or otherwise legislate for the import or export of food,
which has adverse effects for reliable trade flows.

4)Difficulties caused by rising food prices will prompt areaction from government. One response is to widen the260

Food Price Index

105

240

FAO Food Price Index from 1990 to 2011240

Haiti 5 , Egypt 3 ,Cote d'Ivoire 1

220

Sudan 3200

Cameroon 40
Yemen 12180

Somalia 5Tunisia 1

Algeria 4 , Saudi Arabia 1
Mauritania 1 , Sudan 1 , Yemen 300+
Egypt 800+
Libya 10000+
Tunisia 300+

Oman 2 , Morocco 5
Iraq 29 , Bahrain 31
Syria 900+
Uganda 5

160

220

Mozambique 6

140
120

Mozambique 13

100

200

80

India 1 ,Sudan 1

Mauritania 2
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2000

2005

2010

India 4
Somalia 5

180
160
140

Figures in boxes indicate
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Double blow to the poor
In the wake of a food pricing crisis, it is the poor that suffer
most. In fact, poor people spend an estimated
50–70 percent of their wages on food, and are unable toadapt to price rises, with wages for unskilled labor also
unlikely to rise. The result is that households tend to limit
their food consumption, eat less balanced diets, and spend
less on goods and services. A vicious cycle of nutritionaland economic deprivation is thus initiated.

The current economic climate can pose further problems,with falling wages and unemployment widespread in many
parts of the world. Some three quarters of the world’s poor
live in rural areas. They are therefore more exposed to theimpact of commodity price increases occurring in the global
economy. China and India both attempted after 2008–9 tocombat the problem of food price spikes by shielding
themselves from the international market, and keeping all
their national produce for domestic use. While successful inthe short term, protectionist measures of this kind cannegatively affect a country’s global trading position, andtherefore its wealth, in the longer term.

Chapter Eight | Taming Volatile Food Prices: A Prerequisite for Improving Nutrition | Joachim von Braun

Food prices and the Arab Spring

How are food prices set?

While there were other contributing factors to the recent
Arab Spring uprisings, food prices and the inability of
governments to react to their increase were definitely part ofit. The Middle East and North Africa are more dependenton imported food than other regions, and in 2007–8 when
global food prices spiked, countries like Egypt were facedwith rises in local food prices of 37 percent. With
unemployment in the country rising also, people depended
on the government to supply subsidies, but it was widely
felt that not enough was being done. Food inflation in
Egypt continued to rise, and was 18.9 percent when
President Mubarak gave up his seat.

Food pricing today is no longer set by the straightforward
dynamics of supply and demand only. A report published by
the United Nations Conference on Trade and Development in2000 and entitled Commodity Exchanges in a Globalized
Economy provides an introduction to the topic.

Other countries experienced difficulties, with Bahrain,
Yemen, Jordan and Morocco all staging fooddemonstrations during 2008. Many governments offeredsubsidies, but as in the case of Egypt, these were deemed
low quality and not enough. In Egypt and Yemen, over
40 percent of the population live below the poverty line andsuffer malnutrition, while 30 percent of Egyptian adults and35 percent of Jordanians are obese. According to the Gallup
World Poll, between half and three quarters of the Arab
population say they are unhappy with their government’s
poverty reduction efforts. “The food-price spike was the final
nail in the coffin for regimes that were failing to deliver on
their side of the social contract,” Jane Harrigan of London’s
School of Oriental and African Studies told the Economist.
Sources: http://www.economist.com/node/21550328, http://www.guardian.
co.uk/lifeandstyle/2011/jul/17/bread-food-arab-spring“Modern commodity exchanges date back to the trading ofrice futures in the 17th century in Osaka, Japan, although
the principles that underpin commodity futures trading andthe function of commodity markets are still older. The firstrecorded account of derivative contracts can be traced tothe ancient Greek philosopher Thales of Miletus in Greece,
who, during the winter, negotiated what were essentiallycalled options on oil presses for the spring olive harvest. The
Spanish dramatist Lope de Vega reported that in the 17th
century options and futures were traded on the Amsterdam
Bourse [Stock Exchange] soon after it was opened.”
It continues:“Futures’ trading is a natural application to the problems of
maintaining a year-round supply of seasonal products like
agricultural crops. Exchanging traded futures and options
provides several economic benefits, including the ability toshift or otherwise manage the price risk of market or
tangible positions. With the liberalization of agricultural
trade in many countries, and the withdrawal of government
support to agricultural producers, there is a new need forprice discovery and even physical trading mechanisms, aneed that can often be met by commodity exchanges.
Hence, the rapid creation of new commodity exchanges.”
Commodity exchanges are places where commodities andderivatives are traded. This generally covers agricultural
produce and other raw materials (e.g. wheat, sugar and maize)and contracts based on them. These contracts may be the basis
for a range of sophisticated financial products including, forinstance, futures, interest rates and swaps. Futures are futurecontracts on a crop that has not yet been harvested. They set
the sale price in advance for both the producer (the farmer)
and the purchaser (e.g. a food processor). Both producer andpurchaser are thereby protected from potential pricefluctuations at the moment of sale. The price of grain crops– especially of wheat, corn and soy – is set in this manner.
Food commodities are assets worth investing in, and aretreated in the same way as stocks or bonds. Investors will buy
a package of food commodities through a hedge fund, and ask
them to be traded at a time that is financially opportune.

Can containing fortified vegetable oil
Source: Mike Bloem Photography

Milk prices, by contrast, are derived from feed prices, while
rice prices are set at a national level, as rice is such animportant staple food in so many parts of the world.

106

Chapter Eight | Taming Volatile Food Prices: A Prerequisite for Improving Nutrition | Joachim von Braun

107

Case study
Case study: Guatemala
A study conducted in Guatemala in 2008 revealed thatthe price of a diet based on a corn tortilla, vegetable oil,vegetables and beans – containing key recommended
micronutrients – is twice the cost of a less nutritious dietbased only a tortilla and oil. The cost of the diet for one
person with beans and vegetables is also around a third of
the total household income of a family living on $1 a day.
If a person were to eat the diet based only on the tortillaand oil, they would receive no vitamin A and C, andvery low levels of other essential nutrients. This will putthem at risk in terms of health problems and illnesses,
some of which can be long term.
Source: Erick Boy, IFPRI, based on Guatemala City market prices in
November 2008; and data from FAO/WHO 2002

Abstract
A food crisis occurs when rates of hunger and malnutrition
rise sharply at local, national, or global levels. Thisdefinition distinguishes a food crisis from chronic hunger,
although food crises are far more likely among populations
already suffering from prolonged hunger and malnutrition.
A food crisis is usually set off by a shock to either supply or
demand for food and often involves a sudden spike in foodprices. It is important to remember that in a market
economy, food prices measure the scarcity of food, not its
value in any nutritional sense. Except in rare circumstances,
the straightforward way to prevent a food crisis is to have
rapidly rising labor productivity through economic growthand keep food prices stable while maintaining access by thepoor. The formula is easier to state than to implement,
especially on a global scale, but it is good to have both theobjective, reducing short-run spikes in hunger, and the deep
mechanisms, pro-poor economic growth and stable foodprices, clearly in mind. A coherent food policy seeks to use
these mechanisms, and others, to achieve a sustained
reduction in chronic hunger over the long run while
preventing spikes in hunger in the short run.
Source: J. Nutr. 140: 224S–228S, 2010.

Chapter Eight | Taming Volatile Food Prices: A Prerequisite for Improving Nutrition | Joachim von Braun

It is ironic that the prices of many food commodities aretoday partly decided by financial markets that have nothing
to do with the process of producing food by agriculture orwith the procedure for distributing it physically within an
economy. Cuts in food prices can have a drastic effect on
the farmers who actually grow the food. At the same time,
sharp increases in food prices can threaten the well-being of
the poorest sections of society, who have no means toincrease their income in response to the rising cost of food.

Developed nations

Links between the food and financial crises

Sales promotions encourage customers to purchase excessive
quantities, which generates wastage of perishable foodstuffs.
Between 30% and 50% of food bought in developed countries
is thrown away.

Looking at the dates where the worst spikes in rising foodprices occurred recently, in 2007–8 and 2011, one could
easily assume that a direct connection must exist between
the rise of food commodity prices and the more widespread
global economic crisis which occurred during the same period.
The relationship is somewhat more complex, however.
Before the global recession, the consumption of agricultural
products increased in line with income and population
figures, rising energy prices and subsidized biofuel production.
Pressure was placed on production, however, by natural
resource constraints, underinvestment in rural infrastructure
and agricultural science, and weather disruptions.
The much wider financial crisis of 2008, which started in
the USA and resulted in the collapse of the housing andfinancial markets in many parts of the world, led toincreased speculation surrounding agricultural commodities,
introducing volatility and making prices rise further.

Global Food: Waste Not, Want Not
Feeding the 9 Billion: The Tragedy of Waste
By 2075, the United Nations’ predicts human numbers will
peak at about 9.5 billion people – an extra 3 billion mouths tofeed. Substantial changes are anticipated in the wealth,calorific intake and dietary preferences of people in developing
countries. However 30–50% (or 1.2–2 billion tons) of all foodproduced never reaches a human stomach.
Developing nations
In less-developed countries, wastage occurs primarily at thefarmer-producer end of the supply chain due to inefficient
harvesting, inadequate local transportation and poor
infrastructure. As development increases, the problem generally
moves further up the supply chain with regional and national
infrastructure deficiencies having the largest impact.

In fully developed countries such as the UK, a larger
proportion of the food produced reaches markets andconsumers. However produce is often wasted through retailand customer behavior.
Major supermarkets often reject crops because they do notmeet exacting marketing standards. Up to 30% of the UK’svegetable crop is never harvested as a result of such practices.
Globally, retailers generate 1.6 million tons of food waste
annually in this way.

Better use of our finite resources
Wasting food is a waste of land, water and energy. Tackling offood waste involves addressing key resource issues:
Effective land usage
Over the last five decades, improved farming techniques and
12% expansion of farmed land have increased crop
production. Further expansion of crop land would impact on
the world’s natural ecosystems. Per capita calorific intake frommeat consumption is set to rise 40% by mid-century, and meatproducts require significantly more resources and land to
produce. Considerable tensions are likely to emerge, as the needfor food competes with demands for ecosystem preservation andbiomass production as a renewable energy source.
Water usage
Over the past century, fresh water withdrawal for human use
has increased at more than double the rate of population
growth. The demand for water in food production could reach
10–13 trillion m3 annually by mid-century. This is 2.5 to 3.5
times greater than the total human use of fresh water today.
About 40% of the world’s food supply is currently derived
from irrigated land. However, water used in irrigation isoften sourced unsustainably, and we continue to use
wasteful systems. While drip or trickle irrigation methods
are more expensive to install, they can be 33% more
efficient and carry fertilizers directly to the root.
In the production of foods besides crops, especially in meatproduction, there are large additional uses of water. Moreeffective procedures, and recycling and purification of water
will be needed to reduce wastage.

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109

Energy usage
An average of 7–10 calories of input is required in the
production of one calorie of food. This varies dramaticallydepending on crop, from three calories for plant crops to 35
calories for beef.
High productivity in agricultural crops requires appropriate
fertilizer use. In the modern industrialized agriculturalprocess the making and application of agrochemicals suchas fertilizers and pesticides represents the single biggest
energy component. Wheat production takes 50% of its
energy input from these two items alone. Fertilizer
manufacturing consumes 3–5% of the world’s annual
natural gas supply. With production anticipated to increaseby 25% between now and 2030, sustainable energy
sourcing will become an increasingly major issue.
Source: Aggidis G, Arbon I, Brown, C et al, Global Food – Waste Not, WantNot, The Institution of Mechanical Engineers, January 2013

The long-term health risks of risingfood prices
Micronutrient deficiencies can lead to a wide number healthproblems, including impaired cognitive development, lower
resistance to disease, and increased risks during childbirthfor both mothers and children.
It is essential that governments do not undervalue or
underestimate the long-term effects to the population
caused by rising food prices. There is a short-term effectthat food will be hard for the population to budget for andthat bad diets may be eaten, with a serious risk of longterms problems arising from this situation. Carefulmonitoring and assistance should be provided bygovernments when a food pricing crisis is under way, andalso for a suitable length of time afterwards.
This would require funds set aside by the government toensure its recovery from the crisis and also that of the
population. Data will need to be collected, and assessed, in
addition to the right aid and support, and potentially
supplementary foods provided, to limit any long-term effects.
Source: Overcoming the World Food and Agriculture Crisis through Policy
Change, Institutional Innovation, and Science, Joachim von Braun, TAAS
Lecture. New Delhi, March 6, 2009. http://www.taas.in/documents/fdl4_
jvbraun.pdf

How does climate change affectfood prices?
Food production is very sensitive to climate change, and asmall crop yield as the result of drought, too much rainfall,or extremes like flooding or storms, can push prices up. The
effect of global warming is resulting in greater weather
extremes than ever before, with bigger impacts on foodproduction, felt around the world. In Russia in summer
2012, a heat wave destroyed around a third of its crop
yield, while in the US, the worst drought experienced by thecountry in 50 years destroyed almost half the corn crop anda third of the soya bean crop.
Richard Tiffin, director for the Centre of Food Security at
the University of Reading in the UK said:“It should be a major warning that climate change isincreasingly having a global impact on the food supply. If
the problems in Russia and the US were combined with afailure of the Indian monsoon, we could see a major global
food crisis that would have an enormous impact on foodprices and badly affect poor people around the world.”
A recent study by Stanford University suggests that the
global production of maize and wheat since 1980 would
have been 5% higher if not for climate change. Increases incarbon dioxide in the atmosphere is actually said to bebeneficial to the production of certain crops, such as rice,soybean and wheat, but climate change will affect thelength and quality of the growing season, and the overall
effect of climate change on world agricultural production isclearly negative.
Sources: http://www.guardian.co.uk/environment/damian-carringtonblog/2012/oct/10/food-price-rise-uk-crop-harvest
http://www.guardian.co.uk/environment/2012/sep/19/climate-change-affectfood-production

Chapter Eight | Taming Volatile Food Prices: A Prerequisite for Improving Nutrition | Joachim von Braun

What happens next?
While challenges regarding food reserves and pricing have
populated the headlines in recent years, many experts believethat more risks are on the way.
Food consumption is said to have exceeded growth for six ofthe past 11 years, with yields of most crops, excluding rice,
falling. According to the FAO, food prices rose 1.4 percent in
September and 6 percent in July.
The key to solving the global food crisis and preventing prices
from escalating further lies at a global level. It is important that
all countries come together and accept shared responsibility. The
risks regarding food price spikes and their repercussions were
known many years before the dangerous increases occurred, butgovernments failed to give them sufficient credence. For example,
only twice in the past 10 years has food been listed in the top fivefactors for the Global Risk Report.
A potential solution to rising food prices lies in thefollowing areas:
1. Promote sustainable intensification of agriculture growth
Governments should increase their investments in R&D,
rural infrastructure, rural institutions, and information
monitoring and sharing of scientific insight. Smallholders
need improved access to affordable finance. Investments
in agriculture would increase output, helping countries toemerge from poverty.
2. Reduce market volatility
A lack of information can lead to market inefficiencies
and reduce the extent of mutually beneficial exchanges.
Investors need more transparency about market
information and stocks. Appropriate regulation ofcommodity exchanges is called for.
3. Expand social protection and child nutrition action
Preventative actions are needed to address both shortterm and long-term issues. This could include conditional
cash transfers, pension systems and employment programs,
while children could benefit from supplementary feedingin the first two years, school feeding, and increasedfood education.
In addition to this framework, borders must remain open, andsharing scarcity through trade should not be reduced. Export
restrictions should be avoided, as this leads to a smaller
import/export market, which keeps prices high. Food aid
should be allowed to flow freely between countries. The
solution to the problem of food price spikes lies in our hands,
but it will take a global effort of concentrated willpower tomake those hands work effectively together.

My personal view
Joachim von Braun

Director of the Center for Development Research (ZEF)
Professor for Economic and Technological Change,
University of Bonn, Germany

Food security – the availability of andaccess to sufficient and healthy foods
and good nutrition – is central to thewell-being of nations and people. Food
insecurity has increased in the context
of the inter-linked food price andeconomic crises of 2007–08 and again
in 2010–11. The food price crisis ismainly a consequence of neglected
investment in agriculture in many developing countries,
inappropriate agriculture energy subsidization policies inindustrialized countries, and then triggered by adverse
weather events and exacerbated further by export
restrictions. The consequences are volatile and spiking
food prices that undermine food and nutrition security ofthe poor. A comprehensive assessment of the costs of pricevolatility is called for; including human costs, adverse
investment effects, macro-economic and fiscal effects, andmarket distortions such as speculation. Empirical analysisof the inter-linkages of food, energy and financial markets
suggests that food security policy needs to go beyond
traditional mitigation of demand- and supply-side shocks.
And a comprehensive portfolio of policy actions forprevention of price spikes is proposed here, including
better regulation of commodity exchanges and innovative
food reserves policies.

Further reading
IFPRI website: www. foodsecurityportal.org
Food and Agriculture Organization. The State ofFood Insecurity in the World. Rome: FAO 2012.
von Braun J. Increasing and More Volatile Food
Prices and the Consumer. In: The Oxford Handbookof the Economics of Food Consumption and Policy,
2012. DOI:10.1093/
oxfordhb/9780199569441.013.0025

110

Chapter Nine

111

Making Nutrition
Good Politics:
The Power of Governance

Stuart Gillespie
Senior Research Fellow, Poverty, Health and Nutrition Division, International Food Policy
Researc Institute (IFPRI)
CEO of the Transform Nutrition Research Program Consortium
Currently based in Brighton, UK

“There is no sea more dangerous than the ocean of practicalpolitics – none in which there is more need of good pilots and of asingle, unfaltering purpose when the waves rise high.”
Thomas Henry Huxley – physiologist, anatomist, anthropologist and early champion of Darwin’s Theory of
Evolution, (1825–1895)

Key messages•	Undernutrition has certain features which
necessitate a strong focus on governance.
•	Progress in reducing undernutrition
cannot be sustained where governancesystems are weak or absent.
•	As governance relates to power, capacity,commitment, accountability andresponsiveness, it is crucially important for
all levels of action, not just the policy level.
•	Strong leadership – in the form ofambassadors championing the politicalcause, as well as more midlevel, lateralleadership to facilitate intersectoral
action- is fundamental to success.
•	Governance can be measured andmonitored using innovative new tools andindices, with the results used to name,shame and praise.

112

What is good governance, and why is itneeded for nutrition security?
The concept of governance has many definitions.
Governance can be defined with regard to institutional
structures, relationships between actors and/or organizations,decision-making processes, and incentives. It involves thecapacity to act, the power to act and the commitment to act. It
requires accountability, responsiveness and transparency.
Essentially, good governance refers to the effective, efficient,accountable exercise of public authority for the provision of apublic good.
The challenge of undernutrition has several features which
require strong systems of governance to successfully
address it.
First, the nature of the problem itself. Undernutrition isneglected because it is invisible, it is not infectious (unlike
HIV, for example), it requires several actions to beundertaken by many actors in several unconnected sectors,
and at different levels, it is difficult to measure success andto attribute impact to any one decision or action (unlike forexample vaccinating a child against a disease), and thebenefits of improving nutrition often take longer than apolitician’s time in office to fully manifest themselves. These
unique features generate a lack of commitment,
accountability and responsiveness to act, which – linked
with the major challenge of limited leadership, strategic andoperational capacity – all combine to fuel the political
economy of undernutrition reduction.
The second fundamental rationale for a strong focus on
governance is the type of action that is needed to ensure
nutrition security.
Globally the challenge of overweight and obesity is
growing but accelerating the reduction of undernutrition
remains the major challenge in many countries. In thesesituations, ensuring nutrition security requires action on
three broad fronts.
First, there’s a need to enhance and expand the quality andcoverage of nutrition-specific interventions. Second,
maximizing the nutrition-sensitivity of more “indirect”
interventions, such as agriculture, social protection, waterand sanitation etc., And third, there is a need to cultivateand sustain enabling political and policy environments fornutrition. This third level – which largely relates to global andnational governance – has been relatively neglected to date.

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

113

At this third level, the challenge is to understand how
high-level political momentum can drive action to reduce
undernutrition, and what needs to happen to turn thismomentum into results on the ground. How to ensure thathigh-quality, well-resourced direct (nutrition-specific)
interventions are available to those who need them, andindirect (nutrition-sensitive) actions (e.g. agriculture, social
protection, water and sanitation) are re-oriented to support
nutrition goals? These three levels of complementary action
correspond broadly to the three levels of causes ofundernutrition – immediate (individual) level, underlying(household, community) level and basic (national andglobal) levels.

But governance is not only an issue for policy andpoliticians. It is a key cross-cutting issue at all three levels ofaction described above. This is because direct interventions
can fail to scale because of weak incentives, institutions andinfrastructure, indirect interventions are often underleveraged
for nutrition because of commitment and coordination
failures, and the environment for nutrition is more often
disabling due to the invisibility of undernutrition and weakleadership from the state and civil society.
The need for good governance to ensure nutrition security
is thus incontestable. Sustained progress is simply notpossible where governance systems are weak or absent.

Why is it so important now?
Yet the focus on governance has only emerged in recent
years as two types of gaps or disconnects have emerged.
First, the disconnect between the strong evidence of thedamage caused by malnutrition, on the one hand, and therelative inertia with regard to action, on the other. So much
more is now known about the drivers of undernutrition andthe serious and enduring consequences of undernutrition, thebenefits of acting to reduce undernutrition, and the costs ofinaction and/or poorly designed and implemented responses.
Second, the disconnect between sustained economic growthof several high-burden countries and their failure to makesignificant inroads in addressing undernutrition. This has
been seen most dramatically in South Asia, though there are
now signs of positive change in some countries (such as
Nepal, and Bangladesh – see case study). As their nations
grow economically, governments need to decide how
important it is that their children grow. They may have thepower and capacity (including financial resources) to act,but often they don’t act (or not at the scale required)because they lack commitment.
Commitment has been likened to a political will to act – andthis does not fall from the sky, it needs to be created. As James
Grant, the former Executive Director of UNICEF said:“Each of the great social achievements of recent decades
has come about not because of government proclamations,but because people organized, made demands, and made it
good politics for governments to respond. It is the political
will of the people that makes and sustains the political willof governments.”
This then throws the spotlight on accountability andresponsiveness of political systems, how power is distributed,
and how equitable societies and political systems are. Are
governments held accountable for their actions or theirfailure to act? Are they responsive to changing situations,especially in context of humanitarian crises.
Politics and policy processes are now firmly embedded in theagenda of both research and action. No longer is the political
economy of nutrition viewed as an impenetrable “black box”.
Nutrition advocates or champions, adept at navigating andshaping policy arenas, are emerging. More policy research is
being done on these issues – often with multidisciplinary teams– to shine a light on success or failure and what drives it. We
know a lot more now about the pathways and dynamics ofchange, the key levers and catalysts, and what drives success or
failure (see “further reading”).

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

Proportions of countries reporting the content of policies, by WHO region

Policies in all four nutritionareas (undernutrition, obesity,
infant and young child nutrition,
vitamins and minerals)
Undernutrition

AFR(n=22)

AMR(n=24)

EMR
(n=8)

EUR
(n=44)

SEAR
(n=8)

WPR
(n=17)

Total(n=123)

67

63

50

11

75

71

46

90

92

88

82

65

88

76

55

88

71

51

100%
50%
0%
100%
50%
0%

Underweight

88

63

7

90

71

63

7

67

63

7

88

71

50

90

79

50

23

88

76

59

81

58

38

5

88

76

81

92

75

91

57

83

63

89

62

67

50

71

79

63

100

100

100

86

96

75

55

81

83

50

45

100%
50%
0%
100%
50%

90

0%

Low birth weight*

100%
50%
0%

Maternal undernutrition

100%

0%

Obesity and diet-related NCDs

27

90

0%

Wasting

63

100%
50%

Stunting

114

46

100%
50%

75

100

88

88

78

94

75

0%

Child obesity

100%
50%
0%

Adult obesity

63

100%
50%
0%

86

63

66

75

94

73

100

94

85

88

88

76

88

76

66

100

82

73

100%

Diet-related NCDs

50%
0%Infant and young child nutrition

100%
50%
0%

61

100%

Breastfeeding*50%0%Complementary feeding*

100%
50%
0%

International Code ofMarketing of Breast-milk
Substitutes

100%
50%
0%

Source: WHO’s
WHO’s Global
Globalnutrition
nutritionpolicy
policyreview
review
Source:

100

67

100

50

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

115
AFR(n=22)

AMR(n=24)

EMR
(n=8)

EUR
(n=44)

SEAR
(n=8)

WPR
(n=17)

Total(n=123)

AFR

African Region

AMR

Region of the Americas

EMR

Eastern Mediterranean Region

EUR

European Region

SEAR South-East Asia Region
WPR

100%
50%

90

83

75

0%

11

88

82

88

59

63

53

58

100%
50%

81

0%

38

25

33

38

Vitamin A supplementation
for children
37

100%
50%

81

0%

34

100%
50%
0%

71

67

86

75

63

21

13

71

63

75

95

96

25

2

75

53

88

71

40

100%
50%
0%

5

50

100%
50%
0%

43

22

50

47

75

76

88

88

66

75

88

60

100%
50%

9

0%

50

27

50

20

25

2

13

5

50

16

75

100%

88

57

63

100%

0%

47

37

33

58

29

27

100%

Nutrition and infection*

81

67

0%

38

41

46

100%

Trade

50%
0%

29

63

13

7

25

53

29

100%

Gender

50%
0%

38

5

42

88

29

26

71

50

100%
50%
0%

Underlying causes andindirect actions

Conditional cash transfers

50%

50%

Zinc supplementation
for children

Food aid

88

100%

0%

Iron and folic acidsupplementation for women

Food security

90

0%

50%

Iron and folic acidsupplementation for children

48

100%

50%

Vitamin A supplementation
for women

Food fortification

0%

50%

Western Pacific Region

Vitamins and minerals

62

92

Source: WHO’s Global nutrition policy review

Vulnerable groups

38

11

88

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

Age-standardized prevalence of overweight and obesity in adults 20+ years of age by
WHO region. 2008
AFR

Obesity, BMI ≥ 30
Pre-obesity, BMI = 25.0-29.9
Male

AFR

SEAR South-East Asia Region

EMR

WPR Western Pacific Region

Eastern Mediterranean Region

5.3

17.6
11.1

19.4

8.3

0%

18.6

10%

20%

Male

AMR

30%

10%

20%

80%

90%

100%

60%

70%

80%

90%

100%

60%

70%

80%

90%

100%

39.1

35.2

30%

40%

50%

28.7
24.5

26
27.3

18.7

0%

10%

20%

Male

30%

40%

50%

20.4

Female37.9

23.1

Both sexes

28.1

21.9

0%

Male

1.7

Female3.7

Both sexes

2.7

10%

32.9

20%

30%

40%

50%

60%

70%

80%

90%

100%

20%

30%

40%

50%

60%

70%

80%

90%

100%

30%

40%

50%

60%

70%

80%

90%

100%

40%

50%

60%

70%

80%

90%

100%

10
12
11

0%

10%

Male

5.1

20.8

Female6.8

18

Both sexes

5.9

19.5

0%

Male
Global

70%

31.5

13

FemaleBoth sexes

WPR

60%

26.7

Male

SEAR

50%

29.7

0%

EUR

40%

23.5

FemaleBoth sexes

EMR

European Region

AMR Region of the Americas

FemaleBoth sexes

AFR

African Region

10%

20%

10

Female23.8
14

Both sexes

21.1

12.1

0%
Source:policyreview
review
Source:WHO’s
WHO’s Global
Global nutrition
nutrition policy

116

10%

22.4

20%

30%

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

117

Policies, coordination mechanisms and stakeholders, interventions and surveillance incountries with high and low levels of stunting. Data are presented as the percentage of total
number of countries in each group.
Countries withstunting ≥ 20% (n=27)

Policies

Countries with policy documents addressing stunting

Countries withstunting < 20% (n=16)

96

69

96

69

Countries with the following related issues addressed in these documents:
Breastfeeding
Complementary feeding

93

69

Low birth weight/Maternal undernutrition

93

63

Vitamin A supplementation for children

31

85

Food fortification

74

Iron and folic acid supplementation for children

70

44
56
25

41

Zinc supplementation for children
Food security

38

81

Conditional cash transfers

38

37

Coordination mechanisms and stakeholders
Countries with coordination mechanisms addressing stunting

67

31

Countries where these coordination mechanisms can assign responsbility to stakeholders

63

31Countries where these coordination mechanisms can assign budgets

19

Countries with stakeholders addressing stunting

75

89

Interventions being implemented by stakeholders*Countries implementing the following relevant interventions:
Promotion of breastfeeding

3 93

Communication or counseling for improved complementary feeding

15

Vitamin A fortification or supplementation

15

94 6
75 13

81
19

78

Fortification of wheat flour

37

Zinc supplementation for children

14

Iron supplementation for children

11 30

Fortification of complementary foods

13

11

19

38

12

13
30 14

70
45

Most MIYCN interventions relevant to specific situational contexts**

50

30

11 19

Most MIYCN interventions relevant to all contexts**

17

22

13

18

Monitoring and surveillance
Countries measuring children’s height

63

89

Countries with recent data (within past 2 years)

30

Countries conducting surveys every 1-2 year or more often

26
100%

19
6
0%

100%

Note: * For interventions, the darker area indicates implementation at national scale, the lighter area indicates implementation at subnational scale, andthe full bar implementation at any scale (national or subnational). ** This refers to a majority of maternal, infant and young child nutrition (MIYCN)
interventions relevant to please all contexts or in specific situational contexts as identified by Bhutta et al. (2008) and listed in Table 4.

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

What are the core drivers and ingredients of good governance?
At the time of the 2008 Lancet Nutrition Series, thegovernance of the international nutrition system was said tohave been fragmented and dysfunctional. Since then, a
process of reforming UN institutional architecture has been
underway, and the Scaling Up Nutrition (SUN) Movement
has emerged with a core focus on galvanizing national andcountry-led action (see box).
The global architecture is now characterized by an array of
governments, NGOs, international and regionalorganizations, donors, foundations, research organizations,academia and private foundations and companies.
Compared to five years ago, there is much more coherence
and complementarity in the way these different actors andorganizations interact.
But the SUN Movement will ultimately only realize its true
potential through its application in each country. This will
require the maintenance of support and consensus amongst
all SUN stakeholders, and strong country-level ownership.

Strong leadership – in the form of ambassadors
championing the political cause, as well as more mid-level,
lateral leadership to facilitate intersectoral action – isfundamental to success.
In terms of institutional arrangements, nutrition is an issue
that needs an executive body, ideally linked to the Prime
Minister’s office, and a coordinating body that ensureshorizontal (cross-sectoral) and vertical (national to district)coherence in action.
These two bodies need to ensure accountability andresponsiveness through regular collection and managementof key data on nutrition trends and changing drivers,
ensuring the quality and appropriate scale-up of direct
nutrition interventions (targeted to the 1,000-day windowof opportunity), maximizing the nutrition-sensitivity ofwider development programs (especially agriculture andsocial protection), and mobilizing and managing capacityand financing to sustain all these efforts.

United Nations headquarters
Source: http://www.panoramio.com

How is governance measured and monitored?
Governance is key for all stages in the policy process – fromagenda-setting, to policy formulation, program planning,
implementation, monitoring and evaluation. It is fundamental
for creating and sustaining commitment but also crucially forconverting such commitment into real impact on the ground.
Different challenges emerge at this point. The quality, intensity,and equity of implementation may not be as easily tracked as
the existence of a plan or a legal framework, as shown by alandscape analysis. Understanding whether and how wellpolicies are actually implemented and legal instruments are

enforced will require different measures and different
perspectives, including importantly those of nutritionallyvulnerable populations themselves.
In 2012, WHO introduced a comprehensive “‘LandscapeAnalysis” mapping tool in order to assess nutrition
governance in different countries. If a country has most or
all of the following indicators in place, they could be
described as having ‘strong’ nutrition governance, and goodreadiness to accelerate action in nutrition: political

118

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

119commitment and awareness of nutrition, focused policies
and regulation at a central level, with supporting plans andprotocols at subnational level, resource mobilization at
central level and budget provision at subnational level,
coordination of nutrition activities at all levels, involvementof partners, support to districts and facilities, trained staff
with appropriate skills at all levels, capacity and motivationof staff, quality of services and follow up, management,
information systems and supplies in place, and community
engagement strategies.
The SUN Movement has a simple four indicator system totrack country-level progress, including existence of amulti-stakeholder platform, coherent legal and politicalframework, alignment of policies and programs around acommon results framework, and mobilization and trackingof financial resources.
Innovative tools are increasingly available to stimulate andbuild commitment and accountability. For governments anddonors, for example, a Nutrition Commitment Index has
been developed by the Institute of Development Studies forcross-country and country-specific comparisons over time.

This measures political commitment to tackle
undernutrition in 45 developing countries by focusing on aseries of policy, legal and spending indicators. The first
analysis in early 2013 generated some interesting results –for example, some of the poorest developing countries areshowing the greatest political commitment to tacklingundernutrition, e.g., Malawi and Madagascar, while
economic powerhouses such as India and Nigeria are failingsome of their most vulnerable citizens. The index not onlyshows that low wealth is no barrier to committed action, it
also highlights that sustained economic growth does notguarantee that governments will prioritize undernutrition
reduction. This may help explain why many countries in
sub-Saharan Africa and South Asia remain blighted by highlevels of hunger and undernutrition. In naming, shaming
and praising, such tools can be very powerful.
This is quite possible at more decentralized levels too – ICTbased monitoring systems, social accountability mechanisms,
and community-based tools such as community scorecards,
have all been shown to promote accountability and to
improve the provision of direct public services.

