This Topic Guide has been compiled to provide an overview of undernutrition in the context of development. It covers the nature, scale and complex range of causes of undernutrition and summarises the evidence for what works to address the problem. The Guide covers direct nutrition interventions (or nutrition specific development as it is often termed), indirect interventions (nutrition sensitive), and the global coordination structures, governance and funding which are essential for an enabling environment within which undernutrition can be successfully reduced. The focus of this Guide is on undernutrition, defined as the outcome of insufficient (quantity and quality) of food intake (hunger) and repeated infectious diseases. Undernutrition includes being underweight for one’s age, too short for one’s age (stunted), underweight for one’s height (wasted), and deficient in vitamins and minerals (micronutrient malnutrition). This review does not focus on the other component of malnutrition, which is overnutrition.

Where possible the evidence presented in this Topic Guide was taken from systematic reviews of high quality. Where no systematic reviews were available or appropriate, evidence was included from other sources, including primary and empirical studies, as well as theoretical and conceptual research, deemed to be of high quality. This judgement was reached based on various principles, including conceptual framing, openness, transparency, appropriateness and rigour, validity, reliability and cogency. The body of evidence that has been included is summarised for each section. This assessment is based on the quality, size, content and consistency of the studies included.

This document was originally written in April and May 2013 and updated in August 2013 to reflect the latest body of evidence.

Undernutrition is one of the world’s most serious but least addressed health problems. In developing countries nearly one-third of children are underweight or stunted (low height for their age). The human and economic costs are enormous, falling hardest on the very poor and on women and children. Undernutrition interacts with repeated bouts of infectious disease, causing an estimated 3.1 million preventable maternal and child deaths annually (Black et al, 2013), and its economic costs in terms of lost national productivity and economic growth are huge.

1a) The scale of undernutrition

Child undernutrition is commonly measured by:

• Anthropometric measures, including a child’s height relative to the median for their age (a measure of stunting or chronic malnutrition); its weight relative to height (a measure of wasting or acute malnutrition); its weight relative to the median for its age (underweight, a composite measure of stunting and/or wasting), and being born with a low birth weight (under 2.5kg).
• Deficiencies in vitamins and minerals (micronutrient malnutrition) such as vitamin A, iron and zinc.

Key messages

• Stunting – Globally, an estimated 162 million children under-5 years of age, were stunted in 2012. Over 90 per cent of the world’s stunted children live in Africa and Asia.
• Underweight – Globally, an estimated 99 million children under-5 years of age, were underweight in 2012. The prevalence of stunting and underweight among children under-5 years of age worldwide has decreased since 1990, however overall progress is insufficient and millions of children remain at risk.
• Wasting – Globally, an estimated 51 million children under-5 years of age, were wasted in 2011, a 10 per cent decrease from an estimated 58 million in 1990. 67 per cent of the world’s wasted children live in Asia, most in south-central Asia. These children are at substantial increased risk of severe acute malnutrition (SAM) and death (UNICEF, WHO, World Bank, 2012).
• 45 per cent of all child deaths (<5 years) globally is attributed to nutritional disorders (stunting, wasting, micronutrient deficiencies and foetal growth restriction).

Nutrition and the Millennium Development Goals

Improving nutrition is essential for the achievement of the Millennium Development Goals (MDGs), many of which are dependent on good nutrition outcomes.

MDG 1: Eradicate extreme poverty and hunger

Reducing prevalence of underweight children under 5 years of age is an agreed target for MDG 1. Reducing undernutrition also increases economic growth.

MDG 2: Achieve universal primary education

Reducing undernutrition increases cognitive development and contributes to learning and school completion rates.

MDG 3: Promote gender equality

Promoting better nutrition practices contributes to empowering women and to reducing discrimination against girls in family feeding practices.

MDG 4: Reduce child mortality

Over 45 percent of deaths in children under 5 years of age are attributed to undernutrition as the underlying cause, directly, through acute malnutrition and more commonly through the many childhood diseases which become fatal in undernourished children.

MDG 5: Improve maternal health

Maternal undernutrition contributes to maternal mortality and other complications during pregnancy and childbirth. Maternal health can be improved through programmes of behaviour change and micronutrient supplementation.

MDG 6: Combat HIV/AIDS, malaria and other diseases

Undernutrition makes individuals more susceptible to disease, which in turn increases nutritional needs and weakens the capacity of the body to assimilate food. Nutritional care is therefore a key dimension of successful clinical treatment of HIV/AIDS patients.

MDG 8: Global partnership for development

Addressing hunger and malnutrition around the world is a key element of, and argument for, the global partnership for development. This applies particularly for the least developed countries, where levels of undernutrition are highest.

While there has been good progress toward MDG 1c (to halve the proportion of people who suffer from hunger) in a number of regions (East Asia and the Pacific, Latin America and the Caribbean and Central and Eastern Europe) progress in South Asia, all regions of Africa, and the Middle East, has been insufficient and is not on track to meet the target by 2015 (UNICEF, 2012).

The Causes of Undernutrition

The causes of undernutrition are complex and span across sectors. Figure 1 illustrates the immediate, underlying and basic causes of undernutrition. Understanding this framework is important, as interventions at every level can have an impact on maternal and child nutrition outcomes.

Figure 1. Causal framework of malnutrition (UNICEF 1990, reproduced in Black et al. 2008)

1b) The consequences of undernutrition

Maternal and child undernutrition is highly prevalent in low and middle-income countries, resulting in substantial increases in mortality and overall disease burden. Undernutrition weakens the immune system, stunts physical growth and cognitive development and can have a lifelong and intergenerational effect on educational attainment and economic potential for individuals, families and whole nations. It has been estimated that co-exposure to a range of related factors which have undernutrition as their underlying cause (including a weakened immune system and susceptibility to infectious diseases such as malaria, diarrhoea and pneumonia) combined with the effects of growth restriction, micronutrient deficiencies, and suboptimum breastfeeding accounts for 45 per cent of all child deaths (Black et al. 2013). The consequences of stunting and cognitive development tend to be irreversible after the age of two, with the period from conception until a child’s second birthday becoming known as the 1,000 day ‘window of opportunity’ to prevent irreversible damage. Children who are undernourished in the first two years of life and who put on weight rapidly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition for example, obesity.

