Hunger Alleviation & Nutrition Landscape Analysis

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Hunger Alleviation & Nutrition Landscape Analysis

7 December 2009


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Objectives of the Landscape Analysis

The objectives of the Hunger Alleviation & Nutrition landscape analysis are to:

1. Provide a concise overview of the impact of hunger & undernutrition onchildren

2. Outline the current evidence base for different hunger & nutritioninterventions

1


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Summary of Landscape Analysis

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3.5 million child deaths per year and 35% of the total disease burden for children under 5 can beattributed to undernutrition

Stunting typically occurs either in the womb (resulting in low birth weight) or in the first two years of life.The physical and cognitive damage from stunting is largely irreversible after age 2-3

This irreversible damage can self-perpetuate undernourished girls become undernourished women,who give birth to low birth weight infants, who suffer from poor nutrition from the very beginning of life.This results in impaired physical and mental development being passed from generation to generation

The most direct response of CIFF to break the cycle of intergeneration stunting should be to increasebirth weight and improve nutritional status during the critical window of opportunity of -9 to 24 months

The highest burden of hunger & undernutrition is found in South Asia, though the burden is alsosubstantial in Sub Saharan Africa

Food availability, food access, child & maternal care, and health must all be taken into account whenanalyzing the causes of hunger & undernutrition

Effective hunger & nutrition interventions already exist; implementing them at scale could avert 25% ofchild deaths in the highest burden countries

Unfortunately, funding for hunger & nutrition is currently dominated by food aid, much of which isineffective at improving outcomes for children


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Focus Areas for Hunger Alleviation and Nutrition

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The most direct response of CIFF to break the cycle of intergeneration stunting should be to increase birth weightand improve nutritional status during the critical window of opportunity of-9 to 24 months by supporting:

Infant &Young Child

Nutrition

Technical assistance to encourage the local production of complementary foods and marketing ofthese products to the poor

Development of models to promote breastfeeding and appropriate complementary feeding at scale

Rigorous evaluation of breastfeeding promotion at scale in a country with high HIV prevalence

Work with Government of India to improve the targeting of its nutrition programs to children under 2

Research into the effectiveness and cost effectiveness of interventions for which there is currentlymixed evidence. This includes calorif ic supplementation of adolescent girls and women likely tobecome pregnant, calorific supplementation of pregnant women, and infection control of pregnantwomen

Given the lack of proven interventions to reduce low birth weight, the development of innovativeapproaches is urgently needed

For the few proven interventions such as iron-folate supplementation, delivery science research onhow to implement programs at scale is required, as large-scale programs are rare

Development of new delivery models to provide supplementation to women likely to become pregnantinstead of waiting until a pregnancy is identified

Efficacy and cost-effectiveness analysis of ready-to-use food supplementation in pregnant andlactating women

MaternalNutrition


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4

Treatment ofSevere AcuteMalnutrition

Development of effective delivery models for preventive zinc supplementation

Maternal nutrition interventions as described above

Address the political issues that have prevented the use of ready-to-use therapeutic food in Indiathrough the development of local production and funding the first efficacy studies of Ready-to-UseTherapeutic Food (RUTF) in Indian children

Remove the barriers to local RUTF production such as the patent issue, the slow process of foodsafety certification and the lack of in-country technical expertise

Development of new delivery models to deliver ready-to-use foods

Development and efficacy testing of complementary foods appropriate for feeding children under

two that can be added to the standard food aid basket

Development of local production and procurement of food products appropriate for feedingchildren under two

Improve the targeting of food aid to pregnant women and children under two, including rigorousanalysis of the impact on young children of alternative food aid modalities such as vouchers andcash transfers

Improving theEffectivenessof Food Aid

MicronutrientSupplemen-

tation


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Hunger & Nutrition Technical Definitions

6

The following technical definitions are provided for the convenience of the Board:

DALY: The disability-adjusted life year (DALY) is a measure of overall disease burden. Originally developed by the World HealthOrganization, it is becoming increasingly common in the field of public health and health impact assessment. For each disease, DALYsare calculated as the sum of years lost due to premature mortality and the years of productive life lost due to disability

Hunger: The discomfort, weakness, or pain caused by a prolonged lack of food

Low Birth Weight: An infant born weighing less than 5.5 pounds (2500 grams) regardless of gestational age

Malnutrition: Various forms of poor health caused by a complex array of factors including dietary inadequacy, infections and impropercare. Underweight, obesity, stunting, wasting and micronutrient deficiencies are all forms of malnutrition

Protein-Energy Malnutrition: An energy deficit due to chronic deficiency of protein and calorie intake

Stunting: Failure to reach linear growth potential because of inadequate nutrition or poor health. Defined as height-for-age twostandard deviations below the international reference, stunting implies long-term undernutrition and poor health. Sometimes referred toas chronic malnutrition

Undernutrition: Malnutrition resulting from a lack of proper quantities of nutritious food or failure of the body to absorb or assimilatenutrients properly

Underweight : Low weight-for-age. Defined as two standard deviations below the international reference, underweight impliesstunting or wasting and is an indicator of hunger and undernutrition

Wasting: When weight-for-height is two standard deviations below the international reference. Usually a consequence of acutestarvation or severe disease, often caused by emergency situations such as famine. Severe wasting is referred to as severe acutemalnutrition


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What Is Included Under Hunger Alleviation & Nutrition?

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Hunger Alleviation:Hunger is the discomfort, weakness, or pain caused by a prolonged lack of food. The level ofhunger is measured by caloric intake per child, % of children who are underweight (stuntedand/or wasted) and the number of meals consumed per day

Examples of hunger alleviation interventions include emergency food aid, the distribution ofgeneral food rations, food subsidies, school feeding programs, gardening & livestockprograms and cash transfers

Nutrition:Undernutrition is poor health resulting from a lack of proper quantities of nutritious food or thefailure of the body to absorb nutrients properly. The impact of undernutrition on children ismeasured by child mortality, morbidity, stunting, wasting and micronutrient deficiencyprevalence

Examples of nutrition interventions include vitamin supplementation, fortification, provision oftherapeutic foods, and breastfeeding and complementary feeding promotion


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Table of Contents

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I. Introduction to Hunger Alleviation & Nutrition

A. DefinitionsB. A Framework for Analyzing Hunger Alleviation & NutritionC. The Impact on ChildrenD. Geography and History

E. International Architecture

II. Evidence Base for Hunger Alleviation & Nutrition Interventions

A. Introduction to the EvidenceB. Food InterventionsC. Care InterventionsD. Health InterventionsE. Poverty Interventions

III. Conclusion


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Inadequate dietary intake Disease

Food:Household food insecurity(access and availability)

Care:Inadequate care ofchildren and women

Health:Unhealthy household

environment and lack ofhealth services

Poverty

Lack of capital: financial,human, social, natural

Social, economic andpolitical context

Short-term consequences:

Mortality, morbidity, disability,weakness, discomfort, pain

Long-term consequences:

Adult size, intellectual ability,economic productivity, reproductive

performance, metabolic and

cardiovascular disease

UnderlyingCauses

ImmediateCauses

BasicCauses

Analytical Framework: Poverty, Food, Care and Health

9Source: UNICEF


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Table of Contents

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III. Conclusion


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High Mortality Burden

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Child and maternal undernutrition isthe underlying cause of 3.5 million child

deaths worldwide per year and 35% ofthe disease burden for children under 5

The vast majority of deaths are dueto increased susceptibility to infectiousdisease. Only 140,000 deaths are

directly attributed to starvation (i.e.insufficient intake of calories and/orprotein), less than 4% of the totaldeaths due to undernutrition

