Nutrition in Nepal: Three decades of commitment to children and women.

South Asia has made significant progress in reducing child undernutrition. The prevalence of stunting declined by one third between 2000 and 2019; as a result, in 2019, there were 34 million fewer stunted children than in 2000, indicating that progress for child nutrition is possible and is happening at scale. However, no country in South Asia is on track for all nutrition targets of Sustainable Development Goal 2, and the region has the highest prevalence of stunting (33.2%) and wasting (14.8%) in the world. Nepal, the best performing country in the region, narrowly missed the Millennium Development Goal (MDG) target to half the prevalence of child underweight between 1990 and 2015 and achieved the fastest recorded reduction in stunting prevalence in the world between 2001 and 2011. In 2019, UNICEF Nepal completed a series of papers to examine Nepal's progress on maternal and child nutrition during the MDG era. The series explores the trends, distribution and disparities in stunting, micronutrient deficiencies and feeding practices in children under 5 years and anaemia in adolescents and women. Besides, it reviews national micronutrient programmes (vitamin A supplementation, iron and folic acid supplementation and universal salt iodization) and Nepal's first Multi-Sector Nutrition Plan, to illuminate the success factors and enduring challenges in the policy and programme landscape for nutrition. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy and programme actions to improve maternal and child nutrition in Nepal and other similar contexts.

Aiming higher for maternal and child nutrition in South Asia.

The sustainable development of nations relies on children developing to their full potential and leading healthy, productive, and prosperous lives. Poor nutrition in early life threatens the growth and development of children, especially so in South Asia, which has the highest burdens of stunting, wasting, and anaemia in the world. Targeted actions to reduce stunting and other forms of child malnutrition in South Asia should be informed by an understanding of what drives poor nutrition in children, who is most affected, and effective programme approaches. To this end, the UNICEF Regional Office for South Asia commissioned a series of papers in 2016-2017 to fill knowledge gaps in the current body of evidence on maternal and child nutrition in South Asia, including analyses of: (a) the links between anthropometric failure in children and child development; (b) the time trends, current distribution, disparities and inequities of child stunting, wasting and anaemia, and their direct and underlying causes, including maternal anaemia, low birth weight, breastfeeding, and complementary feeding; (c) policy and programme actions to increase the coverage of nutrition interventions during pregnancy, improve breastfeeding practices, and care for severely wasted children. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy, and programme actions to improve maternal and child nutrition in South Asia.

First foods: Why improving young children's diets matter.

Globally, only 52% of children aged 6-23 months meet the minimum meal frequency and a mere 29% meet the minimum dietary diversity, with large disparities across and within regions. With most of the stunting occurring during the first thousand days-from conception to age 2 years-improving complementary feeding in children 6-23 months old is an urgent priority. With this evidence in mind, UNICEF collaborated with the governments of India and Maharashtra to convene a global meeting in Mumbai, India, under the theme: First Foods: A Global Meeting to Accelerate Progress on Complementary Feeding in Young Children (November 17-18, 2015). The global meeting provided a platform that aimed to (a) synthesize the biological and implementation science on complementary feeding; (b) review the practice and experience in improving access to nutritious complementary foods and good complementary feeding practices; and (c) consolidate a strong evidence base that can inform the development of strategies and approaches to improve complementary feeding that are fit to context. This overview paper summarizes the rationale on why improving complementary foods and feeding for infants and young children matters and what it takes to improve them. It builds on the papers presented at the First Foods Global Meeting and those commissioned as a follow on to it.

Feeding practices for infants and young children during and after common illness. Evidence from South Asia.

Global evidence shows that children's growth deteriorates rapidly during/after illness if foods and feeding practices do not meet the additional nutrient requirements associated with illness/convalescence. To inform policies and programmes, we conducted a review of the literature published from 1990 to 2014 to document how children 0-23 months old are fed during/after common childhood illnesses. The review indicates that infant and young child feeding (IYCF) during common childhood illnesses is far from optimal. When sick, most children continue to be breastfed, but few are breastfed more frequently, as recommended. Restriction/withdrawal of complementary foods during illness is frequent because of children's anorexia (perceived/real), poor awareness of caregivers' about the feeding needs of sick children, traditional beliefs/behaviours and/or suboptimal counselling and support by health workers. As a result, many children are fed lower quantities of complementary foods and/or are fed less frequently when they are sick. Mothers/caregivers often turn to family/community elders and traditional/non-qualified practitioners to seek advice on how to feed their sick children. Thus, traditional beliefs and behaviours guide the use of 'special' feeding practices, foods and diets for sick children. A significant proportion of mothers/caregivers turn to the primary health care system for support but receive little or no advice. Building the knowledge, skills and capacity of community health workers and primary health care practitioners to provide mothers/caregivers with accurate and timely information, counselling and support on IYCF during and after common childhood illnesses, combined with large-scale communication programmes to address traditional beliefs and norms that may be harmful, is an urgent priority to reduce the high burden of child stunting in South Asia.

Stop stunting: improving child feeding, women's nutrition and household sanitation in South Asia.