Maternal undernutrition and the stress this causes upon the foetus in utero (in the womb) can increase the risk of intrauterine growth retardation (causing babies to be born Small-for-Gestational Age – SGA), and can have long lasting effects on the health of an individual throughout the life course, and longer term implications for chronic diseases including cardiovascular diseases and type II diabetes (Victoria et al. 2008). Micronutrient or protein deficiencies can also have serious effects during pregnancy. For example there is also evidence suggesting that iron deficiencies may have a negative effect on maternal health and maternal mortality.

Adolescent pregnancy (for which rates are exceptionally high in some developing countries) has been shown to have a significant impact on nutritional status of both the mother and the child. Adolescents are usually understood to be young people between the ages of ten and 19 years. Adolescent girls have a much higher risk of dying from maternal causes compared to women in their 20s and 30s. These risks increase greatly as maternal age decreases. Moreover, babies born to adolescents also face a significantly higher risk of death compared to babies born to older women. Poor adolescent nutrition combined with stunted growth, resulting in stunted mothers increases the likelihood of a child being born low birth weight (LBW) and being a stunted child. This intergenerational effect is illustrated below in figure 2.

Figure 2. Negative intergenerational effects of undernutrition on growth

 

 

 

 

Key messages:

• Poor foetal growth or stunting in the first two years of life leads to irreversible damage, including shorter adult height, lower attained schooling and reduced adult income.
• Children who are undernourished during the first two years of life are at high risk of chronic diseases.
• Maternal undernutrition has immediate and long term negative consequences for the offspring.
• Adolescent pregnancy greatly increases the risk of mortality to mother and child.

1c) The benefits of scaling up undernutrition reduction

Firstly and most importantly, undernutrition is preventable. Reducing undernutrition not only saves millions of lives, but investing in scaling up represents significant value for money in comparison with other development interventions. The Copenhagen Consensus,  in which economists weigh the value for money of a number of potential development interventions – ranked three nutrition interventions in the top five development solutions in 2008, with vitamin A and zinc micronutrient supplements for children ranked first. In the 2012 update they ranked bundled micronutrient interventions to fight hunger and improve education as the top investment.

Recent analysis suggests the current total of deaths in children younger than 5 years can be reduced by 15 per cent if populations can access ten evidence-based nutrition interventions at 90 per cent coverage. These ten interventions are:

Folic acid, multiple micronutrient, calcium and balanced energy-protein supplementation for pregnant and women of reproductive age.

Promotion of exclusive breastfeeding, complimentary feeding, vitamin A supplementation, preventative zinc supplementation and management of moderate and severe acute malnutrition for infants and children.

The estimated total additional annual cost involved for scaling up access to these ten direct nutrition interventions in the 34 countries with the highest burden of undernutrition is $9·6 billion per year.

The benefits of scaling up interventions to reduce undernutrition are usefully summarised in the new framework developed for The Lancet series 2013 (see Figure 3).

 Figure 3: Framework for actions to achieve optimum foetal and child nutrition and development

This framework shows the means to optimum foetal and child growth and development, rather than the determinants of undernutrition as shown in the conceptual model developed by UNICEF (Fig. 1). This new framework shows the dietary, behavioural, and health determinants of optimum nutrition, growth, and development and how they are affected by underlying food security, caregiving resources, and environmental conditions, which are in turn shaped by economic and social conditions, national and global contexts, resources, and governance. The 2013 Series examines how these determinants can be changed to enhance growth and development through scaling up activities in three domains: nutrition specific, nutrition sensitive and through building an enabling environment. The framework shows the potential effects of nutrition-specific interventions which address the immediate causes of undernutrition and nutrition-sensitive interventions that address the underlying determinants of malnutrition, incorporating specific nutrition goals and actions. It also shows the ways that an enabling environment can be built to support interventions and programmes to enhance growth and development and their health consequences.

Key messages:

• Effective interventions are available to reduce stunting, micronutrient deficiencies, and child deaths.
• Nearly 15 per cent of deaths in children under 5 could be reduced (1 million lives) if the ten interventions identified from the latest evidence are scaled up.
• These interventions, if scaled up to 90per cent coverage in the 34 highest burden countries, could reduce stunting by 20 per cent (33.5 million children) and reduce prevalence of severe wasting by 61.4per cent.
• Interventions with the greatest potential to reduce mortality in children under 5 years are: management of SAM, preventative zinc supplementation and promotion of breastfeeding.
• Improvement of complementary feeding through strategies such as counselling about nutrition for food-secure populations and nutrition counselling, food supplements, conditional cash transfers, or a combination of these, in food-insecure populations could substantially reduce stunting and related burden of disease.
• Interventions for maternal nutrition (supplements of iron folate, multiple micronutrients, calcium, and balanced energy and protein) can improve outcomes for maternal health and births, but few have been assessed at sufficient scale. Delivery mechanisms remain a logistical challenge to scale up.
• Although available interventions can make a clear difference in the short term, elimination of stunting will also require long-term investments to improve education, economic status, and empowerment of women.

Nutrition specific interventions refer to those programmes and approaches which have a direct impact on nutritional outcomes, addressing the immediate causes of undernutrition i.e. inadequate food intake, poor feeding and care practices and high burden of infectious disease. There have been countless studies in different contexts looking at the effectiveness of nutrition interventions. The 2008 Lancet Series provided the first review of the evidence base to summarise ‘what works’ and this has been updated in 2013, reflecting the progress that has been made in implementing at scale providing a growing body of evidence of effectiveness for both nutrition specific interventions and their delivery platforms.