Vitamin A and zinc deficiencies havethe largest disease burden among

micronutrients

Stunting and iron deficiency anemiaaccount for over 20% of maternalmortality

Source: Black et al. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. (2008)

Note: Total is greater than 3.5 million due to co-exposure and joint distribution


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Hunger Persists in Many Countries

12Source: FAOSTAT

In many countries, per capita caloric intake is less than the recommended 2100 calories per day

Almost all of these food insecure countries are located in Sub-Saharan Africa

The most severe food insecurity is usually due to conflict or natural disaster

= does not consume minimum per capita requirement of 2100 calories/day


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The Impact of Hunger on Children

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Age CaloricRequirement / Day

Impact of Insufficient Calorie Intake

Pregnant Women Additional 100-300 Intrauterine growth restriction, low birth weight

0-6 Months 650 Wasting, stunting, irreversible cognitive damage

6-12 Months 850 Wasting, stunting, irreversible cognitive damage

1-2 Years 1200 Wasting, stunting, irreversible cognitive damage

2-6 Years 1800 Temporarily impaired cognitive function, weakness, wasting, lowereducational achievement

7-10 Years 2000 Temporarily impaired cognitive function, weakness, wasting, lowereducational achievement

11-18 Years 2200-3000 Temporarily impaired cognitive function, weakness, wasting, lowereducational achievement, stunting due to failed adolescent growth

Adults 2100 Temporarily impaired cognitive function, weakness, wasting

In the short term, insufficient caloric intake causes discomfort, weakness and pain. This has an impact on attention span andcognitive function and can therefore lower educational achievement

Prolonged calorie and protein deficiency leads to chronic malnutrition, which compromises the immune system and leaves children

susceptible to infectious disease

Hunger is a subset of undernutrition. All hungry children are undernourished, as they are not receiving sufficient caloric and proteinintake. It is possible, however, to be undernourished but not hungry if the food one consumes has sufficient calories but insufficientmicronutrient content, or if disease leads to the failure of the body to properly absorb nutrients

Source: WHO, CIFF research. Specific caloric requirement varies by sex, height and weightNote: There is mixed evidence on the exact causes of stunting and cognitive damage, though studies have shown that insufficient caloric intake likely plays a role in certain contexts


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The Consequences of Undernutrition on Under 2s

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Stunting typically occurs in the first 2 years of life, and is difficult to reverse after age 2 to 3

Undernutrition in under 2s does not only affect physical development, it also can cause permanent damageto cognitive ability [i]

Infants are particularly at risk when they first receive complementary foods (i.e. after 6 months of age), asthis is when their nutritional needs are greatest and when they are first exposed to foods which potentiallycontain diarrhea causing microorganisms [ii]

Studies have found that caloric intake, micronutrient intake, care, maternal health, sanitation and childhealth all likely play a role in stunting, though the precise contribution of each factor is unknown and is

expected to vary across geographies

[i] Victora at al. Maternal and child undernutrition: consequences for adult health and human capital. The Lancet. (2008)[ii] Black et al. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. (2008)Repositioning Nutrition as Central to Development, World Bank

We

ightfor

Age

ZScore

Source: Shrimpton et al 2001

Growth Faltering Time Frame


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Long-Term Studies Have Confirmed the Importance of Under 2 Nutrition

Recently published studies show that many caloric and micronutrient supplementationinterventions only have a statistically significant impact on children under 2-3 years of age [iii] [iv]

Long term studies across several geographies (Brazil, Guatemala, India and the Philippines)have shown that undernutrition at age 2 is linked to adult outcomes such as schooling, incomeand offspring birth weight [v]

[iii]

Alderman, H. Improving nutrition through community growth promotion. World Development. (2007)[iv] Maluccio et al. The impact of improving nutrition during early childhood on education among Guatemalan adults. The Economic Journal. (2009)[v] Victora at al. Maternal and child undernutrition: consequences for adult health and human capital. The Lancet. (2008)Note: Years of schooling lost includes losses due to both grade attainment (years of schooling) and achievement

Source: World Bank

The Consequences of Undernutrition on Under 2s


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Maternal Undernutrition Results in Low Birth Weight

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% of Infants with Low Birth Weight Number of Infants Per Year with Low Birth Weight

Source: Progress for Children. UNICEF. (2007)

Low birth weight infants are much more likely to die in infancy than heavier babies

Those who survive are more susceptible to infectious diseases and inhibited growth and cognitive development. They

are more likely to suffer from chronic illnesses in later life

Major causes of low birth weight are poor maternal nutrition, anemia, malaria, sexually transmitted infections and otherdisease. Anemia is also a major contributor to maternal mortality

Key interventions to prevent low birth weight include improved food intake for pregnant women, micronutrientsupplementation, prevention and treatment of such infections as malaria, reduction of teenage pregnancy and maternaleducation


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Intergenerational Stunting

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Many indicators of undernutrition at

age 2 are highly correlated with low birthweight in the subsequent generation, aneffect called intergenerational stunting

Child undernutrition can self-perpetuate undernourished girlsbecome undernourished women, whogive birth to low birth weight infants, whosuffer from poor nutrition from the verybeginning of life

This results in impaired physical andmental development being passed from

generation to generation

Source: Victora at al. Maternal and child undernutrition: consequences for adult health and human capital. The Lancet. (2008)Ending Malnutrition by 2020: An Agenda for Change in the Millennium. United Nations University. (2000)

Source: United Nations University


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Table of Contents

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III. Conclusion


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The Geography of Hunger & Undernutrition

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The worlds undernourished children are concentrated in CIFFs geography - 81% of the worlds underweight children live inSub-Saharan Africa or South Asia

Undernutrition is much more common in rural than in urban areas, though undernutrition in large urban slums is increasing in

many countries

Contrary to common perceptions, undernutrition prevalence rates in the populous South Asian countriesIndia, Bangladesh,Afghanistan, Pakistanare much higher (38 to 51 percent) than those in Sub-Saharan Africa (26 percent)

High levels of inequality, the low status of women, poor hygiene and sanitation, and poorly functioning child nutritionprograms are the most commonly cited reasons for Indias high rate of undernutrition

Stunting Prevalence in Children Under Five

Source: The Lancet Maternal and Child Undernutrition Series. (2008)

Stunting Prevalence in Children Under Fivein India by State


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Chronic Undernutrition and Famine in Sub-Saharan Africa

Main Areas of Chronic

Undernutrition

Common Food Shortages

Main Areas of Famine in

the last 30 years

Conflicts

Source: UNDP Human Development Report, FAO

Historically, famine has been highly

correlated with conflict and politicalinstability in areas with marginal foodproduction capability

Major famines and food emergenciessince World War II:

1946-1947: Soviet Union

1958: Ethiopia 1959-1961: China Great Leap Forward 1966: Bihar, India 1968-1972: Sahel 1973: Ethiopia 1974: Bangladesh 1975-1979: Khmer Rouge Famine in Cambodia 1984: Ethiopia 1991-1993: Somalia

1996: North Korea 1998: Sudan 1998-2000: Ethiopia 1998-2004: Second Congo War 2003-Present: Darfur

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Food Insecurity in 2008

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Food insecurity remains highly correlated with political instability today

