SCN News No 36 - UNSCN

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20 FEATURES www.unsystem.org/scn were looked at very extensively. The effect of these intervention programmes was found to be less that what we had hoped, and I think there is tremendous room for improvement and a need for more research and evaluation of how to best implement these programmes for improving complementary feeding. Maternal interventions during pregnancy, such as energy/protein supplementation, intermittent preventive treatment in malaria areas and provision of multiple micronutrients, may also contribute to reducing child mortality. When looking at other outcomes than mortality, zinc supplementation, improved complementary feeding and hygiene promotion would be expected to reduce stunting, whereas iron supplementation would reduce maternal mortality (Table 4). Other interventions not shown here include iodization of salt. Conclusion In summary, effective interventions are available to reduce stunting, micronutrient deficiencies, child mortality as well as maternal health conditions. The most promising interventions with regard to reducing mortality and disease burden would be the promotion of breastfeeding and complementary feeding and supplementation or, if possible, fortification with vitamin A and zinc, as well as appropriate management of severe acute malnutrition. So, our key message concerning interventions, is that we have evidence-based interventions that work. The task ahead lies in implementing these interventions at scale to the entire population of mothers and children who need them. If we were able to deliver these interventions at scale, we could very quickly reduce the prevalence of stunting by a third, and reduce child deaths by at least one quarter. We need to focus on the critical window from conception to 24 months of age, which should be our target for interventions and where we should direct our programmes. This may sometimes require shifting efforts that are directed at other age groups. Progress is definitely possible, nutrition needs to become more of a priority, and an essential component of human, social and economic development. If we were able to implement these programmes, we would not only achieve - or come close to achieving - MDG1 on hunger, but we would also make more major contributions to achieving MDGs 4 and 5 on child and maternal mortality. Contact: rblack@jhsph.edu References de Onis M (2008) Child undernutrition based on the new WHO growth standards and rates of reduction to 2015. SCN News 36:12-6. (See p.12) Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS and Shekar M; Maternal and Child Undernutrition Study Group (2008) What works? Interventions for maternal and child undernutrition and survival. Lancet 371( 9610):417-40. (online) Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J; Maternal and Child Undernutrition Study Group (2008) Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371(9608):243-60. (online) Bryce J, Coitinho D, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P; Maternal and Child Undernutrition Study Group (2008) Maternal and child undernutrition: effective action at national level. Lancet 371(9611):510-26. (online) Maternal and Child Undernutrition Study Group (2008) Maternal and child undernutrition. Lancet 371(9608-12). Available from http://www.thelancet.com/collections/series/undernutrition Morris SS, Cogill B, Uauy R; Maternal and Child Undernutrition Study Group (2008) Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet 371(9608):608-21. (online) The Bellagio Study Group on Child Survival (2003) Child Survival Series. Lancet. www.thelancet.com/collections/ child2004 Veneman AM (2008) Opening speech at the 35th SCN Session. SCN News 36:4-6. (See p.4) Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS;Maternal and Child Undernutrition Study Group (2008) Maternal and child undernutrition: consequences for adult health and human capital. Lancet 371 (9609):340-57. (online) SCN NEWS # 36 back to contents
www.unsystem.org/scn FEATURES 21 Addressing the underlying determinants of undernutrition: Examples of successful integration of nutrition in poverty-reduction and agriculture strategies Marie T. Ruel, Director, Food Consumption and Nutrition Division, International Food Policy Research Institute (IFPRI) Introduction The third paper of the Lancet Series on Maternal and Child Undernutrition argues that effective, targeted nutrition interventions exist; and that if implemented at scale during the window of opportunity (pregnancy and up to the child’s second birthday), these interventions could reduce undernutrition-related mortality and disease burden by 25% in the short term (Bhutta et al 2008). The set of interventions recommended addresses mainly the “food” (and nutrient) intake needs of mothers and children because this is where most of the quantitative evidence of efficacy and effectiveness lies. Interventions to directly improve health and care – the other two proximal determinants of undernutrition - are largely absent from the discussion, as are interventions targeting the more distal, underlying determinants of undernutrition such as poverty, food insecurity and lack of education. These omissions are justified, given the dearth of quantitative data on the effectiveness of interventions aimed at improving the underlying determinants of malnutrition. Examples of such programme and policy actions include strategies to reduce poverty, empower women and reduce gender inequality; agriculture development approaches to increase food production, income and food security and to stimulate overall economic growth; education to build human capital and empower future generations; and health systems strengthening to achieve high-quality health coverage for all. The Lancet Series’ review of interventions also applies an additive model, which assumes that interventions act independently of one another. No allowance is given for interventions implemented jointly with the possibility of interactive, synergistic effects on improving nutrition, health and education, or for integrated packages of interventions that simultaneously address the direct and underlying determinants of nutrition. This paper highlights the importance of addressing the global context in which undernutrition occurs, and argues that significant and sustained progress in improving maternal and child nutrition cannot be achieved unless appropriate actions are put in place to address the underlying determinants of undernutrition. The paper also emphasizes the importance of using a life-cycle approach to address undernutrition. While the nutrition community has finally reached a consensus on the importance of focusing on the window of opportunity for intervening in nutrition – i.e. the period between -9 months (pregnancy) and the child’s second birthday (24 months) (Black et al 2008) – it is important to also ensure that other phases of the lifecycle are addressed and that the specific nutritional needs of individuals throughout the lifecycle are adequately met. The paper’s main line of argument is that in order to address, in a sustainable way, the multiple causes of undernutrition and the different needs of individuals throughout the life-cycle, we need to: 1) work across sectors ; 2) mainstream nutrition within the health, agriculture and social development sectors, among others; and 3) scale up nutrition as part of cross-sectoral initiatives. The Conceptual Framework of the determinants of undernutrition The UNICEF conceptual model, which has been widely used since it was first developed in the early 1990s, clearly distinguishes the immediate, underlying and basic determinants of child undernutrition and their interdependence (UNICEF 1990). Figure 1 illustrates where, in the impact pathway, the targeted nutrition interventions with demonstrated effect highlighted in the Lancet Series will act (e.g. breastfeeding, complementary feeding, vitamin A, zinc, hygiene; see top left column). It shows that all these interventions focus on the immediate causes of undernutrition, i.e. improving food and nutrient intake and health. These types of interventions are referred to here as “short routes” to reducing undernutrition, borrowing from the terminology used by the World Bank (World Bank 2005). The present paper focuses on the “long routes” 1 to improving nutrition (bottom part of the framework; also 1. The terms “short-route” and “long-route” to reducing undernutrition are borrowed from the World Bank Repositioning Nutrition (World Bank 2005) publication. The interpretation is that: “short-route” interventions are more likely to achieve impact on nutrition in the relatively short term, say within 1 or so, whereas “long-route” interventions may take longer to confer nutritional benefits. This is because these latter types of interventions are less “direct”, as they address the underlying causes of malnutrition rather than the immediate causes. back to contents SCN NEWS # 36
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