The latest available data indicate that 38% of South Asia's children aged 0-59 months are stunted. Such high prevalence combined with the region's large child population explain why South Asia bears about 40% of the global burden of stunting. Recent analyses indicate that the poor diets of children in the first years of life, the poor nutrition of women before and during pregnancy and the prevailing poor sanitation practices in households and communities are important drivers of stunting, most likely because of underlying conditions of women's status, food insecurity, poverty, and social inequalities. With this evidence in mind, UNICEF Regional Office for South Asia convened the Regional Conference: Stop Stunting: Improving Child Feeding, Women's Nutrition, and Household Sanitation in South Asia (New Delhi, November 10-12, 2014). The Conference provided a knowledge-for-action platform with three objectives: (1) share state-of-the-art research findings on the causes of child stunting and its consequences for child growth and development and the sustainable growth and development of nations; (2) discuss better practices and the cost and benefits of scaling up programmes to improve child feeding, women's nutrition, and household sanitation in South Asia; and (3) identify implications for sectoral and cross-sectoral policy, programme, advocacy and research to accelerate progress in reducing child stunting in South Asia. This overview paper summarizes the rationale for the focus on improving child feeding, women's nutrition, and household sanitation as priority areas for investment to prevent child stunting in South Asia. It builds on the invited papers presented at or developed as a follow on to the Stop Stunting Conference.

A review of the vitamin A supplementation program in India: reasons for success in the states of Bihar and Odisha.

BACKGROUND: Preventive vitamin A supplementation (VAS) is an essential child survival intervention. In India, VAS program coverage has remained relatively low, with wide interstate variation. OBJECTIVE: To review the VAS program in India, particularly in Bihar and Odisha, the two states that have had the most successful VAS programs, to define best practices and identify critical success factors. METHODS: A thorough review of existing relevant literature was carried out, supplemented by field visits and interviews with selected partners. RESULTS: Both states have adopted a biannual approach to reach out to children 1 to 5 years of age with VAS every 6 months, while infants below 1 year of age receive their first VAS dose with the measles immunization at 9 months. The critical success factors for the VAS program in the two states include strong leadership and ownership by the state government; close coordination between the two departments that are involved in the VAS program; effective microplanning prior to each biannual round; flexible dosing mechanisms that enhance coverage in hard-to-reach areas; a stable procurement and distribution mechanism to ensure an adequate, timely, and sustainable supply of VAS; intensive social mobilization and communication; and appropriate training and supervision of staff. CONCLUSIONS: The governments of Bihar and Odisha have demonstrated that it is feasible to implement a successful and inclusive VAS program in India. The challenge now is to reach out to the remaining 30% to 40% of children who are undoubtedly the hardest to reach and potentially the most vulnerable.

Reaching the poor with adequately iodized salt through the Supplementary Nutrition Programme and Midday Meal Scheme in Madhya Pradesh, India.

PROBLEM: In India, adequately iodized salt needs to be made accessible to the most marginalized. APPROACH: In an effort to provide adequately iodized salt to the most vulnerable, in 2009 Madhya Pradesh launched a state-wide initiative through two national flagship nutrition programmes: the Supplementary Nutrition Programme of the Integrated Child Development Services and the Midday Meal Scheme. Programme staff members were taught how to correctly store salt and monitor its iodine content. Field monitors assessed the iodine content of the salt in the common kitchens of participating schools and anganwadi centres monthly. LOCAL SETTING: Madhya Pradesh, a state in central India, is home to a substantial proportion of India's poor. In 2009, household coverage of adequately iodized salt in the state was nearly 90% among the richest but only about 50% among the poorest. RELEVANT CHANGES: Two hot meals prepared with adequately iodized salt were served daily for more than 21 days per month to approximately 89% of the 12,113,584 children aged 3 to 6 years enrolled in anganwadi centres (June 2011 to March 2012). One meal on school days was served to 78% of 5,751,979 primary-school children and to 79% of 2,704,692 secondary-school children (April 2011 to March 2012). Most of the kitchens visited in 2010 (79%) and 2011 (83%) were consistently using adequately iodized salt to prepare hot meals. LESSONS LEARNT: India has large-scale social safety net programmes for the poorest. Both national and state policies should mainstream the use of adequately iodized salt in these programmes.

The Adolescent Girls' Anaemia Control Programme: a decade of programming experience to break the inter-generational cycle of malnutrition in India.

OBJECTIVE: To document the scale-up of India's Adolescent Girls' Anaemia Control Programme following a knowledge-centred framework for scaling up nutrition interventions and to identify the critical elements of and lessons learned from a decade of programme experience for the control of anaemia in adolescent girls. DESIGN: We reviewed all articles, programme and project reports, and baseline and endline assessments published between 1995 and 2012 regarding the control of anaemia through intermittent iron and folic acid supplementation; key programme specialists and managers were interviewed to complete or verify information wherever needed. SETTING: India. SUBJECTS: Adolescent girls. RESULTS: The scale-up of India's Adolescent Girls' Anaemia Control Programme followed a knowledge-centred programme cycle comprising five phases: Evidence, Innovation, Evaluation, Replication and Universalization. By the end of 2011, the programme was being rolled out in thirteen states and was reaching 27.6 million adolescent girls of whom 16.3 million were school-going girls and 11.3 million were out-of-school girls. Building on the critical elements of and lessons learned from the programme, the Government of India launched in 2012 the national Weekly Iron and Folic Acid Supplementation (WIFS) programme to universalize the benefits of anaemia control to the overall population of Indian adolescents. CONCLUSIONS: The Adolescent Girls' Anaemia Control Programme in India provides a good example of how a knowledge-centred approach can successfully guide the scaling up of public health nutrition interventions and facilitate intersectoral convergence among different government departments and development partners to break the inter-generational cycle of undernutrition and deprivation.