Food

Red = Iraq, Lesotho, Somalia, Swaziland and ZimbabweOrange = Afghanistan, Burma, Eritrea, Liberia, Mauritania, North Korea and Sierra LeoneGreen = Bangladesh, Bolivia, Burundi, Central African Republic, Chad, China, Congo, DR Congo, Ethiopia, Ghana, Guinea, Guinea-Bissau,Ivory Coast, Kenya, Nepal, Philippines, Sri Lanka, Sudan, Tajikistan, Uganda


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Historical Data Projections

Source: World Bank

Historical Trends

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There has been great success in China, but hunger remains a major problem in Africa and India

In Sub-Saharan Africa undernutrition is still on the rise, in part due to the HIV pandemic. Undernutrition and HIV/AIDS

reinforce each other, so the success of HIV/AIDS programs in Africa depends in part on paying more attention to nutrition

In Asia undernutrition is decreasing due to tremendous success in China

Undernutrition prevalence rates in South Asia have been relatively stagnant, and the region still has both the highest ratesand the largest numbers of undernourished children

Source: Repositioning Nutrition as Central to Development, World Bank

Prevalence of Underweight Children


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What Has Worked in the Past? Thailand

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Thailand was able to achieve remarkable progress between 1979 1991 through acoordinated nationwide nutrition plan first launched in 1977. The plan set out ambitious and

comprehensive goals to improve the nutritional status of infants, pre-school children andpregnant women

Source: Garg, Samir. Reducing Childhood Malnutrition, the Thailand ExperienceTontisirin et al. Food and Nutrition Bulletin. (1995)

The components of Thailands nutrition strategy were:

1. Focus on infants, pre-school children and pregnantwomen

2. Child growth monitoring

3. Nutrition education on breastfeeding promotion andcomplementary feeding

4. Promotion of local production of nutritious foods likelegumes, sesame, fish and poultry

5. Provision of supplementary food containing fats andprotein through 1,200 child-nutrition centers

6. Iodisation of salt

7. Provision of iron, vitamin A, iodine andriboflavin/thiamine supplements


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Table of Contents

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III. Conclusion


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International and National Architecture

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The hunger & nutrition architecture is fragmented and dysfunctional

Many of the largest international actors implementing hunger interventions focus almostexclusively on volume of food delivered, with little regard for nutrition outcomes forchildren

Nutrition interventions are often neglected and under resourced, as they do not fitcleanly under health, agriculture or childhood development programs

Donors have weak counterparts at the national level with very limited (if any)government resources allocated to nutrition programs

Current processes for producing national guidelines for hunger & nutrition are laboriousand duplicative, and fail to produce guidance that is prioritized, succinct, and evidence-based

Source: Morris SS, Cogill B, Uauy R, for the Maternal and Child Undernutrition Study Group, Effective international action againstundernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet. (2008)


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International and National Architecture

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Multilaterals Bilaterals/Foundations

NGOs/Alliances Universities/Research

PrivateSector

FAO CIDA ACF HeiferInternational

AIIMS IFPRI Compact

UNICEF DFID AED HKI CGIAR LSHTM Danone

SCN & REACH ENN CARE MicronutrientInitiative

Cornell NIN Nutriset

WFP Gates Foundation CHAI MSF JohnsHopkins

Tufts Nestle

WHOIrish Aid Concern Save the

ChildrenCHNRI UC Davis Unilever

World Bank USAID GAIN Valid Nutrition IDS

Red = have partnered with CIFF on hunger or nutrition programs in the past

No clear leader exists in hunger & nutrition internationally. At the national level, programsare often divided between agriculture and health ministries

Source: CIFF research


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Funding is Dominated by Food Aid

27Morris SS, Cogill B, Uauy R, for the Maternal and Child Undernutrition Study Group, Effective international action against undernutrition: whyhas it proven so difficult and what can be done to accelerate progress? Lancet. (2008)Ravishankar et al. Financing for global health: tracking development assistance for health from 1990 to 2007. Lancet. (2009)Note: all numbers are international development assistance except for food subsidies, which are usually financed by national governments

Funding provided by international donors is dominated by food aid Food aid dwarfs spending on nutrition; over $8 billion per year in food aid was provided

by major donors in 2008, up from $4 billion at the beginning of the decade The United States is the largest donor of food aid, providing over 50% of the total

National governments also spend a tremendous amount on food subsidies India alone is expected to spend over $10 billion this year subsidizing the cost of staplefoods for low income families

Source: OECD


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Lower Spending on Nutrition

28

Source: OECD

Source: Morris SS, Cogill B, Uauy R, for the Maternal and Child Undernutrition Study Group, Effective international action againstundernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet. (2008)

Investment in nutrition is lower than in food aid Nutrition investment by donors was less than $300 million per year between 2000-05,significantly less than spending on single diseases such as malaria or HIV which are

responsible for far fewer child deaths

The Lancet has estimated that over $2 billion per year in nutrition spending would beneeded to implement nutrition interventions that have already been proven effective inthe highest burden countries


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Table of Contents

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III. Conclusion


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Overview of the Evidence

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Effective hunger & nutrition interventionsalready exist. Simply implementing proveninterventions at scale could reduce all childdeaths by 25% in the short term [i]

The 2008 Copenhagen Consensus, an

expert panel of economists including five Nobellaureates, selected malnutrition programs asthree of the top five most effective developmentinterventions, with micronutrient supplements forchildren as the number one intervention overall

The 2008 Lancet Maternal and ChildUndernutrition Series ranked breastfeedingpromotion and vitamin A and zincsupplementation as the interventions with thegreatest potential impact on child morbidity andmortality

A disease for which we already have the cure Paul Farmer

Solution Sector

1. Micronutrient supplements for children Malnutrition

2. The Doha development agenda Trade

3. Micronutrient fortification Malnutrition

4. Expanded immunization coverage for children Diseases

5. Biofortification Malnutrition

6. Deworming and other nutrition programs at school Malnutrition & Education

7. Lowering the price of schooling Education

8. Increase and improve girls' schooling Women

9. Community-based nutrition promotion Malnutrition

10. Provide support for women's reproductive health Women

[i] Bhutta et al. What Works? Interventions for Maternal and Child Undernutrition and Survival. The Lancet. (2008)


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Lancet Series Recommendations

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Maternal andBirthOutcomes

Maternalsupplements ofmultiple

micronutrients Iron folatesupplementation Maternal iodinethrough iodizationof salt Maternal calciumsupplementation

NewbornBabies

Promotion ofbreastfeeding(individual andgroupcounseling)

Infants andChildren

Promotion ofbreastfeeding Improvedcomplementary feeding

Zincsupplementation Zinc in managementof diarrhea Vitamin A fortificationor supplementation Universal saltiodization Hand washing or

hygiene interventionsTreatment of severeacute malnutrition

Maternal andBirth Outcomes

Maternalsupplements ofbalanced energy andprotein

Maternal iodinesupplements

Maternaldeworming inpregnancy Intermittentpreventive treatmentfor malaria

Insecticide-treatedbed nets

Newborn

Babies Neonatalvitamin Asupplements

Infants andChildren

Conditional cashtransfer programs(with nutritioneducation) Deworming

Iron fortification Insecticide-treated bed nets

Interventions with Sufficient Evidence toImplement in All Countries

Interventions with Sufficient Evidence toImplement in Specific Contexts

Source: The Lancet Maternal and Child Undernutrition Series (2008)


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Impact of Major Hunger & Nutrition Related Interventions