The 2008 Lancet paper categorised the effective interventions into the following two sections:

1)      Interventions with an evidence base sufficiently strong to warrant the recommendation to implement in 36 of the world’s highest burden countries

2)      Interventions those where the evidence was strong in specific contexts.

These interventions are focused on maternal and child health and are outlined in Figure 4.

 Fig 4. The Lancet 2008, Key Interventions

Building from these interventions, the SUN framework for action (2010) identified a more selective package of 13 highly cost-effective interventions.

Most recently, The Lancet 2013 series includes an updated review of the evidence, including the evidence for effectiveness of nutrition interventions and delivery strategies. Ten interventions were identified, which if delivered at scale could reduce deaths in children younger than 5 years by 15 per cent. The ten interventions identified include providing folic acid, calcium, and balanced energy protein and micronutrient supplements to pregnant women; promoting breastfeeding and delivering appropriate complementary feeding to infants; providing vitamin A and zinc supplements to children up to the age of five; and using proven treatment strategies to manage moderate and severe malnutrition in children. The authors also evaluated delivery strategies and concluded that community based delivery strategies had much potential to improve nutrition and reduce deaths among the poorest sections of the population.

While these interventions were chosen for their proven ability to reduce illness and deaths in women and children in a cost-effective way, the authors also examined a much wider range of nutritional interventions, many of which have the potential to make a substantial difference in the fight against malnutrition

Table 1 below looks at the similarities and differences between the 13 interventions from SUN and the latest Lancet 2013 ten costed interventions.

Table 1: Comparison of the 13 recommended interventions from SUN 2010, with the 10 interventions from 2013

Intervention	Year of inclusion
Vitamin A supplementation/fortification	Both
Promotion of breastfeeding	Both (2013 stress exclusive BF)
Management of SAM	Both
Management of MAM	Both
Complimentary feeding	Both
Iodine through salt*	Both
Zinc management for diarrhoea	2008
Iron/ Folic acid supplementation	2008
De worming	2008
Iron fortification of staples	2008
Hand washing/Hygiene	2008
Multiple micronutrient powders	2008
Maternal  multiple micronutrient supplementation	2013
balanced energy-protein supplementation	2013
Folic acid supplementation	2013
Calcium supplementation	2013
Preventative zinc supplementation	2013

*Salt iodisation is included in The Lancet 2013 costing of interventions, but not in the full impact modelling

There are six interventions which feature in both (Vitamin A supplementation, promotion of breastfeeding, management of SAM and MAM, complementary feeding and in part salt iodisation).

There are six which were in the Sun list but are not in The Lancet 2013 (Zinc management for diarrhoea, iron and folic acid for pregnant women, deworming, iron fortification of staple foods, hand washing/hygiene and multiple micronutrient powders for children). Each missing intervention has a different reason for omission: hand washing / hygiene and therapeutic zinc for diarrhoea management are still fully endorsed by The Lancet authors and water and sanitation programmes in particular are widely considered as important in the fight against malnutrition but for categorisation reasons (they are about disease control) they were not listed in The Lancet 2013 list. Iron and Folic supplementation is now subsumed by maternal multiple micronutrient supplementation. Iron fortification of staples is listed as beyond scope of review. There are increasingly mixed views on the evidence of benefits for multiple micronutrient powders for children and deworming.

Five of The Lancet 2013 are new inclusions which did not feature in SUN (maternal multiple micronutrient supplementation, maternal balanced protein energy supplementation, folic acid supplementation, calcium supplementation and preventative zinc supplementation). These reflect new evidence and new understandings about the importance of maternal nutrition.

The following sections provide a brief review of the evidence for the interventions for each target group.

2a) Maternal and birth outcomes

The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome and during this time women often become more deficient in nutrients, with the need to provide nutrition for the baby too. Maternal malnutrition is a key contributor to poor foetal growth, LBW babies and short- and long-term infant morbidity and mortality.

The 2013 Lancet Series provides a comprehensive update of the evidence for the intervention identified in the previous series.

Key messages:

• Interventions to address adolescent nutrition are critical to affect the period before first pregnancy
• Maternal supplementation with key micronutrients (iron folate, calcium and multiple micronutrients) are effective at improving maternal and birth outcomes
• Increasing iodine intake through iodized salt is an effective intervention and delivery mechanism.
• A package of 4 interventions to provide optimal nutrition during pregnancy (maternal multiple micronutrients, use of iodised salt, calcium, and balanced energy protein supplementation) is estimated to save 102,000 lives at a cost of $571 per life year saved.

2b) Newborn babies

Infants who are not breastfed are at a far higher risk of infectious diseases like pneumonia and diarrhoea, and mortality than those who are breastfed. A mother’s breast milk provides more than just essential nutrients for the newborn baby, but contains a unique mix of proteins, fats, sugars, enzymes and antibodies to develop the baby’s immunity and help its digestive system to grow and function properly. The mother’s first milk, called colostrum, is produced only in the first days after birth and contains a powerful and concentrated mix of these immune, growth and tissue repair factors. It is not only ensuring that more babies are breastfed that is important, but reducing the time delay from when breastfeeding is initiated. It is estimated that early initiation of breastfeeding (within the first hour of birth) could prevent 22 per cent of newborn deaths (Edmond et al. 2006).

Breastfeeding support was highlighted in The Lancet (2008 and 2013) series as an effective intervention to increase breastfeeding rates, which in turn have a significant positive effect on child mortality and morbidity. Counselling and education for mothers on breastfeeding has been shown to be effective, while the forum through which this counselling is provided has been shown to be important (Sudfeld et al. 2012).