Definitions and ingredients of good governanceIn possibly the first statement defining “governance”, in
1999, the World Bank defines national governance as:“the traditions and institutions by which authority in a country is
exercised. This includes the process by which governments are
selected, monitored and replaced, the capacity of the government
to effectively formulate and implement sound policies, and therespect of citizens and the state for the institutions that govern
economic and social interactions among them.
(Source: Kaufmann, D. and Kraay, A. (2008) Governance Indicators: Where
are We, Where Should We Be Going? The World Bank Research Observer 2391), 1–30.)“Governance is….the exercise of economic, political, andadministrative authority to manage a country’s affairs at alllevels. It comprises mechanisms, processes, and institutions
through which citizens and groups articulate their interests,
exercise their legal rights, meet their obligations, andmediate their differences.”(Source: Governance for Sustainable Human Development: A United Nations
Development Program Policy Document, 14 April 2005)“Good governance refers to governing systems which arecapable, responsible, inclusive and transparent. All
countries, developed and developing, need to work
continuously towards better governance.”(Source: Helen Clark, Administrator of the UNDP, Fourth United Nations
conference on the Least Developed Countries High Level Interactive Thematic
Debate on Good Governance at All Levels, Istanbul, 11 May 2011)

President Obama at the G8 Summit At Lough Erne
Source: WPA Pool (GETTY)

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

Hunger and Nutrition Commitment Index (HANCI) Scores

Country
HANCI
1 Guatemala
240
2 Malawi
220
3 Madagascar
213
4 Peru210
5 Brazil
210
6 Philippines
205
7 Indonesia
204

Low commitment

Moderate commitment

High commitment
HRCI
109
105
101
105
96
100
90

NCI
131
115
112
105
114
105
114

Country
HANCI
8 Gambia
201
8 Tanzania
201
10 Burkina Faso 198
10 Ghana
198
12 Bangladesh 190
13 Mozambique 186
14 Vietnam
179
14 Rwanda
179
16 Mali
177
17 Zambia
176

HRCI
71
91
104
94
74
68
86
90
104
74

NCI
130
110
94
104
116
118
93
89
73
102

Key
High commitment >201

Low commitment 132-175

Medium commitment 176-201

Very low commitment <175

Hunger Reduction Commitment Index(HRCI) Scores

120Country
HANCI
18 Nepal
175
18 Cambodia
175
20 Uganda
173
21 Senegal
172
22 China
168
23 South Africa 167
24 Niger162
25 Ethiopia
160
26 Sierra Leone 147
26 Pakistan
147
26 Benin147
29 India
138
30 Nigeria
135
31 Cote d’Ivoire 132

Very low commitment
HRCI
50
87
81
89
103
105
72
96
59
63
54
67
55
45

NCI
125
88
92
83
65
62
90
64
88
84
93
71
80
87

Sub
indices

Hungerreductioncommitment
High commitment

Very low commitment

Nutrition Commitment Index (NCI) Scores

High commitment

Very low commitment

NCI
45
75
68
47
34
96
53
69
28
63
51
33
47
50

ThemesIndicators

Legal
framework

4

Policies &programs

4

Publicexpenditures

2

Legal
framework

1

Policies &programs

10

Publicexpenditures

1

HANCI

Nutritioncommitment

Key

HRCI
78
47
46
65
70
8
48
28
64
26
35
47
29
24

The structure of the HANCI
Index

Key

Country
HANCI
32 Togo123
33 Cameroon
122
34 Kenya114
35 Liberia
112
36 Lesotho104
36 Afghanistan 104
38 Mauritania
101
39 Yemen
97
40 Sudan92
41 Myanmar
89
42 Burundi
86
43 Angola80
44 Congo,DR
76
45 Guinea Bissau 74

Source: www.hancindex.org, June 2013

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

Landscape Analysis:

Insufficient progress

On track

Country progress in reaching MDG1 nutrition target

No progress

121

PRSP*

UNDAF**

Nutrition
Governance

Afghanistan
Bangladesh
Cambodia
Ghana
GuatemalaIndonesia
MalawiPeru
TurkeyViet Nam
Côte d’Ivoire
DRC
Egypt
Ethiopia
India
Iraq
Kenya
Mali
Mozambique
Myanmar
Nepal
Nigeria
Pakistan
Philippines
UgandaUnited Rep. of Tanzania
ZambiaBurkina Faso
BurundiCameroon
Madagascar
Niger
South Africa
Sudan
Yemen

Source: *Poverty Reduction Strategy Papers; **United Nations Development Assistance Framework“Assessing countries’ commitment to accelerate nutrition action demonstrated in PRSPs, UNDAFs and through nutrition governance.” Engesveen et al (2009) SCN NEWS 37

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

How does the SUN Movement work?
The Movement recognizes that malnutrition has multiple causes. That’s why it requires people towork together across sectors to put nutrition into all development efforts.
Nutrition-specific interventions: Support for exclusive breastfeeding up to 6 months of age andcontinued breastfeeding together with appropriate and nutritious food up to 2 years of age,
fortification of foods, micronutrient supplementation, treatment of severe malnutrition
Agriculture: Making nutritious food more accessible to everyone, and supporting small farms
as a source of income for women and families

Clean Water and Sanitation: Improving access to reduce infection and disease

Education and Employment: Making sure children have the energy that they need to learn
and earn sufficient income as adults

Health Care: Improving access to services to ensure that women and children stay healthy

Support for Resilience: Establishing a stronger, healthier population and sustained prosperity
to better endure emergencies and conflicts

And at the core of all efforts, women are empowered to be leaders in their families andcommunities, leading the way to a healthier and stronger world.

Source: TBC

122

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

123

Case study
What worked: Thailand’s big pushThailand outlined their first multi-sectoral nutrition policy
in 1977, under the national economic and social
development plan (1977–1982). One of the early key
messages was that malnutrition should not be perceived as
simply a health problem, but should be regarded also as asocial and economic problem with human impact. The
policy stated that investment in nutrition would not be ashort term ‘fix’, but a national investment for intermediateand long-term growth. In addition, it was agreed that“nutritional literacy should be an integral part of planningand implementing nutrition programs.”
Establishing a multi-sectoral policy and plan was the firstand major step in nutrition improvement efforts. The
challenge was then to implement the program in an
integrated manner. The fifth national development plan,
Thailand’s “Poverty Alleviation Plan (PAP)” was aspearhead of the rural development program, focusing on
poverty stricken areas. Nutrition programs were employed
as stopgap measures to relieve the most severe forms of
malnutrition until systematic solutions could bring about
long-term, sustainable improvement.
The PAP was one of Thailand’s first efforts to bring about
effective and efficient infrastructural reforms conducive torural development. Effective organizational structure andmanagerial mechanisms to coordinate and integrate
multi-sectoral efforts at various administrative levels andwithin the communities was critical. Four major
ministries, i.e., Health, Agriculture, Education, andInterior (Community Development Unit), were involved
and streamlined the integrated budgetary allocations totarget poor villages. Each ministry also strengthened theintra-sectoral collaboration among its various departments
or divisions.
PAP employed four key programs, namely, (1) Rural Job
Creation to create jobs for rural people during the dry
season so that they remain in the communities andparticipate in community development; (2) Village
Development Projects included village fish ponds, water
sources and other development projects to improve
economic status and household food security; (3)Provision of Basic Services, i.e., health facilities and healthservices; and (4) Agricultural Production Programs
including nutritious food production (e.g., crops for
producing complementary foods), upland riceimprovement and a soil improvement project.

Income generation and household food security were thedirect benefits.
During the five years of PAP, 32 development projects
were implemented in 12,562 poor villages in 38 provinces.
By 1986, 550,000 village primary healthcare volunteers
were trained, covering almost every rural village in the
country. Nutrition activities were integrated within the
PHC with other health services. The PHC movement
mobilized the community to address malnutrition. It wasrecognized that successful nutrition programs should not
be centrally planned and made into ready-made packages.
Rather, they should serve as guidelines.
Another major breakthrough in nutrition governance wasthe adoption of the Basic Minimum Needs (BMN)
approach in village-based social planning, empoweringvillagers in decision making using BMN indicators inproblem identification and prioritization. This was a key
contributor to reduction in malnutrition.
In nutrition governance, policies such as primary
healthcare and poverty eradication are as relevant as foodand nutrition policies. Community-based nutritionintervention programs have a better chance ofsustainability if the people themselves become agents ofchange and if certain elements are in place: community
organization for planning and management; community
manpower development based on appropriate technology
and information and a viable self-perpetuating community
financing scheme.
(Source: Abridged from Keynote Talk on ‘Thailand’s Community-Based
Nutrition Improvement’ by Pattanee Winichagoon, at the ‘Leveraging
Agriculture for Improving Nutrition and Health’ International Conference,
2011, Delhi, India)

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

Case study
Scaling up nutrition in Bangladesh
There has been rapid economic growth and substantial
poverty reduction in Bangladesh over the past two
decades. Poverty rates declined by 8 percent between 2005
and 2010, per capita GDP doubled from 1990 to 2010,
and agricultural growth averaged 3.3 percent, due toimpressive gains in rice yields (FAO 2012). In line with theMillennium Development Goals (MDG), current estimatessuggest that Bangladesh has achieved a 50 percent
reduction in undernourishment, will achieve the same forunderweight, has achieved the required child mortality
figures, and will achieve the target for maternal health. It
has also performed well in terms of nutrition
improvements, particularly in the 1990s. While progress
reduced between 1999 and 2004, it improved again fromthen onwards.
There are other figures released, highlighting the various
success stories. For example, literacy rates for young

124

females aged 15–24 years are said to have doubled, risingfrom 38 percent in 1991 to 77 percent in 2009. Also thecoverage of vitamin A supplements for children is now
nearly universal, the use of oral hydration salts has
increased, and there has been a substantial rise in
exclusive breastfeeding during the first six months of life,
from 43 percent in 2007 to 64 percent in 2011. There
have been several government initiatives that have helped
to arrive at these figures, with research and surveys toidentify where continued development is needed.
For example, it is acknowledged that nearly one third of
women in Bangladesh are undernourished still, and there
are challenges regarding population growth, cropvulnerability, poverty and natural resources. Malnutritionin Bangladesh costs an estimated US$1 billion a year inlost economic productivity, there are known to be
widespread vitamin A, iron and zinc deficiencies, andcases of anemia remain strong in groups of young
children, adolescent girls and pregnant women.
As a member of the Scaling Up Nutrition (SUN)Movement, the Government of Bangladesh (GoB) is
recognized for its commitment to improving nutrition.
Various initiatives have been launched since 1995, withthe current Health, Population and Nutrition Sector
Development Program planned to run until 2016, at
which point it will be reviewed and updated.
The GoB has mainstreamed nutrition within the existing
health system, with improved access to nutritioninterventions for those in remote areas. There is a strong
focus on the first 1,000 days of a child’s life througheducation and support, with infant and young childfeeding schemes throughout the country, as well as
substantial investments in agriculture and health.
Specific programs operated by the GoB include theVulnerable Group Distribution (VGD) and Vulnerable
Group Feeding (VGF) schemes, which distribute fooditems at subsidized rates, based on a rationing system. The
VGF program helps those who find it difficult to meet thebasic needs for survival, providing food to low-income
groups, and VGD promotes self-reliance amongst women.
A school feeding initiative has also been started in poor
areas with help from the World Food Program, providing
high-energy biscuits to children.
Source: The Hunger And Nutrition Commitment Index (HANCI 2012):
Measuring the Political Commitment to Reduce Hunger and Undernutrition in
Developing Countries, Dolf te Lintelo, Lawrence Haddad, Rajith Lakshman
and Karine Gatellier, Institute of Development Studies, UK, April 2013

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

125Case study
Global governance: the rising of the SUN

improvement in nutrition, health and development.

A number of factors served as background to thelaunching of the Scaling Up Nutrition (SUN) Framework
and Roadmap in 2010. These factors include therecognition of the importance of early childhood
nutrition, the increased political support for nutrition as
being central to development strategy, and theacknowledgement that a wide range of stakeholders,
including governments, civil society and the private sector,
needed to collaborate if significant advances in improving
nutrition were to be achieved.

SUN represents an unprecedented opportunity for
coordination, collaboration, cross-learning and advocacy
to catalyze sustainable nutrition gains at national andglobal levels. Membership of the SUN Movement implies anational commitment to address undernutrition. By July
2013, SUN had grown to include 41 countries committed toscaling up direct nutrition interventions and advancing
nutrition-sensitive development, including 18 of the 31
highest burden countries.

The SUN Movement is founded on the principle that all
people have the right to food and good nutrition. It unites
people – from governments, civil society, the UN, donors,
businesses and researchers – in a collective effort toimprove nutrition.
Following on from the publication of the SUN Framework
and Roadmap in 2010, the US and Irish governments
committed, in September 2010, to promote the SUN atinternational level. By the end of 2012, 33 countries had
made a commitment to implement the principles andassociated programs of the SUN. The Global Movement is
supported by a series of Networks, including a Country
Network, Civil Society Network, UN System Network,
Donor Network and a Business Network. In April 2012,
the UN Secretary-General appointed a SUN Lead Groupof 27 high-level leaders charged with improving
coherence, strategic oversight, resource mobilization andaccountability across the Movement.
The key focus of the SUN must be at the national level ofthe 33 countries committed to the Movement. A particularfocus of the Movement is aimed at reducing the level ofstunting in these countries. The early indication is that the
average annual rate of reduction in stunting in the 33
SUN countries is 1.8%. It is hoped that operational
research such as the RAIN project in Zambia – see box– will provide policy insights which can accelerate
progress in reducing stunting.
The SUN Movement is defined as “a country-led, global
effort to advance health and development through improved
nutrition.” Not a new institution, organization or fund, SUN
is a shared approach that supports the implementation of
direct nutrition interventions, while also looking to address
the underlying causes of malnutrition and engage themultiple sectors that could contribute to an overall

In broad terms, the roles and responsibilities of “SUN
members” are first, that countries are in the lead and must
work to establish coordinated national plans of action,
allocate national resources to nutrition and foster a policy
environment supportive of nutrition goals. Second,
supporters align with this approach by committing toback country-developed plans and build coordination andalignment to leverage resources, knowledge and capacity
in a more effective and efficient manner.
The intended “value-added” of the SUN approach is tocreate a platform to bring governments, businesses andother entities together, both globally and nationally, tofind new opportunities to advance nutrition bydetermining best practices, tracking the effectiveness ofefforts, promoting cross-sector learning and strengthening
the enabling environment – and ultimately by aligning
stakeholders behind a shared goal. A strength of the
movement is the depth of expertise and experience
represented by the more than 100 organizations andentities that have endorsed the SUN Framework. The
collective ability, resources and reach of these supporters
has the potential to impact far more communities andnations than any one group could alone. Working toward
a common goal through a shared platform such as SUN,
stakeholders have an opportunity to maximize theeffectiveness of actions and investments.
As it reaches its third birthday, the SUN Movement is wellaware that it needs to progressively increase the focus on
results on the ground. The success of high-level discourseand commitments made by politicians from the podium
can only be judged by their impact on the lives ofnutritionally vulnerable young children and women.
For more, please see: www.scalingupnutrition.org

Chapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

126

The SUN approachhipards
Stew msent
orernm al Platf
v
o
G
n
atio
of N

Within eachcountry a
SUN Focal Point
is identified

Focus on People’s rights

Action atcountry
level
Country support
and capacity
development
Globalfunctions
Financing
pathways
Governance

NGOs

Civil
SocietyBusiness
Community

Government(lead)UN
SystemDonorsResearch
Community

Country
governments
lead national
efforts to scale
up nutrition

The multi-stakeholder
platform

The Focal Point brings people together in a
multi-stakeholder platform

Works to align andcoordinate action
across sectors

Technical
Community

HealthWomen’s
Empowerment
Education

Multi-sector,
multi-stakeholder
platform

These efforts are underway in all SUN countries
using a unique approach that works for each country
Together the combined efforts of all countries
make up the core of the movement:

The SUN Country Network

Source: TBC

SocialProtection
Agriculture
Development& Poverty
Reduction

UnitedNations
Government
Partners

Civil
Society
DonorsBusinessChapter Nine | Making Nutrition Good Politics: The Power of Governance | Stuart Gillespie

127

My personal viewStuart Gillespie

Senior Research Fellow, Poverty, Health and Nutrition
Division, International Food Policy Research Institute (IFPRI)
CEO of the Transform Nutrition Research Program
Consortium. Currently based in Brighton, UK

In the last five years momentum has
been building and malnutrition is
finally being taken seriously as amajor development challenge. At longlast there is a degree of harmony withregard to the scaling up of nutritionspecific and nutrition-sensitive
actions, driven and supported byenabling political and policy environments. Various
actors and organizations are converging on the core
challenge and developing partnerships andcollaborations. The energy of the SUN Movement –which would probably not have survived ten years ago– is driving this momentum and raising the stakes. As
the political and multisectoral nature of the challenge
is taken on board, issues of governance become evermore prominent.
Research is more operational and more policy-relevant
than before. In the past, nutritionists did their research,made recommendations and then implored politicians todo the right thing. More often than not, it didn’t happen.
Now, there is a new focus on opening up the black boxof “political will” to better understand (and ultimately
shape) governance and policy processes, to makenutrition outcomes, and the policy pathways that lead tothem, more visible.
In reality, political will is a political choice – to act toensure children grow healthily, or not to act. New tools
and indices and greater access to information for more
stakeholders will help to continue to shine a light on
governance systems at different levels. In this way,political leaders will increasingly be held to account if
they choose not to act, and they stand to reap therewards if they do.

Further reading
Gillespie S, Haddad L, Mannar V. The politics of
reducing malnutrition: Building commitment andaccelerating impact. Maternal and Child Nutrition.
The Lancet Series, 2013.
Pelletier DL, Frongillo EA, Gervais S et al. Nutrition
agenda setting, policy formulation and implementation:
Lessons from the mainstreaming nutrition initiative.
Health Policy Plan 2012;27:19–31.
Garrett JL, Natalicchio M. Working multisectorally
in nutrition: Principles, practices, and case studies.
IFPRI research monograph, 2010.
Gillespie SR, McLachlan M, Shrimpton, R.
Combating malnutrition: Time to act. Washington
DC: World Bank, 2003.
Mejia Acosta A, Fanzo J. Fighting maternal and childmalnutrition: analysing the political and institutional
determinants of delivering a national multisectoral
response in six countries. A synthesis paper. Brighton,
UK: Institute of Development Studies, 2012.

Chapter Ten

The Power of Advocacy
128

Tom Arnold
Member of Lead Group of SUN
Former CEO Concern Worldwide

“The day hunger is eradicated from the earth, there will be thegreatest spiritual explosion the world has ever known. Humanity
cannot imagine the joy that will burst into the world on the day ofthat great revolution.” Federico Garcia Lorca, Spanish poet and dramatist (1889–1938)

129

Key messages

Advocacy is a key tool in the battle against
malnutrition.

Key messages

Advocacyrequiresa solidbase in order• Advocacy
is a key
toolevidential
in the battle
to succeed.
against malnutrition.
The
to present
a casein evidential
powerful and• ability
Advocacyrequiresa solidbasesimplelanguageis one of the prerequisites forin orderto succeed.
effective advocacy.
• The ability to present a case in powerful
Advocacy
is important,butis acting
and simple
languageone ofontheit is evenmoreprerequisites
so.
for effective advocacy.
Therewill be a is
great
work ofbut
advocacy
to be• Advocacy
important,acting on
it isdoneevenin thedecadestocome.
more so.
• There will be a great work of advocacy to
be donein the decades
to come.
Advocacy
is important,but acting
on it is even

Food and nutrition security have moved to the politicalcenter stage over recent years, both at national andinternational level. This chapter attempts to identify the key
political factors, the changing policy landscape and thepeople which and who have brought this about. The
particular focus of the chapter is the role and power of
advocacy in changing politics and policy. But while
advocacy has played an important role in this change, it is
the combination of shifting political priorities in response tochanges in the real world; evidence which demonstrates
costs and benefits of particular policies; insights into how
policy can be more effective; and the influence and use of
power by individuals which bring about real change.
I would like to try to identify some of the most significant
factors which have led to food and nutrition security
becoming a more important political issue in recent years.
This is not the definitive story: that would require a longer
and more comprehensive narrative. This is my subjective
and selective account of some of the main political andpolicy milestones which have got us to where we are.

more so.

The politics

There will be a great work of advocacy to bedone in the decades to come.

In 2008 food price riots occurred in over thirty countries.
This was the flashpoint which led to food security receiving
more serious political attention. The last time food security
was high on the political agenda was in the early 1970s
when a combination of crop failures, low stock levels andthe first Middle East oil crisis drove world food prices tounprecedented levels. But between 1974 and 2005, the FAO
index of real – inflation adjusted – food prices fell by 75%.
The simple explanation for this steady fall in real foodprices was that supply on world markets outpaced demandand prices fell. The increased supply was due to theincreased agricultural productivity from the Green
Revolution, mainly in Asia, and subsidized production fromthe developed world which was exported to world markets.
One consequence of steadily falling food prices was thatmany governments began to take food security for granted,
investment in agriculture declined and aid programs for
agriculture were reduced.
The last two decades of the 20th century saw big changes in
the global food economy, as economic growth rates in
China and India increased, bringing significant increases inthe demand for food and changes in food consumption
patterns. At the same time, agricultural productivity slowed,
both in developing and developed countries. These trends
led to tighter and more volatile food markets during theChapter Ten | The Power Of Advocacy | Tom Arnold

130

A farmer in Kenya
Source: CIAT

first decade of the 21st century, a situation accentuated bysevere weather events in some of the main agricultural
exporting countries.
World food prices increased dramatically in the 2005–2008
period, starting with a moderate upward trend until early
2007, and then accelerating to a peak in mid-2008. Pricesof cereals more than doubled during this time while theprice of rice doubled over a four month period in 2008. The
price of key inputs, particularly fertilizer, and fuel prices
increased fourfold in 2008.
This was the background which required political action
and policy change. In April 2008, the UN SecretaryGeneral, Ban Ki-moon, established a High Level Task Forceon Global Food Security, led by Dr David Nabarro, toprovide leadership and a coherent UN policy response to
the food price crisis. The Task Force produced theComprehensive Framework for Action (CFA), proposing a
set of short- and longer-term policy measures needed torespond to the food price crisis. The World Bank, the EU
and the 2008 G8 Summit all took action during 2008
through increased investment in agriculture.
In early 2009, the incoming Obama Administration increased
the political prioritization for agriculture and food security. It
introduced ‘Feed the Future’, a program aimed at increasing
food security in its partner countries, as a priority USAID
program. A further important influencer of policy within the
Obama Administration was Secretary of State Hillary Clinton,

who took a significant interest in early childhood nutrition,
particularly in promoting better nutrition for pregnant womenand for children up to two years, the so-called crucial 1,000
day ‘window of opportunity’.
The G8 Summit meeting in L’Aquila, Italy, in 2009 adopted
a major package valued at US$20 billion aimed at increasing
global food security. US government leadership was seen to
be important in reaching agreement on this, but there wasalso strong support from the EU and other G8 members.
While there was subsequent criticism that these G8
commitments made in 2009 were not fully delivered upon,
the G8 meeting of 2012 in Camp David, USA, returned tothe issue when they committed to a New Alliance for Food
Security and Nutrition, a partnership involving the G8, anumber of African governments and the private sector.
In addition, between 2009 and 2012, a number of the main
aid donor nations increased their support for food andnutrition security. Within the EU, the more notable
examples of this were the UK, the Netherlands, Spain and
Ireland. Canada was another important supporter forchange. Over this same period, the evolution of the G20
group of nations brought a potentially important newpolitical grouping, with some significant food producing
and exporting countries – for example Brazil and South
Africa – into the debate on the global food economy.

Chapter Ten | The Power Of Advocacy | Tom Arnold

131

The changing policy landscape
While the above-mentioned events represent some of thehigh-level political changes, the policy landscape was alsochanging in tandem. Indeed some of these policy changes were
underway well in advance of the 2008 food price crisis.
The policy changes on which I will focus are the following:• Significant Policy Change in Africa;• Changes in Nutrition Policy;

Significant policy change in Africa.
The Green Revolution in the 1960s and 1970s had rescued
Asia from the specter of major food shortages and had,arguably, laid some of the foundations for the region’s
economic development. However, for a variety of reasons,the Green Revolution had little positive impact in
sub-Saharan Africa. For the last three decades of the 20th
century, African agriculture experienced low productivity
growth, inadequate investment and significant neglect frompolicy-makers and political leaders.
The political recognition that this situation needed tochange came in 2003 when an African Union Summit
meeting in Mozambique adopted the Maputo Declaration
which committed African governments to spend 10 percent
of national budgets on agricultural and rural development.
Subsequently African leaders adopted the Comprehensive

Struggling African farmer
Source: Photo taken in 2010 in Kenya by Klaus Kraemer

African Agricultural Development Program (CAADP). The
goal of CAADP is to contribute to the elimination of hunger
and poverty through agricultural development. The aim isthat the investment of 10 percent of national budgets for
agriculture, allied to improved coordination of efforts, atthe continental, regional and national levels, should lead toan annual growth rate of 6 percent in African agriculture
by 2015.
In 2006, the Alliance for a Green Revolution in Africa(AGRA) was formed, aimed at increasing African
agricultural productivity and production. AGRA is financed
by a grant from the Bill and Melinda Gates Foundation andthe Rockefeller Foundation. The Board of AGRA is chaired
by Kofi Annan, the former UN Secretary-General.
The Copenhagen Consensus is an international project thatseeks to establish priorities for advancing global welfare using
methodologies based on the theory of welfare economics. The
project considers possible solutions to a wide range ofproblems, presented by experts in each field. These are
evaluated and ranked by a panel of leading economists.
The project has held conferences in 2004, 2008, 2009 and2012. The 2012 conference ranked bundled micronutrientinterventions the highest priority and the 2008 report
identified supplementing vitamins for undernourishedchildren as the world’s best investment.

Chapter Ten | The Power Of Advocacy | Tom Arnold

The Irish Hunger Task Force132

The Irish Hunger Task Force was established by the Irish
Government to identify how Ireland’s foreign policy and aid
budget could have the maximum impact on poverty andhunger. The Task Force started its work in September 2007
and produced its final report in September 2008.
The report examined the particular contribution that
Ireland can make in tackling the root causes of hunger,
especially in Africa. It concluded that hunger could best be
tackled by increasing the productivity of (mainly female)smallholder farmers in Africa; implementing programs focusedon maternal and infant undernutrition; and ensuring realpolitical commitment, at national and international levels, togive hunger the absolute priority it deserves.
The report recommended that Ireland, through its
government and civil society organizations, should seek toprovide leadership on hunger and nutrition issues atinternational level. The impulse was to try to make Ireland
to hunger what Norway was to conflict: Norway has a
50-year history of helping other countries to resolve
conflicts peacefully. With a deep folk memory of famine ona national scale, Irish people have a powerful motivation to
help other countries combat the scourge of malnutrition;
they also have credibility in the eyes of others.
The report was launched at the UN in September 2008 by
Taoiseach (Prime Minister) Brian Cowan and UN SecretaryGeneral Ban Ki-moon. In launching it, Taoiseach Cowan
said that ‘Ireland’s history and experience of famine echoes
through the generations and influences our approach inhelping those with whom we share our humanity in thefight against poverty and hunger’. The report quoted thewords uttered by the UN Secretary-General at the HighLevel Conference on World Food Security held in Rome on
June 3, 2008: ‘Nothing is more degrading than hunger,
especially when man-made. It breeds anger, social
disintegration, ill health and economic decline’.

The role of advocacy
This chapter has provided a limited narrative about the scaleand direction of change in thinking on food and nutrition
security over the past decade. Major changes in the global
food economy have provided the political backdrop to this. In
tandem with these changes, there have been significant shifts inpolicy, based on evidence that undernutrition had large humanand economic costs, and that nutrition interventions provided
high economic and social returns.

Staple grains on sale in a market place in Bangladesh, 2008
Source: Mike Bloem Photography

Advocacy has been a key tool in bringing about thesechanges. It is much more than simply articulating a caseabout a specific topic, although the power of reason,
analysis and expression is an essential component of it.
Advocacy involves articulating a case with a view toachieving a specific change in a proposed direction. Morethan this, it requires an understanding of the people andorganizations that might be able to effect this change, and agrasp of how to communicate with them and engage themfor the desired change. Advocacy is therefore more thanChapter Ten | The Power Of Advocacy | Tom Arnold

133

having a message: it is about understanding how to get thatmessage across and, crucially, following through so that atransformation is indeed achieved. This requires time, acommitment to dialog, and identification of the right people
to address.
This chapter has identified a number of the key documents
which have been effectively used by advocates in helping toachieve change. The World Bank’s policy document in 2006
on repositioning nutrition was very significant, particularly
for the focus it gave to the critical importance of goodnutrition during pregnancy and the first two years. The
Lancet series on nutrition in 2008 gave the world a new
way of looking at the subject of dietary intake, particularly
among mothers and young children, and a new language inwhich to discuss it. It also brought home to politicians
and policy-makers the scale of the cost of undernutrition
and the high economic and social returns of effective
nutrition interventions.
The Irish Hunger Task Force report was highly influential
for a number of reasons. It was produced at a time, justafter the peak of the 2008 food price crisis, when the world
was focused on food security. Its recommendations wereclear – there should be a greater focus on African
smallholder productivity and supporting women farmers: agreater emphasis on nutrition; and that Ireland should playa leadership role in advocacy in the fight against global
hunger. The fact that the Irish government accepted thatrecommendation about its advocacy role was also of
considerable importance.
The SUN Movement may indeed be seen as the culmination ofmany of these separate developments. Although the Movement
is not without its critics, it has provided a framework to tackle
undernutrition in the countries now committed to it, which
involves a range of stakeholders, including governments,
donors, civil society and the private sector. In terms of
coordination, it has had the benefit of strong leadership from
Anthony Lake, the Chair of the Lead Group, and Dr David
Nabarro, Coordinator of SUN.
These various developments have also changed the generalperception of malnutrition over the past decade.
Malnutrition used to be equated in the general imagination
with starvation. In fact, starvation only accounts forapproximately ten percent of the incidence of malnutrition
worldwide. The problem of chronic malnutrition is bothbigger and more complicated than many had previously
thought – bigger in terms of its scale, and longer-lasting interms of its impact. The world needs to be aware of this,and advocacy has done much to bring about a change ofperception on this score.
It is essential to understand that advocacy, while needing astrong evidence base, requires much more than this to beeffective. Messages have to be kept simple, clear and to thepoint, they have to be repeated and repeated, and theimpetus for transformation has to be maintained: policies
are not changed overnight. Moreover, even when a policychange has been effected, it will not bear fruit without
rigorous monitoring. One has to demonstrate whether achanged policy is having the desired results. If it is, it should

Chapter Ten | The Power Of Advocacy | Tom Arnold“Civilization as it is known today could nothave evolved, nor can it survive, without anadequate food supply.”– Dr Norman Borlaug
Norman Borlaug
Source: http://whatsthebigga.blogspot.co.uk/2011/02/greendaddy.html

be further supported. If it is not, it should be adapted or
abandoned. Proof of effectiveness is key.
By 2050, we are told the world’s population should reach 		
9 billion, placing greater pressures than ever on water, landand energy. The key international institutions dealing withfood and nutrition security – the UN Food and Agriculture
Organization, the UN World Food Program, theInternational Fund for Agricultural Development, theWorld Bank, the Committee for Food Security – have a
profound responsibility to work together to bring about
positive change. They are already collaborating moreclosely than they used to, but this collaboration needs to begreatly intensified, not only with each other but also withdonor governments, civil society organizations and leading
non-governmental organizations such as Concern
Worldwide, Helen Keller International, Bread for the Worldand Save the Children. There will be a great work of
advocacy to be done in the decades to come, using a robust
evidence base, simple messages and persistent effort tobring about the necessary changes to the way we live, lookafter the planet, and feed ourselves.

An exemplary advocate: Norman Borlaug
Widely remembered as the pioneer of the “Green
Revolution,” Nobel Peace Prize-winning American
agricultural scientist Norman Borlaug spent his career
seeking ways to improve crop production and fight hunger.
The Green Revolution, a series of technological advancesthat enabled developing nations to improve crop
production, often establishing agricultural self-sufficiency,
owes much to his revolutionary work.

Of Norwegian descent, Borlaug was born in 1914 on a
farm in Iowa, USA. He studied forestry and plant pathology
at the University of Minnesota, completing his PhD in plant
pathology and genetics there in 1942. After two years as a
microbiologist, he signed on to lead the Cooperative
Mexican Agricultural Program’s wheat improvement efforts
with the support of the Mexican government and theRockefeller Foundation.
It was during his work in Mexico that Borlaug developed
new varieties of wheat with special properties. Resistant todisease and high yielding, these were soon introduced inconjunction with cutting-edge agricultural technology not
only to Mexico, but also to Pakistan and India, where
demand for wheat was reaching alarming highs. In 1967,
India imported 18,000 tonnes of improved Mexican wheat
seed, with Pakistan following suit. As a result, between
1965 and 1970, the two countries nearly doubled theirwheat production, greatly improving food security.
Meanwhile, by 1963, Mexico had become a net exporterof wheat.
These remarkable success stories set off what came to be
known as the “Green Revolution” – the adoption of
improved crop varieties and the integration of newtechniques into previous agricultural practice in thedeveloping world. Borlaug himself went on to help apply
these methods of increasing food production to other Asianand African nations. The social and economic benefits ofthis movement were recognized worldwide when the Nobel
Peace Prize was awarded to Borlaug in 1970.
Sources:International Maize and Wheat Improvement Center (CIMMYT), Mexico
http://www.cimmyt.org/en/about-us/who-we-are
Rothamstead Research
http://www.rothamsted.ac.uk/Content.php?Section=AboutUs&Page=Borlaug
The Borlaug Institutehttp://borlaug.tamu.edu/about/dr-norman-e-borlaug

134Chapter Ten | The Power Of Advocacy | Tom Arnold

135

An inspiration to advocacy: The Great
Irish Famine of the 19th century
Ireland’s Great Famine, or The Great Hunger, as it is morecommonly referred to today, ranks among the worst
tragedies in human history. Between 1845 and 1850,
approximately 1.5 million Irish citizens died of starvationor malnutrition-related diseases.
The cause of the famine was a deadly new fungus,
Phytophthora infestans – to which there was then no
known antidote – which first attacked and partiallydestroyed the potato crop in Ireland in late summer 1845.
The nation’s peasants relied on the potato as their primary
food source, and as a result, starved. This blight was tocontinue over the next several years with the partial failureof the potato crop in 1849, and again in 1850, prolonging
the crisis and the suffering into the early 1850s.
By 1855, more than two million people fled Ireland to avoid
the fate of those who had died. The population of Ireland,
which was close to 8.5 million in 1845, had fallen to 6.6
million by 1851. It would continue to fall – due to relentlessemigration – for many decades to come. This decimation of
Ireland’s population makes Ireland’s Great Hunger both theworst chapter in the country’s history, and arguably, thesingle worst catastrophe in 19th century Europe.
Source: http://www.thegreathunger.org/

Famine memorial statue in present-day Ireland

A 19th century depiction of the Irish famineChapter Ten | The Power Of Advocacy | Tom Arnold

Case study

136

An integrated approach to combatting malnutrition

Project objective

The RAIN Project in Mumbwa District,ZambiaTo develop a sustainable model that integrates andrealigns agricultural and nutrition/health interventions toeffectively prevent child and maternal undernutrition
among rural poor communities, which can be replicatedand brought to scale.