32Source: Bhutta et al. What Works? Interventions for Maternal and Child Undernutrition and Survival. The Lancet. (2008)Note: Includes only the reduction in mortality due to reduced stunting in the 36 highest burden countries. The impact is understated for interventionssuch as zinc supplementation that also have an effect on diarrhea prevalence. Assumes scaling up to 99% coverage of all interventions* Maternal deaths averted

In the highest burden countries,universal coverage with these

interventions could prevent abouta quarter of child deaths under 36months and reduce theprevalence of stunting by a third,averting some 60 million DALYs

If universal coverage cannot beachieved, even lower coverage(70%) would avert over 40 millionDALYs

Calcium, iron and folic acidsupplementation of pregnant

women would prevent 105,500maternal deaths


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There are Several Inexpensive and Cost Effective Interventions

Source: Disease Control Priorities Project and CIFF analysis* Large-scale breastfeeding promotion and support programs have not been rigorously analyzed

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Intervention Cost ($) Per death averted ($) Per DALYgained ($)

SUPPLEM

EN-

TATION

Vitamin A .90 1.25 per child 162 327 6 12

Zinc .47 per child 2,100 73

FORTIFI-

CATION

Iodized Salt .02 0.05 per child 1,000 34 36

Iron 0.09 per child 2,000 66 70

Vitamin A 0.17 per child 1,000 33 35

BREAST-

FEEDING Promotion and Support* .30 16 per child 100 282 3 11

COMPLE-

MENTARY

FEEDING

Powdered ComplementaryFood Supplements

1.62 18.26 pertreatment

--------- ---------

Ready-to-Use Food 15.60 39.60 pertreatment

1800 60

DEWORM-

ING

Deworming $2 --------- 20


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Quick Reference for Hunger Alleviation & Nutrition Interventions

34Source: CIFF research
http://c/Documents%20and%20Settings/afarnum/Desktop/Nutrition%20Landscaping%20v7.xlsx


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Table of Contents

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A. Introduction to the EvidenceB. Food InterventionsC. Care Interventions

D. Health InterventionsE. Poverty Interventions

III. Conclusion


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Care:

Inadequate care ofchildren and women



Poverty







performance, metabolic and

cardiovascular disease

UnderlyingCauses

ImmediateCauses

BasicCauses

Analytical Framework: Food

36Source: UNICEF

Food


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The Role of Food in Hunger and Undernutrition

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Surprisingly, hunger & nutrition outcomes are not closely correlated with food availability

Food is of course important. But hunger & undernutrition rates vary tremendously among countries with thesame level of per capita food supply

Many countries in Sub-SaharanAfrica and South Asia have the

same level of food availability butvastly different hunger & nutrition

outcomes

Source: World Banks Repositioning Nutrition as Central to Development

Food


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The Role of Food in Hunger and Undernutrition

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Current food production for the world as a whole is 2,800 calories per

capita (33% more than is needed to adequately feed the entire population).Despite continued rapid population growth, production is projected toincrease to 3,050 calories per capita by 2030. Insufficient agricultureproduction on a macro basis is not the major cause of hunger andundernutrition [i]

India produces 20% more calories than it needs to feed its population andis a net food exporter, and yet it has some of the worlds worst hunger &nutrition indicators (43% of its children are underweight compared to theSub-Saharan Africa average of 26%) [ii]

Amartya Sen and many others have argued that hunger and famine arecaused not by macro food shortages, but when the poor are unable to gainaccess to food for their personal use. Therefore, famine can take place evenin countries with sufficient food availability [iii]

[i]

World Agriculture 2030. Food and Agriculture Organization. (2003)[ii] State of Food Insecurity 2008. Food and Agriculture Organization. (2008)[iii] Sen, Amartya. Poverty and Famines: An Essay on Entitlement and Deprivation. Oxford University Press. (1983)

Food


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Food Prices are Still High

39Source: Food and Agriculture Organization of the United Nations

Food prices have dropped substantially from their 2008 peak but are still high compared tohistorical levels

While these prices are beneficial to agriculture producers, the high cost of food has resulted inincreased hunger in many developing countries, particularly among the urban poor

2002 = 100

Food


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A summary slide based on:Investing in Agriculture: Far-Reaching Challenge, Significant Opportunity Deutsche Bank Climate Change Advisors, June 2009Produced by The Special Initiative for Climate Change The Children's Investment Fund Foundation

Due to shifting precipitationpatterns, movement of insectpopulations, more dramatic shifts indaily temperature regimes, and

other large scale ecological changesthat come with climate change,agriculture is the economic sectorthat will be most severely impactedby climate change

Various studies have shown thatan increase in global average

temperatures could have significantimpacts on cereal prices

The Impact of Climate Change on Food

Cereal Prices Versus Mean Global Temperature Change

Solely due to climate change, 50 million additional people could be at

risk of hunger if temperatures rise 2 C by 2080

40

Food


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Table of Contents

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Food Interventions Food Aid and Subsidies

School Feeding Agriculture Personal Food Production Ready-to-Use Food Fortification & Supplementation

Food

F d Aid d S b idi P l I l d


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Food Aid and Subsidies are Poorly Implemented

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Inadequate Nutrition: Much of the food aid provided by international donors is in the form of blendedgrains such as wheat/soy and corn/soy blends. These foods are often not nutritionally adequate forfeeding infants and young children or for treating acute malnutrition

While certain food subsidies can be effective in increasing access to food among the poor, in somesituations they can actually have a negative effect on outcomes for children. Subsidizing staple foods canactually increase malnutrition in certain contexts by incentivizing families to substitute consumption tofoods with lower nutritional value [i]

Political Ties and Economic Distortions: In 2004, 74% of food aid was tied to the procurement ofgoods and/or services from the donor country. 12% of aid was triangular (purchased in neighbouringcountries) and only 14% of food was purchased locally. 99% of US food aid is tied. Australia, Canada,China, and South Korea provided over 80% tied aid [ii]

Tied US food aid means that it can take up to 4-5 months for food aid from the US to arrive in therecipient country. It must be shipped on US flag carriers, dramatically increasing shipping cost. It alsodistorts local economies by undermining the market for local farmers

A recent analysis of USAIDs food aid found that they could lower costs by 35% and reduce deliverytimes from an average of 147 days to 35 days by locally procuring foodstuffs [iii]

[i]

Jensen et al. Do Consumer Price Subsidies Really Improve Nutrition? Social Science Research Network. (2008)[ii] OECD. The Development Effectiveness of Food Aid. Does Tying Matter? (2005)[iii] Government Accountability Office. International Food Assistance: Local and Regional Procurement Can Enhance the Efficiency of U.S. Food Aid,but Challenges May Constrain Its Implementation. (2009)

Food

F d Aid d S b idi P l T d


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Food Aid and Subsidies are Poorly Targeted

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Food Aid: Flows of United States food aid have been shown to be negatively correlated with food insecurity, meaning thatUS food aid flows are not targeting countries with the greatest need. This poor targeting is due to the fact that politicalfactors and support for domestic agriculture and shipping interests play a greater role in U.S. food aid policy than the

needs of the poor in the developing world [i]

However, a similar study of the World Food Program, the largest multilateral food aid donor, found that it was muchmore efficient at targeting food insecure areas than the U.S. [ii]

A large proportion of food aid is not even designed to target the poor. Instead it is sold by NGOs on local markets toraise money for other development programs (this is called monetization). This can have a negative impact on locallivelihoods by reducing food prices in areas where the vast majority of the population earn a living from agriculture [iii]

