Scaling up Nutrition for sustainable results Why and how. A focus on prevention

Stunting prevalence Stunting affects approximately one-third of under-fives in the developing world While underweight prevalence is an MDG 1 indicator, stunting remains a problem of greater magnitude than underweight or wasting. Most countries have stunting rates much higher than underweight rates. Stunting also more accurately reflects nutritional deficiencies and illness that occur during the most critical periods for growth and development in early life. Africa and Asia have high stunting rates – 40 per cent and 36 per cent, respectively – and more than 90 per cent of the world’s stunted children live on these two continents Of the 10 countries that contribute most to the global burden of stunting among children, 6 are in Asia. These countries all have relatively large populations: Bangladesh, China, India, Indonesia, Pakistan and the Philippines. Due to the high prevalence of stunting (48 per cent) in combination with a large population, India alone has an estimated 61 million stunted children, accounting for more than 3 out of every 10 stunted children in the developing world More than half the children under 5 years old are stunted in nine countries, including Guatemala, whose stunting rate of 54 per cent rivals that of some of the highest prevalence countries in Africa and Asia. Of countries with available data, Afghanistan and Yemen have the highest stunting rates: 59 per cent and 58 per cent, respectively. Source: UNICEF Global Database, Nov 2009 Compiled from MICS, DHS and other national surveys

(UN Lancet 2008: Causal pathways in undernutrition, UNICEF 1991 Highlight causes of maternal malnutrition, inadequate breastfeeding and complementary feeding, insufficient micronutrient intake, combined with infectious diseases. Crucial period is the period from conception to 2 years of life; we need to act during this time. Indirect causes of poverty, unemployment, harvest failure which influence food security is an important issue in several countries. Lancet 2008: Causal pathways in undernutrition, UNICEF 1991 UNICEF

Impact of undernutrition during pregnancy and early childhood Increased risk of dying from infectious diseases (one-third of child deaths) Stunting is associated with reduced school performance equivalent to 2-3 yrs of schooling Stunting associated with reduced income earning capacity (22% average; up to 45% has been reported!) Increased risk of non-communicable diseases in adult life Stunted girl is more likely to give birth to undernourished baby Reduced GMP by 2-3% About 20 million children suffer from severe acute malnutrition which greatly increases risk of death Stunting has an odds ratio of 1.6 to 4.1 for risk of dying from infectious disease (diarrhoea, pneumonia, malaria, measles). Wasting has an odds ratio of 3.0 to 9.4. Globally more than one-third of child deaths have maternal and child undernutrition as underlying cause. Optimal breastfeeding could prevent about 14% of child deaths. Risk of non-communicable disease such as cardio vascular disease is stronger when rapid weight gain happens later in childhood.

Nutrition interventions in the life cycle needed to reduce stunting and wasting and their coverage rates Pregnancy Iron & folic acid supplements Multi micronutrient supplementation Iodized salt Food supplements - 71% Birth Initiation of breastfeeding within 1 hr (Colostrum) 43% 0-6 months Exclusive breastfeeding Implementation of the Code on marketing of formula 37% 100 countries 6-24 months Introduction of complementary feeding Continued Breastfeeding up to 1 yr Vitamin A supplementation (& de-worming) Zinc supplementation Treatment of severe malnutrition Treatment of moderate malnutrition 60% 75% 20 countries 66% <10%* 24-60 months Social safety net programmes Need to be linked with infectious disease prevention and treatment, improved hygiene. Household food security can be issue 100 countries have some form of regulation on the implementation of the Code on the marketing of breast milk substitutes, 19 of these countries have a voluntary monitoring system. Developing country data based on SOWC 2012; * based on estimation

24 countries with increases in exclusive breastfeeding > 20 percentage points Other examples of increases >20 percentage points which fall outside the parameters of this trend analysis include Timor Leste (31% in 2003 to 52% in 2009); Burundi (44% in 2005 to 69% in 2010), Guinea Bissau (16% in 2006 to 38% in 2010). 56 countries out of 89 with trend data between 1998 and 2008 have an increasing trend (63%). The big challenge remains the largest countries – such as India, Indonesia, Bangladesh, Ethiopia, DRC and Nigeria – which have shown no progress. Source: UNICEF database 2011. The baseline is defined as between circa 1998 (1995-2001) and circa 2008 (2005-2011)

Status of complementary feeding Selected countries with data on “minimum acceptable diet” (breastfed children 6-23 m), and “introduction of complementary foods” (6-8m old, BF & non BF children) It shows minimum acceptable diet - a composite indicator which shows proportion of children with both recommended dietary diversity and recommended feeding frequency for their age.   In other words, these are children receiving good quality and frequency of complementary feeding.

Programme Success Factors Situation analysis: The starting point for good programme design Political commitment and partnership: Strong and clear government ownership, leadership and commitment are required Evidence based policies and linkages with other sectors: the essential nutrition package needs to be implemented with key interventions from other sectors (WASH, HIV, etc) Food security. Capacity-building: is required at all levels Communication for behavioral change: essential and often lacking Community based programmmes: essential and often inappropriately done or not done at all Corporate social responsibility: Should increase availability of appropriate and affordable products (e.g. high-quality complementary foods, micronutrient-fortified staple foods, etc) Resources: Adequate financial investment is required. Costs vary– but ‘A Good Start in Life’ in Peru led to a significant stunting reductions for ~US$117/child/yr.