In Zambia, 45% of children below five years of age sufferfrom chronic malnutrition, or stunting. The Government ofZambia recognizes the importance of prioritizing nutrition,
but undernutrition has multi-sectoral causes which
traditional impact pathways are often unable to address. The
links between nutrition, health, agriculture, food security
and livelihoods are well recognized, however, and there isincreasing agreement on the importance of multi-sectoral
approaches to sustainably address undernutrition.
The RAIN project, based in Zambia’s Mumbwa District,
Central Province, aims to do just this. By integrating
agriculture with nutrition and health interventions at all
project levels, it aims to improve nutritional status within
the critical 1,000 days from conception until a childreaches its second birthday.
Approximately 3,480 households with pregnant women
and/or children below two years of age are eligible. With
four intervention wards within Mumbwa District, andtwo adjacent wards selected as comparison sites, theoverall intervention area is randomized into smaller areasthat will receive either agriculture and nutrition/healthinterventions, or agriculture interventions only.
Agricultural activities focus on homestead gardening andsmall-scale animal husbandry; nutrition and healthactivities focus on behavior change communication forimproved child and maternal nutrition, and linkages tothe existing health system.
Concern Worldwide Zambia and the International Food
Policy Research Institute (IFPRI) collaborated to design andimplement this project together with key line ministries, andlocal NGOs. Irish Aid and the Kerry Group are both project
funders. Concern leads the overall implementation, while
IFPRI leads the learning and evaluation component andtechnically supports the integration component. With local
support ensuring ownership and sustainability, this is an
example of a feasible project model that can be scaled-up
and replicated in other areas of Zambia or within the region.

Specific objectives
1) To reduce the prevalence of chronic malnutrition among
young children and improve the nutritional status of
pregnant and lactating women in Mumbwa District
through targeted interventions during the first 1,000 days.
2) To realign and integrate activities and mechanisms within
the Ministries of Agriculture and Health, especially atDistrict level, to more effectively and efficiently achievesustainable nutritional outcomes.
3) To use and share evidence generated at the District toinfluence the local, national and international policy
agenda to prevent child stunting.

Target groupHouseholds with children under two years of age, lactating
and pregnant women; some activities will include men andthe wider community. The RAIN project will ensure theinclusion of extremely poor and vulnerable households.
Number of direct beneficiaries
3,480 households or approximately 20,500 people
Project duration2011 – 2015
Project area
Nalubanda, Shichanzu, Chona and Milandu Wards in
Mumbwa District, Central Province, Zambia
Implementing partners
Ministry of Agriculture and Livestock, Ministry of
Health, Mumbwa Child Development Agency, Women for
Change, International Food Policy Research Institute(IFPRI), and Concern Worldwide Zambia

Project title

Project funding

Realigning Agriculture to Improve Nutrition (RAIN)

The overall budget is approximately 3 million euros,
which partially is funded by Irish Aid, Kerry Group/Ireland.
Source: RAIN Project Brief no. 1, November 2011

Chapter Ten | The Power Of Advocacy | Tom Arnold

World Population: 1950-2050
10

9

9

8

8

7

7

Population (billions)

6

6

5

5

4

4

3
3

2

1

Source: U.S. Census Bureau, International Data Base, December 2009 Update

2050

2040

2030

2020

2010

2000

1990

1980

1970

1960

0

1950

137

Year

The growing place of nutrition on the global agenda
1992 – The UN Food and Agricultural Organization’s‘World Declaration and Plan of Action for Nutrition’
The World Declaration and Plan of Action for Nutrition
arose from the FAO’s 1992 International Conference on
Nutrition in Rome. Representatives of 159 states declared
their determination to eliminate hunger and reduce allforms of malnutrition, stating: “Hunger and malnutrition
are unacceptable in a world that has both the knowledge
and the resources to end this human catastrophe.”At the conference, delegates came up with a ‘Plan of Action
for Nutrition’ designed to provide guidelines forgovernments, NGOs, the private sector, local communities
and families to help them achieve the outlined objectives.
The plan of action contained recommendations on policies,
programs and activities resulting from an intensive
consultative process.

Chapter Ten | The Power Of Advocacy | Tom Arnold

2000 – The United Nation’s Millennium
Development Goals
The Millennium Development Goals (MDGs) of the United
Nations are eight international development goals to beachieved by the target date of 2015, agreed by all 193
United Nations member states, and the world’s leading
development institutions.

health and development agendas. It provided an evidencebased call to action, which showed that the first 1,000 daysof a child’s life are a ‘window of opportunity’, where
actionable nutritional interventions can make a significant
difference. Global advocates were able to cite this important
evidence to lobby policy-makers and opinion leaders toprioritize and invest in nutrition – this led to the foundationof the Scaling Up Nutrition (SUN) Movement.

1. Eradicating extreme poverty and hunger
2. Achieving universal primary education
3. Promoting gender equality and empowering women
4. Reducing child mortality rates
5. Improving maternal health
6. Combating HIV/AIDS, malaria, and other diseases
7. Ensuring environmental sustainability and8. Developing a global partnership for development

According to the Global Alliance for Improved Nutrition(GAIN), while nutrition is not specifically included within
the UN’s Millennium Development Goals, it has a direct
impact on at least 7 out of the 8.
2008 – The Copenhagen Consensus
The Copenhagen Consensus is a project that exists toestablish priorities for advancing global welfare, applying
welfare economics to proposed interventions. It has held
regular conferences since 2004.

2010 – Scaling Up Nutrition (SUN) Movement
The SUN Movement is a response to the evidence-based
call to action of the 2008 Lancet Series on Maternal andChild Undernutrition.
In 2010 a diverse coalition including the World Bank, UN
agencies and the Centre for Global Development releasedthe ‘Scaling Up Nutrition Framework for Action’, outlining
plans to integrate nutrition interventions and policies acrosssectors. The SUN Movement now includes 40 countries
that could in theory reach an estimated 60 million children.
The SUN Movement is a ‘country-led, global effort’,
focusing on nutrition in the first 1,000 days of a child’s life.
As its 2012-15 Movement Strategy states:“Good nutrition in the 1,000 days between pregnancy anda child’s second birthday is vital preparation for a healthy
adult life with maximum learning and earning potential
combined with greatly reduced risk of illnesses like diabetes
and heart disease.”

The 2008 Copenhagen Consensus report identified
supplementing vitamins for undernourished children as theworld’s best investment.
The 2012 conference ranked bundled micronutrientinterventions as the highest priority and committed
US$75 billion over four years to this strategy.

2008 – The Lancet Series on Maternal and Child
Undernutrition
The Lancet Series on Maternal and Child Undernutrition in2008 was a wake-up call for the international community.
It stated in its Executive Summary:“Nutrition is a desperately neglected aspect of maternal,
newborn, and child health. The reasons for this neglect areunderstandable but not justifiable.”
The series concluded that a shared approach was needed inorder to ensure that nutrition was incorporated into global

The Scaling Up Nutrition movement brings together governments, non-governmentalorganizations, academia, business and civil society in a multi-sectoral approach to the
problem of malnutrition

138

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139

The 2012 Copenhagen Consensus
The goal of Copenhagen Consensus 2012 was to set
priorities among a series of proposals for confronting ten
great global challenges. The ten challenge papers,
commissioned from acknowledged authorities in each areaof policy, included nearly 40 proposals for the panel’s
consideration. Based on the costs and benefits of thesolutions, the panel ranked the proposals in descendingorder of desirability.
The Copenhagen Consensus 2012 Expert Panel found thatfighting malnourishment should be the top priority forpolicy-makers and philanthropists. Nobel laureate
economist Vernon Smith said: “One of the most compellinginvestments is to get nutrients to the world’s undernourished.
The benefits from doing so – in terms of increased health,schooling, and productivity – are tremendous.”
New research by John Hoddinott et al. of the International
Food Policy Research Institute showed that for just $100
per child, interventions including micronutrient provision,
complementary foods, treatments for worms and diarrheal
diseases, and behavior change programs, could reducechronic undernutrition by 36 percent in developing
countries. Research by Peter Orazem of Iowa State
University pointed to the educational benefits of thisspending, because malnutrition slows learning.

2012 – The UN Secretary General’s High-Level Panel ofeminent persons on the post-2015 Development Agenda
In July 2012, Secretary-General Ban Ki-moon announced
the 27 members of a High-Level Panel to advise on the
global development framework beyond 2015, the target
date for the Millennium Development Goals (MDGs). The
Panel was co-chaired by President Susilo Bambang
Yudhoyono of Indonesia, President Ellen Johnson Sirleaf of
Liberia, and Prime Minister David Cameron of the United
Kingdom. It includes leaders from civil society, private
sector and government.
The Panel was part of the Secretary-General’s post-2015
initiative mandated by the 2010 MDG Summit. UN
Member States had called for open, inclusive consultations
involving civil society, the private sector, academia andresearch institutions from all regions, in addition to the UN
system, to advance the development framework beyond
2015. The work of the Panel reflected new development
challenges while also drawing on experience gained in
implementing the MDGs, both in terms of results achieved
and areas for improvement. The Panel’s work was closely
coordinated with that of the intergovernmental working
group tasked to design sustainable development goals, as
agreed at the Rio +20 conference.

Illustrative goals and targets post-2015
1

End Poverty

7

Secure Sustainable Energy

2

Empower Girls and Womenand Achieve Gender Equality

8

Create Jobs, Sustainable Livelihoods
and Equitable Growth3

Provide Quality Educationand Lifelong Learning

9

Manage Natural Resource
Assets Sustainably

4

Ensure Healthy Lives

10 Ensure Good Governanceand Effective Institutions

5

Ensure Food Security and Good Nutrition

11 Ensure Stable and Peaceful Societies

6

Achieve Universal Accessto Water Sanitation

12 Create a Global Enabling Environment& Catalyse Long-Term Finance

The report of the High-Level Panel of Eminent persons on the post-2015 Development agenda. http://www.post2015hlp.org/

Chapter Ten | The Power Of Advocacy | Tom Arnold

2013 – The Lancet 2013 Series onMaternal and Child Nutrition

140

In June 2013, The Lancet published an updated review ofthe status of maternal and child nutrition worldwide. Fiveyears after the initial series, its authors re-evaluated the
problems of maternal and child undernutrition and also
examined the growing problems of overweight and obesity
for women and children and their consequences in
low-income and middle-income countries (LMICs). Manyof these countries are said to have the double burden of
malnutrition— continued stunting of growth anddeficiencies of essential nutrients along with the emerging
issue of obesity.
The authors also assessed national progress in nutrition
programs and international efforts toward previous
recommendations. They observed that: “The nutrition
landscape has shifted fundamentally since 2008. The 2008
Series showed that the stewardship of the nutrition system
was dysfunctional and deeply fragmented in terms of
messaging, priorities, and funding. Much progress has been
made since then, largely driven by the new evidence
introduced in the 2008 Series, which identified the first
1,000 days of life as the window for outcomes, pinpointed
a package of highly effective interventions for reduction ofundernutrition, and proposed a group of high-burdencountries as priorities for increased investment.”

The 2013 Lancet Series on Maternal and Child Undernutrition builds
on the ground-breaking work of the series published five years
previously
Source: http://www.thelancet.com/series/maternal-and-child-nutrition, June 20132013 – Global Nutrition for Growth Compact
In June 2013, UK Prime Minister David Cameron, Brazilian
Vice President Michel Temer and the Children’s Investment
Fund Foundation president Jamie Cooper-Hohn led a highlevel summit in London of developing and developed nations,businesses, scientific and civil society groups, committing themto supporting a historic reduction in “undernutrition”.

Donors secured new commitments of up to £2.7 billion(US$4.15 billion) to tackle undernutrition up to 2020,£1.5 billion ($2.9 billion) of which is core funding with theremainder secured through matched funding. The UKcommitted an additional £375 million of core funding and£280 million of matched funding from 2013 to 2020.

The participants – who signed a Global Nutrition for
Growth Compact – committed their countries andorganizations by 2020 to:

Source: https://www.gov.uk/government/news/world-leaders-sign-globalagreement-to-help-beat-hunger-and-malnutrition• improving the nutrition of 500 million pregnant women andyoung children• reducing the number of children under five who are stunted
by an additional 20 million• saving the lives of at least 1.7 million children by preventing
stunting, increasing breastfeeding and better treatment ofsevere and acute malnutrition

Chapter Ten | The Power Of Advocacy | Tom Arnold

141

My personal view
Tom Arnold

Member of Lead Group of SUN
Former CEO Concern Worldwide

Food and nutrition security has
significantly moved up the national
and international political agenda inrecent years. High food prices in
2007-08 and the political unrest
which followed were importantfactors in this changed prioritization.
But strong evidence that inadequate
nutrition, particularly for pregnant women and children
up to the age of two years, produces physical and mental
stunting of children, with long negative long-term human,economic and social costs, has also been influential inchanging policy. Drawing on both the changing
geopolitics of food and the powerful evidence, effective
advocacy has contributed to political and policy change.
This changed environment provides a major opportunity
over the coming 5–10 years to make significant inroads
in reducing hunger in the world. The latest figures suggest
there are 872 million hungry people and 165 million
stunted children. An important political and policy
mechanism for achieving progress is the Scaling Up
Nutrition (SUN) Movement, which brings together
governments, civil society, and the private sector to workin a coordinated way to reduce early childhood
undernutrition. As at July 2013, 41 countries havecommitted to scaling up their nutrition efforts, including
developing country plans. These plans should reflect
political leadership from a high level, as well as
engagement with civil society and business, and theyshould specify the level of financial and human resources
necessary. We need to learn what works best across these41 countries, and to share that learning. Real progress
can be made over the next decade if we deliver on what
we know is possible.

Further reading
Hunger task force: Report to the Government of
Ireland.
Food and Agriculture Organization. The State ofFood Insecurity in the World. Rome: FAO 2012.
The SUN Movement website: www.
scalingupnutrition.org
UNICEF. Improving Child Nutrition: The achievable
imperative for global progress. New York, NY, USA:
UNICEF, 2013.
Concern Worldwide website: www.concern.net.
Fan S. 2011 Global Food Policy Report, International
Food Policy Research Institute 2012.

Chapter Eleven

The Power of Innovation
142

Alain Labrique
Director, JHU Global mHealth Initiative; Assistant Professor, Department of International
Health & Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD, USA

Marguerite B Lucea
Research Associate, Department of Community and Public HealthJohns Hopkins School of Nursing
Baltimore, MD, USA

Alan Dangour
Senior Lecturer, Department of Population HealthLondon School of Hygiene & Tropical Medicine (LSHTM) London, UK

“Discovery consists of seeing what everybody has seen andthinking what nobody has thought.”
Albert von Szent-Gyorgy

143

Key messages
For centuries, innovations across the entire spanof human nutrition, from plant to population, havetargeted aspects of the farm-to-table continuum.
• For centuries, innovations across theThrough these innovations, humans have sought
entire span of human nutrition, from plantways to improve mechanisms to assess,to population, have targeted aspects ofunderstand and meet nutritional requirements,
the farm-to-table continuum. Throughboth locally and globally.
these innovations, humans have sought
Recenttransformative
innovations targetingways
to improve mechanisms
to assess,
distribution
systems,leveraging
public-private
understandand meetnutritional
partnerships,
andutilizing
technologicalrequirements, both locally and globally.
advances have the potential to catalyze research• Recent transformative innovations targetingand improve nutrition in both the developed anddistribution systems, leveraging publicdeveloping world.
private partnerships, and utilizing
technological advances have the potential
to catalyze research and improve nutrition inboth the developed and developing world.

Key messages

Introduction
In a world of over 7 billion people today, access to sufficientnutrition plays a crucial role in the well-being of the
population. Currently, nearly 45 percent of deaths inchildren under age 5 can be attributed to nutrition-related
factors. Others, who are undernourished but survive, face
health concerns such as stunted growth and limited
neurodevelopment, which impact livelihoods in adulthood.
Sir Gordon Conway, one of the world’s foremost experts on
global food needs, has stated: “Hunger is a daily reality fornearly a billion people. More than six decades after thetechnological discoveries that led to the Green Revolution
aimed at ending world hunger, regular food shortages,
malnutrition, and poverty still plague vast parts of the world.”
Innovation is essential to alleviate this enormous burden, as
it seeks to improve the mechanisms necessary to meet thedemands associated with the growth of the world’s
population and to thwart the morbidity and mortality
associated with malnutrition in children and adults.
Innovation in nutrition has occurred since the planting of
the first seeds intended to grow food for consumption. In
early agricultural societies, the selection of crops directly
affected the well-being of local populations, and local
solutions were developed for local problems. In the 21st
century we live in an interconnected society faced withclimate change and an ever-growing population. Increasing
yield, enhancing nutritional quality, ensuring diversity ofcrops and improving access to nutritional interventions
have become global priorities. At the same time, we arechallenged to define specific nutritional needs anddeficiencies at a population level so that programs andpolicies are responsive to local and regional needs.
This chapter presents examples of innovations that target
aspects of the farm-to-table continuum, from plant topopulation. Recent potentially game-changing innovations
are discussed that target distribution systems, leverage
public-private partnerships, and utilize technologicaladvances. We first present innovations in production anddistribution mechanisms. We then discuss collaborations in
the food industry as a mechanism to create an enabling
environment for enhanced nutrition. We also review
technological innovations that have improved the areas ofdiagnostics, delivery, and communication. We close with a
discussion of new frontiers and directions that further
address sustainable nutrition in the world today.

Chapter Eleven | The Power of Innovation | Alain Labrique, Marguerite B Lucea, Alan Dangour

Farm-to-table continuum
The five steps in the farm-to-table continuum provide several
access points for nutritional innovations (see Figure 1).
Throughout the chapter, we refer to this continuum, in
terms of both existing and potential innovations. Many
innovations couple one aspect of the continuum withanother, illustrating that the innovations along thecontinuum are most effective when not directed at one
aspect in isolation. For ease of reference, each case study
title contains the stages along the continuum most relevantto the given innovation.

Production
Farm production is the first stage in the continuum. In the pastwhen facing food deficits, the focus of innovation was on
simply producing an increased yield of staple crops such as
wheat and rice. However, surpassing the growth of demandwith greater production is a necessary but not sufficient
response for modern societies. The focus has turned tohighlight the nutritional benefits provided with a greater
variety and diversity of food as well as the economic
enhancement this diversity can bring to individuals,
corporations, and governments. In 2011, Rachel Nugent

noted that if farm and food systems are to meet human needs
and contribute to human health and longevity, they must
produce affordable, diverse, and healthy food. Decisionmakers at all levels, both public and private, must participate
in steering the food environment in such a direction*. As aconsequence, the priority agenda of donors and governments
has become one that increases not only the quantity but also
the quality and diversity of food production.
As a mechanism for altering food production in a sustainable
manner with more nutritional options, some innovations havebeen developed to combat malnutrition and related healthconcerns that are specific to certain geographic localities. The
first example is the development of β-Carotene-rich orangeflesh sweet potatoes, which have been biofortified throughconventional breeding rather than through transgenic
approaches. These biofortified potatoes have been introduced
in regions with populations suffering from vitamin A deficiency
and have been found to be an effective way of reducing
deficiencies in women and children (see Case Study 1).
A second case study presents an innovation in the fortificationof rice (see Case Study 2).
Souce: *Bringing agriculture to the table, Rachel Nugent, The Chicago Council on
Global Affairs, USA, 2011

The farm to table continuum

FarmTransportation

Processing
Source: USA Federal Drug Administration

Table

Retail144

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145

Case study 1
Continuum: Production and Table
β-Carotene rich orange sweet potatoes
Vitamin A deficiency (VAD) is a global problem, estimatedto affect over 200 million women and children and toaccount for over 600,000 deaths globally each year amongchildren under 5 years of age. Deficiency in vitamin A
increases the risk of mortality, xerophthalmia and night
blindness. Even subclinical deficiency can lead to increased
risk for infections, severe diarrhea, and anemia. African
regions account for the greatest number ofpreschoolchildren with night blindness and for more than
one quarter of all children with subclinical VAD.
Sweet potato remains a major staple food in several
African countries. A preponderance of the varieties grown
are white or pale yellow and contain no or relatively little
provitamin A carotenoids.In contrast, orange-fleshedvarieties of sweet potato (OSP) can contain large amountsof β-Carotene, which is a precursor for vitamin A.
Recently several large-scale intervention programs were
implemented in Mozambique and Uganda to evaluate theimpact of introducing orange sweet potato rich in
β-Carotene to rural communities.
Mozambique is a country with modest use of sweet potato
as a staple food. A 3-year-long, large-scale intervention inrural communities of Zambezia Province integrated threemajor components. An agricultural component supported
the distribution of vines as planting material for OSP andprovided training. A demand creation/behavior change
component included education on maternal and childhealth and nutrition topics targeted to women inparticipating households and a campaign for the generalpublic to raise awareness of the benefits of OSP as asource of vitamin A through community drama, field-day
events and radio spots and programs. A marketing andproduct development component included training for
OSP traders and the establishment of distinct market stalls
selling and providing information on OSP. Theintervention successfully integrated OSP into the diet of
women and children and significantly increased theadequacy of vitamin A intake. No significant differences
existed between more or less intensive intervention
designs, indicating that future interventions can use lessintensive models with the same success.
The large-scale intervention in Uganda resulted in asignificant increase in the dietary intake of OSP amongchildren and women in farmer group member households.
This resulted in a substantial increase in total vitamin A
intake from β-Carotene in all three age groups. It also
resulted in a significant decrease in the prevalence of
inadequate vitamin A intake among non-breastfed
12-35-month-old children. These children are at elevatedrisk of VAD, as breast milk is the primary source ofvitamin A and the vitamin A requirements for this groupare still relatively high; therefore this finding wasparticularly important. Increased vitamin A intake from
OSP led to improved vitamin A status in children andwomen and reduced the prevalence of marginal vitamin A
status in children by nearly 10%.
Because sweet potato is a seasonal crop, this type ofintervention will not provide the same amount ofadditional vitamin A throughout the entire year. However,in these communities, sweet potato is harvested 2 to 3
times per year, and OSP would be available for around 9
to 10 months of the year.
(Sources: ‘A large-scale intervention to introduce orange sweet potato inrural Mozambique increases vitamin A intakes among children and women’
Christine Hotz, Cornelia Loechl et al. Published in the British Journal of
Nutrition, 2011.
‘Introduction of β-Carotene-Rich Orange Sweet Potato in Rural Uganda
Resulted in Increased Vitamin A Intakes among Children and Women and
Improved Vitamin A Status among Children’ Christine Hotz, Cornelia
Loechle et al. Published in the Journal of Nutrition, 2012.
Low JW, Arimond M, Osman N, Cunguara B, Zano F, Tschirley D. A
Food-Based Approach Introducing Orange-Fleshed Sweet Potatoes Increased
Vitamin A Intake and Serum Retinol Concentrations in Young Children in
Rural Mozambique. Journal of Nutrition. 2007. 137(5):1320-7.)

The β-Carotene-rich sweet potato has a characteristicorange-colored flesh

Chapter Eleven | The Power of Innovation | Alain Labrique, Marguerite B Lucea, Alan Dangour

Case study 2
Continuum: Production, Transportation,
Retail and Table
Ultra Rice® Technology
PATH is an international nonprofit organization whose
work focuses on transforming global health throughinnovation. The organization’s Ultra Rice® technology isdesigned to be an effective micronutrient delivery systemthat is culturally appropriate and cost-effective. It uses awarm extrusion process to make rice grains from rice flour
fortified with vitamins and minerals, including iron, zinc,thiamin, and folic acid. The extruded grains called Ultra
Rice® resemble normal rice in size, shape, and color. Whenmixed with milled rice, usually at a 1:100 ratio, the fortified
rice is nearly identical to traditional rice in smell, taste, andtexture. Because the added micronutrients are inside thegrains, they are less vulnerable to nutrient loss during
preparation and cooking.
In India, a large local miller, Usher Agro, now has thecapabilities to produce Ultra Rice®. At the same time, PATH
is working within the state systems to widen the distributionof fortified rice within India’s public-sector food programs.
This work encompasses the Public Distribution System,
which provides subsidized commodities to families below
the poverty line.
In Brazil, Urbano Agroindustrial is one of the country’s
largest rice millers. PATH has transferred the Ultra Rice®
technology to this miller. In conjunction with the Global
Alliance for Improved Nutrition (GAIN), an organization
dedicated to fostering private sector investment in
adaptation to climate change, PATH and Urbano will be
introducing fortified rice through commercial retailers,
accompanied by a social marketing campaign to enhancedemand for the product.
These case studies illustrate how innovations implemented at
the production level can be coupled with enhancements to
subsequent steps in the continuum, including processing,transportation, retail and table, to directly address
malnutrition. Fortified rice and orange-flesh sweet potato areboth good examples of how improved production, in
conjunction with robust, targeted population supplementation
strategies, stands to increase the pace of progress against
malnutrition and its consequences. To bolster the uptake of
OSP, production was combined with a marketing strategy for
OSP traders, dedicated market stalls for OSP sellers, andcommunity education efforts for consumers. Partnering

146

In Burundi, PATH has partnered with World Vision to
distribute fortified rice to children through a school meal
program. Supplementing the program, supported by theWorld Food Program (WFP), with fortified rice aims to
improve nutritional status of children who participate. The
impact in this country can provide data to support inclusionof Ultra Rice® as an approved commodity for the WFP.
Source: PATH, www.path.org, (June 2012. Ultra Rice® is a registered US
trademark of Bon Dente International, Inc.).

NutriRice™ Technology
A similar technology, created by DSM, uses hot extrusion tocreate fortified rice kernels with encapsulated
micronutrients. As compared to some other fortified rice,these grains look, taste and behave exactly like normal rice,and the embedded nutrients are well protected during
washing and cooking. The recomposed, vitamin-andmineral-enriched rice kernels have shown demonstrated
success in being incorporated into the usual diet. Thoseingesting the fortified rice have also seen improvement inhealth. In Beijing, the Chinese Center for Disease Control
and Prevention implemented a pilot project wherein they
introduced NutriRice™ into a school’s meal plan. The
students ate NutriRice™ and vitamin-A-enriched oil andiron-enriched soy sauce for eight months. The students’nutritional condition was improved, and micronutrient
deficiencies were reduced by 50%.
Similarly, in Bangalore, India, schoolchildren aged 6-12
participated in a trial of NutriRice™. After six months,
the children who were eating NutriRice™ had improved
vitamin B levels, and they experienced improvements inphysical performance, particularly pertaining to endurance.
Source: A breakthrough in rice fortification http://www.dsm.com/en_US/nip/public/home/pages/productsservices-nutririce.jsp

UltraRice™ with school meal programs (in Burundi) andgovernment and non-government distribution channels (India
and Brazil) coupled production with other components of thecontinuum. Aiming to establish an agriculture system that is
highly productive, stable, resilient and equitable with explicit
recognition of the critical role of smallholder agriculture isessential. Small-scale agriculture is once again playing animportant role in production that supports diverse food choices
and improved nutrition. Women are becoming more prominent
players in successful agricultural initiatives. Empowering womenin successful farming at local levels improves both their healthand their children’s health (see Case Study 3).

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147

Case study 3
Continuum: Production and Table
Women in small-scale agriculture
Helen Keller International (HKI) is well known in
Bangladesh for its homestead food production (HFP)
program. The program seeks to improve nutritional
outcomes for women and children through promoting
small-scale agriculture among women. Nutritional
outcomes of interest include dietary diversity andknowledge of maternal self-care and infant/young childfeeding practices.
The program was introduced in Bangladesh two decadesago, targeting women with limited land and promoting
an integrated package of home gardening, small
livestock production, and nutrition education. The
program’s design specifically seeks to combat
micronutrient deficiencies, including vitamin A, broughton by food insecurity and dietary monotony over time.
Project monitoring and evaluation data show that thiswork has directly benefited more than five million people
in rural Bangladesh. Among HFP farmers, vegetable yields
have improved greatly. At the “table” stage of the
farm-to-table continuum, HFP monitoring has shown amarked increase in the household-level consumption of
micronutrient-dense foods, particularly of iron- andvitamin-A-rich dark green leafy vegetables and eggs.

Distribution
Innovations to bridge the gap between production, market
availability, and household consumption can improve thediversity of choices available to consumers in remote, rural
populations. Yet, distribution is often seen as merely ameans to an end rather than a means to grow, develop andinnovate in the domain of nutritional access. Yet it is in thephases of the continuum that involve distribution (processing,transportation, and retail) where innovation has yielded
potentially life-saving initiatives in the field of nutrition.
One of the best illustrations of innovation in the area of
distribution also highlights how partnerships can yield
untold health and nutritional benefits. In this example,
pre-existing private-sector supply chain systems were
utilized to deliver health promotion commodities, keeping
the costs low but the coverage extensive. The ColaLife
project leveraged Coca-Cola’s existing distribution systems
to piggy-back the distribution of AidPods in a simple, smart
manner that ensured oral rehydration kit coverage in themost remote communities in Zambia (see Case Study 4).
While oral rehydration could be considered more of a healthintervention, similar partnerships could be leveraged to include
nutritional products such as micronutrient supplements.

Source: Hillenbrand, Emily (2010). Transforming gender in homesteadfood production. Gender & Development, 18(3), p411-425.

Aidpods utilizing the Coca-Cola distribution system
Source: A Refreshing Development by Andrew Marshall, Development Asia
www.development.asia, January–March 2012.

A woman farmer at work in Bangladesh
Source: CIAT

Chapter Eleven | The Power of Innovation | Alain Labrique, Marguerite B Lucea, Alan Dangour

Case study 4
Continuum: Transportation
Medicine via Coca-Cola“In remote, impoverished places where clean water andmedicine are hard to find, people can still buy a Coke. In
1988, when Simon Berry was a British aid worker in Africa,
he made two observations that would change his life.
“Fact 1: In remote parts of Zambia, where families
scratched out a subsistence living by farming, many
young children died of preventable diseases, such as
dehydration from diarrhea.
“Fact 2: In these same rural areas, you could almost
always buy Coca-Cola.”
Berry, then a technical cooperation officer for the British
aid program, posed a question of possible connections:“Could Coca-Cola’s unrivaled local distribution networks
be harnessed to deliver simple but potentially life-saving
medicines to hard-to-reach places?”“Twenty years later, in a concerted attempt to answer thatquestion, Berry and his wife Jane launched an independent
non-profit organization called ColaLife. The organization’s
goal was to leverage Coca-Cola’s distribution channels tocarry so-called social products – oral rehydration solution(ORS), zinc supplements, water purification tablets – thatlast mile in an effort to save lives.”
They developed the AidPod: a crush resistant, wedgeshaped canister that fits snugly between the necks of the
Coca-Cola bottles when in their crates. By using theunused space, the products can reach the same places that
Coca-Cola does. Rather than reinventing the process, theyfound a pre-existing, efficient mechanism to distribute thekits to the most remote of locations.
Source: A Refreshing Development by Andrew Marshall, Development Asia
www.development.asia, January–March 2012.

Collaboration
Collaboration between public and private sectors has had an
unprecedented global impact on health in areas such as
vaccine delivery and medication access, but this synergy has
just begun to grow in the field of nutrition. At this point, thepotential opportunity for harnessing public-private
collaboration exists in several forms, including developing
food products and systems, scaling up effective nutrition
solutions, providing sustainable cost-effective solutions for
information sharing, and conveying much-needed educational
messages to consumers. Inroads to improve health andnutrition outcomes could be made on a global scale and canbe enacted at all stages of the continuum.
However, these partnerships have been slow to grow. At the
Building Effective Partnerships for Improved Nutrition
meeting in 2012, companies, donors, researchers, and funders
assessed the barriers and explored the potential for innovative
partnerships. Several barriers were identified but were notinsurmountable, provided buy-in from both sides could be
garnered. Partnerships would need to develop sharedobjectives and mutually meaningful targets. In order toaccomplish scalability, the food industry would need toconsider corporate social responsibility (CSR) projects as corerather than supplemental strategies. For the partnerships andinitiatives to be sustainable, firms need to see a valuable
return on investment (ROI) through sustained demand while
the public partners would need to see improved health andcapacity strengthening at the local level.
Private sector innovations in product development,
manufacturing, financial sustainability, message delivery,
behavior change and distribution can be applied to publichealth nutrition strategies. In Case Study 4, a public-private
partnership between Coca-Cola and ColaLife has resulted in
improved distribution of essential oral rehydration anddiarrhea prevention kits. Such a partnership could also be
used to distribute interventions more directly relevant tonutrition such as micronutrient supplements.
Successful innovations identify opportunities of value to boththe private sector and the public health community.
Collaborations between corporations and initiatives for public
nutrition expand the value of the corporations’ brands andpotentially expand the consumer base for the other products
manufactured by the company. An important caveat in thisrealm, however, is the potential for conflict of interest, where
public health programs are concerned about exposing alreadyvulnerable populations to commercial exploitation. In aneffort to find a more equitable and agreeable bottom-line, aninnovative financial model in the private sector is thelong-term investment known as ‘patient capital’, where
investors do not expect a quick return on their initialinvestment (see Case Study 5).

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Case study 5
Continuum: Farm
Acumen Fund
Acumen Fund is a venture capital fund that invests inenterprises dedicated to serving poor people in developing
countries. Patience regarding the speed in which the ROI is
felt has shown to pay off in the long run. Founder andchief executive Jacqueline Novogratz believes that suchpatience pays, giving the example of an investment
Acumen Fund made into an international development
project in India.
“In 2002, after nearly ten years of running a nonprofit tohelp poor farmers in India get the most out of their land,
Amitabha Sadangi was frustrated. Government aid toalleviate poverty had largely bypassed individuals earning
less than $1 day. Instead, it was subsidizing large farms
and being invested in technology he said his farmers didn’twant. Sadangi sought to treat the poor as customers, notpassive recipients of charity. He decided he would adapt awater-saving drip irrigation system to the specific needs ofIndian smallholders and sell it at an affordable price.
“Acumen Fund gave Sadangi’s nonprofit International
Development Enterprises India a US$100,000 grant andloans to experiment. In 2006, we invested $1 million in
equity in Global Easy Water Products (GEWP), a
for-profit spinoff Sadangi created in western India tofurther increase the technology’s reach among the poorand sell other products to them.
To date, GEWP and its parent nonprofit have sold
irrigation systems to some 350,000 farmers. Including thefarmers’ family members, roughly 2 million people are
now benefiting from higher income levels- for some, $5 to$6 a day instead of $1 to $2. With 101 employees andsales that have tripled since 2008, GEWP is now one of
Acumen’s most profitable enterprises. It has even begun topay dividends to its shareholders. By all measures, that is
the kind of return on investment we need to see in a world
with more than 2 billion people living in poverty.”
Source: (Bloomberg Businessweek, The Case for Patient Capital, May
2011, http://www.businessweek.com/smallbiz/content/may2011/
sb20110524_877194.htm

With private-public partnerships, some debate exists overwhether patents should be allowed on life-saving foodsupplements or other innovations. A balance may be able
to be achieved if the ROI is sufficient for firms, but not
being able to patent an innovation may reduce the
incentive to develop such supplements in the private sector.