Food Subsidies: The design of food subsidies varies tremendously from country to country and by commodity, souniversal statements regarding the effectiveness and targeting of food subsidies are not possible

However, it is clear that many food subsidies are poorly targeted. It is not an easy task to identify the poor in thedeveloping world where household financial data is often nonexistent. This makes it very difficult to design schemes underwhich the non-poor are excluded from food subsidy programs [iv]

Indias Public Distribution System (the largest portion of Indias $10 billion food subsidy program), is a prototypicalexample. While there are an estimated 65 million households eligible for the program, over 100 million householdsclaimed benefits last year. In other words, at least one third of the programs budget is used to provide subsidized food tofamilies with incomes above the eligibility threshold. Some economists estimate that over 50% of the budget is wasteddue to poor targeting and corruption [v]

[i] Barrett, CB. Does Food Aid Stabilize Food Availability? Economic Development and Cultural Change. (2001)

[ii] Barrett et al. How Effectively Does Multilateral Food Aid Respond to Fluctuating Needs? Food Policy. (2002)[iii] Emmy Simmons. Monetization of Food Aid. Partnership to Cut Hunger & Poverty in Africa. (2009)[iv] van de Walle, D. Targeting Revisited. The World Bank Research Observer. (1998)[v] Business Standard. Serious Problems with PDS Foodgrain Distribution. June 14, 2009

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How Can Food Aid and Subsidies Be Improved?

44

Food

1. Improve the targeting of food aid and subsidies Food aid and subsidies are often inefficiently targeted and not correlated with food insecurity. Given the billions of dollars

spent each year on these programs, increases in targeting efficiency could have a large impact on outcomes for children

2. Transition to untied aid that allows feeding programs to purchase food on local markets when available Moving large amounts of commodities from one place to another across thousand of miles is seldom a good use of

resources, although exceptional emergencies may make it necessary on occasion. All food aid should move towardbeing untied from the obligation to source food in the donor country. In most situations, sourcing food aid near the regionwhere the food is needed offers the most promising results for a cost and time-effective intervention.

3. Phase out sales of food aid on local markets (monetization) The provision of food aid to governments and NGOs to resell on local markets should end. The evidence consistently

shows that sales of food aid are disruptive of local production, local markets and therefore of long-term food security.

4. Provide foods that are appropriate for feeding children under 2 and treating acute malnutrition In addition to grains, foods with higher fat and micronutrient content should be provided to ensure appropriate

nourishment of children under 2. Programs that directly target children under 2 and pregnant and lactating womenshould also be developed.

5. Encourage the distribution of fortified products as part of all food aid packages In some cases food aid is not fortified with essential micronutrients. Given the low cost and proven benefits of staple

food fortification, food aid should be fortified whenever possible

6. Gather evidence on the effectiveness of food voucher and cash transfer programs There is the potential for cash or voucher food aid to address some of the shortcomings of food aid by providing targeted

families with resources in areas where food is available in local markets. Unfortunately, unconditional cash transfer andvoucher programs have rarely been rigorously analyzed, so there is limited evidence on their effectiveness.

Source: Institute for Agriculture and Trade Policy. U.S. Food Aid Time to Get it Right. (2005)Black et al. Effect of Preparation Method on Viscosity and Energy Density of Fortified Humanitarian Food-aid Commodities. Food Sciences and Nutrition. (2009)CIFF research

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School Feeding Interventions

45Source: World Banks Repositioning Nutrition as Central to DevelopmentAdelman et al. How Effective are Food for Education Programs? International Food Policy Research InstituteCIFF research

Short-term hunger affects cognitive function, particularly attention span Hunger has been shown to have a negative effect on educational achievement However, the impacts are small compared to the effect on school performance of cognitive damage due to

undernutrition at a young age

School feeding programs do improve learning and nutritional outcomes, but theimpacts are small

There is evidence that school feeding programs have an impact on education outcomes, though thestrongest evidence is only for increased attendance School feeding programs have only very small impacts on nutrition outcomes such as weight, height or

morbidity

Investing in early childhood nutrition may be a more cost effective way toachieve nutrition and educational outcomes

Children who were undernourished early in life score worse than other school children on tests of cognitivefunction, fine motor skills, attention span and activity levels These cognitive skill deficits persist into adulthood and have a direct effect on earnings

School feeding programs are quite expensive, often ~$75/child/year There is the potential to reduce further stunting among adolescents through food supplementation.However, there has been little research on the impact of this intervention, as the cost of supplementing alladolescents and women of childbearing age (as opposed to targeting pregnant women) is prohibitively high Infant and young child feeding and micronutrient programs are both less expensive and have strongerevidence of effectiveness

Food

A i l I i


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Agriculture Interventions

46

Agriculture interventions affect hunger & nutrition outcomes through two distinct pathways:

Increased Food Availability:Improved agriculture results in greater overall food production. However, as we saw earlier,national per capita food supply is not strongly correlated with hunger & nutrition outcomes forchildren. In addition, increased production will not have an effect on food prices in openeconomies. Therefore, this pathway is unlikely to have a strong impact on hunger & nutritionoutcomes for children in most contexts.

Increased Food Access:In Sub-Saharan Africa, agriculture accounts for two-thirds of employment and one-third ofGNP. The majority of the billion people living on less than $1 per day rely on farming for theirincome. Improving agriculture productivity therefore results in increased income for the ruralpoor, improving their access to food.

Food

Source: World Bank, World Development Report: Agriculture for Development (2008)CIFF research

Agriculture programs reduce undernutrition through the same mechanismas other economic development interventions, by increasing income

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Personal Food Production Interventions

47

Food

Source: Lancet Maternal and Child Undernutrition SeriesBerti et al. A Review of the Effectiveness of Agriculture Interventions in Improving Nutrition Outcomes. Public Health Nutrition. (2004)Leroy et al. Can Interventions to Promote Animal Production Ameliorate Undernutrition. The Journal of Nutrition. (2007)

Interventions Potential Effectiveness Coverage Barriers

Home Gardening

and LivestockProductionPrograms

Home gardening and livestock

programs have not been shown to beeffective at improving hunger ornutrition outcomes for children

Evaluations have shown increasedproduction and food availability, butlittle to no evidence on outcomes forchildren

Some programs have demonstratedan effect on reducing anemia, but noprograms have demonstrated animpact on reduced stunting or wasting

It is generally believed that issues ofintrahousehold allocation (i.e. failureto share available food with womenand children) have played a role in thefailure of these programs to achieveoutcomes for children. While morenutritious food may be available,

without addressing the care andhealth issues these programs areunlikely to impact children

A large scale program has been

implemented in Bangladesh, andsmaller programs have beenimplemented throughout Africa

Limited evidence of impact on children

Very labour and resource intensiveintervention that makes it difficult toimplement on a very large scale

T ti A t M l t iti ith R d t U F d


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Weight-for-heightpercent of median


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F tifi ti d S l t ti I t ti F d


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Fortification and Supplementation Interventions

50

Food


Biofortification Biofortification is the breeding or geneticmodification of staple crops to improvemicronutrient content

Theoretically effective, but research formost crops is still at an early stage

Research stage for most crops so not yetimplemented

Sweet potato and rice biofortified with

vitamin A has been proven to improve thevitamin A status of children

Long-term research is required before cropswill be available

Will need to ensure that micronutrient content

of the crops is bio available

Home Fortification Home fortification is the addition ofmicronutrients to complementary food byadding a micronutrient powder (often calledsprinkles ) to the meals eaten by youngchildren