Key messages

• Breastfeeding is rated as the single most effective intervention to improve neonatal mortality rates.
• Exclusive breastfeeding is when the infant only receives breast milk without any additional food or drink, not even water. Oral rehydration salts (ORS), drops and syrups (vitamins, minerals and medicines) are regarded as an exception to this. Babies who are not exclusively breastfed are at four times higher risk of death.
• Early initiation (within one hour of birth) of breastfeeding could reduce neonatal mortality by 44 per cent.
• Breastfeeding promotion and counselling through (both individual and group) improves rates of exclusive breastfeeding, but promotion programmes should also emphasize early initiation.

2c) Infants and children

Breastfeeding remains the single most effective intervention to improve infant and young child nutrition. The WHO recommends six months of exclusive breastfeeding and up to two years of continued, partial breastfeeding. As discussed above, interventions to promote breastfeeding and increase rates of exclusive breastfeeding through individual or group counselling and education have been shown to be effective (Sudfeld et al. 2012).

When breast milk is no longer enough to meet the nutritional needs of the infant, complementary foods should be added to the diet of the child. In cases where the nutrient needs of the child are not being met through complimentary foods, fortification or supplementation with micronutrients, specifically zinc, vitamin A and iodine has been proven to be effective. The evidence base has tended to be strongest for supplementation with micronutrients, but fortification of staple foods, whether by the manufacturers (such as salt iodization) or at home fortification (often through micronutrient rich powders) is increasingly being shown to be an effective intervention for improving the micronutrient status (Bhutta et al. 2008).

The 2013 Lancet series (Bhutta et al. 2013) included a review of 16 trials and programmes that assessed the effect of nutrition education and provision of additional complementary foods. Studies of nutrition education in food secure populations showed a significant increase in height and weight and in food insecure populations significant effects on height for age, weight for age and stunting prevalence. The provision of complementary foods in food insecure populations was associated with significant gains in height for age and weight for age but did not show a significant effect on stunting prevalence.

One of the consequences of sub optimum infant and child feeding is acute malnutrition, estimated to affect 52 million children under five globally in 2011. Severe Acute Malnutrition (SAM) which refers to those children with a very low weight for height – below -3 z scores of the median WHO growth standards, poses the most immediate threat to child mortality. Treatment of SAM was identified in the 2008 Lancet Series as a key intervention to be implemented in all high burden countries. Approaches for treatment of acute malnutrition have evolved in recent years with a shift from facility based to community based care, an approach which includes the early detection of malnourished children and the use of specifically formulated therapeutic foods (WHO, WFP, UNSCN, UNICEF, 2007).

Key messages

• Breastfeeding remains the most effective intervention for infant and young child nutrition.
• Promotion and counselling to improve rates and duration of exclusive breastfeeding is recommended.
• Appropriate complimentary feeding, including a sufficient intake of micronutrients is essential.
• Supplementation programmes for vitamin A and zinc are effective for improving micronutrient status of children and reducing incidence of some diseases and deaths.
• Fortification of foods with micronutrients has also been shown to be effective at improving micronutrient status of children.
• Treatment of SAM through the community based model using specially formulated therapeutic foods has been shown to be effective.

The 1990 UNICEF framework (see figure 1) is particularly helpful in identifying the ways in which the basic and underlying determinants of undernutrition move beyond considerations of food and basic care practices, to wider considerations of household income and resources, the role of gender and other factors in the intra-household allocation of these resources, or wider environmental factors affecting health and sanitation. Furthermore, nutrition specific interventions that address the immediate causes of undernutrition have been estimated to be effective at addressing only 20% problem. Therefore interventions that tackle some of these underlying causes are thus an essential part of the response to tackle 80% of the problem. These nutrition sensitive approaches address the underlying factors that contribute to malnutrition, including hunger, poverty, gender inequality, and poor access to safe water and health services by integrating nutrition actions into other sectors. These include measures ranging from cash transfers (and other forms of social protection) to augment household resources; agricultural development to improve rural incomes and increase basic household food security; women’s empowerment; wider health systems strengthening; and improved water and sanitation supply.

3a) Agriculture

Agricultural interventions have long been thought to have an effect on nutrition. Hoddinott (2011) described six pathways commonly associated with agricultural production impacting on nutrition and health:

i.          Changes to incomes: When changes in agricultural production lead to increases in household income, the income can be used to purchase goods that affect health status.

ii.          Changes in crops, farm practices, and markets: Changes in agricultural production can result in the introduction of new foods into diets.

iii.          Changes to crop varieties and production methods: Changes in the types of crops that are grown or changes in production processes may make agricultural work either more or less physically intensive.

iv.          Changes to the use of time: Where changes increase the returns to time spent in agriculture, households may increase the amount of labour they devote to agricultural production (often particularly applicable in terms of womens time allocated to care).

v.          Changes to savings: Where changes in agricultural production result in higher incomes, individuals and households may choose to save some of these higher incomes in the form of assets that improve health.

vi.          Changes in intra-household resource allocation: Changes in agricultural production may result in changes in the allocation of resources within the household. If this change results in women earning greater income, then this may affect how households spend money, how food is allocated, and the types of assets that are accumulated. Holding all other factors constant, this may improve health and nutrition.