Technology
In our efforts to satisfy the nutritional needs of the world’s
growing population, we put significant pressure on the
resources of our planet as well as on agricultural systems anddistribution networks. At the same time, if nutritional needsof populations are not addressed, the healthcare systems andbudgets of nations will come under intense stress as thecomplications of malnutrition are addressed in acute andchronic care. The systems are interconnected andinterdependent. For instance, agricultural systems may beaffected by climate extremes (droughts and floods), a deficit ofmanual labor, a lack of technical resources, or a lack ofexpertise. Healthcare systems, meanwhile, might be impacted
by lack of trained staff and equipment and an influx ofpatients with nutrition-related illnesses as well as
communicable and non-communicable diseases. While
technology is not the universal panacea, technologicalsolutions have been developed that have potential to bringabout positive and much needed change in several of thesesystems and at many stages of the farm-to-table continuum.
This section examines technological innovation in terms of
diagnostics, treatment and delivery (food fortification,
supplementation and increasing dietary diversity),
and communications.

Diagnostics
Anticipating complex nutritional emergencies and intervening
appropriately depends on accurate and efficient analysis of a
population’s nutritional status and knowledge of the nutrient
content of foods. Understanding potential healthconsequences of nutritional deficits and how to address themearly is crucial in all settings. Preventive treatment can beprovided and resources properly allocated when reliable data
are available.
Deficiencies of key nutrients such as iron and vitamin A canhave dramatic health consequences, severely influencing
morbidity and mortality rates of populations. Anemia affects
more than 1.6 billion people globally and contributes to atleast 100,000 maternal deaths and 157,000 child deaths
annually. Vitamin A deficiency affects over 200 million
women and children and accounts for over 600,000 deaths
globally each year among children under 5 years of age.
At the beginning of the 20th century with the discovery ofvitamins, research began on the nutritional composition of foods.
Since then, multiple technological innovations in diagnostics haveenhanced our ability to analyze the nutrient content of foods,
and current methods allow the assessment of several
micronutrients rapidly and accurately (see Case Study 6)

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Case study 6

Case study 7aContinuum: Farm, Processing, Retail

Continuum: Table

iCheck and vitamin A

Screening for anemia

BioAnalyt is a manufacturer of equipment used foranalyzing micronutrients in food. It has just created aportable device, the iCheck FLUORO, which determines
levels of vitamin A in food. Its use has already been
incorporated by non-governmental organizations, thefood and food processing industry, laboratories,
universities and monitoring agencies. It extracts a sample
from any fortified food, such as flour, sugar, or premix,
as well as biological fluids, into a disposable extraction
vial containing necessary reagents for efficient extractionof vitamin A. Using fluorescence measurement throughLED technology accurately determines the vitamin A
concentration in food.
The device is said to be as reliable as the gold-standard
laboratory-based methods that require significant andcostly laboratory equipment and a substantial amount oftime. Its portability means that the iCheck FLUORO canbe used in multiple sites from the factory productionlines to markets in remote areas. The process is userfriendly and the three steps of injection, reaction, andmeasurement take only a few minutes to complete.
Source: http://www.bioanalyt.com/products/icheck-fluoro-and-iex-mila

Assessing the nutrient content in food is important forthe prevention of dietary deficiency, but technologicalinnovations are also required to assess the current
nutritional status of populations. Technological advances
have been rapid in this area, and include screening
diagnostics for both iron and vitamin A status (see Case
Study 7a and 7b).

A rapid, cost-effective, and culturally acceptablescreening mechanism was essential to identify individuals
in need of iron supplementation. In recent years,
advances in technology have brought about a number of
non-invasive screening devices that do not require thetraditional blood-draw. For instance, a portabletranscutaneous hemoglobin (Hb) meter uses a probe
applied to a clean fingertip or arm. The probe emits
infra-red light and uses photo-plethysmography andreflectance spectroscopy to establish the Hb absorption
pattern in the individual. Crowley and colleagues (2012)
tested two similar methods of non-invasive Hb screening
and found that both classes of non-invasive Hb recording
devices performed acceptably in field conditions.
In keeping with the common phrase, “There’s an app forthat,” a team of biomedical engineering undergraduates
at Johns Hopkins University in Baltimore, Maryland,
USA, have developed a mobile phone application forscreening for anemia. Their ‘prick-free’ device, theHemoGlobe, converts mobile phones of healthcare
workers into ‘hemoglobinometers’ at a cost of $10-20
per phone. The phone can then read the Hb levels, which
are displayed on the cellphone screen. Concurrently, an
automated text message sends the data to a central
server. The students received seed funding from global
health organizations and are currently testing thisinnovative “app” in the field.

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Case study 7b
Continuum: Table
Screening for vitamin A deficiency
Night blindness is a common manifestation of moderate
to severe vitamin A deficiency and is also associated witha host of poor health indicators.
In 2008, Congdon and colleagues demonstrated acorrelation between serum retinol and pupillary response,
advancing work in Dark Adaptometry pioneered by Waldand others in the 1930s. Basically, this earlier work
established that individuals with low circulating levels ofvitamin A (retinol) frequently suffered from night
blindness attributable to associated low levels of
rhodopsin, the molecule necessary for vision under
low-light conditions. In the 1930s through 1950s abattery of tests were developed to assess, subjectively, thelowest level of light at which dark-adapted individuals
could recognize shapes or words. In the 1990s fielddevices were used in a number of settings to evaluate thethreshold of light intensity required for a ‘major’ pupillary
response to be observed; these tests were not practical dueto the requirement for dark-room conditions in difficult
field settings, but also unpopular due to the subjective
nature of the data. In the late 2000s Labrique et al. of theJohns Hopkins Bloomberg School of Public Healthdeveloped the Portable Field Dark Adaptometer (PFDA),
harnessing digital technology to revitalize these principles.
While low-cost and accurate screening for key nutrients is a
crucial innovation to enhance our ability to respond to theglobal burden of malnutrition, nutritional status is now widely
recognized as the outcome of a highly complex and dynamic
body system. The field of nutrition now fully recognizes thiscomplexity and incorporates the fields of proteomics (study ofproteins expressed by a person’s genes), metabolomics(measurement of metabolites at a cellular level), andnutrigenomics (effects of food on gene expression).
These emerging fields enable us to identify biomarkers, or
biological specimens, that can be used as proxy indicatorsof nutritional status, revealing the intake of food energy, fat,protein, minerals, vitamins, and other components notclassed as nutrients. For instance, in the area of anemia
prevention, an antimicrobial-like peptide hormone called
hepcidin has emerged as the master regulator of ironmetabolism, controlling the absorption of dietary iron andthe distribution of iron among cell types in the body. Its
synthesis is regulated by both iron and innate immunity.

This new method
uses lightweight,
head-mounted ‘lightstimulus andpupillary response’
goggles run by alaptop computer toexpose participants
to a series ofcalibrated lightstimuli and digitallymeasuring pupillary
diameter changes. The Portable Field Dark Adaptometer(Labrique, West & Sommer), being validated
The device requires in Kenyan schoolchildren as a proxy forserum-based assessments of VAD.
no dark room
environment and is 2010 Alain B. Labriqueboth novel and time saving, a potential alternative toexisting invasive biochemical assessments of vitamin A
status which require drawing blood and laboratory
analytics. This device is in the process of being validated
as a proxy for vitamin A status in a number of South
Asian and African populations.
Sources: Validity and correspondence of non-invasively determinedhemoglobin concentrations by two trans-cutaneous digital measuring
devices. By Caitlin Crowley, Gabriela Montenegro-Buthaneart, Noel W.
Solomons and Klaus Schuman.
Article on HemoGlobe innovation, NewsMedical, July 25 2012
An advanced, Portable Field Dark Adaptometer for assessing functional
vitamin A deficiency. By Alain B. Labrique, Keith P West Jr, Parul Christianand Alfred Sommer.

Once low-cost and accurate screening tools for these new
biomarkers are developed, major advances in health andnutrition programs may result.
In the field of proteomics, analysis of the entire complementof proteins in cells, tissues, or organisms, has led to thedevelopment of diagnostic tests that will not diagnose justone major nutrient deficiency, but have the capacity toassess multiple micronutrient deficiencies in populations.
Significant further development is required in this area but
such innovations could
provide another vital toolwith which to tackle
nutrient deficiencies.

Everyone should have access tothe health benefits of fruit andvegetables
Source: Gates Foundation

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Case study 8
Continuum: Table
Proteomics in research and food science
A new proteomics approach utilizing mass-spectrometry
technologies is revolutionizing our understanding of
diagnostics in food science. The proteome is thecomplement of proteins expressed at a cellular level andis dynamic and highly positional in character.
Stephen Barnes and Helen Kim pointed out in their 2004
review paper that the study of proteomes and theirinteraction networks is crucial in understanding
biological systems, and tissue and fluid proteomes
provide novel biomarkers for the detection andprogression of disease. In their conclusion they state:“Clearly, proteomics and protein mass spectrometry
technologies can provide rich resources to investigators
in nutrition and related areas of biomedical research.
Those who are able to include their technologies in theirexperiments will make the meaningful contributions overthe next decade.”
Nutritional scientists recognize the problem of the‘hidden’ aspect of micronutrient deficiencies. The new
field of proteomics could hold the key. Groups are
currently working on establishing the validity of a‘plasma nutriproteome,’ which could be the basis fordeveloping tests that assess multiple micronutrient
deficiencies in populations on a single methodologicalplatform. Senechal and Kussmann (2011) state thepossibilities when they wrote,

DeliveryTechnological advances discussed in this section have more
to do with delivery of micronutrients through mechanisms
such as biofortification than the enhancement of delivery/
distribution systems discussed previously. Current
understanding of the complexity of nutritional processes
has led to a significant change in nutritional interventions
aiming to improve nutritional status. Improving nutrient
intake in this area can occur through nutrient
supplementation and food biofortification.
A shift has occurred away from interventions that provide
single nutrient supplements and toward those innovations
that provide multiple nutrients simultaneously. Industrial
food fortification is a convenient method of delivery for
multiple nutrient interventions at the population level.
Foods such as breakfast cereals, rice, margarine andcooking oils have been targeted for the delivery of multiple
micronutrients, with favorable results so far. For instance,
Nestle’s ‘Maggi’ cube, fortified with iron and iodine, can befound on the shelves of shops and market stalls throughout
West and Central Africa.
Nutrient-dense and safe foods in the form of ready-to-use
therapeutic foods (RUTF) are now also being delivered tochildren suffering from malnutrition. These high-energy
nutrientdense foods are typically delivered in small sealed
packages and fed directly into the mouths of children. The
foods are often made from groundnuts or other locallyavailable staple foods, and mixed with oils and nutrients.
One of the first RUTFs to be developed, called Plumpy’nut®,
resulted from a public-private partnership (see Case Study 9).

“Nutritional proteomics holds great promise to (a)profile and characterize body and dietary proteins,
including digestion and absorption of the latter; (b)identify biomarkers of nutritional status and health/disease conditions; and (c) understand functions of
nutrients and other dietary factors in growth,
reproduction and health.”
Sources: Nutriproteomics: Identifying the Molecular Targets of Nutritive
and Non-nutritive Components of the Diet 2004. Stephen Barnes andHelen Kim Assessing Multiple Micronutrient Deficiences In
Undernourished Populations Through The Plasma Nutriproteome2010.
Ingo Ruczinski, West, Cole et al Nutriproteomics: technologies andapplications for identification and quantification of biomarkets andingredients. 2011. Sandra Senechal and Martin Kussmann

Rice fields in Uruguay
Source: CIAT

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Case study 9
Continuum: Retail and Table
Ready-to-use Plumpy’nut®
Plumpy’nut®, a ready-to-use therapeutic food (RUTF),
was conceived in 1999. It was developed by a publicprivate partnership between Nutriset, a French private
firm specializing in therapeutic food, and the Institute of
Research for Development, a French public research
institute. A groundnut-based protein-packed, nutrientdense paste, Plumpy’nut® needs neither refrigeration nor
preparation. The ongoing use of Plumpy’nut® to fightchild malnutrition is regarded as a success story in
Ethiopia, based on 2008 field research.
A key to its success was the community-based
management of its provision, using some existing andsome new community networks. Another key was
Nutriset’s willingness to share knowledge and to allow
manufacture through franchises.
However, while Plumpy’nut® was successful in Ethiopia,
a 2010 study in a slum area in Dhaka found that eightout of ten women did not like it as a food supplement.
This shows the importance of adapting RUTF to the
local context for acceptability.
Sources: Management of Moderate Acute Malnutrition with RUTF in
Niger. Innovation to Fight Hunger: The case of the Plumpy’nut®. Jose
Guimon, University of Madrid. Engy Ali et al, Kamrangirchar Slum

Information & Communications
The global proliferation and widespread reach of mobile
phones over the past decade has led to several innovationsin information and communication strategies and nutrition.
New mobile technologies can be applied in a variety ofinnovative ways to impact the farm-to-table continuum andbeyond, through supporting farming (mAgriculture) andhealthcare systems (mHealth).
Applied to mAgriculture, mobile technologies can be used
to share important information among farmers. Much likemodern agricultural extension which began during the 19th
century Irish potato famine when agricultural instructors
traveled out to teach farmers about alternate crops, mobile
technology has become a 21st century extension worker. It
is a mechanism by which essential information can bedisseminated in a time-efficient and effective manner.

Farmer with his mobile phone in Buhar, India
Source: CIMMYT - TBC

New technologies have made information more accessible toall, including the smallest scale of farmers. “Plantwise” (www.
plantwise.org) is an initiative focused on benefitting small-scale
farmers through improving food security for the rural poor byhelping them to reduce crop losses. As a modern twist on the
19th and 20th century agriculture extension work,community-based plant clinics share the latest information andresearch and offer practical advice. The clinics also store
feedback information from the farmers in a central knowledgebank. Farmers can access the knowledge bank, which includes
information such as the local pest distribution, at the clinic or
via a community computer.
Additionally, mobile technology can facilitate the initial stepsof getting food from farm-to-table. An illustration in action is
the purjee system in Bangladesh (see Case Study 10).

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Case study 10

154

Continuum: Farm and Processing
e-Purjee system and sugarcane farmers
Communication is key to successful small-scale agriculture,and in Bangladesh the lives of sugarcane farmers havebenefitted from the use of SMS technology. Traditionally, a‘purjee’ is a legal permit given to the sugarcane farmers by
the sugar mill, informing them that they wish to buy theircrops. On receiving it, the farmers then have three days togather their sugarcane and deliver it to the mill. It is asystem that has been in place for over 200 years, since
Bangladesh was a British colony.
However, the process has always had flaws. In manycases, the purjees would take more than two days toreach the farmers, who then would not have sufficient
time to prepare their crops and bring them to the mills.
The purjee system was also fraught with corruption: inthe delivery process and in price manipulation.

Drying maize in Himachal Pradesh
Source: CIAT

A system set up as a joint initiative between the Accessto Information (A2I) Program at the Bangladesh Prime
Minister’s Office and the Bangladesh Sugar and Food
Industries Corporation (BSFI), known as e-Purjee,
intends to resolve some of the issues. Using SMS, thepurjee is sent direct to the farmer’s mobile phone, alongwith information on when/where to deliver, how much,and such. The intention with this mobile system is to
bypass the myriad problems of the past system.
Source: http://manthanaward.org/section_full_story.asp?id=986

Harvesting cauliflowers in Himachal Pradesh

In addition, mobile networks can be mobilized to assistin efficient delivery and distribution of food in crisis
situations. Whether helping to organize the multiple
actors who are mobilized in times of natural disasters
and humanitarian emergencies or simplifying the
distribution of emergency foodstuffs, mobile technologies
have shown to impact nutrition of those impacted bythese situations (see Case Study 11).

Source: CIAT

A farmer in Nicaragua
Source: CIAT

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Case study 11
Continuum: Transportation, “Retail”,
and Table
Texts and Food Aid
About two million Iraqis have fled their country since2003, and an additional 60,000 are leaving each month.
Prior to the Syrian civil war following the Arab Spring,
Syria received the majority of these refugees. At lastestimate, there were 1.4 million Iraqis in Syria, many ofwhom needed food aid, according to the World Food
Program (WFP) To meet this need, as part of the WFP
program in conjunction with the Syrian Red Crescent,eligible refugee families could receive monthly rations.
Each family would receive basic food commodities, such as
rice, lentils, and oil, and other items such as sugar, tea,
pasta, tomato paste, and bulgur.
As the organization responsible for distribution, WFP
alerted eligible families about food rations and directed
them to the appropriate distribution centers. Ordinarily,
the WFP uses local non-governmental organizations(NGOs) working with the refugees to notify groups
when aid became available. However, in this instance,
because not all eligible families had regular contact withlocal NGOs, the strategy needed updating.
In 2007, the UN agency developed and implemented atext messaging program to notify refugees when andwhere food aid became available. WFP bought text
messages in bulk, thereby securing a volume discount,
and accessed a list of phone numbers held by the UN
High Commissioner for Refugees (UNHCR) to target its
text-based food distribution alerts. Initially, text
messages to 800 families were piloted. Proving
successful in reaching the desired participants, theprogram expanded dramatically. By the end of the firstsix months of operation in 2007, 35,000 text messages
had reached 140,000 eligible people, the equivalent of
one message per WFP-registered family.
Source: Humanitarian Assistance, Wireless Technology for Social Change:
Trends in Mobile Use by NGOs.

In the arena of mHealth, mobile systems have also beendeveloped to enhance the capacity of field workers tomonitor the growth and nutritional status of children, an
outcome of the farm-to-table continuum. The mobile

phones have a place in diagnostics and the reporting ofscreening results (as illustrated in Case Studies 7a and 7b).
Information collected can be analyzed immediately totrigger a response, and accumulated data can be
aggregated to produce reports for policy decision-makers
and program managers.
Another mHealth application is the use of Rapid-SMS, atext-message-based data platform developed by UNICEF
and partners, for nutrition surveillance in sub-SaharanAfrica. Increasingly used in field settings to support thedelivery of interventions, Rapid-SMS allows formonitoring, data collection and information-sharing on alarge scale, using mobile telephones. SMS messages havethe advantage that they can be sent to multiple recipients,
so are ideal for informing a large group very quickly. For
data collection, the speed of SMS response means reporting
can happen in real time, with no delay while the monitors
return from the field. SMS messaging helps information
sharing, and the speed means that gaps, for example, in
medical supplies or food aid in one area can be identified
quickly and also remedied. It is hoped that Rapid-SMS will
help to reduce child mortality by shortening the lag time
between identifying nutritional emergencies and scaling up
treatment in affected areas.

New frontiers
One of the biggest challenges facing the agriculture systemcurrently and looking into the future is how it will respondto climate change. ‘Climate-smart agriculture’ that increases
productivity and resilience to environmental pressures while
reducing greenhouse gas emissions requires urgent
innovations. The former Director General of the United
Nations Food and Agriculture Organization, Jacques Diouf,
has given examples of the changes needed to makeagriculture climate-smart such as crop diversification,
seaweed farming and urban farming, and many of these
innovations could be increased in scale in years to come.
The breeding of plant cultivars more able to respond tochanging climates may prove a critical innovation for the
future. A variety of maize with significantly increased
resilience to drought, and a variety of rice able to withstandlong periods of flooding (Scuba-rice) are excellent examples
of such innovative breeding that are already being used.
Some innovations, such as the use of algorithms to provide
tailored insurance policies for farmers (see Case Study 12),have yet to be instituted in developing countries, but theirpotential can already be seen.

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Case study 12
CASE STUDY 12 (Continuum: Farm)consumption present important challenges for the future,requiring continued innovations to develop, produce anddeliver optimal nutrition to the continuously expanding
human population.

Agriculture and algorithms
In India, where delayed onset of monsoons can bringabout crop failure, farmers often struggle to repay thedebts they incurred to purchase seeds. More than 15,000
commit suicide every year in desperation. Farming has
always been a gamble, but the growing number of
unusual weather events, as experts call these changes
attributed to global warming, makes seeding, farming,and harvesting an even riskier business.
The Climate Corporation, based in Silicon Valley, wants
to reverse the trend and reduce farmers’ financial risks
by crossing agriculture with information technology’s
trend of big data. The firm collects all kinds ofinformation, including on weather patterns, climate
trends and soil characteristics, and analyses the data
down to an individual field. These insights are then used
to offer farmers tailored insurance policies against thedamage from extreme weather events.
So far, the Climate Corporation offers its policies only in
the United States. If its combination of agriculture andalgorithms succeeds there, however, it has potential toapply these methods on a global scale. Australia, Canada
and Brazil are next on its list of countries to apply theassessments. Perhaps insurance policies based on thesekind of analytics will one day also protect Indian farmers
against the changing weather patterns.

Cattle raised within a silvopastoral system, in which trees are planted
at wide spacings into grazed pastures
Source: CIAT

Source: http://www.economist.com/blogs/schumpeter/2012/11/
weather-insurance

Conclusions
Innovations across the entire span of human nutrition, fromplant to population, have impacted and improved aspects ofthe farm-to-table continuum. In doing so, humans havesought ways to improve mechanisms to meet growing
nutritional requirements, on local and, more recently, global
scales. The game-changing innovations discussed in thischapter target farming and distribution systems, develop
collaborations, leverage public-private partnerships andutilize technological advances. They have the potential to
improve nutrition in both the developed and developingworld. Transformative innovations are often born ofinterdisciplinary collaboration and increasingly, a ‘systems’approach is necessary to address intractable problems inglobal nutrition. The interdependencies from production to

Biofortified beans
Source: CIAT

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Our personal view
The process of innovation has been most successfulwhen driven by public health need. Whether in reference
to new technologies, transformative methods ofcultivation, or simple system processes, innovations thatare grounded firmly in the contextual realities of the
populations which they aim to serve stand the greatest
chance of successful scale. Some have recently criticizedthe development space as suffering from “technologic
solutionism”, referring to the tendency of technologies,
developed in relatively isolated settings, to search forentrenched problems to solve.
Another often neglected perspective is that of theend-users or beneficiaries of the innovations we seek todevelop. Increasingly, researchers are identifying thevalue of substantial inclusion of these stakeholders in theprocess of priority-setting, identifying barriers andconstraints to optimal outcomes and in the design andimplementation of innovations themselves. Not only is
the likelihood of achieving better “fit” with the target
populations increased, but a local ownership of thestrategy is fostered through such methods.
Finally, the importance of continued prioritization andinvestment in high-quality research cannot be
understated. Donors and implementing agencies must
focus considerable energy not only on “implementation
science”, that is exploring how best to deliver what weknow is efficacious, but also on developing and testing
the efficacy of new solutions. To quote Dean Emeritus
Alfred Sommer of the Johns Hopkins Bloomberg Schoolof Public Health, “Today’s research forms the basis for
tomorrow’s programs.” Investment is necessary into
research that is rigorous, problem-driven, collaborative,
interdisciplinary and which seeks to build and engage
local capacity.

Further reading
Hilary Green J, Van Bladeren PJ, Bruce German J.
Translating Nutrition Innovation into Practice.
Institute of Food Technologies. www.ift.org.
Eggersdorfer M. Tackling poverty with nutrition
innovations. The Chicago Council on Global Affairs.
Inclusive Agriculture Sector Growth. Feed the Future,
the US government’s global hunger and food security
initiative.
Ash C, Jasny BR, Malakoff DA, Sugden AM. Feeding
the future. Science Magazine.
Mobile agriculture. Float Mobile Learning website:
floatlearning.com/magriculture
Brugger F. Mobile Applications in Agriculture.
Syngenta Foundation.
Woodill G, Udell C. The Application of Mobile
Computing to the Business of Farming. Float Mobile
Learning.

Chapter Twelve

Speaking Up for Nutrition:
The Role of Civil Society

Asma Lateef
Director, Bread for the World InstituteWashington DC, USA

158

“The evidence is clear that governments can’t do this alone.
Momentum for improving nutrition is strong, in large part thanks
to our civil society partners who have worked tirelessly to mobilize
support around the world behind the evidence that nutrition matters.”
159

Rajiv Shah, Administrator, USAID

Key messages• Civil society has helped to shape the
Scaling Up Nutrition (SUN) Movement at
global level and helps to deliver improved
nutrition at country level.
• As the deadline for the Millennium
Development Goals approaches, hunger
and malnutrition remain part of theunfinished agenda.
• As the international community debates
the post-2015 development framework,
food security and nutrition should be
explicitly addressed in the goals, andstunting should be a priority indicator.
• Civil society organizations work closely
in, and with, communities, and haveexperience in implementing multi-sectoral
programs. They are uniquely positioned
to advocate for greater attention tohunger and malnutrition.
• By engaging national governments on the
post-2015 agenda, civil society can play
an important role in elevating nutrition asa priority for the next set of goals.

From its first beginnings, the Scaling Up Nutrition (SUN)Movement has been a multi-stakeholder effort. Civil society
organizations have been engaged in establishing SUN andcivil society is represented on the SUN Lead Group.
At the global level, as noted in Chapter 10 of the present
volume, civil society has helped shape and build support for
SUN with donor governments. At the country level, civilsociety organizations have an important role to play instrengthening the political will, engaging in policy
development/reform; in designing and implementing
programs; and in monitoring and feedback.
In June 2011, the first international meeting to helporganize the voice of civil society in the SUN Movement
was held in Washington. The focus was on building politicalcommitment to scaling up nutrition as part of the 1,000
Days Partnership and Call to Action. Participants discussed
the unique role of civil society. Specifically, it was noted thatcivil society organizations work closely in and with
communities. They have extensive reach, often working inareas that are not being served by government programs.
They also have a great deal of experience with
implementation and a greater understanding of the causesof undernutrition in each community that can and shouldbe leveraged. Participants also noted that civil society
organizations work across sectors and have developed
integrated solutions in their programs.
Civil society also has an important role to play in advocacy.
Political leadership and support is essential to making
progress on any given issue. Civil society organizations canhelp develop leaders and champions and improve theenabling policy environment for addressing maternal andchild nutrition through advocacy. They can :Educate and rally support• Draw attention to and define the issues;• Build consensus among other civil society actors andpolicy advocates;• Work together to shape and advance policy solutions andrecommendations.
Persuade• Elevate the importance of an issue;• Urge leadership on an issue;• Identify and engage effective and credible messengers.

Chapter Twelve | Speaking Up for Nutrition: The Role of Civil Society | Asma Lateef

Leverage• Engage the debates that are happening within or between
governmental ministries or departments or between theparliament and the administration;• Lend support to a specific point of view within the debate
and make the case for a specific set of policy solutions.
Broker• Carry information and messages between different players;• Help identify common objectives;• Add pressure when needed or helpful.
Engage and mobilize grassroots constituents• Inform and educate grassroots and the engaged public
about issues – show connections between issues and how
specific policy actions can help;• Demonstrate public support for specific measures being
debated;• Build relationships with members of parliament and theirstaff – to show that there is a long-term constituency
around the issues.

In the two years since the first civil society gathering, there
has been much progress in deepening the engagement ofcivil society in the SUN Movement. To date, 11 SUN
country civil society alliances have received funding fromdonors to support their efforts, including through the SUN’s
Multi-Partner Trust Fund. In June 2013, the SUN Civil
Society Network was launched and held its inaugural
meeting alongside a civil-society-led event, Sustaining
Political Commitments to Scaling Up Nutrition, to mark thefirst 1,000 days of SUN and to look ahead to the next 1,000
days. The two events served to highlight some of civilsociety’s successes in elevating nutrition as a priority and inbuilding nutrition champions.
In Peru, a coalition of civil society organizations called theChild Nutrition Initiative (CNI) has worked together toobtain commitments to reduce malnutrition among children
under 5 by 5 percent in 5 years from the 10 presidential
candidates running in the national elections in 2005 . They
followed up with specific recommendations and a 100- dayaction plan for the newly-elected President Alan Garcia,
who pledged to reduce malnutrition by 9 percent. To
sustain political commitments, CNI also worked with otherstakeholders, regional leaders and the World Bank, to build
long-term support and commitment to nutrition. When

Mothers laugh during a nutrition education seminar hosted by Care Development Organization, a Nepali NGO that receives support from
Maryknollers, in Bandarkharka, Nepal, on Friday, April 27, 2012. About 30 women plus their kids and grandkids attended the seminar.
The seminar focused on recognizing the signs of malnutrition in children and learning how to prepare foods hygienically. A health worker
taught the women about vaccinations for children, prolapsed uterus and the importance of cutting an umbilical cord with a sterilized knife.
She also stressed that children need to be fed multiple times a day, which doesn’t always happen since the women labor in fields all day.
All produce used in the seminar is locally available.
Photo by Laura Elizabeth Pohl/Bread for the World

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161

President Ollanta Humala came into office in 2011, he
pledged to continue the commitment to nutrition. He
established the Ministry of Development and Social
Inclusion (MIDIS), with a specific mandate to coordinate
government agencies, private sector and civil society to
reduce child chronic malnutrition by 10 percent. The firstlady of Peru is on the SUN Lead Group.
Since 2011, civil society organizations in Zambia havehelped elevate the issue of maternal and child nutrition as anational priority. In 2012, they have established the Zambia
Civil Society Scaling Up Nutrition Alliance (CSO-SUN),
which has raised awareness of the impact of chronicmaternal and child malnutrition on Zambia’s development
through the media. The Post Newspaper in Zambia wrote
in December 2012 :“We are told that 45 percent of our children under the ageof five – a terrifying percentage – are affected bymalnutrition. The painful truth is that, despite the goals toeradicate it, malnutrition among our under-fives still persists
and tends to grow. For 45 percent of our children under theage of five, malnutrition is not a mere conceptual reference,but rather a tragic daily experience, a disgraceful reality for

all of us ...This is an affront to our collective conscience. It
is an imperative need of our times to be aware of thisreality, because of what a situation affecting 45 percent ofour children under the age of five entails in terms of humansuffering and the squandering of life and intelligence …We
appreciate and exalt the work being done by Zambia Civil
Society Scaling up Nutrition Alliance in creating anawareness of the inevitable need for profound socioeconomic structural changes that are needed to addressthese problems.”
The editorial went on to call on the government to takeaction. In February 2013 the civil society alliance hosted a
media capacity building workshop to educate journalists on
the issue.
In April 2013 the government launched the National Foodand Nutrition Strategic Plan 2011– 2015 and the First
1,000 Most Critical Days Program (MCDP). Dr Joseph
Katema, Minister of Community Development, Mother andChild Health; Mr Malcom Geere, DfID Deputy Head of
Office and representative of the SUN donor convenor in
Zambia; and William Chilufya, Coordinator of the
CSO-SUN in Zambia spoke at the launch. The alliance’s

People hold a candlelight vigil at Immanuel Baptist Church in Albuquerque, New Mexico, on October 22, 2011, to pray for a Circle of Protection
around US federal programs that help poor and hungry people in the United States and abroad.
Photo by Laura Elizabeth Pohl/Bread for the World

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162

Sandesh Rai (leaning forward), 5, and his mom Sapana Rai (inyellow) wait for a health worker from Care Development
Organization to conduct a nutrition education seminar in
Bandarkharka, Nepal, on Friday, April 27, 2012.
Sapana said she often attends CDO seminars and came on this day
because she wanted to learn more about health.
Care Development Organization is a Nepali NGO that receives
support from Maryknollers. CDO runs various education and healthseminars every month or two in poor, rural areas of Nepal. About
30 women plus their kids and grandkids attended the Bandarkharka
seminar.
Photo by Laura Elizabeth Pohl/Bread for the Worldeffective advocacy has also succeeded in building champions
in the parliament. At the June 2013, Sustaining Political
Commitments event, representatives of Zambia’s
government, parliament and civil society alliance spoke
about Zambia’s experience in scaling up nutrition.
In Tanzania, the Partnership for Nutrition in Tanzania(PANITA) was launched in 2011. It now includes 280 civilsociety organization members implementing nutrition
programs across Tanzania. PANITA’s mission is “to advanceadvocacy efforts and improve mobilization andcoordination of civil society organizations to contributetowards a more effective national and local response toaddressing undernutrition.1 PANITA has engaged 34
members of the Tanzania Union Parliament and House ofRepresentatives in Zanzibar “to act as ‘nutrition
champions’.” It also works with the Tanzania Associationof Journalists for Children that represent the 15 major
media agencies.” PANITA is also represented on Tanzania’sHigh Level Steering Committee on Nutrition.

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163

Nutrition and the Post-2015 Development Agenda – the role of civil society
There is gathering momentum around the post-2015
development agenda. Civil society engaged in nutrition andnutrition advocacy globally and in SUN countries
specifically should pay attention to the debate and engage
constructively to ensure that nutrition is strongly
represented in whatever framework is agreed.
Since 2000, the Millennium Development Goals (MDGs)
have been the dominant global development framework.
The MDGs have come to represent the most holistic
approach yet to human development. They have galvanizedpublic support around the world for ending hunger andextreme poverty. In 2012, the World Bank announced thatthe percentage of people living below the international
poverty line had already fallen by more than half, thusachieving a 2015 target for MDG 1, which calls for cutting
extreme poverty and hunger in half. More people escapedpoverty during the 2000s than in any decade in history.
Even more importantly, progress was made in every major
region of the world. In addition, since 1990, the baseline
year for measuring progress towards the MDGs, at least
75 percent of all participating countries have made progressin reducing poverty, hunger, and maternal/child mortality,
and in providing clean drinking water. Nearly two-thirds ofcountries have made progress in gender equality by
improving girls’ enrollment in primary school. Between
1999 and 2005, the number of children dying of measles
fell by 75 percent – from more than 500,000 deaths eachyear to about 126,000. Overall, there has been a two-thirds
reduction in child mortality, due largely to the continued
rollout of vaccines. Clear, time-bound and measurable
targets have certainly been important in focusing politicalattention and resources on the MDGs and improving
accountability for results.
Despite these successes, much remains to be done, andchallenges remain. Significantly, hunger and malnutrition are
still part of the unfinished agenda. At the current rate ofprogress, the hunger target will not be met by 2015. The
MDGs measure progress in reducing hunger by calorie intake
and children’s weight. Yet even combining efforts to improvecalorie intake and children’s weight with the dramatic
reduction in extreme poverty that has been achieved has notbeen effective in speeding up progress against malnutrition,
particularly the continued high rates of stunting (when a childis far too short for age) and wasting (when a child weighs far too
little for height) - both of which are signs of chronic malnutrition.

Over the next two years, as we approach the MDG deadlineof December 2015, it is imperative to invest more resourcesin strategies to reduce malnutrition that we know to beeffective. In 2015, through a process shepherded by theUnited Nations, national leaders are expected to decide on a
new set of global development goals. A vigorous debate
about what these goals should be is already under way.
There are many ideas now being put forward about what a
new set of goals should include. It is critical to include
hunger and malnutrition targets. National leaders will
identify these based on the recommendations of theinternational development community, reflecting the best
medical and scientific evidence, and there is growing
consensus on how to do this.

