SCN News No 36 - UNSCN

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.
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