Despite the clear pathways, from the current evidence available, the effectiveness of agricultural interventions on nutrition is not clear. Data indicates the relationship is complex, producing either mixed results or demonstrating no impact (Masset et al. 2012). Part of the reason for lack of conclusive evidence can be explained by programmes not originally being designed to address nutrition outcomes or evidence collected for nutrition outcomes, and an over reliance on Randomised Controlled Trials (RCTs) as the gold standard of proof (Ruel and Alderman 2013).  RCTs do not lend themselves to the assessment of health and nutrition effects resulting from agricultural programmes, are generally impossible to apply to the food system, except in small projects. The impact of agriculture on health and nutrition is difficult to assess with RCTs, partly because treatments cannot be randomised and because of the intrinsic length of the effect pathway (Pinstrup-Andersen 2013). Despite limited evidence surrounding the impact of agricultural interventions on nutrition, there is agreement between stakeholders on main principles that should be included in any programmes designed to improve them both. With regards to planning, it is recommended that explicit nutrition objectives are included in agricultural projects, programmes, and policies. Opportunities must be maximised by multisectoral coordination. Women play an important role, in terms of maximising impact of household income on nutrition, in their role as the main producers of domestic food in many countries and also with regards to targeting the most vulnerable groups. Effective and transparent monitoring and evaluation of interventions should take place to measure its impact on beneficiaries and enable learning of experience and sharing of knowledge (Herforth, 2012).

Key messages

• Evidence suggests that agricultural interventions may have a positive effect on the production of the agricultural goods, but not on households’ total income.
• To improve nutrition through agriculture, access to rural markets must be improved. Also the legal rights of farmers must be recognised and protected.
• Improvements in agricultural programmes need to be matched by complementary actions in health, sanitation, other direct interventions for nutrition, and female empowerment
• Agricultural interventions were successful in promoting the consumption of foods rich in protein and micronutrients, but the effect on the overall diet of poor people remains unclear.
• No evidence was found of an effect on the absorption of iron, but some evidence exists of a positive effect on absorption of vitamin A.
• Biofortified vitamin A-rich orange sweet potatoes have been shown to be both effective for increasing maternal and child vitamin A intake and status. Very little evidence was found of a positive effect on the prevalence of stunting, wasting, and underweight among children aged under-5.
• Despite the lack of evidence demonstrating the impact of agricultural interventions on nutrition, most stakeholders are in agreement on main principles regarding good practice for programmes linking the two. Strong monitoring and evaluation of new programmes is needed to inform future programmes. Results from research are needed to fill the current gap in evidence available.
• Although evidence is lacking, food security is believed to improve as a result of agricultural programmes.

3b) Social protection

Social protection in this context refers to policy instruments used to address poverty and vulnerability, including social assistance, social insurance and efforts at social inclusion, as well as subsidies. Social protection programmes may aim to improve food security by providing ‘entitlement’ to food by means of labour (public works programmes), trade (food price subsidies, grain reserve management), or transfers (school feeding, supplementary feeding, and cash transfers – both conditional and unconditional). Results from individual studies indicate some effects on younger children exposed for longer durations, but weaknesses in nutrition goals and actions, and poor service quality probably explain the scarcity of overall nutritional benefits. Before the benefits of these programmes in terms of improved maternal and child nutrition is realised, nutrition goals and the quality of services must be strengthened. Many of the programmes that are not originally designed to improve nutrition, have great potential to do so (Ruel & Alderman, 2013).

Cash transfers can be direct and predictable non-contributory cash payments that help poor and vulnerable households to ‘even out’ food consumption and income over the year. There is consistent evidence that households receiving cash transfers spend more on food, resulting in significant gains in children’s weight and height in several countries (Arnold et al. 2011). However the latest evidence shows an absence of overall effect of both unconditional cash transfers and conditional cash transfers on child nutritional status globally (Ruel & Alderman, 2013). The gender of the recipient has also been shown to be an important factor, with programme designs often favouring women, with the aim of increasing their control over the intra-household allocation of resources, which has been shown to impact on child health and nutrition status. However, the programme design must be handled with care, with some studies reporting an increase in household violence when women are targeted as cash recipients (Richards et al. 2011).

Cash transfer programs are being used to meet a variety of needs in humanitarian and transitional settings. The relationship between cash transfer interventions in crisis contexts and malnutrition has received little attention, even though cash transfers can improve access to quantity and quality of food (Bailey & Hedlund, 2012)

School feeding programmes are a form of conditional transfer and can reduce hunger and stimulate learning. Over the past two decades, many governments and organisations have renewed efforts to develop more effective school-based health and nutrition programmes in low-income countries. There is a growing body of evidence linking children’s health and education; and the impact of school health and nutrition. Evidence indicates that school feeding programmes have small effects on school-age children’s anthropometry, particularly in low-income settings (Ruel & Alderman, 2013). Food for education programmes can provide iron and other key micronutrients, but these programmes are not designed to address the most critical nutritional constraints in low-income settings, simply because they are not targeted at the most vulnerable period in child development, which is between conception and 2 years of age (Alderman & Bundy, 2011).

School feeding programmes are designed to improve attendance, achievement, growth, and other health outcomes. Results from higher quality studies indicate that school feeding in low-income countries resulted in a weight gain of 0.39 kg over an average of 19 months. In lower quality studies weight gain was on average 0.71 kg over 11.3 months. For height, school feeding resulted in the greatest height gain for younger children. School feeding was found to increase average attendance between 4 to 6 days per year. Maths gains were consistently higher for children who were fed and in short-term studies, small improvements in some cognitive tasks were found. It can be concluded that school meals may have some small benefits for disadvantaged children, but further research is needed (Kristjansson et al. 2007).

Some evidence suggests that school feeding programmes may be an effective method of both improving nutritional status and reducing poverty. School feeding can use value chains to link agriculture and nutrition, with potential livelihood and income benefits for farmers and nutrition benefits for young children and their families. School feeding may also assist with iron intake, which is particularly important for teenage girls (Ruel & Alderman, 2013).

Key messages

• Social safety nets have the potential to improve the nutritional status of mothers and children.  For this to happen nutrition goals and the quality of services need to be strengthened.
• School feeding programmes are popular but costly, and the evidence of their effectiveness is weak and there is no agreement on best practice for implementation.
• CCT programmes provide a potentially powerful delivery mechanism for improving child nutrition, but require clearer nutrition objectives and actions, as well as monitoring and evaluation if they are to meet their potential.
• CCTs are found to have positive impact on nutrition in certain settings but it is unclear how dependent their success is on the context in which they are implemented and how effective they would be if they were replicated in a different setting.
• Evidence shows an absence of overall effect of both unconditional cash transfers and conditional cash transfers on child nutritional status.
• Children who are fed at school attend school more frequently than those who are not fed.
• School meals may have small physical and psychosocial benefits for disadvantaged pupils.

