AND BUILD A HEALTHY
FOOD ENVIRONMENT
A large body of evidence for nutrition improvement and impact has been provided by the 2008 Lancet Series on Maternal and Child Undernutrition99 and the 2013 Lancet Series on Maternal and Child Nutrition,100
building momentum for nutrition. Improving nutrition throughout the life-course requires effective interventions to address the immediate causes of malnutrition, such as inadequate and/or inappropriate dietary intake and infectious diseases, as well as the underlying causes. It should be noted, however, that the first 1000 days of a child’s life from conception through the first two years are the most crucial period for preventing the lifelong effects of undernutrition, particularly stunting (see Figure 22). This period of time is also known as the “window of opportunity”.
Nanai, a ‘cadre’ (volunteer community health worker), chats with Sujilah, who is breastfeeding her 5-day- old infant in a room of the family’s home, in Dukuh Village in Central Java Province, Indonesia. Photo credit: ©UNICEF/UNI152364/Ferguson
A number of evidence-based effective nutrition actions have been recommended111 112 to address the
persistent challenge of undernutrition, as well as the increasing challenge of overweight, obesity and diet- related NCDs. Protection, promotion and support of optimal breastfeeding and complementary feeding practices are critical early interventions to address all forms of malnutrition, protecting children from the harms of undernutrition as well as from overweight, obesity and NCDs later in life.75 113 This is followed
by ensuring nutritious and healthy diets of optimum quantity and quality. In addition, interventions that promote physical activity are important to support the prevention and control of overweight, obesity and NCDs.
Interventions to improve nutrition can be classified into nutrition-specific actions and nutrition-sensitive actions. Evidence on the effectiveness of nutrition-specific and nutrition-sensitive interventions is compiled by WHO in its electronic Library of Evidence for Nutrition Actions (eLENA).114
Figure 22: The window of opportunity: pregnancy to 2 years of age
Note: Figure adapted from Victora et al.110 for the UNICEF EAPRO Approach to Nutrition Programming in the East Asia and Pacific Region.19 Blue line displays height for age, and it represents the mean anthropometric z scores for all 54 studies reviewed in this publication, relative to the WHO standard (1–59 months). This figures shows that height for age starts close to the standard and falters dramatically until 24 months. Therefore, it is important that nutrition interventions are focused on the first 1000 days of life, from pregnancy (9 months) until the second year of life (24 months).
Z-sc or es ( WHO ) 5 10 15 20 25 30 35 40 45 50 55 60 -10 -5 0 Pregnancy Post-natal Age (months)
Height for age (HAZ)
Victora et al 2010 Prediatrics 2010;125;e473-e480;
110 Victora CG, de Onis M, Hallal PC, Blossner M, Shrimpton R (2010). Worldwide timing of growth faltering: revisiting implications for
interventions. Pediatrics, vol.125 no. 3.
111 Bhutta ZA, Das JK, Rizvi A, Gaffey MF et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition:
what can be done and at what cost? Lancet; 382: 452–77. The Lancet (2013) Series on Maternal and Child Nutrition.
112 Ruel MR, Alderman H, and the Maternal and Child Nutrition Study Group (2013). Nutrition-sensitive interventions and programmes:
how can they help to accelerate progress in improving maternal and child nutrition? Lancet; 382: 536-51. The Lancet (2013) Series on Maternal and Child Nutrition.
113 WHO (2014). Exclusive breastfeeding to reduce the risk of childhood overweight and obesity: Biological, behavioural and contextual
rationale. Geneva; World Health Organization (http://www.who.int/elena/bbc/breastfeeding_childhood_obesity/en/, accessed January 12, 2016). 114 eLENA (http://www.who.int/elena/about/en/) 1.00 0.75 0.50 0.25 0 -0.25 -0.50 -0.75 -1.00 -1.25 -1.50 -1.75 -2.00
Nutrition-specific actions (Box 1) address the immediate determinants of malnutrition, including fetal and child nutrition and development, and/or the nutritional status of older children and adults (adequate food and nutrient intake, feeding, caregiving and parenting practices, and burden of infectious disease).
Nutrition-sensitive actions (Box 2) address the underlying determinants of malnutrition and development,
and/or the nutritional status of older children and adults (food security; adequate resources at the individual- (especially maternal and caregiver), household- and community levels; access to health services and a safe and hygienic environment; access to information about healthy food choices) and incorporate specific nutrition goals and actions. Nutrition-sensitive programmes can be used as delivery platforms for nutrition- specific interventions, which can increase their scale, coverage and effectiveness.112
Box 1: Nutrition-specific actions
112Nutrition-specific actions
1. Strengthening of nutrition literacy through social marketing, counselling, education (knowledge and skills to diversify diets and being empowered to make informed healthy decisions, including complementary foods)
2. Counselling, education and screening specifically to women of reproductive age, pregnant and lactating women (to improve adolescent, preconception and maternal health)
3. Promotion and support of optimal IYCF (breastfeeding and complementary feeding practices)
4. Dietary supplementation for eligible children, pregnant women and lactating women 5. Prevention and management of micronutrient deficiencies through supplementation, home
fortification interventions and/or delayed cord clamping
6. Food fortification (with vitamins and minerals, as necessary), and food reformulation [salt, sugar and fat reduction in processed foods]
7. Deworming or control of parasitic infections in children and pregnant women 8. Prevention and management of moderate and SAM
9. Disease prevention and management (including infectious diseases, obesity and diet-related NCDs)
Based on existing evidence, it is undeniable that an essential package of nutrition-specific and nutrition- sensitive interventions needs to be implemented and scaled up “as a package” in order to address all forms of malnutrition. The complementarity between nutrition-specific and nutrition-sensitive interventions needs to be taken into account. For example, interventions to promote the consumption of healthy diets can consist of both nutrition-specific and nutrition sensitive interventions. Nutrition-sensitive interventions to improve the diet of the population most importantly consist of agricultural interventions to increase and incentivize the production and sale of diversified and nutrient-rich foods, including fruits and vegetables, animal source foods and legumes. Furthermore, nutrition-sensitive interventions include consumer protection and empowerment (through the provision of adequate food and nutrition labelling and the restriction of marketing of food and non-alcoholic beverages to children), implementation of fiscal measures (taxation and subsidies) to reduce for example the purchase of unhealthy foods, and implementation of trade policies to reduce the importation of unhealthy foods, for example. On the other hand, nutrition-specific interventions to improve the diet of the population consist of the promotion of optimum nutrition practices (through strategies such as education, counselling or communication), by promoting the increased consumption of fruit and vegetables and the reduced consumption of free sugars, salt and fats, promoting optimum breastfeeding, promoting optimum complementary feeding or promoting dietary diversification.