Chapter Two

Food Security andNutrition: Linkages andComplementarities

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

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

25

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

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

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

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

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

The causes of malnutrition are interconnected

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

Inadequate access to

HEALTH

FOOD

sanitation & cleanwater services

throughout the year

ROOTED IN
Political & Cultural
Environment
Source: TBC

Poverty

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

Linkages between food and nutrition security

Nutrition status /mortality

Exposure to shocks and hazards

27

Individual
level

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

Health andhygieneconditions

Livelihood
outcomes

Household
Level

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

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

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

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

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

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

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

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

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

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

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

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

The four dimensions of food security and their determinants
Availability

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

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

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

Source: Adapted from FAO

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

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

CHRONIC FOOD INSECURITY

TRANSITORY FOOD INSECURITY

Is...

long-term or persistent.

short-term and temporary.

Occurs when...

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

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

Results from...

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

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

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

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

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

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

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

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

30

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

Food insecurity, malnutrition and poverty are
deeply interrelated phenomena

PovertyFoodinsecurity
hunger andmalnutrition

Low
productivity

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

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

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

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

Foodrelated

Diversification /change inlivelihood
activities

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

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

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

Change tocheaper,lower-quality
andless-preferred
foods

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

Reduced size /number ofmeals

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

Begging for
food

Skip entire days
without eating

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

Engage in illegal/ healththreatening
activities as lastresort coping

Consequences for health and nutrition
Health outcome

Depletion of body nutrient
stores and lowered immunity

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

Increased early childhood
mortality

Increased overall mortality

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

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

Hunger1 statistics

Malnutrition statistics

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

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

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

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

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

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

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

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

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

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

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

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

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

Source: Mike Bloem Photography

Source: Mike Bloem Photography

32

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

33

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

DiseaseImmediate
causesImmediate causes
operating at
the individual level

Unhealthy household
environment and lackof health services

Underlying
causesUnderlying causes
influencing households
and communities

Basic
causesBasic causes aroundthe structure andprocesses of societies

Inadequate dietaryintakeHousehold foodinsecurity

Underlying
causesInadequate care

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

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

Social, economic,
and political context
Source: TBC

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

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

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

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

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

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

NUTRITION OPPORTUNITIESPOLICY TOOLS

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

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

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

AVAILABLE, ACCESSIBLE, DIVERSE , NUTRITIOUS FOODS

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

Gender roles and environmental sustainability

Economic, social, cultural and physical environment

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

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

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

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

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

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

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

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

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

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

My personal view
Marie Ruel

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

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

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

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

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

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

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