3c) Water, sanitation and hygiene (WASH)

A growing body of evidence has demonstrated the critical importance of water, sanitation and hygiene (WASH) for children for many reasons, including improved nutrition. Along with several other factors, poor hygiene and sanitation cause high levels of maternal and child undernutrition in developing countries (Ahmed et al. 2012). The total number of deaths caused directly and indirectly by malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene is estimated at 860,000 deaths per year in children under-5 years of age (Prüss-Üstün et al. 2008).

Diarrhoea is a major cause of death and disease, especially among young children in low-income countries. Many of the microbial agents associated with diarrhoea are transmitted via the faecal-oral route and are associated with exposure to human faeces. A review by Clasen et al. (2010) found that interventions to improve excreta disposal are effective in preventing diarrhoeal disease, but that the quality of the evidence is generally poor and does not allow for quantification of any such effect. The authors acknowledge that the review does not address the potential contribution of improved excreta disposal to preventing important health threats associated with inadequate sanitation, including malnutrition. A review by Dangour et al. (2013) found that WASH interventions may result in a small benefit on the growth of children who are under five years old. However, the authors urge caution in using this conclusion, as it is based on data from relatively short-term studies of low methodological quality.

Key messages

• 860,000 deaths per year in children under-5 years of age are caused directly and indirectly by malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene.
• Interventions to improve excreta disposal are effective in preventing diarrhoeal disease, and are likely to have a positive impact on nutritional status, but the potential effectiveness of excreta disposal on diarrhoea is not currently known.
• One tenth of the global disease burden is preventable by achievable improvements in the way we manage water, meaning improvements are crucial to improve nutritional status.
• WASH interventions may result in a small benefit on the growth of children who are under five years old

This section gives an outline on the coordination structures that exist to address undernutrition. In addition, it considers how both governance and funding impacts on the challenge of addressing undernutrition.

4a) Coordination structures

The global architecture of organisations and institutions focusing on tackling nutrition, and more specifically undernutrition, has changed over the years. So have the targets and frameworks that define their work. In May 2012, Ministers of Health attending the World Health Assembly (WHA) agreed a range of maternal, infant and young child-focused undernutrition targets to be achieved by 2025, including a target to reduce stunting by 40 per cent (WHO, 2012).

In 1977 the UN set up an Administrative Committee on Coordination (ACC) subcommittee on nutrition. With reform of the UN ACC this became the United Nations System Standing Committee on Nutrition (UNSCN). It acts as a forum, allowing the UN to harmonise nutrition policy. The UNSCN has a mandate to promote cooperation among UN agencies and stakeholders involved in nutrition. Its goal is to end malnutrition in the current generation. It works through improving advocacy, awareness and mobilising commitment for improved nutrition (UNSCN, 2013).

In response to a global food crisis, world leaders convened in Rome in 2009, at the UN Food and Agriculture Organization (FAO) Headquarters for the World Summit on Food Security. They unanimously adopted a declaration pledging renewed commitment to eradicate hunger from the face of the earth sustainably and at the earliest date. It was agreed to work to reverse the decline in domestic and international funding for agriculture and promote new investment in the sector, to improve governance of global food issues in partnership with relevant stakeholders from the public and private sector, and to proactively face the challenges of climate change to food security (FAO, 2013).

Scaling Up Nutrition (SUN) is a collective movement focused on improving nutrition. It involves actors from governments, civil society, the United Nations, donors, businesses and researchers to address malnutrition. It calls on country leaders and governments to develop and commit to policies which prioritise dealing with poor nutrition. Collaborating with partners is encouraged to implement programs with shared nutrition goals. SUN advocates for the mobilisation of resources to effectively scale up nutrition, with a core focus on empowering women. The movement was founded on the principle that all people have a right to food and good nutrition. SUN was started in September 2010, and the governments of 41 countries have committed to it as of September 2013 (SUN, 2013).

The SUN framework supports the specific nutrition interventions of support for exclusive breastfeeding up to 6 months of age and continued breastfeeding, together with appropriate and nutritious food, up to 2 years of age; the fortification of foods; micronutrient supplementation; and the treatment of severe acute malnutrition (SAM). It also supports the nutrition-sensitive approaches including agriculture, clean water and sanitation, education and employment, health care, support for resilience and women’s empowerment (SUN, 2013).

In 2012, leaders of the world’s wealthiest eight countries (the G8) and African leaders committed to the New Alliance for Food Security and Nutrition, a shared commitment to achieving global food security. The goals of the New Alliance are to increase responsible domestic and foreign private investments in African agriculture, take innovations that can enhance agricultural productivity to scale, and reduce the risk borne by vulnerable economies and communities. The significance of the critical role played by smallholder farmers, especially women, in transforming agriculture and building thriving economies is recognised. (Feed the future, 2012). The New Alliance has published a progress report that focuses on progress in implementing mutual commitments and issues and challenges emerging from the early stages of the initiative (The New Alliance for Food Security and Nutrition, 2013). The report identified the following key challenges and opportunities that will need to be addressed by the New Alliance in the future:

• Country-level leadership
• Facilitating a new type of dialogue
• Institutional ‘pace’ and capacity
• Joined-up government
• Access to finance
• Leveraging and focusing public investment
• Women’s economic empowerment
• Learning how to work with smallholders at scale
• Engaging local and global civil society organisations (CSOs)

There are also several broad approaches and partnerships focused on improving nutrition, including the Renewed Efforts Against Child Hunger and undernutrition (REACH) initiative and 1,000 Days. REACH was established in 2008 as an approach that UN agencies adopt to better provide joint and coherent support to governments of countries with a high burden of child and maternal undernutrition. It aims to help them to accelerate the scaling up of food and nutrition actions. As of April 2013 it operates in 12 countries. The UN agencies involved in the consortium are the FAO, the UN Children’s Fund (UNICEF), the World Food Programme (WFP), and the World Health Organization (WHO). The International Fund for Agricultural Development (IFAD) joined REACH later on with an advisory role (REACH, 2013).

