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

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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.

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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.

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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.

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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

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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.

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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.

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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