Been shown to be effective in reducinganemia but not other micronutrient

deficiencies. Not been shown to affectgrowth

Low, though potential to add homefortification packets to package of goodsdistributed in emergency feedingprograms

Behavior change required, as parents mustregularly add the powder to their childs meals

Regular distribution of the sachets to the ruralareas where micronutrient deficiency is thehighest may be difficult and expensive

Iodization of Salt Shown to reduce goiter and increase IQ in avariety of studies

70% of all households in developingcountries (GAIN), though rate varieswidely by country

GAIN and UNICEF are active inexpanding coverage

Remaining households are in the hardest toreach areas

Staple FoodFortification

Fortification of commodities with vitamin A,iron, zinc and other vitamins has been

shown to reduce morbidity and mortality ina variety of settings

Varies by staple, geography and type offortification

Requires cooperating between governments,donors and private sector producers

Except for iodized salt, there is only weakevidence for the effectiveness of staple foodfortification on children under 36 months

Vitamin ASupplementation

Proven to lead to 24% reduction in all-cause mortality among children under 5

72% of children in the developing world(UNICEF), though rate varies widely bycountry

Remaining children are in the hardest toreach areas, often without functioning healthsystems which can be utilized for Vitamin Acapsule distribution

Zinc Supplementation Reduces stunting, diarrhea incidence andleads to a 9% reduction in all causemortality

Very low There is a critical need to develop zincsupplementation models that can be deliveredat scale

Source: Lancet Maternal and Child Undernutrition Series, CIFF analysis

PotentialHumanitarian

Program


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III. Conclusion

A l i l F k C

Care


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Poverty







performance, metabolic andcardiovascular disease

UnderlyingCauses

ImmediateCauses

BasicCauses

Analytical Framework: Care

52Source: UNICEF

Care

What Care Behaviors Need to Be Addressed? Care


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What Care Behaviors Need to Be Addressed?

53Source: World Banks Repositioning Nutrition as Central to Development

Due to inappropriate household food allocation, the diets of women and young children often donot contain enough micronutrients or protein even if sufficient food is available

Mothers often have too little time to take care of their young children or themselves duringpregnancy

Mothers of newborns often discard colostrum, the first milk, which strengthens the childs immunesystem

Mothers often feed children under 6 months foods other than breast milk even though exclusivebreastfeeding is the best source of nutrients and the best protection against many infectious andchronic diseases

Caregivers often start introducing complementary solid foods too late

Caregivers feed children under age two years too little food, or foods that are not energy dense

Caregivers often do not know how to feed children during and following diarrhoea or fever

Caregivers poor hygiene contaminates food with bacteria or parasites

Care

The Role of Womens Status and Family Planning Care


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The Role of Women s Status and Family Planning

54Source: Smith et al. The Importance of Womens Status for Child Nutrition in Developing Countries. IFPRI (2002)Martorell et al. Reproductive Stress and Womens Nutrition. Nutrition and Population Links: Breastfeeding, Family Planning, and Child Health. (1992)

Care

Womens status affects childrens carethrough four separate channels:

(A) directly

(B) indirectly through the quality of the care womenthemselves receive

(C) womens health influences the quality of care forchildren

(D) womens health influences childrens birth weights

Improving womens status is likely to be themost effective method of addressing theissue of inappropriate household foodallocation, i.e. men not sharing sufficientquantities of food with women and children

Short birth spacing has been shown toresult in worse nutrition outcomes for bothmothers and children. Family planningaffects nutrition both by enhancing the abilityof a mother to care for each child and byenhancing womens health

Infant & Young Child Feeding Interventions Care


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Infant & Young Child Feeding Interventions

55

Care


BreastfeedingPromotion

Optimum breastfeeding could save 1.4mmlives/year

There is evidence that breastfeeding

promotion increases the duration ofexclusive breastfeeding

There is little evidence on long-termsustainability of breastfeeding promotionor impact at very large scale; follow-upstudies are needed

Group and individual counselling has beenshown to be effective, but there is noevidence for mass media promotion

There is good evidence linkingbreastfeeding to reduced diarrhoea,pneumonia and mortality, but notincreased growth

Large scale breastfeeding promotionprograms have been implemented inGhana, Ethiopia, Madagascar andZambia, though they have not been well

evaluated

The Gates Foundation is currentlylaunching a new large scale promotionprogram in Bangladesh, Ethiopia andVietnam

Many smaller scale programs have beenimplemented, and breastfeeding promotionhas also been added as a component ofseveral heath care projects

Breastfeeding promotion requires behaviorchange

Evaluations of previous large scale projects

have not had rigorous evaluations and haveoften depended on self-reported data

There is no evidence for the sustainability oflarge scale programs

Rigorous evaluations that track mortalityand morbidity outcomes directly are needed

ComplementaryFeeding Educationand Supply SideInterventions

Complementary foods are foods thatprovide sufficient nutrition to children age6-24 months

Nutrition education has been shown toincrease growth; interventions are mosteffective when promoting simple messagesuch as provide animal source food

Stronger effects on growth seen whencomplementary food was provided to foodinsecure populations

Interventions that simply providedcomplementary foods often did notincrease growth and most programs haveshown little impact on morbidity

Current coverage of counseling forimproved complimentary feeding isapproximately 2% (WHO)

GAIN has begun to provide grants toencourage the production of appropriatecomplementary foods marketed to low-income families, but coverage is still verylow

Complementary feeding education requiresbehavior change

Many studies have demonstrated thatfamilies in many rural areas do not haveaccess to foods that provide sufficientnutrition to children age 6-24 months, soincreasing local production of and access tonutritious complementary foods will benecessary

Source: Lancet Maternal and Child Undernutrition SeriesBandari, Nita. Mainstreaming nutrition into maternal and child health programmes: scaling up of exclusive breastfeeding. Maternal and Child Nutrition. (2008)Dewey et al. Systematic Review of the Efficacy and Effectiveness of Complementary Feeding Interventions. Maternal and Child Nutrition. (2008)

Maternal Nutrition Interventions Care


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Maternal Nutrition Interventions

56

Care


CalciumSupplementation

Trials have shown that calciumsupplementation can reduce the risk ofpre-eclampsia by 50%, with the effect

largest in women with low baselinecalcium intake or risk of hypertensivedisorder

Very low Identifying women with inadequate calciumintake or potential hypertensive disordersmay be difficult in areas with inadequate

prenatal care

Additional research on the effect of calciumsupplementation on child outcomes iswarranted to ensure that on balance theintervention is beneficial

Energy and ProteinSupplementation

Mixed evidence to date, but calorific andmicronutrient supplementation forpregnant mothers may prevent stillbirths,increase birth weight (and so reducesusceptibility to infections) and improve

infant growth and cognitive development

Low Requires regular delivery of supplementaryfoods during pregnancy and is thereforeexpensive compared to micronutrientinterventions

Some researchers fear that increased birthweight could result in negative birthoutcomes among stunted mothers, thoughthere is not yet any research to confirm thishypothesis

IodineSupplementation

In iodine deficient populations, iodinesupplementation has been shown toreduce deaths during infancy and earlychildhood by 29%

Very low Iodizing salt is likely to be much more costeffective than identifying pregnant womenand delivering iodine supplements in areasof endemic deficiency

Iron Folate

Supplementation

73% reduction in anemia at term andreduction in neural tube birth defects

Low To be most effective, supplementationshould target women before conception

Iron supplementation may have adverseeffects in malaria endemic areas

MultipleMicronutrientSupplementation

Shown to result in a 39% reduction inmaternal anemia, 17% reduction in lowbirth weight

