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.

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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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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.