WHO nutrition targets for 2025
In 2012, the UN World Health Organization (WHO) agreed
a set of six nutrition targets to be achieved by 2025.
These are:
• A 40 percent reduction in the global number of children
under age 5 who are stunted;• 50 percent reduction in anemia among women of
reproductive age;• 30 percent reduction in low birth weight;• No increase in childhood overweight;• An increase to 50 percent in the proportion of infants
breastfed exclusively (no other food or water) for the
first 6 months.
• A reduction of childhood wasting to 5 percent andmaintenance of the rate at 5 percent or lower.

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164

Jane Sebbi tends to her goats in Kamuli, Uganda. Sebbi grows corn, bananas, coffee, amaranth, potatoes, soy beans, common beans and sweet
potatoes. She also takes care of pigs, goats and chickens
Photo by Laura Elizabeth Pohl/Bread for the WorldA villager poses for a photograph in Chiquimula, Guatemala. Chiquimila is in the Corredor Seco (Dry Corridor), an area near the Honduran borderthat recently suffered a severe drought, thus exacerbating poverty and malnutrition in a country that has the highest malnutrition rate in theWestern Hemisphere.
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165

At a February 2013 consultation on “nutrition in the
post-2015 development agenda” in Washington, DC,nutrition experts agreed that nutrition should be more
explicitly addressed in the next set of development goals
and that stunting should be the priority indicator. Stunting
is a powerful indicator, not only of the impact of malnutrition
on a child, but also of chronic inequality and deprivation in
a community. Experts also agreed that the next set of goals
need more than one nutrition indicator, and that the WHOtargets provide a sound set of alternatives.
In May 2013, the Report of the High-Level Panel ofEminent Persons on the Post-2015 Development Agenda
released their recommendations and illustrative goals andtargets . The panel proposed five transformative shifts
needed to achieve a more equitable and peaceful world:

leave no one behind, put sustainable development at thecore, transform economies for jobs and inclusive growth,build peace and effective open and accountable institutions
for all, and forge a new global partnership. In order toachieve these shifts, the panel recommended a set of
illustrative goals and targets, including one that would“Ensure Food Security and Good Nutrition.”
In September 2013, UN Secretary-General Ban Ki-moon will
present his report on the post-2015 agenda. Then, over the
next two years, governments will begin to negotiate amongst
themselves with the objective of reaching an agreement by
2015. It is crucial at this stage that civil society in all countries
engages governments about the importance of a new set ofgoals and about ensuring that nutrition is integrated into thepost-2015 development framework.

Faustine Wabwire (left) from Bread for the World Institute receives a banner of the Development Action Association from Lydia Sasu (right) as atoken appreciation for coming to Ghana and talking with women farmers that DAA has trained.
Photo by Todd Post/Bread for the World InstituteChapter Twelve | Speaking Up for Nutrition: The Role of Civil Society | Asma Lateef

Case study

Case study

Guatemala: Gilma’s Story

Ghana: Lydia’s Story

In a country like Guatemala, where social norms change
slowly, gender parity in education can’t come soon
enough. Guatemala is a middle-income country, but it
has the highest rate of malnutrition in the Western
Hemisphere and one of the highest in the world. It alsoranks near the top of an index measuring inequality in
Latin America.

The Development Action Association (DAA) provides
training to women farmers in Ghana, working in someof the poorest communities in the country. Lydia Sasu isthe executive director of DAA, which she co-founded in
1997. Before DAA, Ms Sasu worked in Ghana’s
Ministry of Agriculture and served as the country’s firstfemale agriculture extension agent. Working withwomen farmers has been her life’s work, shaped by her
experiences as a child watching her mother struggle
against obstacles that have hardly changed for the
women she works with today.

Gilma, a five-year-old girl, lives in a Guatemalan village
precariously on the edge of food insecurity in the best oftimes. In more challenging times, children like her are atgrave risk. In 2011, a severe drought struck her regionof the country, leading the US government to send foodaid. Without the food aid, many children there might
have died from malnutrition, and this is what almost
happened to Gilma.
Gilma has four siblings, all of them boys, and thatmeans she and her mother eat last and often there isnothing left for them. Her greatest disadvantage is notthat she is a poor child in a region where food is often
scarce, but that she is a poor girl there. By November
2011, Gilma was suffering from a condition known as
severe acute malnutrition (SAM). Her legs were swollen
and ulcerated, as happens when children suffer suchsevere malnutrition. In Guatemala, when a child falls
below the SAM threshold, government health officials
must be alerted and they will then assume responsibility
for care.
Gilma was fortunate in that her village was receiving
food aid. Save the Children, the nongovernmentalorganization (NGO) administering the program,contacted health officials when Gilma slipped frommoderate to severe acute malnutrition, but the officials
didn’t respond right away. She is alive today because of
the persistence of Save the Children staff in getting theofficials’ attention.
Before long, Gilma will be going to school; hopefully,
her education will enable her to prevent what happened
to her from happening to her daughters.
Source: Bread for the World 2013 Hunger Report

In spite of the success Ghana has had in reducing
hunger - meeting the 2015 MDG target before any othercountry in sub-Saharan Africa - progress has not beenshared equally by all. Rural women and girls are themost disadvantaged members of society. This remains
true of Ghana, even though its record of progress ongender equality is stronger than that of many other
African countries. Progress on the MDGs is bound tostall until it is a top priority to confront and correct thestructural inequalities that hold marginalized groups insociety back.
In recent years, Sasu, now 65, has been invited to speakat international events on women in agriculture, mostrecently at the United Nations on International
Women’s Day 2012. UN Secretary-General Ban
Ki-moon has pledged to incorporate consultations withmultiple stakeholders into efforts to develop post-2015
global development goals. Consultations are planned in
50 countries and are supposed to include civil society
organizations such as DAA. The participation of civilsociety is critical in developing a post-2015 development
consensus that reflects the views of poor and hungry
people themselves.
Source: Bread for the World 2013 Hunger Report

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167

Case study
Bangladesh: Tohomina’s Story
The afternoon hours are Tohomina Akter’s favorite time ofday. That’s when she can take a break from her householdtasks, rest, and play with her 17-month-old daughter,
Adia. Like any toddler, Adia much prefers movement.
Adia runs through the four rooms of their home, herpink sundress and plastic pink shoes contrasting against
the gray tin walls. First is her parent’s bedroom, thenthe room where her father’s parents and brothers sleep.
Then a small room that contains clothes and dishes, andfinally the kitchen, a skinny corridor that opens to theoutside on one end, where her mother prepares theirfood over a fire.
Adia stops suddenly at the front steps, looking out at
the familiar faces of Char Baria, a village in the Barisal
district of Bangladesh. In front of her lies Tohomina’s
garden, a 25-foot square of spinach, amaranth, chili,
and pepper plants, an important source of nutrients for
Adia and her family. Spinach and red amaranth are
Adia’s favorites.
Tohomina planted the garden after receiving training in“Nobo Jibon,” a program administered by Helen Keller
International, a nongovernmental organization thatworks in several Bangladesh districts. The vegetables she
harvests have increased the nutrients available to herfamily, especially her daughter. What’s more, the extra
money the family earns selling the surplus vegetables
goes toward buying additional food for Adia.

Guatemalan mother and daughter
Photo: http://www.flickr.com/photos/breadfortheworld. Source: Marsh, Molly.
“Improving Nutrition Outcomes in Bangladesh.” Within Reach: Global Development
Goals – 2013 Hunger Report, Bread for the World Institute, pp. 14-15. Available at
http://www.hungerreport.org/

In the program, Tohomina learned why a diverse,
healthy diet is important, and also about the importanceof breastfeeding her daughter. Tohomina attended
classes for almost two months, hearing from healthworkers the benefits of giving Adia only breast milk
during her first six months of life.
Tohomina has stuck to that schedule, introducing
supplementary foods only after the initial six-month period,and she’ll continue to breastfeed Adia until she is two.
“I did not do many things [before taking the class],”
Tohomina said through a translator. “But after learning,
I am keeping things clean and hygienic to prevent
diseases, and cooking nutritious foods to keep me andmy family healthy.”
Source: Bread for the World 2013 Hunger Report

Tohomina Akter and her daughter Adia, 17 months old
Photo: http://www.flickr.com/photos/breadfortheworld. Marsh, Molly. “Improving
Nutrition Outcomes in Bangladesh.” Within Reach: Global Development Goals – 2013
Hunger Report, Bread for the World Institute, pp. 14-15. Available at http://www.
hungerreport.org/

Chapter Twelve | Speaking Up for Nutrition: The Role of Civil Society | Asma Lateef

Further reading
UN Civil society declaration.
Bread for the World Institute. Hunger Report 2013:
Within reach: Global development goals. Bread for
the World Institute, 2013.
Save the Children. A life free from hunger: Tacklingchild malnutrition. Save the Children, 2012.
Save the Children. Food for thought, tackling childmalnutrition to unlock potential and boost prosperity.
Save the Children, 2013.
Action Against Hunger. Aid for nutrition: Mobilizing
innovative financing for the fight against
undernutrition. Action Against Hunger, 2013.

1

http://www.bread.org/event/gathering-2011/international-meeting/2

http://www.bread.org/event/gathering-2011/international-meeting/pdf/
meeting-summary-report.pdf

3Asma Lateef. “The Role and Capacity of Civil Society Organizations in
Responding to the Economic and Food Price Crises”, in IOM (Institute ofMedicine). 2010. Mitigating the Nutritional Impacts of the Global Food
Price Crisis: Workshop Summary, Washington , DC: The National
Academies Press.

4

www.bread.org/meeting5

http://scalingupnutrition.org/wp-content/uploads/2012/10/SUN-MPREPORT_EN.pdf p.19

6

http://www.postzambia.com/post-read_article.php?articleId=29815;
additional media stories include: http://www.qfmzambia.com/news_story.
php?idx=11770&gone=11771&v1; http://zambiadailynation.
com/2013/03/08/empower-women-to-end-poverty-cso-sun/7

http://www.qfmzambia.com/blog_details.php?idx=11494

8

http://scalingupnutrition.org/sun-countries/tanzania/progress-impact/
bringing-people-together/civil-society

9World Bank (February 29, 2012), New Estimates Reveal Drop in Extreme
Poverty 2005-2010, Washington, DC.

10 Charles Kenny and Andy Sumner (2011), “More Money or More
Development: What Have the MDGs Achieved.” CGD Working Paper
278. Washington, DC: Center for Global Development.
11 Kenny and Casabonne (2008), “The Best Things in Life are Nearly Free:
Technology, Ideas, and Global Quality of Life,” Center for Global
Development.
12 See Charles Kenny and Andy Sumner (2011).
13 http://thousanddays.org/wp-content/uploads/2012/05/WHO-TargetsPolicy-Brief.pdf
14 http://documents.worldbank.org/curated/en/2013/02/17428493/
nutrition-post-2015-development-agenda-report-expert-consultation
15 United Nations (2013), A New Global Partnership: Eradicate Poverty andTransform Economies Through Sustainable Development. The Report of
the High-Level Panel of Eminent Persons on the Post-2015 Development
Agenda.
16 HLP Report, pp. 29-30

My personal view
Asma Lateef

Director, Bread for the World InstituteWashington DC, USA

Over the past four years, the nutrition
landscape has been completelytransformed. New knowledge,
increased attention to hunger and foodinsecurity as a result of the food pricecrisis, and effective collaboration
across stakeholders have led to the riseof the SUN Movement.
Civil society played an important role in making the casefor action on nutrition. As a result of the governments of
the United Kingdom and Brazil and Children’s
Investment Fund Foundation’s Nutrition for GrowthHigh Level Meeting in London on June 8, 2013, we now
have impressive new financial and nutrition outcome
commitments from donors, international organizations,the private sector and non-governmental organizations.
One could be forgiven for thinking that the work is
done! Now is not the time for complacency, however.
The commitments have to be fulfilled. More importantly,
resources and policies must result in dramatic reductionsin the number of stunted children.
In order to ensure sustained political commitment, civilsociety needs to speak with unified, clear messages about
the importance of nutrition in the post-2015
development goals. Communicating how fundamental
good nutrition in the pregnancy and early childhood is
to ending extreme poverty must be part of advocacy
efforts in the near future.
There will be many interests and issues that will be
under consideration. Countries that are taking steps toscale up nutrition are uniquely placed to make the casefor including a nutrition goal, indicators and targets.
Civil society can advocate for them to do just that.

168

Chapter Thirteen

169

The Evolving Worldof Nutrition

Saskia de Pee
Technical Advisor Nutrition and HIV/AIDS, WFP,
Adjunct assistant Professor Friedman School of Nutrition Science and Policy,
Tufts University, Boston, USA
Visiting Assistant Professor, Wageningen University, the Netherlands

“He who has health has hope, and he who has hopehas everything.”
Arabian Proverb

170

Key messages• Almost everyone plays a role in nutrition
through taking care of their own diet andhealth, as well as through involvement in
the food system in one way or another.
• Nutrition is multi-disciplinary, ranging
from agriculture to medicine to behavioral
science and economics.
• Throughout the 20th century, knowledge
and approaches for addressing
malnutrition developed within therespective disciplines, but there waslimited cross-disciplinary coordination,even with other players in the food andhealth systems.
• Understanding the forms andconsequences of undernutrition, being able
to cost the economic impact ofundernutrition, and having examples ofwhat is required and what works to prevent
undernutrition, including good governance,
has generated the strong momentum
behind nutrition that exists today.

Nutrition is everybody’s business
Everyone deals with nutrition – individuals who are looking
after their own diet and health; mothers and fathers whoare caring for their families; farmers who grow food forthemselves and others; medical doctors, teachers, sports
coaches and others who support people in understanding
the importance of health and nutrition; food processors
who produce, preserve, package and distribute foods; andcommunity leaders, politicians and business owners, who
impact other people’s ability to access an affordable, healthy
and nutritious diet. Food systems around the world arediverse, increasingly industrial, commercial and global, andmany of us play an active role in shaping them.
However, while we affect our own and other people’s
nutrition every day, directly or indirectly, there are manydifferent ways in which nutrition and health are
understood, and our ability and decisions to actively
influence them, either by ourselves or by seeking assistancefrom others, ranges widely. Furthermore, as the preceding
chapters discuss, many factors that impact on the healthand nutrition of individuals and populations are beyond the
direct influence of the individual, as these are determined bytheir environment and circumstances.

Silvopastoral cultivation, in which livestock live in wooded areas
Source: CIAT

Chapter Thirteen | The Evolving World of Nutrition | Saskia de Pee

171

Early discoveries in nutrition
Throughout the centuries, there has been a growing
understanding of the relationship between diet and health andabout how poverty and related living circumstances affect a
population’s health, for a substantial part through the diet.
In the late 19th and early 20th centuries, scientists in the fields
of chemistry, biology and medicine started conducting animal
experiments in which they supplemented basic diets consistingof carbohydrates, fat and protein, with specific foods or foodcomponents such as milk and butter to determine which
components made the animals live or die. While doing so, theyobserved conditions in the animals that were comparable tosymptoms that had been described in humans, such as inrecords from naval medicine in the 19th century.

Vitamin

Alternative nameVitamin A

Over the course of a few decades, the various vitamins wereisolated and named, and their deficiency states described.
For several of the deficiencies, the ultimate consequence wasdeath. It was realized that severe deficiencies could occur
without starvation, and that many people were probably
affected by nutritional deficiencies. To address vitamin A
deficiency, some European countries and the US introduced
school milk distribution schemes (fortified with vitamin A inthe case of skimmed milk) as well as encouraging, or evenenforcing, consumption of butter and/or cod liver oil in the
1920s–1940s.

Discovery

Isolation

Structure

Synthesis

Retinol

1909

1931

1931

1947

Provitamin A

β-Carotene

1831

1831

1930

1950

Vitamin D

Calciferol

1918

1932

1936

1959

Vitamin E

Tocopherol

1922

1936

1938

1938

Vitamin K

Phylloquinone

1929

1939

1939

1939

Vitamin B1

Thiamin

1897

1926

1936

1936

Vitamin B2

Riboflavin

1920

1933

1935

1935

Vitamin B3

Niacin

1936

1936

1937

1994

Vitamin B5

Pantothenic acid

1931

1938

1940

1940

Vitamin B6

Pyridoxine

1934

1938

1938

1939

Vitamin B7

Biotin

1931

1935

1942

1943

Vitamin B9

Folic acid

1941

1941

1946

1946

Vitamin B12

Cobalamin

1926

1948

1956

1972

Vitamin C

Ascorbic acid

1912

1928

1933

1933

From November 1944 to December 1945, 36 conscientious
objectors participated in the historical Minnesota Starvation
Experiment, which was designed to study the physiologicaland psychological effects of severe and prolonged dietary
restriction and the effect of dietary rehabilitation strategies,
as was a reality for many people in Europe during theSecond World War. This work, led by Ancel Keys, provided

key insights into nutrition, including the understanding thatstarvation dramatically alters personality and that nutrition
directly, and predictably, affects mind as well as body.
During that first half of the 20th century, undernutrition was
primarily of interest a) as a medical condition with specificsymptoms characterizing specific nutrient deficiencies, and b)
as a problem of lack of food resulting in starvation.

Chapter Thirteen | The Evolving World of Nutrition | Saskia de Pee

Different worlds of nutrition
Between the 1940s and 1970s, the medical field evolved
dramatically, and after the Second World War, the economic
development of Western Europe and North America
increased access to a more nutritious diet for a large part ofthe population, while living circumstances such as hygiene
and education continued to improve substantially. Together,
these developments resulted in lower child mortality,
increased life expectancy, and a marked reduction ofnutrient deficiency diseases (e.g rickets and night blindness).
With these developments, the momentum behind nutritionin Europe and North America from the early part of the20th century was not sustained, as undernutrition was not
perceived to be much of a problem anymore. The attention
for the role of nutrition in health continued in developing
countries and among international agencies, and regained
strength globally when case reports and survey data on
health and nutrition started to be reported from more andmore developing countries from the early 1970s.
In the period following the Second World War, most of theattention regarding diet and food was focused on ensuringthat there would be enough food for the growing world
population, and on making sure that protein deficiency wasprevented or treated (see the chapter in this volume byVictoria Quinn on the ‘protein fiasco’). This meant that
agriculture was largely focused on the production of cereals(green revolution, increase of scale) to ensure that caloric
requirements were met, and on cash crops for income.

Women farmers in East Africa
Source: CIAT172

The signs of undernutrition from developing countries thatdrew attention from professionals in the biomedical field wereparticularly those related to micronutrient deficiencies, which
could be solved by a medical-type intervention, such asproviding supplements of vitamin A, iron, iodine and/or zinc.
Meanwhile, it was also realized that the causes of nutrition
problems were rooted in poverty, and that, besides being
related to food, they were also related to water, hygiene,
sanitation and caring practices, and that approaches foraddressing malnutrition therefore had to be multidisciplinary. Due to this, social and behavioral scientists
also became involved in nutrition, and there was anincreasing sense that individuals and communities should be
able to rely on their own resources and means, including
food production, to achieve adequate nutrition.
The UNICEF Conceptual Framework of causes ofmalnutrition, which was developed at the time of the Iringa
project in Tanzania in the early 1980s, clearly illustrated themulti-factorial causes of malnutrition and indirectly assigned arole for many disciplines for addressing malnutrition.
However, for a couple of decades, there was limited focused
attention on addressing malnutrition, because thecomprehensiveness of the framework indicated that there weremany factors involved but at the same time it was not clear
which one(s) to prioritize where and who should take which
action. There was also limited awareness of the consequencesof not tackling the problem, and several signs of undernutrition
were not yet properly understood.

Women have a key role to play in improving the nutritional status of theworld’s population
Source: The Gates Foundation

Chapter Thirteen | The Evolving World of Nutrition | Saskia de Pee173

Momentum for concerted action on nutrition
Fortunately, the past ten years have seen a marked increaseof attention as well as momentum for action on nutrition,
due to several coinciding developments:• Advances of our knowledge of the consequences ofundernutrition, which goes beyond the signs andsymptoms of specific deficiencies on the one hand andstarvation on the other, to lifetime consequences of
inadequate nutrition in early life in terms of early morbidity
and mortality, as well as impact on cognitive ability
affecting performance in school and income-earningpotential, and non-communicable diseases later in life suchas cardiovascular disease and diabetes;• Increased understanding of the biology ofmalnutrition, including the relationship between two
apparently different forms of malnutrition, i.e.,undernutrition and overnutrition, that are actually very much
related (both include micronutrient deficiencies, both are
related to poverty – the world’s wealthier and well-educatedpeople have the healthiest diet, and undernutrition in early life
predisposes to overnutrition and non-communicable disease
later in life);• Evidence of effective nutrition interventions,
including their cost-benefit ratio. Also, the Copenhagen
Consensus 2012 expert panel of economists, which
included four Nobel laureates, identified that the smartest
ways to allocate money to respond to ten of the world’s
biggest challenges is by fighting malnourishment. Nobel
laureate economist Vernon Smith said: “One of the mostcompelling investments is to get nutrients to the world’s
undernourished. The benefits from doing so – in terms ofincreased health, schooling, and productivity – are tremendous”;• The observation that economic development andlarge-scale production of cheap, convenient fooddoes not lead to better health but instead is related toan epidemic of obesity and related non-communicablediseases, has led to people’s rethinking of food systems
and healthy and sustainable diets (it has become
everybody’s problem);• Increased ownership of nutrition and collaboration
by a wide range of disciplines, including biomedical,
behavioral, agricultural, and economics;• Increased access to information through media such
as Internet and mobile-phone technology, which increases
the awareness as well as the ability to act and hold politicians,
companies and others accountable for their actions;• A more connected world where heads of state agree on
mutual goals (Millennium Development Goals, post-2015
development agenda), low-income countries evolve to
become middle-income countries and grow from being therecipients of donor funding to being donors themselves,
and the private sector becomes involved in solving the
problems of the most vulnerable.

The first Lancet series on Maternal and Child Nutrition,
which was published in 2008, summarized the magnitudeand consequences of the nutrition problem, and provided
evidence of a number of proven and low-cost solutions.
This publication galvanized substantial action on multiple
fronts, and not only the questions of ‘why to address
undernutrition, by doing what, and where’, but also thequestion of ‘how to do it’ received attention. Moreover, thishappened at a time when it was realized that everyone has arole to play, including, for example, the private sector,
which had previously been regarded by some as mainly
contributing to the problem rather than building a path tothe solution. It also showed convincingly that poor fetal
growth or stunting in the first two years of life leads toirreversible damage, including shorter adult height, lower
attained schooling, reduced adult income, and decreased
offspring birth weight. This very much focused everyone’s
attention on the prevention of stunting and on prioritizing
nutrition during the first thousand days from conception
until two years of age.
Furthermore, in May 2012, the 65th World Health
Assembly (WHA) endorsed six global nutrition targets to beachieved by 2025 as part of WHO’s comprehensive plan onmaternal, infant and young child nutrition, including
reducing by 40 percent the number of children under age 5
who are stunted from 171 million in 2010 to 100 million
by 2025. This means that there is very broad commitment
to these goals, as the WHA is the forum through which
WHO is governed by its 194 member states and it iscomposed of health ministers from these states.

Chapter Thirteen | The Evolving World of Nutrition | Saskia de Pee

Malnutrition remains a serious impediment to the progress
towards achieving the Millennium Development Goals. Yet
many of the nutrition challenges that have persisted for
decades can be resolved within our generation.
Recognizing that accelerated global action is needed toaddress the pervasive and corrosive problem ofmalnutrition, the World Health Organization (WHO)recently identified a set of global targets designed toreduce the unacceptably high burdens of disease and deathcaused by poor nutrition, particularly during the critical
1,000 days between a woman’s pregnancy and a child’s
second birthday.* By aligning the glocal community
behind six targets aimed at improving the nutritional
status of mothers, infants and young children andcommitting to a decade of investement to expand
nutrition interventions, we can prevent the deaths of one
million children per year and help to build the foundations
for healthier and more prosperous societies.

GLOBAL TARGET 1

GLOBAL TARGET 3

GLOBAL TARGET 5

By 2025, reduce by 40% thenumber of children under age 5
who are stunted.

By 2025, achieve a 30% reductionof the number of infants born withlow birth weight.

By 2025, increase to at least 50%
the rate of exclusive breastfeedingin the first six months.

Problem:
Stunting is the irreversible result of chronic
nutritional deprivation during the mostcritical phase of child development - the1,000 days between a woman’s pregnancy
and her child’s 2nd birthday. Stunted
children have weaker immune systems
making them more likely to die from
common illnesses and disease, and sufferfrom impaired brain development making
them less able to learn in school and earn agood living as an adult.

Problem:
An infant’s weight at birth is a strong
indicator of his or her chances for survival,
growth, and long-term health anddevelopment. In the developing world, lowbirth weight stems primarily from poormaternal nutritional status before conception,maternal short stature due mostly toundernutrition and infections during childhoodand poor nutrition during pregnancy.

Problem:A non-breastfed child is 14 times more likely
to die in their first six months of life than achild who is exclusively breastfed. Thoughbreastfeeding is the single most effective
nutrition intervention for saving lives, global
breastfeeding rates have stagnated or
dropped in most regions of the world to an
estimated 37%.

Results:
3.9% relative reduction in the number of
infants born with low birth weight per year.

Results:
2.3% relative increase per year would leadto approximately 10 million more children
per year being exclusively breastfed until six
months of age.

GLOBAL TARGET 2

GLOBAL TARGET 4

GLOBAL TARGET 6

By 2025, achieve a 50%
reduction in anemia in womenof reproductive age.

By 2025, ensure that there is no
increase in the number of children
who are overweight.

By 2025, reduce and maintainchildhood wasting to less than 5%

Problem:Anemia in women increases the risk of dying
during childbirth and increases the risk ofbabies being born with low birth weight. Iron
deficiency anemia affects 1/3 of all womenof reproductive age throughout the world.

Problem:
Obese children are likely to grow into obese
adults, have an increased risk of diabetes
and liver disease, and have poorer
economic prospects later in life.

Results:
A reduction in the number of stunted
children from 171 million in 2010 toapproximately 100 million.

Results:
A reduction in the number of anemic,
non-pregnant women from 468 million toapproximately 230 million.

Results:
The number of overweight children underage 5 would not increase from current levelsof 43 million to forecasted levels of
approximately 70 million.

Problem:Commonly used to indicate the severity of afamine of food crisis, wasting is the result ofgrave disease and/or deprivation of nutritious
food at a specific point in time and is seen
as an early warning for future increases inchronic undernutrition. The proportion ofchildhood wasting rose in the second half ofthe last decade, likely as a consequence ofthe dramatic spikes in food prices.
Results:
Current global prevalence of wasting of
8.6% should be reduced to less than 5% by2025 and maintained below such levels.

*These targets were endorsed by the 65th World Health Assembly in May 2012 as part of WHO’s comprehensive plan on maternal, infant and young childnutrition. Sources: Black, R. et al “Maternal and Child Undernutrition” The Lancet, January 2008; Save the Children “The Child Development Index
2012”; UNICEF, “Committing to Child Survival: A Promise Renewed” Progress Report 2012.

174

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175

The second Lancet series of 2013 has reaffirmed thefindings of the first series and particularly emphasizes theimportance of adequate nutrition for pregnant and lactating
women as well as for adolescent girls (before they become
pregnant). It also highlights the potential for nutritionsensitive fields and programming to contribute topreventing undernutrition and/or deliver some nutritionspecific interventions.

Conclusion
The world of nutrition has evolved substantially over thelast century and a half, reaching a high level of knowledge,
convergence and momentum, especially during the past ten
years. This should result in more sustainable and nutritious
diets and in better health and life chances for children beingborn in the next few decades.

The current momentum in nutrition is particularly
coordinated through the SUN (Scaling Up Nutrition)
Movement, to which more than 40 countries have now
committed themselves. They have committed to
implementing nutrition-specific and nutrition-sensitive
action, and have joined a movement that is coordinated bya special representative to the UN Secretary-General andhas been endorsed by more than 100 organizations.

My personal view
Saskia de Pee

Technical Advisor Nutrition and HIV/AIDS, WFP
Adjunct assistant Professor Friedman School of Nutrition
Science and Policy, Tufts University, Boston.
Visiting Assistant Professor, Wageningen University, theNetherlands

Having worked in the field of
nutrition for almost 20 years, I findthis time very exciting because of thegreat momentum to improve
nutrition and health worldwide andthe increased understanding andcommitment among a very wide
range of stakeholders and experts.
The involvement of so many is essential, and while
everyone should focus on what they are good at, there isa great deal of cross-disciplinary work to be done in atarget-oriented manner.
It is important to develop context-specific solutions
based on the global body of knowledge and expertise,
and to monitor, evaluate and share these experiencesusing the information and communication technology
available today.

Further reading
Bloem MW, de Pee S, Semba RD. How much do data
influence programs for health and nutrition?
Experiences from Health and Nutrition Surveillance
Systems. In: Semba RD, Bloem MW (eds). Nutrition
and Health in Developing Countries (2nd ed).
Totowa, NY: Humana Press, 2008.
Copenhagen Consensus. http://www.
copenhagenconsensus.com/projects/
copenhagenconsensus-2012/outcome
Food and Agriculture Organization. The State ofFood and Agriculture. Rome: FAO, 2013.
Kalm LM, Semba RD. They starved so that others bebetter fed: Remembering Ancel Keys and theMinnesota Experiment. J Nutr 2005;135:1347–1352.
Sight and Life. Micronutrients, macro-impact: Thestory of vitamins and a hungry world. Basel,
Switzerland: Sight and Life, 2012.
The SUN Movement website: www.
scalingupnutrition.org

Chapter Thirteen | The Evolving World of Nutrition | Saskia de Pee

Table 1: Progress in Micronutrient Science and Policy
1975

Formation of International Vitamin A Consultative Group (IVACG)

1991

Ending Hidden Hunger: The Montreal Micronutrient Conference, Montreal, Canada

1992

Helen Keller International Bellagio Meeting on Vitamin A Deficiency and Childhood Mortality

2002

UN General Assembly special session on children
Creation of GAIN (Global Alliance for Improved Nutrition)

2006

Creation of Micronutrient Forum

2007

World Bank report Repositioning Nutrition as Central to Development

2008

Lancet Series, Maternal and Child Undernutrition
Copenhagen Consensus places micronutrients center stage
World Economy Forum formed the Global Agenda Council (GAC) on Food Security

2009

Castel Gandolfo Declaration
Private Sector Declaration and United Call to Action on Vitamins and Mineral Deficiencies during
Micronutrient Forum, Beijing
Creation of Amsterdam Initiative for Malnutrition (AIM)
Obama administration signals its commitment to addressing hunger
International Congress on Nutrition in Bangkok – Nutrition Security for All
G8’s $20 billion commitment on Food Security and Nutrition
Scaling Up Nutrition (SUN): A Framework for Action – up-scaling of 13 highly cost-effective interventions

2010

G20 pledge additional $5.0 billion over the next five years towards achieving MDGs 4&5
African Union summit places safe motherhood and child health high on Africa’s agenda
SUN Framework and Roadmap launched
Feed the Future (FTF), the new US government global hunger and food security initiative, is launched
The Global Strategy for Women’s and Children’s Health launched by UN Secretary-General
UN Secretary-General includes nutrition security and the importance of nutrition at the MDG summit
Nutrition included in the 2010 MDG outcome document
1,000 Days Partnership: Change a Life, Change the Future launched by Hillary Rodham-Clinton,
the United States Secretary of State, and Irish Minister of Foreign affairs, Micheál Martin
African First Ladies sign a call for action to put nutrition at the heart of development.

2011

High-level event on Scaling Up Nutrition at UN Headquarters, New York (September)

2012

Copenhagen Consensus – bundled nutrition interventions ranked highest
Hunger Summit at Olympic Games, London

2013

Hidden Hunger Conference, Hohenheim, Germany
Launch of Lancet Series on Maternal and Child Nutrition
Nutrition for Growth meeting, London - $4.1 billion new funding for nutrition-specific actions and$19 billion for nutrition-sensitive activities
International Congress on Nutrition in Granada – Joining Cultures Through Nutrition
Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda

Source: Amended after Micronutrients, Macro-Impact: The story of vitamins and a hungry world, Sight and Life, 2012. Copyright Sight and Life.

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Table 1: Important Milestones in Nutrition Policy Development
Year

Organization

Purpose

Goals

Achieved in Moving theAgenda Forward

2002

The
International
Vitamin A
Consultative
Group (IVACG)
Annecy Accord

Leading the campaign
against vitamin A
deficiency disorders(VADD)- Provide a forum to exchange new ideas, todiscuss research findings and their policy
implications, and share experiences with programinterventions.

Comprehensive
recommendations for theassessment and control ofvitamin A deficiency (VAD) were
rigorously reviewed and revised
by a working group andpresented for discussion at the
XX International Vitamin A
Consultative Group meeting in
Hanoi, Vietnam.

- Provide technical guidance through state-of-theart publications on VADD.
- Collaborate with international organizations indeveloping and establishing policy guidelines fordiagnosis, treatment, and prevention of VADD.

2007

2008

2008

The World
Bank; ReportonRepositioning
Nutrition as
Central toDevelopment

Provide a global
framework for action
and to complement thesimilar analyses
undertaken by theWorld Bank’s regional
units for Africa andSouth Asia.

- Reinvigorate dialogue regarding what to do about
malnutrition;

Lancet Series;
Maternal andChild
Undernutrition

Given that that nutrition
is a major risk factor for
disease, the Lancet
series sought to gather
scientific evidence about
the importance ofmaternal and childnutrition and aimed to fillthis gap in global publichealth and policy action.

- Catalogue the long-term effects of undernutrition;

Copenhagen
Consensus

To set priorities amonga series of proposals forconfronting thefollowing global
challenges: Air
Pollution, Conflicts,
Diseases, Education,
Global Warming,
Malnutrition and
Hunger, Sanitation andWater, Subsidies andTrade Barriers,
Terrorism, Womenand Development.

The panel was asked to address the ten challenges
by considering the question, “What would be thebest ways of advancing global welfare, andparticularly the welfare of the developing countries,
illustrated by supposing that an additional $75
billion of resources were at their disposal over a four
year initial period?”- Encourage the development community toreevaluate the priority it gives nutrition;- Facilitate an agreement on new ways forstakeholders to work together;

This report highlighted theburden of malnutrition andimportance of addressing it,
thereby justifying the increased
funding for nutrition from theWorld Bank.

- Scale up proven interventions for tackling
malnutrition.
- Identify proven interventions to reduce
undernutrition;- Call for national and international action to
improve nutrition for mothers and children.

Provided objective evidence that
there are effective interventions
to reduce stunting andmicronutrient deficiencies andthat improved governance isdesperately needed to scale up
nutrition interventions, monitor
and evaluate those plans, andimplement laws to enhance therights of women and children.
Among all the worlds challenges
identified at Copenhagen, thepanel ranked malnutrition very
highly, given the tremendously
high benefits compared to costs.
The expert panel ranked fighting
malnutrition as follows, providing
tremendous clout to our cause:
1. Micronutrient supplements forchildren (vitamin A and zinc);3. Micronutrient fortification (ironand salt iodization);
5. Biofortification;
6. Deworming and other nutrition
programs at school;
9. Community-based nutrition
promotion.