Low Some researchers fear that increased birthweight could result in negative birthoutcomes among stunted mothers, thoughthere is not yet any research to confirm thishypothesis


T bl f C t t


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III. Conclusion

A l ti l F k H lth

Health


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Poverty








UnderlyingCauses

ImmediateCauses

BasicCauses

Analytical Framework: Health

58Source: UNICEF

Health

The Role of Health in Child Undernutrition Health


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Profile of a child showing infections, infectious diseases and weight during first three years of life

Children are well protectedfrom infections during periodof exclusive breastfeeding(from birth to 6 months)

Infections appeared early inlife and were most common

after the first year of life Diarrhoea also increased,especially during weaning

Growth in weight wasadequate during exclusivebreastfeeding. Subsequently,many infectious diseases

coincided with growth arrestor weight loss

The Role of Health in Child Undernutrition

59Source: Leonardo Mata, Diarrheal Disease as a Cause of Malnutrition. Am. J. Trop. Med. Hyg. (1992)

Health

Child Age (Months)

ChildWeig

ht(kg)

The Role of HIV/AIDS in Child Undernutrition Health


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The Role of HIV/AIDS in Child Undernutrition

60Source: WHO, CIFF research

Model of Interaction Among HIV, Infection,

Malnutrition and Immune Function

ea t

Two Million Children Under 15 are Living with HIV

Water Sanitation & Hygiene

Health


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3,664

70,720

159,597

34,595

1,004,768

602,584

46,6907,000

16,100

Mate rnal Sepsis/infe ction Neonatal Diarrhoe a

Neonatal Sepsis/pneumonia Neonatal Pre-term birth


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Health Interventions

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Deworming DuringPregnancy

Studies have shown that dewormingpregnant women results in increasedchild growth and reduced anemia,though the effects were very small

Very low Only effective in areas with high rates ofintestinal helminthiasis (worm infection)

Handwashing orHygieneInterventions toPrevent Diarrhoea

A pooled analysis of differentinterventions show a reduction indiarrhoea of 33%

< 25% Women and children often do not havethe water resources or available time towash their hands or to maintain hygienicconditions as recommended

ORS and Zinc inManagement ofDiarrhoea

Use of ORS/Zinc in the treatment ofdiarrhoea is estimated to have thepotential to save 1.5 million child livesand has been shown to reduce growthfaltering

Coverage rates of ORS vary from 20-50% depending on the country

Zinc treatment rates are less than 5%

Increase in care seeking behavioramong caregivers and local access toORS is the greatest barrier

For zinc, increase in awareness andavailability are needed

Prevention andTreatment ofMalaria

Preventive malaria treatment ofpregnant women (recommended twodoses) in endemic areas has beenshown to increase birth weight andreduce anemia

Use of bed nets during pregnancy hasbeen shown to increase birth weight

WHO estimates show coverage withthe first dose ranging from 23-93%,and the second dose from 5-68%

Based on country data from theUNICEF 2007 Malaria and Childrenreport, an average of 12% ofhouseholds have at least oneinsecticide-treated net

Despite the gains in production anddistribution of bed nets, end-usercompliance is still a major challenge. A2004 survey showed that of nets owned,only 56% had been slept under the nightprior in Nigeria, 62% in Zambia, and61% in Ethiopia


Health interventions are covered in the Child Survival landscape analysis, but a quick overview of the impactof health interventions that have strong links to nutrition outcomes is provided here

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III. Conclusion

Analytical Framework: Poverty

Poverty


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Poverty








UnderlyingCauses

ImmediateCauses

BasicCauses

Analytical Framework: Poverty

64Source: UNICEF

Would Addressing Poverty Solve Undernutrition?

Poverty


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Reduced hunger and undernutrition is not solely a by-product ofpoverty reduction

Income is correlated with hunger and nutrition outcomes. Doubling income per capita from $1000 to$2000 leads to an average reduction in underweight rates from 32 to 23 percent [i]

Economic growth is not a panacea however. Other factors play a major role. In India (with GNP percapita of $2,700), over 43% of children are underweight. Even in Indias richest income quintile, 64% ofchildren suffer from iron deficiency anemia and 26% are underweight [ii]

[i] Haddad et al. Reducing Child Undernutrition: How Far Does Income Growth Take Us? Food Consumption and Nutrition Bulletin. IFPRI. (2002)[ii] World Banks Repositioning Nutrition as Central to Development

Relationship Between Child Underweight

and GNP Per Capita

Would Addressing Poverty Solve Undernutrition? Poverty


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There are two-way causality and feedback loops among poverty, hunger andmalnutrition Reducing malnutrition will reduce poverty by decreasing:

1. Loss in productivity from poor physical status2. Indirect loss in productivity from poor cognitive development3. Loss in resources from increased health care costs

Source: World Banks Repositioning Nutrition as Central to Development

Cash Transfers and Food for Work InterventionsPoverty


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Cash Transfers and Food for Work Interventions

67


Cash Transfers(Unconditional) andVoucher Programs

There is the potential for these programsto increase food consumption and reducehunger in situations where adequatesupplies of food are available locally but

families do not have adequate resourcesto procure them. However, theseprograms have not been rigorouslyanalyzed and it is unclear when and if theycan be effective at improving hunger &nutrition outcomes for children

While still nowhere near as widespreadas traditional food aid, a number ofNGOs and the WFP have attemptedthese programs in small pilot projects

Only possible in situations where adequatefood can be sourced locally, thoughresearch shows this is the majority ofsituation in which food aid is currently

provided

In many areas, a lack of adequate bankingfacilities requires alternative distributionmechanisms

Questions remain on the marginal impactof cash and voucher programs, and what %of the funds provided will be diverted topurchases of social bads such as alcohol

Conditional CashTransfers

There is strong evidence from rigorous

evaluations that many conditional cashtransfers (programs that provide a cashpayment to families that meet certainrequirements such as vaccinations, childschool attendance, etc) have an impact onchild stunting

Common in Latin America but limited

reach in Sub-Saharan Africa or India

Nationwide programs are very expensive,

often up to 2-3% of GNP

For conditional cash transfer programs tobe successful, health and educationdelivery mechanisms must be available andof sufficient quality

Food for Work Guaranteed employment schemes inwhich the government or NGO provideswork opportunities in exchange forpayments in food

There is very limited evidence on theeffectiveness of such programs versusgeneral employment programs

India has the largest guaranteedemployment/ food for work program

Less common in Africa, though Ethiopiahas initiated some projects

The WFP has implemented pilotprojects

Requires projects with large demand forunskilled labour

Can be very expensive

Theoretically only preferable to standardlabour programs in areas with failures inlocal food markets

General EconomicDevelopment

Potentially effective in the long-run, butthere is limited correlation between shortrun economic growth and nutritionoutcomes

Wide variety of economic developmentprograms implemented throughout Africaand India

Not a focus of CIFFs strategy

Source: Lancet Maternal and Child Undernutrition Series, CIFF analysisBassett, Lucy. Can Conditional Cash Transfer Programs Play a Greater Role in Reducing Child Undernutrition? World Bank. 2008

PotentialHumanitarian

Program

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III. Conclusion

Summary


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Summary

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3.5 million child deaths per year and 35% of the total disease burden for children under 5 can beattributed to undernutrition