At the United Nations Millennium Development Goals Summit in September 2010, the former U.S. Secretary of State Hillary Clinton and former Irish Foreign Minister Micheál Martin launched the 1,000 Days Partnership. The purpose of creating the partnership was to draw attention to the critical window of opportunity that exists during the first 1,000 days between a woman being pregnant and the child’s second birthday. During this period, the impact of maternal and child undernutrition is potentially irreversible. The partnership promotes targeted action and investment in interventions during this period to scale up nutrition. Targeted action during this period can have a life-changing impact on a child’s future and help break the cycle of poverty. The right nutrition during the 1,000 day window can have a profound impact on a child’s ability to grow and learn. It can also shape a society’s long-term health, stability and prosperity. The 1,000 Days partnership brings together a wide range of partners including NGOs, donors, and the private sector. The partnership transcends a variety of sectors including health, agriculture and food security, water, sanitation and hygiene, economic development and gender equality. As an advocacy hub, the 1,000 Days initiative promotes action and investment in early nutrition through informing key stakeholders about the impact and cost-effectiveness of investing, engaging new stakeholders, and catalysing collaboration and partnership across sectors (Thousand Days, 2013).

4b) Governance

It is doubtful that the world will be able to feed its growing population in a nutritious way without a substantial scale up of political commitment (Haddad, 2013). In recent years, the context or the wider ‘enabling environment’ for undernutrition reduction at national level has drawn increasing interest. This is believed in part to be down to the recognition that systemic capacity constraints at the governance level need to be addressed if the burden of undernutrition is to be permanently and sustainably reduced.

At the Nutrition for Growth Event held in June 2013 and organised by the UK’s Department for International Development, a compact was endorsed by 90 stakeholders made up of partners, businesses, scientific and civil society groups. All the signatories committed to:

• Improving the nutrition of 500 million pregnant women and young children.
• Reduce the number of under-fives who are stunted by a further 20 million.
• Save the lives of at least 1.7 million children by preventing stunting, increasing breastfeeding and better treatment of severe and acute malnutrition.
• Financial commitments by donors, philanthropy and CSOs included new commitments of up to £2.7 billion to tackle under-nutrition up to 2020.
• An estimated £12.5 billion for improved nutrition outcomes from nutrition sensitive investments in agriculture, social protection and water, sanitation and hygiene.
• A pledge from 27 businesses to improve the nutrition, and consequently the productivity and health, of over 927,000 members of their workforces in more than 80 countries.
• New partnerships between business and science to research new solutions and scale effective technologies.
• Commitments from 14 governments to scale up their national nutrition plans, and many announced targets for reductions in stunting. (DFID, 2013)

The Hunger and Nutrition Commitment Index (HANCI) is one result of the recent drive towards researching the enabling environment. It was launched in 2013. It ranks governments on their political commitment to tackling hunger and undernutrition and measures what is being achieved and which policies are failing in an effort to provide greater transparency and public accountability. It praises governments where due, and highlight areas for improvement. The HANCI findings support civil society to reinforce and stimulate additional commitment towards accelerating the reduction of hunger and undernutrition. It also assesses whether improving commitment levels lead to a reduction in hunger and undernutrition. An important finding was that economic growth has not necessarily led to a commitment from governments to tackle hunger and undernutrition and conversely low wealth or slow economic growth in a country does not necessarily imply low levels of political commitment. Significantly, within areas of high and growing hunger and undernutrition prevalence, some countries are clearly showing much greater political commitment to address these problems than others. There is also variation between relative commitment to hunger reduction and the relative commitment to nutrition (te Lintelo et al. 2013).

The research base on how to improve the enabling environment for nutrition is limited. However, the inclusion of a paper by Gillespie et al. (2013) that was focused solely on this topic in the 2013 Lancet Series on Maternal and Child Nutrition indicates its importance and relevance to the undernutrition agenda, reflecting the increase in political discourse on this topic. Commitments from many national governments, international organisations, and donors have increased, with momentum driving and being driven by The Scaling Up Nutrition movement. Harmonisation has increased among stakeholders, with regard to their understanding of the main causes of malnutrition and to the various options for addressing it. An enabling environment is vital for nutrition before the positive impact of policies and processes can be experienced by those that need improved nutrition the most. High quality and well-resourced nutrition interventions are vital. These can be bolstered by ensuring that programmes involving agriculture, social protection, and water and sanitation systems are aligned with nutrition goals. Sustained and effective political support to improve nutrition status must be based on knowledge and evidence, and reinforced through policies and governance. To be a success the resources must be available to gather and analyse the evidence, and to make, monitor and evaluate the policies.

A review of four recent principal research streams finds that all note the importance of visibility, commitment and accountability but do not provide much guidance how they should be attained, suggesting further research is needed (Haddad, 2013).

Previous work on the enabling environment found that capability, accountability and responsiveness are three key aspects of effective nutrition governance. Capability in this context refers to coordination between government ministries to improve diet, sanitation, health and education. Undernutrition is often invisible until it becomes highly acute. As such, citizens may need to generate public awareness and demand officials take accountability and deliver appropriate action. The window of opportunity for preventing irreversible damage from undernutrition is only 1,000 days, so a rapid government response is needed to address the needs of the most vulnerable in society (Haddad et al. 2012).