Acceptability of multiple micronutrient supplements by pregnant and lactating women in Mali.

BACKGROUND: In Mali, an estimated 73% of pregnant women are anaemic largely due to iron deficiency. National policy recommends women to take iron and folic acid supplements daily from first prenatal contact until 3 months postpartum. However, many pregnant women in Mali could benefit from multiple micronutrient supplements. OBJECTIVE: To assess pregnant women's acceptability of and adherence to a daily multiple micronutrient supplementation scheme compared with the current daily iron and folic acid supplementation scheme. DESIGN: Seventy pregnant women were allocated to either the daily multiple micronutrient or daily iron and folic acid supplementation scheme. Women started receiving supplements at the end of the first trimester of pregnancy until delivery and throughout the first 3 months postpartum. RESULTS: No significant differences were observed between comparison groups with respect to women's perceptions about supplement size, colour, taste or flavour. Adherence to the multiple micronutrient supplementation scheme was better (257.5+/-20.9 tablets; average adherence 95.4%) than that to the iron and folic acid supplementation scheme (238.5+/-32.7 tablets; average adherence 92.2%; P=0.008) although both were very good, as were women's perceptions about the benefits of micronutrient supplements to their health and that of their newborns. CONCLUSION: Malian women adhere to prenatal/postpartum micronutrient supplementation - no matter what supplement is chosen - when access to supplements is guaranteed and when they are provided with minimum, consistent and easily understandable information and counselling, indicating that these are key elements to ensure effective programmes. These findings, together with those of the global research agenda on the efficacy of multiple micronutrient supplements for pregnant women, will inform policy development in Mali for the effective control of iron deficiency and iron-deficiency anaemia in pregnant women.

Sierra Leone--investing in nutrition to reduce poverty: a call for action.

BACKGROUND: Malnutrition rates in Sierra Leone are among the highest in the world. However, policy-makers do not always recognise the fight against malnutrition as a policy priority to ensure the healthy human capital needed to fight poverty and achieve sustained positive economic growth. OBJECTIVE: The analysis presented here was conducted by an intersectoral and inter-agency group of Sierra Leonean senior policy advisors to quantify some of the potential human and economic benefits of improved policies and programmes to reduce malnutrition. FINDINGS: The analysis revealed that 46% of child deaths in Sierra Leone are attributable to malnutrition, the single greatest cause of child mortality in the country. In the absence of adequate policy and programme action, malnutrition will be the underlying cause of an estimated 74000 child deaths over the next five years. The analysis also revealed that if current levels of iodine deficiency remain unchanged over the next five years, 252000 children could be born with varying degrees of mental retardation as a result of intrauterine iodine deficiency. Finally, the analysis showed that, in the absence of adequate policy and programme action to reduce the unacceptable rates of anaemia in women, the monetary value of agricultural productivity losses associated with anaemia in the female labour force over the next five years will exceed dollars 94.5 million. CONCLUSION: Sustained investment in nutrition in Sierra Leone could bring about enormous human and economic benefits to develop the social sector, revitalise the economy, and attain the poverty reduction goals that Sierra Leone has set forth.

Delivery of nutrition services in health systems in sub-Saharan Africa: opportunities in Burkina Faso, Mozambique and Niger.

BACKGROUND: In sub-Saharan Africa, underweight and micronutrient deficiencies account for an estimated 25% of the burden of disease. As the coverage of national health systems expands, increased opportunities exist to address the needs of children and women, the most vulnerable to these deficiencies, through high-quality nutrition services. OBJECTIVES: To assess health providers' knowledge and practice with regard to essential nutrition services for women and children in Burkina Faso, Mozambique and Niger, in order to assist the development of a standard guide and tools to assess and monitor the quality of the nutrition services delivered through national health systems. FINDINGS: The three surveys reveal the extent of missed opportunities to deliver nutrition services during routine prenatal, postnatal and child-care consultations for the prevention and treatment of highly prevalent nutritional deficiencies. CONCLUSION: A commitment to improving the quality of facility-based nutrition services is necessary to impact on the health outcomes of women and children 'covered' by national health systems. Rigorous assessment and monitoring of the quality of nutrition services should inform health programme and policy development. Building on the lessons learned in these three assessments, Helen Keller International has developed a standard Guide and Tools to assess the quality of the nutrition services delivered through national health systems. These tools can be adapted to assess ongoing nutrition services in health facilities, provide a framework for nutrition programming, inform the development of pre-service as well as in-service nutrition training curricula for providers, and evaluate the impact of nutrition training on providers' practices.