Stunting typically occurs either in the womb (resulting in low birth weight) or in the first two years of life.The physical and cognitive damage from stunting is largely irreversible after age 2-3

This irreversible damage can self-perpetuate undernourished girls become undernourished women,who give birth to low birth weight infants, who suffer from poor nutrition from the very beginning of life.This results in impaired physical and mental development being passed from generation to generation

The most direct response of CIFF to break the cycle of intergeneration stunting should be to increase

birth weight and improve nutritional status during the critical window of opportunity of -9 to 24 months

The highest burden of hunger & undernutrition is found in South Asia, though the burden is alsosubstantial in Sub Saharan Africa

Food availability, food access, child & maternal care, and health must all be taken into account whenanalyzing the causes of hunger & undernutrition

Effective hunger & nutrition interventions already exist; implementing them at scale could avert 25% ofchild deaths in the highest burden countries

Unfortunately, funding for hunger & nutrition is currently dominated by food aid, much of which isineffective at improving outcomes for children



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The most direct response of CIFF to break the cycle of intergeneration stunting should be to increase birth weightand improve nutritional status during the critical window of opportunity of-9 to 24 months by supporting:

Infant &Young Child

Nutrition

Technical assistance to encourage the local production of complementary foods and marketing ofthese products to the poor

Development of models to promote breastfeeding and appropriate complementary feeding at scale

Rigorous evaluation of breastfeeding promotion at scale in a country with high HIV prevalence

Research into the effectiveness and cost effectiveness of interventions for which there is currentlymixed evidence. This includes calorific supplementation of adolescent girls and women likely tobecome pregnant, calorific supplementation of pregnant women, and infection control of pregnantwomen

Given the lack of proven interventions to reduce low birth weight, the development of innovativeapproaches is urgently needed

For the few proven interventions such as iron-folate supplementation, delivery science research onhow to implement programs at scale is required, as large-scale programs are rare

Development of new delivery models to provide supplementation to women likely to becomepregnant instead of waiting until a pregnancy is identified

Efficacy and cost-effectiveness analysis of ready-to-use food supplementation in pregnant andlactating women

MaternalNutrition



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Treatment ofSevere AcuteMalnutrition

Development of effective delivery models for preventive zinc supplementation

Maternal nutrition interventions as described above

Address the political issues that have prevented the use of ready-to-use therapeutic food in Indiathrough the development of local production and funding the first efficacy studies of Ready-to-UseTherapeutic Food (RUTF) in Indian children

Remove the barriers to local RUTF production such as the patent issue, the slow process of food

safety certification and the lack of in-country technical expertise

Development of new delivery models to deliver ready-to-use foods

Development and efficacy testing of complementary foods appropriate for feeding children undertwo that can be added to the standard food aid basket

Development of local production and procurement of food products appropriate for feedingchildren under two

Improve the targeting of food aid to pregnant women and children under two, including rigorousanalysis of the impact on young children of alternative food aid modalities such as vouchers andcash transfers

Improving theEffectivenessof Food Aid

MicronutrientSupplemen-

tation


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Appendix

Hunger & Nutrition Acronyms


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AED: Academy for Educational DevelopmentACF: Action Contre Faim (Action Against Hunger)AIDS: Acquired Immune Deficiency SyndromeAIIMS: All India Institute of Medical ScienceBCC: Behavior Change CommunicationCCT: Conditional Cash TransfersCGIAR: Consultative Group on International Agricultural ResearchCHNRI: Child Health and Nutrition Research InitiativeCIDA: Canadian International Development Agency

CIFF: Childrens Investment Fund FoundationCHAI: Clinton HIV/AIDS InitiativeDALY: Disability-Adjusted Life YearDFID: Department for International DevelopmentEC: European CommissionENN: Emergency Nutrition NetworkFAO: Food and Agriculture OrganizationGAIN: Global Alliance to Improve NutritionGNP: Gross National Product

HIV: Human Immunodeficiency Virus

HKI: Helen Keller InternationalIDS: Institute of Development StudiesIFPRI: International Food Policy Research InstituteLSHTM: London School of Hygiene and Tropical MedicineMSF: Mdecins Sans Frontires (Doctors Without Borders)NGO: Non-Governmental OrganizationNIN: National Institute of Nutrition (India)ORS: Oral Rehydration SolutionREACH: Renewed Efforts Against Child Hunger

RUF: Ready-to-Use FoodRUCF: Ready-to-Use Complementary FoodRUSF: Ready-to-Use Supplementary FoodRUTF: Ready-to-Use Therapeutic FoodSAM: Severe Acute MalnutritionSCN: Standing Committee on NutritionUNICEF: United Nations Childrens FundUSAID: United States Agency for International DevelopmentWFP: World Food Program

WHO: World Health Organization

More Hunger & Nutrition Definitions


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Kwashiorkor: Some children with acute protein-energy malnutrition develop oedema.Oedema is an accumulation of fluid in the tissue, especially the feet and legs.Such children may not lose weight when developing acute protein-energymalnutrition because the weight of this excess oedema fluid counterbalances

the weight of lost fat and muscle tissue. These children may look fat orswollen due to kwashiorkor.

Marasmus: Other children, for reasons not entirely understood, develop thinness withoutoedema. This condition is called marasmus.

History of Nutrition Science


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Epidemics of Diarrheal Disease in Paris in 1906

Modern nutrition can be traced back to the mid 19 th

century, when scientists in France and Germany beganto classify foods into the basic groups of protein,

carbohydrates, fats, salt and water

In the early 20th century, the English scientist GeorgeNewman made the first argument for a link betweeninfant nutrition and mortality. He was able to gatherdata in Paris to conclusively demonstrate a link betweenbreastfeeding and reduced infant mortality (see chart)

Vitamins were not identified until the early 20 th

century, and the first vitamin (vitamin A) was notcrystallized until 1937. The dietary importance ofelements and minerals such as iodine was deducedaround the same time period

The United States and Europe acted quickly to beginfortification programs. Iodized salt was introduced in1924, and it became mandatory to fortify bread withthiamine, riboflavin, niacin, iron and calcium in many

countries in 1943

Today nutrition science in the developed world islargely focussed on overnutrition, with the majority offunding directed toward preventing diabetes and heartdisease

Source: Nutrition and Health in Developing Countries, Humana Press (2008)

Hunger & Nutrition Interventions by Age of Child


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Pre-natal stage(-9 months)

Child safelydeliveredand healthyat 1 wk

Healthy childat 1 month

Healthy childat 6 months

Healthy childat 5 yrs

Hunger & Nutrition Interventions by Age of Child

Iron folate ormultiple micronutrientsupplementation forpregnant women

Trials of ready-to-usefood supplementationof pregnant women

Supplementation

Homefortification

Complementaryfeeding

Complementaryfood vouchers

Exclusivebreastfeeding support

Diarrhoeamanagement

Prevention or treatmentof acute malnutrition withready-to-use foods

Vitamin Asupplementation

Early initiationof breastfeeding

School feedingprogram

School-baseddeworming

Healthy child

at 2 yrs

Healthy child> 5 yrs

Food aid withfortified blendedfoods

Fortification

Blue = Window of Opportunity of -9 Months to 2 Years

Source: CIFF research

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Nutrition Interventions: Cost Effectiveness Data


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Source: Disease Control Priorities Project



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UNICEF Hunger & Nutrition Data


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U C u ge & ut t o ata

Source: UNICEF

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UNICEF Hunger & Nutrition Data


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Hunger Alleviation & Nutrition Landscape Analysis

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