Political and system commitment can be generated through sustained efforts from policy entrepreneurs and nutrition champions. Research suggests that mid-level actors from ministries and external partners struggle to capitalise on windows of opportunity. Opportunities may be missed due to capacity constraints and differing opinions on what action to take. Ownership and responsibility may also be a limiting factor. If systematic capacity constraints remain unaddressed, the consequences on the ability to achieve the desired goals are lightly to be negative (Pelletier et al. 2012).

Key messages

• Strong leadership is key to reducing undernutrition through the promotion cooperation between sectors, organisations and stakeholders.
• Different levels of governance must be supported by appropriate structures for effective action to be successful.
• National and global commitment for improving nutrition is needed for change. Capacity to achieve change must be systematically strengthened.
• Sustainable funding sources will be vital to the success of interventions.
• Interventions that can be scaled-up should be prioritised.
• Investment in research, monitoring and advocacy will lead to results. Research in this context may include operational research of delivery, implementation, and scale-up of interventions, and contextual analyses about how to shape and sustain enabling environments.
• Strategic capacities must be strengthened as this will lead to commitment building, policy based balling and ultimately capacity building for nutrition focused operations.
• Economic growth does not automatically result in commitment from governments to tackle hunger and undernutrition and conversely low wealth or slow economic growth in a country does not necessarily imply low levels of political commitment.
• There is variance between the political commitment of different countries to address hunger and malnutrition. There is also variation between commitment to hunger reduction and the commitment to reducing undernutrition.
• Political commitment can be developed in a short time, but commitment must not be squandered—conversion to results needs a different set of strategies and skills
• Framing of undernutrition reduction as an apolitical issue is short sighted and self-defeating. Political calculations are at the basis of effective coordination between sectors, national and subnational levels, private sector engagement, resource mobilisation, and state accountability to its citizens.
• The private sector has substantial potential to contribute to improvements in nutrition, but efforts to realise this have to date been hindered by a scarcity of credible evidence and trust. Both these issues need substantial attention if the positive potential is to be realised.

4c) Funding

Evidence suggests nutrition interventions have the potential to have a significant impact on health and education, preserving human capital. Yet the investment by national governments, non-government organisations and international donors is not currently enough to end undernutrition. Despite the proportion of Official Development Assistance (ODA) focused on basic nutrition increasing from 0.2% in 2004 to 0.4% in 2011, there is still a shortfall when the demand is considered. Basic nutrition ODA funding is still small when compared with emergency and development food aid. Appropriate levels of basic nutrition financing is needed as a key component in the battle to eradicate poverty. (Di Ciommo, 2013).

Between 2005 and 2009, 10 of the world’s leading bilateral and multilateral donors contributed an average of US$73 million per year to direct nutrition interventions which address the immediate determinants of undernutrition. This represents just a fraction of the estimated need and is dwarfed by investment in indirect nutrition interventions (US$365 million), which address the underlying causes of undernutrition. Investments in aid to tackle the escalating challenge of undernutrition remain inadequate (Mutuma et al. 2012).

With a growing global population, the problem is likely to get worse without increased investment. In the current climate, there is increased competition for funding but also increased expectation to invest in the most cost effective interventions. Evidence suggests that a 15 % reduction in deaths in children younger than 5 years can achieved if populations can access ten specific direct nutrition interventions at 90% coverage. The total additional annual cost to scale up access to these ten direct nutrition interventions in the 34 focus countries that have 90% of the world’s children with stunted growth is estimated to be $9.6 billion per year (Bhutta et al. 2013).

In some cases, nutrition aid is not being invested in countries with the highest rates of undernutrition and some donors frequently do not honour their commitments. In addition, there is a major lack of transparency in nutrition aid, highlighting the need for donors to be more accountable to their electorates (Mutuma et al. 2012). Improvement of the monitoring and evaluation of the nutrition financing activities of donors is required, to allow ‘best practices’ to be identified, understood and replicated. Accountability also needs to be improved. It is also suggested that efforts of those working in various sectors including donors, academia and civil society, are combined when dealing with the financing of scaling up nutrition to avoid a fragmented approach. If the current dearth of funds is ever to be overcome, long-term, sustainable and predictable funding will be needed for the full nutrition package which is aligned with complementary initiatives in health, food security and agriculture (Spratt, 2012).

As part of the SUN initiative, signatory countries are in the process of calculating the cost of scaling up nutrition in their respective countries. As many as 20 countries have currently collated costs from budgets and nutrition-related plans. Data on cost estimates of scaling up nutrition are needed to mobilise support and resources at a regional, national and international level. As more data is gathered, a better understanding will be gained of the resources needed to address undernutrition, which will be vital for policy and planning (SUN, 2013).

Key messages

• Undernutrition imposes a significant global human and economic cost.
• Nutrition focused ODA has increased in the last decade, but is still small when compared with emergency and development food aid. Nutrition focused ODA currently does not meet demand.
• Investments in aid to tackle the escalating challenge of undernutrition remain inadequate and significant extra funding is needed to implement direct nutrition interventions that have demonstrated effectiveness.
• Micronutrient supplementation and fortification are found to be cost effective implementations and to work well even when capacities are constrained, making them a sensible option for further investment.
• An estimated $9.6 billion per annum is needed to scale up 10 direct interventions to 90% coverage in 34 focus countries with the most significant stunting burden.
• There is a major lack of transparency in nutrition aid, highlighting the need for donors to be more accountable to their electorates.
• OECD needs to improve monitoring and evaluation of the nutrition financing activities of donors to allow ‘best practices’ to be identified, understood and replicated. Accountability also needs to be improved.
• Donors, academia and civil society need to work together to avoid a fragmented approach to solving undernutrition.
• Innovative financing to provide long-term, sustainable and predictable funding for the full nutrition package which is aligned with complementary initiatives in health, food security and agriculture is suggested.