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178
Year

Organization

Purpose

Goals

Achieved in Moving theAgenda Forward

2010

SUN: A
Framework for
ActionLabeled as the‘forgotten’ Millennium
Development Goal, theprimary objective of the
SUN Framework is tocatalyze actions tomove undernutrition
toward the center stageof international politicaland economic
discourse.

The policy brief hopes to provide both the following:

The SUN brief concluded that the
MDGs cannot be achieved
without urgent attention to
nutrition. SUN is a call to action
for increasing high impact
interventions that address
undernutrition, with more than
100 organizations having
endorsed the Framework to date.

- An outline of the emerging framework of key
considerations and priorities for action to address
undernutrition;- Mobilize support for increased investment in
nutrition interventions.

2010

A Road Map
for Scaling up
Nutrition

Provides the principles
and direction forincreased support for
countries as they scale
up efforts to tackle
undernutrition across a
range of sectors. It
encourages multistakeholder platforms
that promote synergizedactions and simplify
coordination of support.

To serve as a resource for countries wanting toinclude nutrition within the context of nutritionfocused development policies

Galvanizing countries to takenutrition seriously and include itin their development agenda.

2013

LancetSeries 2

An update of issues
dealt with in Lancet 1(2008)

Re-evaluation of the problems of maternal and childundernutriiton and also examination of the growing
problems of overweight and obesity and theirconsequences in low- and middle-income countries

Its aim is to offer evidence-based
consensus recommendations onwhat to do about the continuing
problem of undernutrition.
Particular attention is paid tocosting actions of direct nutritioninterventions in the context ofnutrition-sensitive interventions.

Source: Amended after Micronutrients, Macro-Impact: The story of vitamins and a hungry world, Sight and Life, 2012. Copyright Sight and Life.

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179

List of key organizations
Centers for Disease Control andPrevention (CDC)

Food and Agriculture Organization of
the United Nations (FAO)

Health Protection – Health Equity

For a world without hunger

Founded: 1946

Founded: 1945

Headquarters: Atlanta, GA, USA

Headquarters: Rome, Italy

Website: www.cdc.gov

Website: www.fao.org

Collaborating to create the expertise,
information, and tools that people andcommunities need to protect theirhealth – through health promotion,
prevention of disease, injury anddisability, and preparedness for new
health threats.

Achieving food security for all is at theheart of FAO’s efforts – to make surepeople have regular access to enoughhigh-quality food to lead active,
healthy lives

GAIN (Global Alliance for Improved
Nutrition)
Canadian International
Development Agency (CIDA)
Founded: 1968
Headquarters: Gatineau, Quebec,
CanadaWebsite: www.acdi-cida.gc.ca/home

Leads Canada’s international efforts to
help people living in poverty.

UK Department for International
Development (DfID)
UK Government Department
responsible for promoting
development and the reduction ofpovertyFounded: 1997
Headquarters: London and East
Kilbride, Glasgow, UK
Website: www.DfID.gov.uk

DfID’s mission is to eliminate global
poverty by making a greater impact onachieving the Millennium
Development Goals.

Founded: 2002
Headquarters: Geneva, Switzerland
Website: www.gainhealth.org

GAIN is committed to accomplishing
the global health goals which are
related to its vision of a world
without malnutrition.

Helen Keller International (HKI)HKI is a non-profit organization
dedicated to preventing blindness andreducing malnutrition worldwide
Founded: 1915
Headquarters: New York City, NY, USA
Website: www.hki.org

HKI’s mission is to save the sight andlives of the most vulnerable anddisadvantaged. It combats the causes
and consequences of blindness andmalnutrition by establishing programs
based on evidence and research invision, health and nutrition.

International Food Policy ResearchInstitute (IFPRI)
Sustainable solutions for ending
hunger and poverty
Founded: 1975
Headquarters: Washington, DC, USA
Website: www.ifpri.org

Bill and Melinda Gates Foundation(Gates Foundation)

To provide policy solutions that reducepoverty and end hunger andmalnutrition.

All lives have equal value
Founded: 1994
Headquarters: Seattle, Washington,
USA
Website: www.gatesfoundation.org

To increase opportunity and equity for
those most in need.

International Fund for Agricultural
Development (IFAD)
Founded: 1977
Headquarters: Rome, Italy
Website: www.ifad.org

The goal of the IFAD is to enable poor
rural people to improve their food andnutrition security, increase their incomesand strengthen their resilience. IFAD
also acts as an advocate for poor rural
women and men. The multilateralorientation provides a strong global
platform for discussing rural policy
issues and increasing awareness of why
investment in agriculture and ruraldevelopment is critical to reducing poverty
and improving global food security.

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180

Micronutrient Initiative (MI)United Nations World Food Program (WFP)

World Health Organization (WHO)Solutions for hidden hunger

Fighting Hunger Worldwide‘Working for Health’

Founded: 1997

Founded: 1963

Founded: 1948

Headquarters: Ottawa, Canada

Headquarters: Rome, Italy

Headquarters: Geneva, Switzerland

Website: www.micronutrient.org

Website: www.wfp.org

Website: www.who.int

To develop, implement and monitor
innovative, cost-effective andsustainable solutions for hidden
hunger, in partnership with others.

WFP is the food-assistance agency of theUnited Nations system. Food assistanceis one of the many instruments that canhelp to promote food security, which isdefined as access of all people at all
times to the food needed for an active
and healthy life. The policies governing
the use of WFP food assistance must be
oriented towards the objective of
eradicating hunger and poverty. Recently,
WFP moved its focus from food aid tofood assistance, using different modalities
to improve food security and nutrition of
their beneficiaries.

WHO is the directing and coordinating
authority for health within the United
Nations system. It is responsible forproviding leadership on global healthmatters, shaping the health research
agenda, setting norms and standards,
articulating evidence-based policy
options, providing technical support tocountries and monitoring and assessing
health trends. In the 21st century, healthis a shared responsibility, involving equitable
access to essential care and collective
defense against transnational threats.

Program for Appropriate Technology in
Health (PATH)
A catalyst for global healthFounded: 1977
Headquarters: Seattle, Washington,
USA
Website: www.path.org

PATH’s mission is to improve thehealth of people around the world byadvancing technologies,
strengthening systems, andencouraging healthy behaviors.

The World Bank (World Bank)

United States Agency forInternational Development (USAID)

Working for a world free of poverty

Founded: 1961

Headquarters: Washington, DC, USA

Headquarters: Washington, DC, USA
United Nations International Fund
(UNICEF)‘Unite for Children’
Founded: 1946
Headquarters: New York, NY, USA
Website: www.unicef.org

UNICEF is mandated by the United
Nations General Assembly to advocate
for the protection of children’s rights,
to help meet their basic needs and to
expand their opportunities to reach
their full potential.

Website: www.usaid.gov

The US Agency for International
Development (USAID) is anindependent agency that provides
economic, development andhumanitarian assistance around theworld in support of the foreign policy
goals of the United States.

Source: Micronutrients, Macro-Impact: The story of vitamins and a hungry world, Sight and Life, 2012.
Copyright Sight and Life.

Founded: 1944
Website: www.worldbank.org

To fight poverty with passion andprofessionalism for lasting results. To
help people help themselves and theirenvironment by providing resources,
sharing knowledge, building capacityand forging partnerships in the public
and private sectors.

World Vision International
Founded: 1950
Headquarters: Monrovia, USA
Website: www.wvi.org

World Vision is a global Christian relief,
development and advocacy organization
dedicated to working with children,
families and communities to overcome
poverty and injustice. World Vision
serves all people, regardless of religion,
race, ethnicity, or gender.

181

Afterword:
Now is the Time

Patrick Webb
Dean for Academic Affairs,
Friedman School of Nutrition Science and Policy,
Tufts University, Boston, USA

Does the world really need this book? Do the shelves ofanalysts and policy-makers need the weight of yet anothercompendium of ideas, statistics and rhetoric?
The answer, perhaps surprisingly, is yes. Such a book isneeded now, more than ever, because it reflects the rapid
convergence of opinion around priority problems and likely
pathways towards solutions.
The 2008 Lancet Series on Maternal and Child
Undernutrition highlighted what was then called the“fragmented and dysfunctional” state of the international
nutrition system.1 That “the system is broken” became anoft-repeated mantra of the late 2000s, a signal that perhaps
the biggest challenges to be faced came from within.
Progress towards common purpose in nutrition had long
been plagued by poorly articulated technical definitions,
nutrient-centric debates, and competing institutional mandates.
As a result, donor funding dedicated to nutrition was scarce,
national governments chose to focus on other priorities
offering more obvious gain, and science paid more attention todemonstrating the efficacy of narrowly defined interventions
than to explaining how to make policies and programs work.

The calls have been heard
A mere half decade later, things are starting to lookdifferent. Calls for more resources, for greater politicalprioritization, and for more effective implementation ofnutrition actions are being heeded. There is still a long way
to go, no doubt, but the calls are being heard in the grandhalls of governance, as in the corridors of academia andunder the shade trees of civil society. Commitment tochange is growing rapidly among developing-country
politicians, donor funding has risen, scientists are sheathing
their swords, and even private industry is sometimes invited
to the table of global debate.
The 2013 Lancet series2 update on maternal and childnutrition only used the term “dysfunctional” once, and thento describe how things were, not how they have become.
Instead, the new series focused on the importance ofaccelerating evidence-based actions at scale, the essential
complementarity offered by nutrition-sensitive
programming that address underlying determinants, and on
the need to sustain all initiatives (politically as well as
financially) by shaping effective policy processes.
These changes in the tone of global discourse, linked towidespread adoption of a common lens through which to
scrutinize what we do and how, represent a pivotal momentin humanity’s recurring war on want. There is a sense
running throughout this book that the attainment of soundnutrition for all people everywhere is no longer a fantasticaldream, but a genuine possibility.

It is imperative that we act
If accepted as truly possible, it is imperative that we act inways that make it so. The foregoing chapters articulate that
great progress has recently been made in reducing prevalence
rates of stunting; but 165 million children are still affected.3
Wasting has fallen globally, but only slowly and not much in
Africa. Most micronutrient deficiencies remain poorly
measured and hard to uncouple from the poor diets and poor
health that continue to blight more than a billion people.
Obesity and chronic non-communicable diseases are spreading
rapidly – now manifest as much in developing, as inindustrialized, countries. Thus, the world cannot afford totreat one problem at a time. Improving nutrition in all of its
forms is a massive unfinished social, economic, political andhumanitarian agenda. Progress is still not fast enough or
far-reaching enough to prevent the deaths and blighted lives ofmany hundreds of millions of people, including those still to beborn in the coming decade. It has to be accelerated, made fully
inclusive, and sustained.
None of which is easy. The task at hand is complex, so thesolutions are anything but simple. Evidence-supported actions
are needed on a wide scale to address the very specificrequirements of adolescent girls, pregnant women, mothers
and their infants, and children as they grow and develop into
productive adults. Some actions must be pursued with
universal coverage, but others must be targeted at the mosturgent cases first. Some must prevent, protect and promote,but other actions that save and treat and make whole again are
equally relevant to the common goal. Appropriate policies areneeded to enhance the nutritional resiliency of individuals aswell as of entire populations. Disasters that all too often erode
past gains must be anticipated so that effective responses canbe prosecuted with necessary vigor. And carefully designed
activities supportive of agricultural and income growth, social
protection, quality education and health represent essential
contributions to the solution set. A critical component of all of theabove is the generation of high-quality empirical evidence of whatworks best in what context.
This book captures the fact that there has not been a time inrecent decades when so many people agreed on what needs
to be done or why. The momentum has to be maintained.
The next decade of the 21st century should be focusedsquarely on a global effort to get it done well, while
documenting how. Unless coherent, cost-effective actions
with measurable impacts quickly emerge from the current
cresting wave of goodwill toward nutrition, the wait foranother may be far too long. Now is the time.
References
1. Morris S, B Cogill, R Uauy, for the Maternal and Child Undernutrition
Study Group. Effective international action against undernutrition: why has itproven sodifficult and what can be done to accelerate progress? Lancet
2008:371;608–21.
2. The Lancet. Maternal and Child Nutrition. Special Series of four papers andrelated Commentaries. June 6, 2013. http://www.thelancet.com/series
maternal-and-child-nutrition.
3. UNICEF. Improving Child Nutrition: The achievable imperative for global
progress. New York:UNICEF, 2013.

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183

Profiles of Contributors and Editorial
Board members
I. Contributors

II. Editorial Board members

1. Tom Arnold
2. Hans Konrad Biesalski

1. Manfred Eggersdorfer

3. Martin Bloem

2. Klaus Kraemer

4. Joachim von Braun

3. Marie Ruel

5. Alan Dangour

4. Marc Van Ameringen

6. Stuart Gillespie

5. Hans Konrad Biesalski

7. John Hoddinott

6. Martin Bloem

8. Eileen Kennedy

7. Junshi Chen

9. Alain Labrique

8. Asma Lateef

10.Asma Lateef

9. Venkatesh Mannar

11.Marguerite B Lucea
12.Victoria Quinn
13.Marie Ruel
14.Werner Schultink
15.Patrick Webb

Marc Van Ameringen

Tom Arnold

Current title:

Current title:

Executive Director of Global Alliance for Improved
Nutrition (GAIN), Geneva, Switzerland

Chairman of the Convention on the Irish Constitution

Qualification:

Qualification:

MA in Political Science

MA in Business Administration, Catholic University ofLouvain

Focus:

MA in Strategic Management, Trinity College, Dublin

Leadership roles for nonprofit organizations in the area ofnutrition and development.

BA in Agricultural Economics, University College, Dublin

Biography:
A Canadian national, Marc Van Ameringen has spent morethan twenty years working in the field of international
development. He is the Executive Director of the Global
Alliance for Improved Nutrition (GAIN), which supports
programs aimed at reducing malnutrition with a focus on
micronutrient deficiencies.
Under his leadership, GAIN has become a major alliance ofbusiness, governments and international organizations thatis implementing at scale nutrition programs in more than 30
countries. These innovative market-driven programs are
improving the lives of over nearly 800 million people, of
which more than half are women and children.
Prior to joining GAIN in December 2004, Marc was Vice
President of the Canada-based Micronutrient Initiative(MI), where he was responsible for coordination, planningand management of MI programs. Before this, he wasSpecial Advisor to the G8 Summit within the CanadianGovernment’s Department of Foreign Affairs and International
Trade, assisting the G8 in responding to the New
Partnership for Africa’s Development (NEPAD) initiative.
From 1992 to 2002, Marc was a Director based in Africa
for the International Development Research Centre (IDRC),
responsible for a number of large development programs
across Africa. He played an important role in assistingSouth Africa and other countries in Southern Africa in theirreconstruction and development. Prior to moving to Africa,
he held various senior positions in Canada for IDRC andother organizations.
Marc has served as a Board Member and Trustee of manydifferent development organizations and has published anumber of books on development in Africa. In 2008, he
was appointed a Member of the Institute of Medicine’s
Committee on U.S. Commitment to Global Health. In
2009, he was nominated Vice Chair of the World Economic
Forum’s Global Agenda Council on Nutrition.

Focus:
Governmental and charity organizations in Irelandand internationally; management, policy development
and administration.
Biography:
Mr Arnold was CEO of Concern Worldwide from 2001 until
February 2013. Concern Worldwide is Ireland’s largest
humanitarian organization and has a growing presence in the
United Kingdom and the USA. Its work focuses on helping themost vulnerable people in the world’s poorest countries.
Innovation and influence
During his tenure as CEO, Mr Arnold led Concern
through a period of growth in budget, operations,innovation and influence.
Additional engagements include:• Member of the Lead Group of the Scaling Up Nutrition(SUN) Movement, 2012 - present• Member of the Consortium Board for International
Agricultural Research (CGIAR), 2010-2012• Member of the Consortium Board of the Consultative
Group for International Agricultural Research since 2009
• Member of the International Food Policy ResearchInstitute’s 2020 Advisory Board since 2006
• Chair of the Irish Times Trust and Member of the Irish
Times Board• Chair of European Food Security Group, a network ofEuropean NGOs, from 2005-2010• Member of Irish government’s Commission on Taxationfrom 2005-2009• Member of Advisory Board for the UN’s Central Emergency
Response Fund 2006-2009• Member of Irish government’s Hunger Task Force
2007-2008• Member of UN Millennium Project’s Hunger Task Force
2003-2005

184

185

Hans Konrad Biesalski

Martin BloemCurrent title:

Current title:

Head of Department, Biological Chemistry and Nutrition,
University of Hohenheim , Managing director of the Food
Security Center in Stuttgart, Germany

Senior Nutritionist and WFP’s Global Coordinator UNAIDS– United Nations World Food Program; Adjunct Associate
Professor, – Johns Hopkins Bloomberg School of Public
Health, Baltimore, USA; Adjunct Associate Professor, –Friedman School of Nutrition Science and Policy, Tufts
University, Boston, USA

Qualification:
PhD in Medicine from the University of Mainz, Mainz,
Germany
Focus:
Nutrition physiology and nutrition medicine.
Biography:
Prof. Dr Biesalski is currently heading the Department of
Biological Chemistry and Nutrition at the University of
Hohenheim and the Food Security Center in Stuttgart,
Germany. Born in 1949 in Marburg, he studied Physics at
the University of Mainz (1971–1974) and was appointed
Research Assistant at the Department of Physiology,
Division of Physics, in 1979. He graduated in 1981 with an
MD thesis on ‘Progressive Hearing Disorders in Childhood’.
In 1993, he was appointed Associate Professor, then full C4Professor at the Department of Biological Chemistry andNutrition at the University of Hohenheim.
Prof. Dr Biesalski is editor of the journal Nutrition andMetabolism in Oncology, European editor of the journals
Nutrition and Nutrition and Metabolism. He is member ofthe WHO group nanotechnology and a member of the
Scientific Advisory Board of the US Pharmacopeia. From1994 – 2006 he was chair of the Nutrition group in theGerman Cancer Society and since 2009 he is chair of the
Nutrition group of the German Society of Haematoncology.
Since 2009 he is member of the High-Level Panel of Experts
group of the Global Forum on Food Security and Nutrition.
Prof. Dr Biesalski has given lectures in nutrition physiology,international nutrition and nutrition medicine in European
medical schools. He has chaired several international
conferences; including the World Health Organization(WHO) Conference on Nutrition and Cancer in 1997, theCongress Nutrition Teams every two years since 2002 andthe international congress Hidden Hunger in 2013. He hasedited seven textbooks and is author of the book Hidden
Hunger (2012). He published 235 papers in international
peer reviewed journals. His scientific focus is vitamin A, in
particular consequences of vitamin A deficiency on mucous
membranes and function and bioavailability studies withcarotenoids and antioxidants.

Qualification:
PhD in Nutrition from the University of Maastricht,
Maastricht, the Netherlands;
MD from the University of Utrecht, Utrecht, theNetherlands
Focus:
Vitamin A supplementation, micronutrients, and nutritionand health issues in the developing world.
Biography:
Dr Bloem qualified as a doctor in 1981 from the Universityof Utrecht. He served as Medical Officer for the Ministry of
Defense at The Hague in the Netherlands from 1982–1983.
After this, he worked as a medical scientist for CIVO-TNO
Toxicology & Nutrition Institute, TNO Zeist, theNetherlands from 1983–1989, and as a scientific consultant
for the Nutrition Supplement Cooperation Project inThailand from 1985–1986.
In 1989, Dr Bloem joined Helen Keller International asCountry Director for Bangladesh, a post he held until 1994
when he became Country Director for Indonesia. He took
on the additional post of Regional Director for Asia Pacificfor the foundation in 1996, and in the 2003 he became
Senior Vice President, Chief Medical Officer for Helen
Keller International (2003–2005).
He has been involved in consulting work on vitamin A
supplementation, micronutrients, and nutrition and healthissues in the developing world and for UNICEF for their
Vitamin A program and prevalence surveys; the AsianDevelopment Bank, on nutrition and health impact of the
Asian Economic Crisis in urban areas in Indonesia; the WHO(National Vitamin A program in Laos); and USAID/OMNI(Micronutrient malnutrition intervention programs in the Asia
Pacific, Nepal). He has also been a lecturer at Western Cape
University in South Africa, periodically, from 1998–2004.

Joachim von Braun

Junshi Chen

Current title:

Current title:

Director of the Center for Development Research (ZEF) andProfessor for Economic and Technological Change atUniversity of Bonn, Germany

Senior Research Professor, Institute of Nutrition and Food
Safety, Chinese Centre for Disease Control and Prevention,
Beijing, China. General Scientific Advisor, National Centre
for Food Safety Risk Assessment, Beijing, China

Qualification:
Doctoral degree in Agricultural Economics from the
University of Göttingen, Göttingen, Germany
Focus:
International development economics topics, including
markets and trade; poverty; famine, health and nutrition;science and technology.
Biography:
Prof. von Braun is a Director of the Center for Development
Research (ZEF) and Professor for Economic andTechnological Change at the University of Bonn, Germany.
ZEF is a multi-disciplinary research institute with acomprehensive doctoral studies program held in English.
Prof. von Braun is an economist, with a Doctoral degree inagricultural economics from University of Göttingen,Germany. He joined ZEF as Professor and Director of the
Department for Economic and Technological Change inDecember 2009. He was also Director at ZEF during its
foundation phase 1997–2002.
Prof. von Braun was Director General of the International
Food Policy Research Institute (IFPRI) based in
Washington, DC, USA from 2002–2009. Prof. von Braunserves on various boards of publishers of journals, as wellas national and international advisory bodies of researchand policy organizations.
He has published research on international development
economics topics, including science and technology; on
policy issues relating to trade and aid, famine, health, andnutrition; and on a wide range of agricultural economics
research issues. Prof. von Braun has worked in sub-SaharanAfrica, Central America, Egypt, Russia, and China.
From 2000–2003, he was President of the International
Association of Agricultural Economists (IAAE). He ismember of the Academy of Science of North-Rhine
Westphalia, of the German Academy of Science andEngineering (ACATECH), and a Fellow of the American
Association for the Advancement of Sciences and thePontifical Academy of Science of the Vatican. Amongawards received by Prof. von Braun are an honorary
Doctoral degree from the University of Hohenheim, theBertebos Prize of the Swedish Academy of Agricultural
Sciences for his research on food security, and the Justus
von Liebig Prize for his research on international nutrition.
Further Information:www.zef.de

Qualification:
M.D. - Beijing Medical College. Beijing, China
Visiting Scholar and Adjunct Professor, Division of
Nutritional Sciences, Cornell University, Ithaca, USA
Biography:
Dr Junshi Chen graduated from the Beijing Medical College
in 1956 and was engaged in nutrition and food safety
research for more than 50 years. He has conducted large
epidemiologic studies on diet, nutrition and chronic
diseases, in collaboration with Prof. T Colin Campbell,Cornell University and Prof. Richard Peto, University of
Oxford since 1983. From the late 1980’s, he conducted aseries of studies on the protective effects of tea on cancer,
including laboratory study and human intervention trials.
He is the member of the expert panel who wrote the
WCRF/AICR report “Food, Nutrition and the Prevention ofCancer: a Global Perspective” (1997). Recently, he wasappointed as the Chair of the Chinese National Expert
Committee for Food Safety Risk Assessment and theVice-Chair of the National Food Safety Standard Reviewing
Committee. Internationally, he serves as the chairperson for
the Codex Committee on Food Additives (CCFA) , memberof the WHO Food Safety Expert Panel and Director of ILSI
(International Life Sciences Institute) Focal Point in China.
Dr Chen’s research interests focus on nutrition epidemiology
as well as food safety surveillance and risk assessment.
Further Information:
http://www.chinafoodsafety.net/index.jsp;
E-mail: junshichen@yahoo.com

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187

Alan Dangour

Manfred Eggersdorfer

Current title:

Current title:

Senior Lecturer, London School of Hygiene and Tropical
Medicine (LSHTM); 		

Senior Vice President, DSM Nutritional Products (Memberof the Leadership Council DSM Nutritional Products),
Head of DSM Nutrition Science & Advocacy, Kaiseraugst,
Switzerland, Honorary Professor Healthy Aging atUniversity Groningen

Research Senior Fellow in Nutrition, Department forInternational 				Development (DfID), London, UK
Qualification:
PhD in Biological Anthropology from University College, London
Focus:
Ageing and nutrition; agriculture, nutrition and health;clinical trials; systematic reviews.
Biography:
Dr Dangour joined LSHTM in 2001, and is a seniorlecturer and registered nutritionist (Public Health) with abackground in biochemistry and biological anthropology.
From January 2012, Dr Dangour has been seconded
part-time to the Research and Evidence Division of the UK
Department for International Development as a SeniorResearch Fellow in nutrition. Dr Dangour is Head of the
Nutrition Group at LSHTM.
For the past 10 years, Dr Dangour’s primary research focus
has been nutrition in older age, and he has conducted aseries of trials to determine the effectiveness of nutritioninterventions for the maintenance of health and function inlater life. An increasing focus of Dr Dangour’s research is
the interaction between agriculture, nutrition and health; heis part of the interdisciplinary team behind the Leverhulme
Centre for Integrative Research on Agriculture and Health.

Qualification:
PhD in Organic Chemistry from the Technical University of
Munich, Munich, Germany
Biography:
Prior to DSM, Dr Eggersdorfer worked for BASF,
Ludwigshafen in different positions including Head of
Research and Development Fine Chemicals.
Dr Eggersdorfer studied chemistry at the Technical
University, Munich and did his PhD in organic chemistry in
the field of synthesis and characterization of unusual aminoacid. He undertook post-doctoral work at Stanford
University, California, working with Carl Djerassi on theisolation and characterization of sterols from marine origin.
Dr Eggersdorfer is an active member of the Advisory Boardof the Johns Hopkins Bloomberg School of Public Health,member of the Strategy Board of the Institute of Food
Science University Hamburg, Board member of theGesellschaft für angewandte Vitaminforschung e.V., theFraunhofer-Gesellschaft Curatorial for Innovation, and anaffiliate of various other organizations. Dr Eggersdorfer was
made an Honorary Member of the Oxygen Club of
California for his pioneering work in research anddevelopment of nutraceuticals. He is the author of numerous
publications in the fields of vitamins, innovation in nutritional
ingredients, and renewable resources, and reviewer for avariety of journals, as well as associate editor of theInternational Journal of Vitamin and Nutrition Research.
Further Information:
http://www.hsfs.org/de/strategy_board/mitglieder/
eggersdoerfer.php

Stuart Gillespie

John Hoddinott

Current title:

Current title:

Senior Research Fellow, Poverty, Health and Nutrition
Division, IFPRI, and CEO of the Transform Nutrition
Research Program Consortium, currently based in Brighton,
UK.

Deputy Director, Poverty Health and Nutrition Division,
IFPRI, Washington DC, USA

Qualification:
PhD in Human Nutrition from the London School ofHygiene and Tropical Medicine, London, UK
Focus:
Nutrition, food policy research, HIV/AIDS-food andnutrition security links.
Biography:
Dr Gillespie is senior research fellow with the Poverty,
Health and Nutrition Division of the International Food
Policy Research Institute (IFPRI) and CEO of the Transform
Nutrition Research Program Consortium.
Stuart is also Research Director of the Leveraging
Agriculture for Nutrition in South Asia (LANSA)
consortium, both funded by DfID. A British citizen, Stuart
earned a food science honors degree from the University ofReading, and a master’s degree and PhD (1988) in humannutrition from the London School of Hygiene and Tropical
Medicine. Prior to joining IFPRI in 1999, he had worked invarious international agencies, bilateral agencies, andnon-governmental organizations on nutrition policy
analysis, information systems development, and monitoringand evaluation.
Through most of the last decade, he has specialized inaction research on the interactions between HIV and foodand nutrition security, and their implications fordevelopment policy and practice, having co-founded andmanaged the Regional Network on AIDS, Livelihoods andFood Security (RENEWAL) based in eastern and southern
Africa. Dr Gillespie was director of the International
Conference on HIV/AIDS, Food and Nutrition Security heldin South Africa in April 2005.
In recent years, he has coordinated the Agriculture and
Health Research Platform (AHRP) of the Consultative
Group on International Agricultural Research (CGIAR),
and led the TANDI project (Tackling the AgricultureNutrition Disconnect in India). Past work has focused onunderstanding ‘what works’ in malnutrition reduction,scaling up community-driven development, and developing
methodologies for community capacity analysis. He hasover 100 publications including eight books, eightmonographs and numerous journal articles.
Further Information:
http://www.ifpri.org/staffprofile/stuart-gillespie

Qualification:
DPhil in Economics from the University of Oxford, Oxford, UK
Focus:
Micro-econometric analysis of development issues such as
poverty, food insecurity and undernutrition; interventions.
Biography:
Dr Hoddinott is a Deputy Director in the Poverty Healthand Nutrition Division. Before joining IFPRI, he held
university appointments in Canada and the United
Kingdom, including a University Lectureship in Economics
and Fellowship at Lady Margaret Hall, University of
Oxford. A Canadian citizen, Dr Hoddinott holds a BA in
Economics from the University of Toronto, an MA fromYork University and a DPhil in Economics from the
University of Oxford.
His principal research interest lies in the micro-econometricanalysis of issues in development economics. Dr Hoddinott
is especially interested in the causes of poverty, foodinsecurity and undernutrition, and the design andevaluation of interventions that would reduce these. Muchof his current research has focused on the determinants andconsequences of human capital formation. This builds on
his earlier work on modeling the processes of intrahousehold resource allocation and on labor markets. Dr
Hoddinott has also had involvement in discussions
surrounding aid flows, responses to the 2008 food pricecrisis and reforms to the global food security architecturesuch as the Food Aid Convention.
Further Information:
http://www.ifpri.org/staffprofile/john-hoddinott

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189

Eileen Kennedy

Klaus Kraemer

Current title:

Current title:

Professor of Nutrition and Former Dean of the Friedman
School of Nutrition Science and Policy at Tufts University,
Boston, USA

Director, Sight and Life, Kaiseraugst, Switzerland
Qualification:

Qualification:

PhD in Nutritional Sciences from the University of
Giessen, Germany

Doctor of Science in Nutrition from Harvard School of
Public Health, Boston, MA

Focus:

Focus:

Research and advocacy; micronutrients and nutrition in thedeveloping world.

Assessment of public policy focusing on nutrition, health,food security and poverty alleviation strategies.

Biography:

Biography:
Dr Kennedy is the Professor of Nutrition and Former Deanof the Friedman School of Nutrition Science and Policy at
Tufts University and was the first Director of USDA’s Center
for Nutrition Policy and Promotion. Dr Kennedy holds anundergraduate degree from Hunter College, two masters
degrees from Pennsylvania State University and Harvard
School of Public Health, and a Doctor of Science inNutrition from Harvard’s School of Public Health.
Dr Kennedy has long been involved in the academic arenaof nutrition, conducting research and teaching at Tufts
University, Columbia University, Cornell University andJohns Hopkins University.
From 1997 to 2001 Dr Kennedy was Deputy
Undersecretary for Research, Education and Economics in
USDA; in this role she oversaw the technical agencies
addressing nutrition, agriculture, statistics and university
education. Dr Kennedy has been a member of the United
Nations Advisory Group on Nutrition and the Institute ofMedicine’s Committee on Global Health. She currently is amember of the Policy and Global Affairs Committee of the
National Research Council.
Further Information:
http://whitepages.tufts.edu/ldapentry.cgi?tuftsedutrunk=
661FE86C77AB0EA2 6A8B6799CAC8B4F3Dr Kraemer obtained his first degree and doctorate innutritional sciences from the University of Giessen inGermany. He is currently Director of Sight and Life, thenutrition think tank and humanitarian initiative of DSM, aglobal science-based company active in health, nutrition
and materials, which is committed to fighting micronutrient
malnutrition. Sight and Life believes that the right mix offunding, knowledge, technology and policy will lead tobetter nutrition and health and, as such, works throughadvocacy and thought leadership to address societal
changes affecting dietary quality. As the Director ofSight and Life, Dr Kraemer provides the leadership, vision,and direction to promote research, share best practice, andmobilize support towards building bridges for better nutrition.
Moreover, he is the editor of Sight and Life magazine, one of
the most widely read scientific magazines focusing on
micronutrients and health in the developing world.
As a nutrition scientist with over 25 years of experience inresearch, advocacy, communication, and strategic andorganizational leadership in the fields of nutrition andpublic health, Dr Kraemer has expertise in research andprogram and product development, as well as program
implementation and evaluation.
Dr Kraemer serves on several professional societies
dedicated to nutrition and micronutrients, he is a reviewer
for a number of scientific journals, he has published many
peer-reviewed scientific articles, and co-edited nine books.
Dr Kraemer has been honored for his dedication to the fightagainst micronutrient deficiencies in developing countries by
the Micronutrient Forum and the Oxygen Club of
California. Recently, he has become an appointed memberof the Steering Committees of the Micronutrient Forum,
Biomarkers of Nutrition for Development (BOND) and the
New York Academy of Sciences’ Sackler Institute for
Nutrition Science.

Alain Labrique
Current title:
Director, JHU Global mHealth Initiative; AssistantProfessor, Department of International Health & Dept of
Epidemiology (jt) Bloomberg School of Public Health
Qualification:
PhD in Epidemiology from the Johns Hopkins Bloomberg
School of Public Health, Baltimore, USA
Focus:
Emerging Infectious Disease epidemiology, Information
and Communications Technologies for Health, eHealth,
Health Systems.
Biography:
Dr Labrique is a trained infectious disease epidemiologist,with a background in molecular biology. Dr Labrique serveson the faculty in the Global Disease Epidemiology andControl Program of the Department of International
Health, with a joint appointment in the Department of
Epidemiology of the School of Public Health as well as to
the John Hopkins University School of Nursing. Having
completed graduate research at UNC-Chapel Hill, studying
centromere dynamics in yeast, Dr Labrique shifted focus
from the microscopic to human populations by pursuing amaster’s and doctorate in Epidemiology at the Johns
Hopkins Bloomberg School of Public Health.
With colleagues at the International Centre for Diarrheal
Disease Research, Bangladesh (ICDDR-B), Dr Labriqueconducted the first epidemiologic studies of hepatitis E virus
infections in rural Bangladesh, characterizing this emerging
pathogen. From 2001 to 2008, Dr Labrique served as theresident JHU Project Scientist and Country Representative
for the JiVitA Project, responsible for the oversight ofseveral large randomized controlled community trials; theseincluded a large maternal and child health research projectin north-western rural Bangladesh, testing the impact of
low-dose vitamin A supplementation during pregnancy andlactation on reducing maternal morbidity and mortality, as
well as an infant mortality reduction trial through high-dose
vitamin A supplementation of newborn babies.
In addition to teaching and mentoring students at theschool, and continued involvement as a Lead Investigatorwith the JiVitA micronutrient research projects, Dr
Labrique is working on defining the consequences ofhepatitis E infections in pregnant women in South Asia,
reducing nosocomial infections in hospitalized neonates,and exploring the role of intrapartum infections, such asbacterial vaginosis, on pregnancy outcomes and neonatal
mortality. Dr Labrique is also working to describe the‘trajectories to mortality’ in resource-limited settings
experienced by women of reproductive age and infants, toidentify novel opportunities for intervention. Leading aninterdisciplinary team spanning the Johns Hopkins

University, Dr Labrique and colleagues are exploring thepotential for mobile information and communications
technologies to facilitate timely emergency obstetric andneonatal care to reduce perinatal mortality and maternal
morbidity in rural Bangladesh.
Dr Labrique is also actively engaged in designing andexploring appropriate diagnostic and public healthtechnologies, and is the inventor of a number of devices(three patents pending), including the Portable Field Dark
Adaptometer – a novel device currently being validated as a
non-invasive method for vitamin A assessment.
Further information:
http://bit.ly/JHSPHLabrique
http://www.jhumhealth.org

190

Asma Lateef

Marguerite B Lucea

Current title:

Current title:

Director, Bread for the World Institute, Washington DC, USA

Faculty Research Associate, Johns Hopkins University
School of Nursing (JHUSON), Baltimore, MD, USA

Qualification:
191

BA in in Geography from McGill University, Montreal, Canada.

Qualification:

MA in Economics from Maryland University, Washington
DC, USA.

PhD in Nursing from Johns Hopkins University School of
Nursing, Baltimore MD; MPH from Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD

Post-Graduate Diploma in Economics from the London
School of Economics, London, UK

Focus:

Focus:

Women’s health and gendered health inequities; HIV;
violence prevention; mHealth innovations.

Research and policy analysis for advocacy work.
Biography:
Ms Lateef is Director of the Bread for the World Institute,the research and policy analysis education wing that
underpins Bread for the World’s advocacy work. Bread for
the World is a faith-based anti-hunger advocacy
organization urging our nation’s decision makers to end
hunger at home and abroad.
Formerly, Ms. Lateef was Senior International Policy
Analyst at Bread for the World and Director of Policy andPrograms for Citizens for Global Solutions. She has also
served as a consultant for the United Nations Conference
on Trade and Development (UNCTAD) and theInternational Labour Organization (ILO) in Geneva.

Biography:
Dr Lucea is trained in the area of public health nursing, inaddition to being a family nurse practitioner. She iscurrently a Faculty Research Associate at the School of
Nursing and has been working in the field of women’s
health and violence prevention with both a nursing andpublic health approach for over seven years. Her work has
focused on biobehavioral and demographic data, and her
research interests include addressing gender inequities inhealth, particularly as they pertain to women’s sexual healthand HIV. Dr Lucea is also interested in the intersection
between issues of food security and nutritional needs andHIV risk behaviors. She has developed and implemented
complex analyses of data for research and practice.
Dr Lucea has seven years of biostatistical andepidemiological experience working on research grants
from the NIH and contracts with U.S. Centers for Disease
Control and Prevention, the U.S. Department of Health andHuman Services, the World Health Organization and otherinternational agencies.

Venkatesh Mannar

Saskia de Pee

Current title:

Current title:

President, Micronutrient Initiative

Technical Advisor Nutrition and HIV/AIDS, WFP,
Adjunct assistant Professor Friedman School of Nutrition
Science and Policy, Tufts University, Boston, USA

Qualification:
BSc Chemical Engineering, Indian Institute of Technology
MSc Chemical Engineering, Northwestern University,
Evanston, Illinois
Focus:

Visiting Assistant Professor, Wageningen University, theNetherlands
Qualification:

Supplementation and food fortification to combat hidden
hunger. Sustainable solutions for micronutrient deficiences.

PhD Human Nutrition, Wageningen University, Netherlands(1996). MSc Biomedical Sciences, Leiden University
Netherlands (1991)

Biography:

Focus:M G Venkatesh Mannar, OC is a leader in global healthwith more than 35 years’ experience in pioneering effective
international nutrition and development initiatives focusedon the world’s most vulnerable citizens.

Nutrition for young children, micronutrient deficiencies,
health and nutrition in the context of economic crises,
nutrition in relation to HIV/AIDS and tuberculosis, andmonitoring and evaluation of programs.

As President of the Ottawa-based Micronutrient Initiative(MI), he oversees the organization’s mission to develop,
implement and monitor cost-effective and sustainable
solutions for micronutrient deficiencies, also known as
hidden hunger, in collaboration with others.

Biography:

Under his leadership, MI has grown to play a major role inthe development and expansion of supplementation andfood fortification and programs to address hidden hunger inAfrica, Asia, Latin America and the Middle East. Fundedprimarily by the Canadian International Development
Agency (CIDA), MI works in close partnership withnational governments, the private sector and development
assistance agencies. Several of these programs have alreadyshown an impact.
Every year Mannar’s work through MI directly benefits
500 million adults and children in more than 75 countries.
On December 30, 2012, Mannar was appointed an Officerof the Order of Canada, one of the country’s greatest
civilian honors, for his leadership in the global fight against
malnutrition and micronutrient deficiency.
Further information:
http://www.micronutrient.org/

Saskia de Pee has worked in international nutrition foralmost 20 years. She conducted her PhD research in Bogor,West Java, Indonesia together with Dr Muhilal and Dr
Clive West in the early 1990s on vitamin A deficiency. Since
then, she has worked for Helen Keller International,
primarily in the Asia Pacific region as scientific advisor on
nutrition for 10 years until she joined the United Nations
World Food Program in 2007. Her work focuses on theinteraction between programs and science throughreviewing scientific evidence, developing, implementing andevaluating programs based on the latest scientificknowledge, and using scientific rigor to monitor andevaluate programs. She is also co-chair of the HomeFortification Technical Advisory Group.

192

193

Victoria Quinn

Marie Ruel

Current title:

Current title:

Senior Vice President of Programs, Helen Keller International,
New York, USA

Director, Poverty, Health and Nutrition Division,
International Food Policy Research Institute (IFPRI),
Washington DC, USA

Adjunct Associate Professor, Friedman School of Nutrition
Science and Policy, Boston, USA
Qualification:
PhD in nutrition planning and policy from Wageningen
University, Wageningen, the Netherlands
Focus:
Nutrition policy, planning and surveillance, infant and young
child feeding, micronutrients and women’s nutrition
Biography:
Dr Quinn joined Helen Keller International in 2006 as SeniorVice President of Programs, and is based in Washington, DC.
She has more than 30 years of experience in Africa, Asia, andLatin America, designing and managing complex and largescale nutrition and maternal child health country and regional
programs, including those involving agriculture and nutrition.
Dr Quinn’s areas of expertise include nutrition policy andsurveillance, infant and young child feeding, micronutrients
and women’s nutrition. She received her Bachelor’s andMaster’s in nutrition from UC Berkeley and Cornell
University, respectively, and her Doctorate from Wageningen
University in the Netherlands.
From 1982–1991, she served as the Regional Coordinator ofCornell University’s collaborative program with UNICEF in
Eastern and Southern Africa supporting country initiatives innutritional surveillance and food and nutrition policy.
Thereafter, she worked as a consultant for UNICEF, WHO,
WFP, the World Bank and the Dutch government on a variety
of food and nutrition security issues related to Africa. From
1998–2006 Dr Quinn served as the senior technical manager
for the LINKAGES Project’s flagship infant and young childfeeding programs in Bolivia, Ethiopia, Ghana, Madagascar
and the Horn of Africa. She also co-directed AED’s Center for
Nutrition from 2001–2006.
In 2007, Dr Quinn was appointed Adjunct Associate
Professor, at the Friedman School of Nutrition Science andPolicy at Tufts University in Boston. She is currently on theTechnical Advisory Groups for Tufts’ Nutrition CRSP
Program, Bread for the World, as well as serving as a memberof the International Advisory Panel for GAIN’s Access to
Nutrition Index study. Since 2007 she has chaired the
sub-working Group on ‘Integrating Breastfeeding with theAppropriate Marketing of Complementary Foods’ under the
Maternal, Infant and Young Child Nutrition Working Group.
Dr Quinn has also been an active member of the Scaling Up
Nutrition Civil Society network since its inception.
Further information:
http://www.hki.org/about-us/our-organization/seniorleadership/

Qualification:
PhD in International Nutrition from Cornell University,
Ithaca, USA
Focus:
Poverty and maternal and child malnutrition in developing
countries; related policies and programs
Biography:
Dr Ruel was appointed Director of IFPRI’s Poverty, Healthand Nutrition Division Food in 2004. From 1996 to 2004,
she served as (senior) research fellow in that division andsuccessively led two large multi-country and regional
programs: one on urban food security and nutrition andone on diet quality and diet changes of the poor. Prior to
IFPRI, she was head of the Nutrition and Health Division at
the Institute of Nutrition of Central America and Panama /Pan American Health Organization (INCAP/PAHO) in
Guatemala, where she lived and worked for 6 years. Dr
Ruel received her PhD in International Nutrition from
Cornell University and her Master’s in Health Sciences from
Laval University in Canada.
Dr Ruel has worked for more than 25 years on policies andprograms to alleviate poverty and malnutrition indeveloping countries. She has published extensively innutrition and epidemiology journals on topics such as
maternal and child nutrition, agriculture-and food-based
strategies to improve diet quality and micronutrient
nutrition, urban livelihoods, food security and nutrition, thedevelopment and validation of indicators of child feeding
and care practices, and program evaluation. Her current
research focuses on the evaluation and strengthening of awide range of integrated, multi-sectoral development
programs in the area of social protection and agriculture
and at building the evidence on their role in reducing
maternal and child malnutrition globally. She has served on
various international expert committees, such as the
National Academy of Sciences, the International Zinc in
Nutrition Consultative Group, the Society for International
Nutrition Research, and has recently joined theMicronutrient Forum Steering Committee. She recently led
the development of a large CGIAR program on Agriculture
for Improved Nutrition and Health, and is currently
contributing to its successful implementation.
Further information:
http://www.ifpri.org/staffprofile/marie-ruelJan Werner Schultink

Patrick Webb

Current title:

Current title:

Associate Director, Nutrition Section, Programme Division,
UNICEF, New YorkDean for Academic Affairs, Friedman School of Nutrition
Science and Policy, Tufts University, Boston, USA

Qualification:

Qualification:

PhD in Scientific Research from the Agricultural Universityof Wageningen, Wageningen, The Netherlands

PhD in Economic Geography from the University ofBirmingham, Birmingham, UK

Focus:

Focus:Development and delivery of Nutrition Programes

Food security, humanitarian policy and practice,development policy, agriculture and food systems,
micronutrient deficiencies and methods of delivery.

Biography:
Dr Schultink is the Associate Director of the Nutrition Section,
Programme Division for the UNICEF Headquarters in New
York. He gives guidance and advice on the global overall
direction and strategies for the Nutrition programming of
UNICEF, and he acts as the principal liaison on UNICEF
Nutrition issues for other relevant UN agencies, NGOs anddonor governments and agencies. Dr Schultink is responsible
for the management of the Nutrition Section and its 16
professional staff, and he assists in fund raising.
Prior to this, Dr Schultink was the Officer in Charge of the
Nutrition Section in the UNICEF Headquarters in New York,a role which he fulfilled in addition to his role as Senior
Advisor of Micronutrient Programs at UNICEF Headquarters.
From 1990 to 1999, Dr Schultink acted as long-term
advisor for the “Deutsche Gesellschaft für Technische
Zusammenarbeit (GTZ)” in the field of human nutrition at
the Regional South-East Asian Ministers of Education
Organization (SEAMEO) Center for Community Nutrition,
located at the University of Indonesia, Jakarta.
Dr Schultink achieved his PhD in Scientific Research in1991
from the University of Wageningen. During the writing of
his thesis, Seasonal variation in nutritional status andenergy requirements of rural Beninese women, Dr Schultink
was placed in a rural district of the Republic of Benin, West
Africa, where he carried out research according to theframework of co-operation with the Agricultural Faculty of
the University of Benin.
Dr Schultink was appointed the Adjunct Associate
Professor, at the Friedman School of Nutrition Science andPolicy, Tufts University, Boston in May 2009. He was also
the Vice-Chair of the Standing Committee on Nutrition of
the United Nations System between September 2007 andJanuray 2009; a board member of a Partnership for thesustainable elimination of iodine deficiency through theiodization of salt; a member of the Steering Committee ofthe Micronutrient Initiative, a Canadian-based NGO
funded by the Canadian Government, between April 1999
and October 2001; and Secretary and Co-Chairperson of
the ACC/SCN Working Group on Maternal Nutrition and
Low Birth Weight between May 2000 and December 2002.

Biography:
Dr Webb is former Chief of Nutrition of the World Food
Program of the United Nations; a first-responder to the
Asian tsunami disaster in Aceh; a member of theInternational External Evaluation of FAO; member of the
UN Millennium Project’s Hunger Task Force; former
member of the steering committee of the UN Standing
Committee on Nutrition.				
Dr Webb is involved in research on evidence of impact ofintegrated agriculture-health-nutrition programs in Nepal
and Uganda, policy responses to world food prices; cost andbenefits of ready-to-use foods in nutrition programming;
evaluation of nutrition programming in Burkina Faso,
Malawi, Ethiopia and East Timor; optimal nutrient
formulation of food aid commodities; measures of dietdiversity in emergencies.
In the past he has worked on such areas as: experiences offamine in Ethiopia and North Korea; tobacco use as
displacing food expenditure in Indonesia; optimal design of
public works projects in Niger; and tools for assessing
household food insecurity in Bangladesh.
Further Information:
http://nutrition.tufts.edu/faculty/webb-patrick194Index195

1,000 days 9, 15, 56, 89, 97, 99, 124, 136, 138, 153, 174
Mission 12
Organization 12
Partnership 159, 176
1,000-day window of opportunity 9, 25, 28
25-hydroxy-vitamin D 47, 48

A

Academia 82
Access to Information program 154
Acumen Fund 149
Adrenalin 55
Advocacy iii, iv, 10, 11, 58, 89, 95, 99, 101, 125, 159,
162,163, 168, 180, 187, 189, 191
power of 128–141
role of 132
Agenda 21 7
AGRA, see Alliance for a Green Revolution in Africa
Agriculturaldevelopment 8, 83, 131, 134
science 108, 186
Agriculture 26, 36, 54, 58, 81, 83, 84, 100, 108, 113, 118,
122, 123, 126, 131, 153, 155, 170, 185, 187, 188, 189, 193,
194
African 131, 136
and algorithms 156
and food security 6, 79, 129, 136
climate-smart 155
growth, sustainable intensification of 110
interventions 136
investment in 37, 110, 124, 129, 130, 131
mobile, see mAgriculture
productivity 26, 27, 38, 131, 146
programs and policies 36-8, 100, 129
small-scale 146, 147, 154
Agrochemicals 109
AIDS, see HIV/AIDS
Akter, Asma 20
Akter, Juhora 20
Akter, Tohomina 167
Alcohol 47, 58
Alcott, Louisa May 65
Aldrin, Buzz 25
Algorithms, see Agriculture and algorithms
Alliance for a Green Revolution in Africa (AGRA) 17, 131
Ameringen, Marc Van iii, 183, 184, 196
Amino acids 43, 187
Anemia 31, 42, 43, 62, 68, 72, 82, 83, 85, 95, 96, 124, 145,
149, 151, 163
reduction target 174
screening for 150
Animal husbandry, small-scale 83, 136
Annan, Kofi 17, 131

Antibodies 91
Antivirals (ARV) 80, 90
Appetite 15, 34, 66, 98
Arab Spring 103, 106, 155
Arnold, Tom iv, 10, 128, 183, 184
ARV, see Antivirals
Ascorbic acid, see Vitamin C
Asthma 44
Attention deficit 66
Australia 156
Axon 66

B

β-Carotene 144, 145, 171
Baby-Friendly Hospital Initiative 93
Bacteria 3, 55, 85
Bahrain 105, 106
Banda, Joyce 15
Bangladesh 12, 16, 19, 20, 22, 57, 60, 71, 83, 92, 93, 113,
120, 121, 124, 147, 153, 154, 167, 185, 190
Bangladesh Sugar and Food Industries Corporation (BSFI)
154
Barker Hypothesis 56, 67
Barnes, Stephen 152
Basic Minimum Needs (BMN) approach 123
Bedouins 61
Behavior change 62, 83, 84, 99, 145, 148
communication 80, 136
programs 69, 139
Bellamy, Carol vi
Benefit:cost
analysis 68
ratio 68, 71
Beriberi 43
Berliner Tafel e.V. 44
Berry, Simon 148
Best investment (Copenhagen Consensus) 68, 69, 131, 138
Beverages, marketing of to children 47, 59
Bhutta, Zulfiqar Ahmed 94
Biesalski, Hans Konrad iii, iv, 9, 39, 183, 185, 196
BioAnalyt 150
Biofortification 35, 37, 72, 100, 144, 152, 156, 177
Biofuel 108
Biomarkers 151–2, 189
Biotin, see Vitamin B7
Birthdefects 97
spacing 91
weight, low 5, 15, 34, 49, 56, 67, 75, 81, 90–1, 114,
117, 163, 173, 174, 194
Birthrate 3
Biscuits, high-energy 124
Blair, Mitch 44

Blanketfeeding 3
supplementary feeding program 3, 7
Bleeding, intrauterine 91
Blindness, night, see Night blindness
Bloem, Martin iv, 9, 13, 183, 185
BMI, see body mass index
BMI-for-age
BMN, see Basic Minimum Needs approach
BMS, see Breast milk substitute
Body mass index (BMI) 3, 6, 8, 53–4, 60–1, 94, 116
Bonding, mother-child 91
Borlaug, Norman 134
Brainchemicals 66
development 15, 28, 33, 69, 86, 90, 93, 174
Braun, Joachim von iv, 10, 102, 183, 186
Brazil 19, 60, 73, 120, 130, 146, 156, 168
Bread for the World 11, 134, 158, 165, 168, 191
Breast milk 16, 27, 28, 80, 85, 145, 167
composition, effects of maternal malnutrition on 94
energy 94
intake 94
measurement of 94
volume 94
during acute infection 94
nutrient composition of 4, 92, 94
quality in malnourished populations 94
Breast milk substitute (BMS) 3, 5, 114
Breastfeeding 5, 8, 9, 16, 25, 27, 34, 57, 71, 79, 82, 85, 89,
94, 97, 117, 140, 167, 193
exclusive 3, 4, 5, 12, 16, 25, 27, 34, 66, 80, 84, 85, 89,
90, 91-2, 93, 99, 114, 122, 124, 163, 174
early initiation of 79–80, 84, 89-90, 91, 93
optimal 82–4, 93
sub-optimal 32
British Journal of Nutrition 46
Broca’s area 69
Buck, Pearl S iv
Building Effective Partnerships for Improved Nutrition 148
Burundi 16, 92, 93, 105, 120, 121, 146C

CAADP, see Comprehensive African Agricultural
Development Program
Calciferol, see Vitamin D
Caloric consumption 66
Calorie
intake 54, 73, 108, 163
needs 55, 172
Calorie-dense food 31, 104
Calorie-rich foods 53, 62
Calories 5, 18, 26, 28, 43, 54, 61, 66, 109

Cameron, David 16, 139, 140
Canada 41, 130, 156, 176
Cancer 6, 19, 28, 31, 47, 52, 54, 56, 61
breast 47
prostate 47
Carbohydrates 5, 45, 171
Carbon dioxide, atmospheric 109
Care Development Organization 160, 162
Carotenoids 145
Cash transfer 4, 100
conditional 69, 100, 110, 115, 117
unconditional 100,
CDC, see Centers for Disease Control and Prevention
Centers for Disease Control and Prevention (CDC) 54, 179
Central nervous system 66
CFA, see Comprehensive Framework for Action
Chen, Junshi iii, 183, 186, 196
Child Nutrition Initiative (CNI) 160
Child poverty in USA 45
Child protection 79
Children
6–24 months 23, 72, 92
and caregivers 9, 25, 27, 66, 68, 85
and obesity, see Obesity
and marketing 59, 63
deaths among 9, 12, 30, 32, 34, 66, 77, 83, 85, 91, 93,
143, 145, 149, 163, 174
healthy 3, 7, 8, 65, 68
malnourished 65, 72, 97, 98
overweight, see Overweightpreschool 65–8, 95, 145
school-age 6, 9, 14, 32, 46, 146, 151
stunted, see Stunting
under five 3, 8, 9, 14, 17, 30, 32, 58, 66, 73, 75, 78, 91, 93,
95, 97, 98, 104, 140, 145, 149, 160, 161
under six months 92, 94
under two 12, 82–5, 136
undernourished 78
underweight, see Underweight
vulnerable 23, 59, 99
wasted, see Wasting
young 3, 5, 9, 12, 19, 25, 27, 30, 37, 44, 46, 50, 67,
79–85, 90, 95, 124, 125, 133, 136, 140, 148, 174
Children’s Investment Fund Foundation 18, 140, 168
Chile 21
Chilufya, William 161
China iii, 19, 60, 104, 105, 120, 129
Chinese Center for Disease Control and Prevention 146
Chronic obstructive pulmonary disease 48
CIDA, see Canadian International Development Agency
Cigarette smoke 90
Civil society ii–iv, 5, 7, 9, 10, 11, 15, 19, 20, 47, 82, 83, 95,
113 125, 126, 132–41, 156–168, 182
Civil Society Network, see SUN Civil Society Network

196

197

Civil Society Scaling Up Nutrition Alliance (CSO-SUN) 161
Climate 27, 29, 36, 37, 149change 27, 66, 69, 82, 99, 109, 143, 146, 155
economic 105
trends 156
Climate Corporation 156
Climate-smart agriculture, see Agriculture, climate-smart
Clinton, Hillary 14, 130, 176
CMAM, see Community-based management of acutemalnutrition
CNI, see Child Nutrition Initiative
Cobalamin, see Vitamin B12
Coca-Cola 61, 147, 148
Cocoa 46
Cod-liver oil 46
ColaLife 147, 148
Collaboration
farm-to-table continuum 148
private-public 20, 63, 148,156
Colostrum 80, 85, 90, 91
Commodities 146, 147
food 103, 106, 108, 155market, global 104
prices, global 70, 105, 108
Commodity exchanges 106, 110
Common results framework (CRF) 3, 119Community
participation 3scorecards 119
Community-based management of acute malnutrition(CMAM) 98
Complementary feeding 3, 5, 6, 16, 71, 79, 80–4, 90, 92, 93,
99, 114, 117
Comprehensive African Agricultural Development Program(CAADP) 131
Comprehensive Framework for Action (CFA) 130
Concentration 66
Concern Worldwide 10, 134, 136
Conflict 27, 122, 132, 177
armed 69, 103
social 148
Convention on the Rights of the Child 18
Conway, Sir Gordon 143
Cooper-Hohn, Jamie 140
Copenhagen Consensus 68–72, 97, 99, 131, 138, 139, 173,
176, 177
Corn Soya Blend 4
Corporate social responsibility (CSR) 148
Cortex
auditory 69
prefrontal 66, 69
visual 69
Countries, low- and middle-income (LMIC) 34, 56, 59, 95,
140, 178

Countryhigher-income 52
low-income 52, 62, 63, 78, 90, 140,173
middle-income 78, 140, 166, 173
Cowan, Brian 132
CRF, see Common results framework
Crisisfinancial 108
food, see Food crisis
Cropbiofortified 35, 37, 100
cash 172diversity 35, 143, 155
failure 109, 129, 135, 153, 156
nutrient-dense 37
nutrition-promoting 35
patterns 29
staple 83, 144traditional 55
vulnerability 124
Coverage 3
CSO-SUN, see Civil Society Scaling Up Nutrition Alliance
CSR, see Corporate social responsibility
Cyrus Cylinder 21
Czech men 60

D

DAA, see Development Action Association
Dairy products 16, 19, 31, 104
Dangour, Alan iv, 10, 143, 183, 187
Dark adaptometry 151
de Pee, Saskia iv, 11, 169, 192
Death, premature 53, 59
Declaration of Human Rights, Universal, see Human Rights,
Universal Declaration of
Declaration of Independence 21
Declaration of the Rights of Man and of the Citizen 21
Deficiencies
common micronutrient 43
maternal micronutrient 94
macronutrient 43, 66, 73
micronutrient 5, 8, 10, 15, 43, 53, 62,65, 66, 73–6, 90, 94,
95, 97, 99, 100, 104, 109, 146–7, 172, 173, 177, 182, 192
nutrient 3, 8, 31, 140, 149, 151, 171, 172
nutritional 33, 99, 143, 171
protein 76, 81, 172
specific 54, 173
VAM vi, 34, 36, 81, 176
Deficiency
diseases 46, 172
folic acid 95, 98, 99
iodine 43, 53, 65, 66, 68, 85, 95, 194
iron 42, 65, 66, 75, 95–6, 124, 174, 176multiple micronutrient 152
niacin 43
vitamin A 32, 53, 62, 65, 66, 68, 75, 83, 85, 95, 124,
144, 145, 149, 171, 177, 185, 192
		screening for 151
		subclinical 145
vitamin D 40, 43, 44, 48
		economic impact 48
zinc 32, 62, 65, 66, 95, 124
Dehydration 3, 148
Delivery (farm-to-table continuum) 152
Demand creation 145
Department for International Development (DfID) 30, 161,
179, 187, 188
Deprivation iv, 165
economic 105
nutritional 100, 174
Development Action Association (DAA) 165, 166
Development goals (see Millennium Development Goals andSustainable Development Goals)
Development
agricultural 83, 131
brain 15, 33, 69, 86, 93, 174
cognitive 5, 30, 41, 43, 66, 83, 86, 97, 104, 109
early child 6, 79, 98
economic 5, 14, 19, 23, 86, 97, 99, 131, 172, 173, 180
mental 49, 83, 89, 95
neurological 66
physical 30, 43, 49, 66, 83, 89, 95
Developmental origins of health and disease (DOHaD) 56
Deworming 69, 71, 80, 90, 91, 98, 177
DfID, see Department for International Development
Diabesity 3, 54
Diabetes 3, 6, 14, 16, 28, 31, 44, 47, 52–6, 61, 67, 73, 75,
138, 173, 174
adult-onset, see Diabetes, type 2
juvenile-onset, see Diabetes, type 1
type 1 3, 47, 48, 54
type 2 3, 4, 19, 47, 54, 82, 104
Diagnostics (farm-to-table continuum) 149, 150, 152, 155
Diarrhea 3, 4, 12, 26, 30, 34, 66, 68, 69, 71, 80, 85, 91, 95,
97, 98, 139, 145, 148, 190
Diet 16, 25
balanced 6, 27, 45–46, 50, 57, 105
high-fat 31
maternal 56
minimum acceptable 92
nutritious 6, 12, 16, 36
unbalanced i,, 43, 47
weight-reduction 62
Dietary
behavior 59
diversity 6, 17, 19, 22, 29, 44, 46, 83, 92, 100, 147, 149
intake 6, 33, 34, 77, 78, 95, 133, 145

needs 4, 27, 28, 65
patterns 26, 45, 54, 59, 62, 100
preferences 108
recommendations 36, 43
rehabilitation strategies 171
restriction 171
supplementation, see Supplementation
Diouf, Jacques 155
Disability iii, 18, 59
Disasters 18, 182, 194
humanitarian 26
man-made 30, 82, 104
natural 18, 27, 69, 82, 104, 154
Disease iv, 3, 5, 8, 17, 19, 27, 29, 41, 55, 73, 77, 97, 109,
135, 138, 148, 174
autoimmune 47
burden v, 174
cardiovascular 16, 19, 31, 33, 34, 47, 53, 54, 59, 82,
104, 173
childhood 4
chronic (see also Disease, non-communicable) 6, 14, 19,
28, 36, 49, 52, 60, 63, 67, 69, 75, 85
coronary heart 60, 67
endemic 4
heart, see Heart disease
infectious 4, 30, 38, 52, 60, 69, 79–80, 85, 95, 98
non-communicable (NCD) (see also Disease, chronic) 6,
9, 16, 33, 40, 47, 48, 54, 59–63, 81, 89, 104, 149, 173, 182
obesity-related 48
prevention 79–80, 90, 122, 167
respiratory 6, 47, 54
Disorders, developmental 56
Distribution (farm-to-table continuum) 147
DOHaD, see Developmental Origins of Health and Disease
Double burdenof malnutrition 4, 53–8, 140
maternal and child 57
Drought 30, 66, 104, 109, 149, 155, 164, 166
Drummond, Sir Jack Cecil 46
Dry feeding 4
DSM iii, 97, 146, 187, 189

E

Early warning system 4, 69
Economist, The 106
Ecosystems 108
Edema, hunger 6, 46
Education 5, 6, 10, 12, 14–5, 19, 20, 21, 23, 27, 29, 30, 36,
38, 49, 50, 58, 65–9, 73, 79, 81–6, 92, 99, 100, 104, 122,
124, 126, 138, 139, 172, 173, 182
community-based 91, 146
consumer 35, 148
nutrition 35, 110, 145, 147, 160, 162

198

199

strategies
women’s 30, 99, 166
Eggersdorfer, Manfred iii–v, 183, 187
Egypt 103–6, 121, 186
EHFP, see Enhanced Homestead Food Production
Elements, trace 43
Emergency school feeding, see School feeding
ENA, see Essential Nutrient Actions
Energy (nutrition) 5, 6, 8, 17, 29, 34, 43, 49, 54, 55, 59–68,
85, 91, 92, 94, 96,103, 122, 151
Energy (fuel) 36, 110, 134
prices 103, 108
renewable 108
subsidization, agriculture 110
sustainable 109, 139
usage 109
Englishman’s Food, The 46
Enhanced Homestead Food Production (EHFP) 83
Enrichment 4
Enteropathy 98
e-Purjee 154
Essential Nutrient Actions (ENA) 84
EU, see European Union
European Union (EU) 130
Exercise, see Physical activity
Export (food) 103, 105, 110, 129, 130, 134
Eyesight 43
Ezzati, Majid 60

F

Familias en Acción program (Colombia) 100
Famine (see also Starvation) iv, 4, 30, 55, 60, 82, 132, 135,
153, 174
FAO, see Food and Agriculture Organization
Family planning services 6, 79
Farm production 144
Farm-to-table continuum 10, 143, 144–156
Farma, Elizabeth 11
Fast food 46, 54, 61, 62
calorie-dense, see Calorie-dense
Fat 5, 19, 22, 45, 53–5, 59, 61, 62, 96, 151, 171
saturated 31, 47, 53, 63
total 53, 63trans 35, 47
unsaturated 47
Fatty acids, essential 4
FBF, see Fortified blended foods
Feed prices 106
Feed the Future program 130, 176
Feeding America 45
Feeding, blanket, see Blanket feeding
Feeding, complementary, see Complementary feeding
Feeding program 193

selective 6targeted supplementary 8
supplementary 7
Fergusson, James 46
Fertilizer 35, 66, 108, 109, 130
Fetal programming concept 67
Fiji 53
Financial markets 10volatility of 103, 108, 110
Financial Times 44
Fish 16, 35, 37, 44, 48, 77, 100, 123
Floods 104, 109, 149, 155
Folic acid, see Vitamin B9
Food
access 4, 16, 18, 25–8, 30, 33, 35, 37, 46, 62, 63, 65, 76,
86, 100, 104, 107, 110, 122, 170, 179, 180affordable 26, 33, 46, 63, 100, 144, 170
aid 4, 29, 45, 110, 115, 155, 166, 180, 188		and texting 155
assistance 4, 35, 180
commodity prices 108
complementary (and see Complementary feeding) 3, 4,
16, 19, 27, 66, 69, 71, 89–96, 123, 139		
fortification of 96, 117
consumption patterns 63, 129
crisis 83, 105, 107, 109, 110, 174
demonstrations 106
deserts 45, 46, 47, 62
diversity 4
fortification, see Fortification
fortified 4, 6, 16, 80, 90, 150
imported 53, 106, 134
industry 19, 58, 63 143, 148
inflation 106
insecurity 29–38, 65, 66, 77, 83, 97, 104, 110, 147, 166,168
marketing of 35–7, 47, 59, 61, 63, 93, 108
micronutrient-dense 147
nutrient-dense 23, 100, 147, 152
nutrient-poor 53, 59, 62
policy 107
preservation 37, 100, 108
price fluctuations 29, 37, 103, 106
price spikes 10, 103, 104–110, 174
prices 10, 22, 29, 37, 99, 102–110
processed 9, 19, 40, 46, 53, 61, 63
processing 4, 35–7, 144, 146, 147, 150, 154
quality 4, 22, 27–30, 35, 38, 59, 66, 76, 77, 83, 86, 89,
93, 96, 144, 179
quantity 27, 66, 76, 77
reserves 35, 110
riots 103, 105, 129
security 4, 6, 9, 11, 24–38, 50, 65, 78, 79, 97, 100, 110,
115, 117, 123, 129, 130, 133, 134, 136, 139, 153, 159, 165,

176, 179, 180
stocks 29, 30, 104
storage 27, 30, 35, 37, 100
transportation 29, 30, 35, 108, 144, 146–8, 155
ultra-processed 58
waste 35, 108
Food and Agricultural Organization (FAO) 8, 26, 27, 36, 41,
43, 65, 82, 83, 104, 105, 110, 124, 129, 134, 137, 155, 179
Food Price Index 104–5
Foods
calorie-dense 31, 104
high-end 104
Fortificant 4
Fortification 4, 9, 35, 40, 43, 72, 79, 80, 96–7, 100, 115,
117, 122, 149, 152, 177
home 16, 72, 80, 90, 92, 95, 96
large-scale 96
of complementary foods 96, 117of condiments 95, 96
of processed foods 9, 40
of rice 144of staple foods 9, 40, 71, 95, 96
of wheat flour 72, 99, 117
post-harvest
with folic acid 40
with iodine 40
with iron 71, 72
with niacin 96
with riboflavin 96
with thiamin 96
with vitamin A 96, 117with vitamin B12
with vitamin D 40
with zinc 96, 146
Fortified blended foods (FBF) 4
Fractures 47, 48, 59
France 41, 42
Funk, Casimir 45
Futures 106

G

G8 99, 119, 130, 176
GAIN, see Global Alliance for Improved Nutrition
Gallup World Poll 106
Garcia, Alan 160
Gates Foundation 18, 83, 131, 179
Gates, Bill 18
Geere, Malcolm 161
Gender 115
equality 5, 9, 25, 27, 37, 38, 138, 139, 163, 166roles 35, 36
Genes 55, 134, 151
Germany 9, 10, 41, 44, 176

GEWP, see Global Easy Water Products
Ghana 16, 30, 76, 120, 121, 165, 166
Gillespie, Stuart iv, 10, 111, 183, 188
Global Alliance for Improved Nutrition (GAIN) 138, 146,
176, 179, 184
Global Easy Water Products (GEWP) 149
Global Nutrition for Growth Compact 140
Goiter 53
Governance 10–11, 111–127
concept of 112
core drivers of 118
ingredients of good 118
mechanisms of 59
measurement of 112, 118monitoring of 112, 118
Grant, James 113
Great Britain, see UK
Green Revolution 129, 131, 134, 143, 172
in Africa 17, 131
Greening, Justine 15
Growth (see also Stunting) 3, 4, 5, 12, 15, 22, 27, 33, 46, 66,
68, 75, 81, 86, 89, 91, 92, 96, 152, 155, 174, 176
failure, linear 94
faltering 34, 91
fetal 32, 67, 81, 90, 95, 173
reference 4
retardation, linear 94, 98
standard 5
Guatemala 16, 67, 93, 107, 120, 121, 164, 166
Gyrus, angular 69

H

Harrigan, Jane 106
He, Jiang 61
Healthchallenges ichild 90, 138, 145, 176
claims 35
determinants 23,
indicators 151
interventions 136, 147
maternal 34, 73, 79, 91, 94, 95, 124, 138
mental 6, 18, 27, 30, 61
of girls and women 23, 68, 81, 146
optimal 3, 4
policy 56, 59
public 40, 45, 52, 53, 59, 61, 73, 76, 80, 82, 95–7, 148,
157, 177
right to 5, 18
sector, see Healthcare sector-seeking 9, 25, 27, 29
system, see Healthcare system
Health 2020 59

200

201

Health services, access to 6, 26, 27, 33, 77, 79, 81 98, 123
Health, Population and Nutrition Sector Development Plan
(Bangladesh) 124
Healthcare 19, 20, 23, 91, 104, 123, 150
costs 48, 53, 61, 62, 86
system 5, 9, 18, 48, 91, 93, 95, 124, 136, 149, 153, 170sector 19, 36, 76, 81, 82, 84
Healthy eating 53
Heart disease 44, 52, 56, 61, 138
ischemic 54
Hedge fund 106
Helen Keller International (HKI) 10, 83, 134, 147, 167, 176,
179, 185, 192, 193
HemoGlobe 150
Hepcidin 151
HFP, see Homestead food production
Hidden hunger iii, 5, 9, 39–50, 54, 65, 76, 103, 176, 180
High Level Task Force on Global Food Security 130
Hippocampus 69
Hippocrates 61
HIV/AIDS iv, 9, 23, 34, 69, 80, 82, 90, 94, 112, 138, 175,
188, 191, 192
and infant feeding 80, 93
HIV-exposed infants 80, 90
Hoddinott, John iv, 9, 10, 64, 139, 183, 188
Home fortification, see Fortification
Homestead food production (HFP) 83, 147
Homestead gardening 136
Housing iii, 18, 46, 98
Humala, Ollanta 161
Human rights 5, 18, 21, 23, 48
Universal Declaration of iii, 18, 21
Hunger iv, vi, 4, 5, 11, 14–18, 25, 30, 52, 65–72, 75, 76, 86,
99, 103, 107, 119, 120, 129, 131, 134, 137–8, 140–1, 143,
159, 163, 166, 168, 176, 177, 179, 180
chronic 107
hidden, see Hidden hunger
statistics 32
Hunger and Nutrition Commitment Index (HANCI) Scores
120
Hunger Task Force 132–133
Huxley, Thomas Henry 112
Hygiene 6, 9, 19, 25, 27, 33, 79, 81, 85, 98, 172
Hypertension 52, 53, 56, 59, 67
Hypothermia 91

I

ICE, see Information, education and communicationiCheck FLUORO 150
IFAD, see International Fund for Agricultural Development
IFPRI, see International Food Policy Research InstituteImmune system 12, 34, 43, 47, 83, 85, 91, 95, 174
Immunization 69, 85, 98

Impairment
cognitive 66
mental 95
Implementation science 157
Imports (food), see Food, imported
India 104, 105, 119, 120, 121, 129, 134, 146, 149, 153, 156
Indonesia 16, 57, 83, 93, 120, 121, 139
Infants 3, 4, 5, 9, 12, 22, 25, 27, 34, 56, 66, 79, 81, 83, 91,
92, 94, 132, 163, 174, 182
and young child feeding (IYCF) 5, 34, 75, 84, 124, 147		in emergencies
and young child nutrition (IYCN) 59, 90, 93, 114, 173
formula 5
porridge 16
nutrient needs 27
vulnerable 80
Infections 3, 4, 26, 27 32, 48, 66, 86, 94, 145, 174
Information, education and communication (ICE) 5
Information and communications 153, 175
Infrastructure 27, 35, 37, 108, 113
market 29, 36
rural 108, 110
transport 29
Innovation, power of 10, 142–157
Instability, political 29, 103, 105
Institute of Development Studies 119
Institute of Research for Development 153
Insulin 3, 54, 55, 59, 67
resistance 59
Insurance for farmers 35, 155,156
Interest rates 106
International Covenant on Economic, Social and Cultural
Rights 18
International Development Enterprises India 149
International Food Policy Research Institute (IFPRI) 9, 10, 83,
136, 139, 179, 184, 186, 188, 193
International Fund for Agricultural Development (IFAD) 8,
82, 134, 179
International Vitamin A Consultative Group (IVACG) 176,
177
Interventions
agriculture, see Agriculture interventions
community-based 98
cost-benefit ratio of 72, 173
Investment, return on (ROI) 73, 97, 148, 149
Iodine 9, 28, 40, 41, 42, 72, 90, 95, 152, 172
deficiency, see Deficiency, iodine
Iodization, salt 71, 72, 80, 90, 95–96, 177
IQ 19, 66, 75
Ireland 130, 132–3, 135, 136
Iringa project 76, 77, 172
Irish Aid 136
Irish Hunger Task Force 132–133
Iron 4, 27, 41, 43, 66, 68, 71, 72, 90, 96, 146, 147, 152, 172, 177deficiency, see Deficiency, ironmetabolism 151
status 150
supplementation, see Supplementation, iron
IVACG, see International Vitamin A Consultative GroupIYCF, see Infant and young child feeding
IYCN, see Infant and young child nutrition

LMIC, see Countries, low- and middle-income
Lomborg, Bjorn 68
Lope de Vega 106
Lorca, Federico Garcia 129
Lucea, Marguerite B iv, 10, 142, 183, 191

J

Macronutrients 5, 6, 66, 68, 73
Maggi cubes (Nestlé) 152
Magna Carta 21
mAgriculture 153
Malaria iv, 4, 12, 34, 81, 138prophylaxis 91
treatment 69, 91, 98
Malawi 15, 16, 92, 93, 119, 120, 121
Malnutrition (see also Overnutrition and Undernutrition) i,iii, iv, 5, 7, 9–11, 25–32, 38, 44–7, 50, 52–4, 61, 76, 77, 85,
86, 89, 97, 104–7, 113, 122–5, 127, 129, 132–141, 143–
4,146, 149, 151, 159–63, 170–4, 176–7, 179
acute (see also Wasting) 3, 6, 8, 82, 98
causes of 6, 36, 125, 172
child 9, 22–23, 25, 45, 76, 98, 152, 153, 160–7
chronic (see also Stunting) 3, 7, 133, 136, 161, 163
chronic micronutrient, see Hidden hunger
community-based management of 98, 123
determinants of ii, 9double burden of, see Double burden
economic cost of 9, 64–73
maternal 90, 94
maternal and child 22, 28
moderate acute (MAM) 3, 5–8, 80
protein-energy, see Protein energy malnutrition (PEM)severe acute (SAM) 6–8, 23, 79, 80, 90, 98, 99, 166
statistics 32
MAM, see Malnutrition, moderate acute
Mandela, Nelson iv
Mannar, Venkatesh iii, 183, 192
Maputo Declaration 131
Marketscommodities, see Commodities market
labor, see Labor market
Marriage, age at 91
Martorell, Reynaldo 67
Maryknollers 160, 162
Maternal and child double burden (MCDB) 57
Maternal, infant and young child nutrition (MIYCN) 117
MCDB, see Maternal and child double burden
McLaren, Donald 76
MDG, see Millennium Development Goal
Meal frequency 92
Measles 34, 95, 97, 163
Meat 16, 31, 54, 61, 104, 108
calorific intake from 108

Jaine, Tom 46
Johannesburg Plan of Implementation 7
Johns Hopkins 9, 10, 150, 151, 157
Jordan 106
Junk food 61

K

Katema, Dr Joseph 161
Kaufman, Francine 3, 54
Kennedy, Eileen iv, 9, 51, 183, 189
Kennedy, John F 75
Kenya National Food Fortification Alliance 97
Kerry Group 136
Keys, Ancel 171
Kim, Helen 152
Kim, Jim Yong frontispiece
Ki-moon, Ban vi, 103, 130, 132, 139, 165, 166
Kraemer, Klaus iii, 73, 183, 189
Kwashiorkor 76

L

Labor markets 67, 105
Labrique, Alain iv, 10, 142, 183, 190
Lactation 23, 28, 94
Lake, Anthony 133
Lancet, The i, iii, v, 14, 17, 28, 58, 76, 78, 79, 81, 118, 133,
138, 140, 173–8, 182
Land 30, 36, 103, 108, 134, 147, 149
tenure 37
usage 108
Landscape Analysis mapping tool 118, 121Lateef, Asma iii, iv, 11, 158, 183, 191
Laughlin, Caren 45
Legumes 37, 63
Lethargy 66
Life expectancy v, 48, 49, 53, 172
Lifestylehealthy v, 45, 55, 63
sedentary 54
Western 55
LINKAGES project 84
Literacy 123, 124

M

202

203

Memory, working 66
Metabolomics 151
Mexico 19, 61, 73, 100, 134, 161
mHealth 10, 153, 155
MI, see Micronutrient Initiative
Micronesia 53, 56, 58
Micronutrient Initiative (MI) 180
Micronutrients 4–8, 9, 28, 35, 40, 50, 62–9, 73, 76, 81–5, 89,
92, 98, 107
adequate intake of 9, 40, 41, 43, 94, 100
assessment 149–52
deficiency, see Deficiencies, micronutrientdelivery mechanisms 146, 152
encapsulated 146
essential v 45, 97
fertilizer 35
fortification, see Fortificationintervention 68, 72, 89, 90, 139
intervention, bundled 69, 131, 138
powder 20, 71, 92, 96, 97
science and policy 176–8
status 22, 48, 95, 96, 97
supplementation, see Supplementation
Middle East 61, 72, 105, 106, 129
Mid-upper arm circumference (MUAC) 5, 6
Migration, cell 69
Milestones in nutrition policy development 177
Milk, see Breast milk/ Dairy
Millennium Declaration 5
Millennium Development Goal (MDG) 5, 7, 9, 14, 17, 56,
73, 99, 121, 124, 138, 139, 159, 163, 166, 173–9
Minerals (see also Vitamin and mineral deficiency, VMD) 4–6,
9, 16, 20, 43, 45, 76, 83, 97, 114–5, 146, 151
Minnesota Starvation Experiment 171
MixMe™ 20
MIYCN, see Maternal, infant and young childnutrition
MNP, see Micronutrient powder
Mobile technology 153
Mobility 46
Monitoring systems 119
Morocco 105, 106
Morbidity 16, 31, 34, 104, 143, 149, 173
Morbidity and Mortality Report 54
Mortality 3, 6, 8, 16, 27, 34, 104, 145, 149
all-cause 34
child 31, 61, 71, 73, 75, 85, 95, 124, 138, 143, 155,
163, 172, 173, 176
in pregnancy 48
newborn 48, 49, 91
rate, crude 3
Motor skills 66
Mozambique 16, 93, 105, 120, 121, 131, 145
MPTF, see SUN Multi-Partner Trust Fund
MUAC, see Mid-upper arm circumference

Multi-Partner Trust Fund, see SUN Multi-Partner Trust Fund
Multiple sclerosis 44, 47, 48
Multi-stakeholder platform 5, 7, 119, 126, 178
Murray, Christopher 61
Muscle strength 47
Myelination 69

N

Nabarro, David i–ii, iv, 130, 133
Narcotic substances 90
National Center for Health Statistics (NCHS) 5
National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK) 55
National Institutes of Health (NIH) 55
NCD, see Disease, non-communicable
NCHS, see National Center for Health Statistics
Neel, James 55
Nestlé 152
Net present value (NPV) 71
Netherlands, the 130
Neural tube defects 97
Neurodevelopment 143
Neurogenesis 69
Neuron 66
Neurotransmitters 66
Neurulation 69
New Alliance for Food Security and Nutrition 130
Newborns 48,49, 81, 85, 91
NGO, see Non-governmental organization
Niacin, see Vitamin B3NIDDK, see National Institute of Diabetes and Digestive andKidney Diseases
Night blindness 31, 46, 83, 145, 151, 172
NIH, see National Institutes of HealthNon-communicable disease, see Disease, non-communicableNon-governmental organization (NGO) 52, 68, 83, 118, 126,
134–8, 150, 155, 160, 162, 166, 168
North Africa 49, 72, 105, 106
Norway 132
Novogratz, Jacqueline 149
NPV, see Net present value
NSP see Nutritional Surveillance Project
Nugent, Rachel 144
NuLife 23
Nutrigenomics 151
NutriRice™ 146
Nutrient
absorption 27, 34, 98
bioavailability 92
deficiency, see Deficiency, nutrient
depletion 31		maternal 94
essential 16, 20, 26, 27, 31, 84, 91, 107, 140gap 16
intake 15, 17, 29, 31, 33, 34, 46, 79, 90, 152		for infancy 15, 94
		maternal 90, 94
requirements 6, 15–16, 23, 34
		of adolescent girls and women 23, 94, 182
utilization 6, 15, 17, 27
Nutriset 153
Nutritionand infection, see Infections
and metabolomics, see Metabolomics
and nutrigenomics, see Nutrigenomics
and proteomics, see Proteomics
deficiencies, see Deficienciesdelivery 143, 149, 152, 154
diagnostics 143, 149, 152, 155enhanced 56, 143
governance, see Governanceinterventions i, ii, 3, 6, 9, 10, 16, 25, 28, 34, 35, 56–8,
67–72, 75, 77–87, 89, 97, 100, 112–13, 117, 118, 122, 125,
132,133, 136, 138, 143, 148, 152, 155, 173–78, 182
		community-based 98, 123-24
		
for women of reproductive age and mothers 90, 91
		for children 90
landscape 140, 168
needs 79
policy ii, 123, 131, 177		changes in 131
		development, milestones 177
programming 89, 93, 99
research ii, 10
security 6, 9, 25–7, 36, 38, 100, 104, 110, 112–3,
129–30, 132, 134, 141, 176, 179
status 27, 89, 99
sustainable 125, 136, 143
Nutrition Commitment Index 119
Nutritional Surveillance Project (NSP) 22, 57
Nutrition-sensitive
actions 127, 175, 176
approach 6, 83, 89, 100
development 58, 100, 125interventions 10, 75, 78, 79, 81, 178
programs 79, 182
solutions ii, 3
Nutrition-specificactions 23, 175, 176
interventions 6, 75, 78, 79, 81, 89, 98, 112, 113, 122
programs 7
Nuts 63, 152

O

Obama Administration 130, 176
Obama, Barack 119

Obesity i, 3, 6, 9, 14, 19, 28, 31, 36, 50, 51–63, 67, 75, 81,
99, 103, 112,114
and diabetes 55
in childhood 31, 45, 52, 54, 59, 60, 114, 116, 140, 173,
178, 182
malnutrition and 73
psychological effects of 59
Oil (fuel) 27, 104
crisis 129
One Thousand Days, see 1,000 Days
Oportunidades program( Mexico) 100
Oral rehydration solution (ORS) 148
Orange juice 46
Orazem, Peter 139
ORS, see Oral rehydration solution
OSP, see Potato, orange-fleshed sweet
Overnutrition 50, 58, 73, 81, 173
Overweight 4, 6, 9, 16, 28, 31, 32, 52–63, 67, 73, 75, 78, 89,
99, 103, 112, 116, 140, 178
in childhood 31, 32, 54, 59, 75, 78, 89, 140, 163, 174
Oxfam 30

P

Pacific Islands 53, 54, 60
PANITA, see Partnership for Nutrition in Tanzania
Pantothenic acid, see Vitamin B5
PAP, see Poverty Alleviation Plan
Parasites 66, 85
Partnership for Nutrition in Tanzania (PANITA) 162
Patents 149
PATH 146, 180
Patient capital 148
Pellagra 43, 46
PEM, see Protein energy malnutrition
Pesticides 109
Petition of Right 21
PFDA, see Portable Field Dark Adaptometer
Pharmaceuticals, makers of 61
PHC, see Primary healthcare
Phylloquinone, see Vitamin K
Physical activity 53, 55, 59–63, 73
Pima Indians 54, 55
Plan Bangladesh 12
Plantwise 153
Plumpy’nut® 152, 153
Pneumonia 4, 12, 34, 66, 91, 98
Policy landscape, changing 131
Pollutants, environmental 90
Polman, Paul 17
Popkin, Barry 61
Population growth 69, 78, 82, 108, 124
Portable Field Dark Adaptometer (PFDA) 151, 190
Post Newspaper, Zambia 161

204

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Potato 54, 164
famine in Ireland 135, 153
orange-fleshed sweet (OSP) 144, 145, 146
Poverty Alleviation Plan (PAP) 123
Poverty iv, 5, 12, 17, 20, 26–30, 33, 38, 73, 76, 85, 99,
104,106, 110, 132, 143, 146, 149, 163, 171–3, 179
and malnutrition cycle 86
child 45, 50
eradication 123, 131, 138, 139, 168, 180
extreme 5, 17, 138, 163, 168
in the developed world 44
reduction of 99–101, 106, 121, 124, 126, 163, 179
Prefrontal cortex, see Cortex
Pregnancy i, 11, 15, 16, 28, 34, 36, 49, 69, 71, 75, 80, 85, 89,
90, 94, 97, 99, 133, 138, 168, 174
at short intervals 34, 81, 86
during adolescence 12, 34, 91
unplanned 91
Pregnant mothers/women 8, 16, 23, 25, 27, 28, 43, 44, 48,
53, 56, 68, 72, 79, 82, 83, 91, 95, 124, 130, 136, 140, 141,
175, 182
Pre-pregnancy 15, 94
Primary healthcare (PHC) 123
Private sector vi, 10, 19, 20, 58, 68, 82, 97, 125, 130, 133,
137, 139, 141, 146–149, 161, 168, 173, 176, 180
Problem solving 67
Processing (farm-to-table continuum) 144, 146, 150, 154
Production (farm-to-table continuum) 144–7
Productivity 10, 30, 48, 61, 66, 69, 97, 173
agricultural 26, 27, 38, 103, 104, 109, 129, 131, 139, 155
economic 10, 16, 65, 124, 131
in the food system 10, 103
physical 67, 86
smallholder 132, 133
worker 66 75, 95, 107
Programs, community-based 91
Protein 5, 8, 18, 34, 45, 53, 62, 66, 67, 76, 77, 85, 96, 151–2,
153, 171animal53
deficiency 76, 81, 172
fiasco 76, 172
Protein energy malnutrition (PEM) 43
Proteomics 151, 152
Provitamin A 145, 171
Public-private partnerships 10, 58, 97, 143, 156
Pulses 4, 53, 104
Pupillary response 151
Purchasing power 27, 29, 46, 100
Pyridoxine, see Vitamin B6

Q

Quinn, Victoria iv, 10, 74, 172, 183, 193

R

RAIN, see Realigning Agriculture to Improve Nutrition
Rapid-SMS 155
RCPCH, see Royal College of Pediatrics and Child Health
RDA, see Recommended daily allowance
REACH, see UN REACH
Ready-to-use foods (RUF) 6, 194
Ready-to-use supplementary food (RUSF) 6
Ready-to-use therapeutic food (RUTF) 6, 23, 99, 152, 153
Realigning Agriculture to Improve Nutrition (RAIN) project
125, 136
Recession, global 45, 108
Recommended daily allowance (RDA) 6, 41, 43
Reichstein, Tadeusz 45
Resources, natural 103, 124
Retail (farm-to-table continuum) 144, 146, 147, 150, 153,
155
Retardation, mental 66
Retinol, see also Vitamin A 151
serum concentrations 42
Rheumatoid arthritis 47
Rhodopsin 151
Riboflavin, see Vitamin B2
Rice 22, 65, 70, 106, 109, 110, 123, 152, 155
fortified 144, 146
prices 22, 106, 130
yields 124, 144
Rickets 40, 43, 44, 46, 172
Rio Principles 7River Bend Foodbank 45
Rockefeller Foundation 131, 134
ROI, see Investment, return on
Royal College of Pediatrics and Child Health (RCPCH) 4
Ruel, Marie iii, iv, 9, 24, 183, 193
RUF, see Ready-to-use foods
RUSF, see Ready-to-use supplementary foodRuskin, John 89
RUTF, see Ready to use therapeutic foodS

Sadangi, Amitabha 149
Safety nets, see social safety nets
Salt 31, 47, 59, 63, 69, 96
iodization, see Iodization
tolerance (agriculture) 66
SAM, see Malnutrition, severe acute
Sanitation 6, 18, 19, 25, 26, 27, 29, 33– 38, 68, 69, 78– 81,
85, 90, 98, 112–13, 122, 139, 172, 177
Santa Cruz, Hernán 21
Sasu, Lydia 165, 166
Save the Children 30, 134, 166
Scaling Up Nutrition (SUN) 3, 4, 5, 7, 97, 99, 101, 124, 133,

159, 162
Civil Society Network 160, 161
countries 126
donor convener 7, 161
Framework (for Action) ii, 12, 125, 138, 176
government focal point 7, 126
Lead Group 125, 159, 161
members 125
Movement i, ii, 3, 10, 14, 19, 56, 82, 99, 118,119, 122,
124, 125, 127, 138, 141, 159, 168, 175
Multi-Partner Trust Fund (MPTF) 7
partners 97
Roadmap 125, 176, 178
stakeholders 7, 118, 125
Sustaining Political Commitments to 160
School feeding 6, 110, 124
emergency 4
School meal program 46, 146
Schooling, see education
Schultink, Werner iv, 10, 88, 183, 194
Scuba-rice 155
Scurvy 43, 46
SDG, see Sustainable development goals 7–8,139
Seaweed farming 155
Sebbi, Jane 164
Shah, Rajiv 17, 159
Sirleaf, Ellen Johnson 139
Skillscognitive 10, 65, 67
motor 66
Smallholder 36, 110, 132, 133, 149
agriculture 146
Smith, Vernon 69, 139, 173
SMS messaging 155
Snacking 62
Socialaccountability mechanisms 119
capital 27, 33, 77change 93, 99
marketing campaign 146
protection 35, 36, 93, 100, 110, 112, 113, 118, 126,
182, 193
returns of nutrition interventions 132, 133
safety nets 6, 29, 35, 37, 79, 81, 100, 105
status 30, 99
Sommer, Alfred 157
South Africa 100, 120 121, 130
South Asia 34, 61, 71, 72, 78, 91, 95, 104, 113, 119, 151, 177
Spain 130
Spatial navigation 66
Staple foods 152(and see Fortification of staple foods)
Starch 53, 54
Starvation 3, 8, 52, 55, 100, 133, 135, 171, 173

Stevens, Gretchen 60
Ströbele-Benschop, Nanette 44
Stroke 61, 67
Stunting (see also Malnutrition, chronic) 1, 3, 7, 8, 9, 11, 32,
48, 49, 71, 75, 94, 104, 114, 117, 143
as priority indicator for malnutrition 11, 86, 159, 165,
impact of 67, 97–100, 101, 141
policies addressing 117
prevalence of 43, 78, 136, 141,163, 182
prevention of 13–23, 80–3, 90, 99, 136, 140
reduction of 34, 71, 89, 92, 99, 101, 125, 140, 168, 173,
174, 177
Subsidies, agricultural 103
Sugar 3, 4, 19, 31, 47, 53, 54, 59–63, 96, 103, 106, 150, 154, 155
SUN, see Scaling Up Nutrition
Sunlight 44, 48
Supplementation 6, 7, 34, 76, 80, 90, 97, 122, 146, 149, 152
dietary 79
folic acid 90, 99
iodine 90
iron 90, 95, 99, 117, 150
iron and folic acid for children 115, 117
iron and folic acid for women 71, 115
maternal 79, 94
multimicronutrient 80, 90
protein-energy 91
strategies 146
vitamin A 95, 117
vitamin A for children 71, 80, 82, 95, 115, 117
vitamin A for women 90, 115
zinc for children 71, 115, 117
Supplements, lipid-based 91
Sustainable Development Goals (SDGs) 7
Swinburn, Boyd 61
Switzerland vi
Synapse formation, experience-dependent 69
Synaptogenesis 69
Syria 105, 155
Syrian Red Crescent 155
Syrup 7blackcurrant 46
rosehip 46
Szent-Gyorgy, Albert von 143

T

Table (farm-to-table continuum) 145–7, 150–3, 155
Tanzania 16, 76, 77, 83, 93, 120, 121, 162, 172
Taxation 35, 58, 105
Technology (farm-to-table continuum) 149
Technology 123, 151
agricultural 134
information and communication 11, 175
LED 150206

207

mobile 153, 173
NutriRice™, see NutriRice™
Ultra Rice®, see Ultra Rice®
Temer, Michel 140
Tett, Gillian 44
Thailand 85, 123
Thales of Miletus 106
Thiamin, see Vitamin B1
Thousand Days, see 1,000 Days
Thrifty gene 55
theory 55
Tiffin, Richard 109
Tinnemann, Peter 44
Tobacco 47, 58, 63
Tocopherol, see Vitamin E
Trade 29, 35, 36, 37, 58, 76, 84, 110, 115, 177
agricultural 106
flows 105
Triple A Cycle 78
Trussel Trust 44
Tuberculosis 44

U

Uganda 16, 23, 105, 120, 121, 145, 164
UK 41, 60, 44, 108, 109, 130, 140
UK Department for International Development, see
Department for International Development
Ultra Rice® 146
UN Committee on Economic, Social and Cultural Rights 18
UN High Commissioner for Refugees (UNHCR) 155
UN REACH (Renewed Effort Against Child Hunger andUndernutrition) 8
UNAIDS 9
Undernutrition 4, 8, 9 10, 12, 15, 17, 32, 52, 171–2
acute 36
and governance 112–127
and infection 33, 34, 56
and overnutrition 56–9, 63, 173
and poverty 99
causes of 33, 34, 100, 113, 159
child 10, 12, 32, 33, 34, 75–87, 89, 132, 136, 140, 141,
176, 177
chronic 14, 18, 23, 36, 65–9, 139, 174
consequences of 33, 113, 170, 173
during pregnancy 12
economic consequences of 10, 11, 65, 67, 73
economic cost of 68, 112, 132–3, 170
impact of 16
intergenerational cycle of 15
maternal 12, 32, 33, 34, 114, 117, 132, 136, 140, 176, 177
neurological consequences of 66
prevalence of 65, 104prevention of 6, 12, 16, 18, 23, 89–90, 101, 170, 175

physical consequences of 66
policies 114, 178
rates of 3
reduction of 15, 58, 68, 89, 98, 100, 101, 112, 139, 140,
141, 177
Underweight 8, 14, 61, 114, 124
child 17, 22, 32, 34, 61, 75, 99
maternal 22
UNHCR, see UN High Commissioner for Refugees
UNICEF Conceptual Framework 27, 33–4, 77, 172
UNICEF, see United Nations Children’s Fund
United Kingdom 15, 41, 44, 45, 60, 139, 168
United Nations Children’s Fund (UNICEF) 8, 9, 10, 14, 43,
76–80, 82, 84, 89,90, 113, 155, 180
United States Department of Agriculture (USDA) 46, 47
Universal Declaration of Human Rights, see Human Rights,
Universal Declaration of
Urban farming 155
Urbano Agroindustrial 147
USA 41, 53, 60, 108, 130, 134, 150
US Agency for International Development (USAID) 17,
84,130, 159,180
USAID, see US Agency for International Development
USDA, see United States Department of Agriculture
Usher Agro 146

V

VAD, see Deficiency, vitamin A
VADD, see Vitamin A deficiency disorders
Vegetable oil 107
fortified 106
VFL, see Village Farm Leaders
VGD, see Vulnerable Group Distribution scheme
VGF, see Vulnerable Group Feeding scheme
Village Farm Leaders (VFL) 83
Village Model Farms (VMF) 83
Vilsack, Tom 52
Virus 3, 55
Vitamin A v, 27, 30, 43, 46, 68, 107, 150, 171
assessment 151
capsules 66, 80, 85, 95
deficiency (VAD), see Deficiency, vitamin A		disorders (VADD) 177
enriched oil 146
intake 145levels in food 150
status 145, 150, 151
supplementation, see Supplementation
supplements 69, 124, 172
Vitamin and mineral deficiency (VMD), see Deficiency,
vitamin and mineral
Vitamin B1 96,146, 171
Vitamin B2 96, 171

Vitamin B3 4, 43, 96, 171
Vitamin B5 171
Vitamin B6 171
Vitamin B7
Vitamin B9 9, 40, 41, 71, 90, 95–7, 99 115, 117, 146, 171
Vitamin B12 96, 171
Vitamin C v, 43, 171
Vitamin D v, 47, 171
deficiency, see Deficiency, vitamin D
fortification, see Fortification
intake 41, 48
status 41, 47, 48
supplements 44, 48
Vitamin E 171
Vitamin K 171
Vitamin Murders, The 46
VMD, see Deficiency, vitamin and mineral
VMF, see Village Model Farms
Vulnerability 8, 27, 30, 100
Vulnerable Group Distribution (VGD) scheme 124
Vulnerable Group Feeding (VGF) scheme 124
Vulnerable group 36, 37, 46, 86, 95, 104, 115W

Wabwire, Faustine 165
Wasting (see also Acute malnutrition) 3, 5, 6, 8, 17, 31, 32,
81, 100, 104, 114, 163, 174, 182
in women 94
maternal 94
Water 6,19, 27, 31, 36, 68, 69, 79, 80, 85, 98, 112, 113, 172, 177access to 25, 38, 139
clean 18, 26, 29, 90, 98, 122, 148, 163
drinking 61, 90, 98, 163
for breastfeeding infants 4, 163
natural resource 36, 103, 123, 134
safe 33
shortage 27, 30
usage 108, 149
wastage 108
Weather 29, 108–110, 130, 156
Webb, Patrick 11, 181, 183, 194
Weight Maintainers Study 62
Welfare economics 131, 138
WFP, see World Food Program
Wheat Soy Blend 4
WHA, see World Health Assembly
WHO Childhood Obesity Surveillance Initiative 59
WHO Framework Convention on Tobacco Control 63
WHO Global Strategy on Diet, Physical Activity and Health 63
WHO, see World Health Organization
Whole grains 63
Wigmore, Ann 40
Williams, Cecily 76

Women ii, v, 10, 19, 20, 21, 32, 36, 37, 43, 53, 54, 60, 61,
67, 75, 79, 81, 83, 84, 89, 99, 122, 140, 145, 149, 153
and control of resources 30, 77, 85
as nutrition gatekeepers/caretakers 77, 81
breastfeeding/lactating 9, 23, 25, 27, 83, 136, 175
education of, see Education
empowerment of 6, 26, 36, 37, 73, 79, 82, 122, 126,
138, 139, 146, 177
in small-scale agriculture 122, 133, 146, 147,165, 166, 172
of reproductive age 163, 174pregnant, see Pregnant mothers/women
status of 30, 68, 81, 85, 177
undernourished 80, 90, 91, 124
underweight 61
World Bank 9, 14, 58, 84, 119, 130, 133, 134, 138, 160, 163,
176, 177, 180
World Food Conference 76
World Food Program (WFP) 8, 9, 27, 82, 124, 134, 146, 155,
180
World Health Assembly (WHA) 17, 59, 63, 173
World Health Organization (WHO) 3, 4, 5, 6, 8, 9, 14, 43
52, 53, 54, 56, 59, 60, 63, 75, 82, 95, 114, 116, 118, 163,
165, 173, 174, 180
World Vision International 180
Worm treatment, see Deworming
Wrangham, Richard 61

X

Xerophthalmia 145

Y

Yemen 16, 105, 106, 120, 121
Yields (agricultural) 26, 30, 66, 69, 86, 109, 110, 124, 134,
143, 144, 147
Yudhoyono, Susilo Bambang 139

Z

Zambia 16, 93, 120, 121, 125, 136, 147, 148, 161–2
Zero Hunger Challenge 99
Zinc
deficiency, see Deficiency, zincfortification, see Fortification
powders 68
requirements 28
supplementation, see Supplementation
supplements 69, 72, 148, 172, 177
treatment 80, 90, 98
Z-score 5, 6, 8

208

209

Colophon

Image credits fo chapter introductions

Editorial Board:

Chapter 1
Ellis Van den Berg

Manfred Eggersdorfer
Klaus Kraemer
Marie RuelMarc Van Ameringen
Hans Konrad Biesalski
Martin Bloem
Junshi Chen
Asma Lateef
Venkatesh Mannar

Chapter 2
Mike Bloem Photography
Chapter 3
www.thinkstockphotos.co.uk
Chapter 4
Sight and Life
Chapter 5
Mike Bloem Photography

Communication consultancy,
editing and project management:

Chapter 6© HKI / Bartay

Jonathan Steffen Limited
Cambridge, United Kingdom

Chapter 7
CIAT

Design concept, layout typesetting and graphics:
Mark Austin
V-One Design Solutions Limited
Leighton Buzzard, United Kingdom

Chapter 8
Victoria Quinn
Chapter 9
Sight and Life
Chapter 10
IFPRI

Proofreading and indexing:

Chapter 11
CIAT

Yvonne Bearnetransparent Language Solutions GmbH
Berlin, Germany

Chapter 12
Laura Elizabeth Pohl / Bread for the World
Chapter 13
CIMMYT
Afterword
Sight and Life

“Approximately a third of the world’s children face lifelong
economic and social disadvantage because of poor nutrition
during pregnancy and in the first two years of life.
A significant proportion of these children are disadvantaged
because of unbalanced diets that lead to obesity and its
associated health challenges.
Malnutrition is a phenomenon with many aspects, not all ofthem immediately apparent …The Road to Good Nutrition…brings together the experience and insights of globally
recognized experts in the field of nutrition to create an
in-depth introduction to the subject for the non-expert.
My hope is that The Road to Good Nutrition will help us
all to accelerate our progress along the path to a world
where everyone receives the food and the nutrition to which
they have a self-evident right.”
Dr David Nabarro
Special Representative of the UN Secretary-General for Food Security and Nutrition
SUN Movement Coordinator