Peri-Urban, but Not Urban, Residence in Bolivia Is Associated with Higher Odds of Co-Occurrence of Overweight and Anemia among Young Children, and of Households with an Overweight Woman and Stunted Child.

Background: Urban populations have grown globally alongside emerging simultaneous burdens of undernutrition and obesity. Yet, how heterogeneous urban environments are associated with this nutritional double burden is poorly understood. Objective: We aimed to determine: 1) the prevalence of the nutritional double burden and its components in urban, peri-urban, and rural areas of Bolivia; and 2) the association of residence in these areas with the nutritional double burden and its components. Design: We surveyed 3946 randomly selected households from 2 metropolitan regions of Bolivia. Census data and remotely sensed imagery were used to define urban, peri-urban, and rural districts along a transect in each region. We defined 5 nutritional double burdens: concurrent overweight and anemia among women of reproductive age (15-49 y), and children (6-59 mo), respectively; concurrent overweight and stunting among children; and households with an overweight woman and, respectively, an anemic or stunted child. Capillary hemoglobin concentrations were measured to assess anemia (women: hemoglobin <120 g/L; children: hemoglobin <110 g/L), and overweight and stunting were calculated from height, weight, and age data. Results: In multiple logistic regression models, peri-urban, but not urban residence, was associated with higher odds of concurrent overweight and anemia among children (OR: 1.8; 95% CI; 1.0, 3.2) and of households with an overweight woman and stunted child (1.8; 1.2, 2.7). Examining the components of the double burden, peri-urban women and children, respectively, had higher odds of overweight than rural residents [women (1.5; 1.2, 1.8); children (1.5; 1.0, 2.4)], and children from peri-urban regions had higher odds of stunting (1.5; 1.1, 2.2). Conclusions: Peri-urban, but not urban, residence in Bolivia is associated with a higher risk of the nutritional double burden than rural areas. Understanding how heterogeneous urban environments influence nutrition outcomes could inform integrated policies that simultaneously address both undernutrition and obesity.

Joint environmental and social benefits from diversified agriculture.

Agricultural simplification continues to expand at the expense of more diverse forms of agriculture. This simplification, for example, in the form of intensively managed monocultures, poses a risk to keeping the world within safe and just Earth system boundaries. Here, we estimated how agricultural diversification simultaneously affects social and environmental outcomes. Drawing from 24 studies in 11 countries across 2655 farms, we show how five diversification strategies focusing on livestock, crops, soils, noncrop plantings, and water conservation benefit social (e.g., human well-being, yields, and food security) and environmental (e.g., biodiversity, ecosystem services, and reduced environmental externalities) outcomes. We found that applying multiple diversification strategies creates more positive outcomes than individual management strategies alone. To realize these benefits, well-designed policies are needed to incentivize the adoption of multiple diversification strategies in unison.

The Program Assessment Guide: an approach for structuring contextual knowledge and experience to improve the design, delivery, and effectiveness of nutrition interventions.

As evidence from small-scale trials has accumulated concerning the efficacy of low-cost interventions to address undernutrition, the design, implementation, and strengthening of large-scale programs to deliver these interventions has become a high priority. This scaling up process involves a large number of technical, logistical, administrative, political, and social considerations and little research exists on how to address these in a systematic way. This paper introduces the Program Assessment Guide (PAG), a set of analysis and decision tools that seeks to fill this gap, and reports on its application in Kyrgyzstan and Bolivia. The PAG places a special focus on eliciting and systematizing contextual knowledge and experience through a structured, participatory workshop and is grounded in theory, principles, and experience from program planning, management, change management, and intervention planning. When applied in Kyrgyzstan and Bolivia, the PAG was successful in helping workshop participants identify key implementation bottlenecks, questionable assumptions in the program theory, and feasible ways to address some of the shortcomings. These experiences also identified the need for a number of modifications to the PAG related to the workshop design itself, the preparations prior to the workshop, and follow-up after the workshop. The PAG represents one approach for strengthening decisions related to the design and large-scale implementation of interventions. The development and full-scale testing of alternative methods such as these for strengthening program analysis and decision making is an important and intellectually challenging subject for further research.

Bolivia's multisectoral Zero Malnutrition Program: insights on commitment, collaboration, and capacities.

A number of multilateral and bilateral food security and nutrition initiatives have been launched in the wake of the 2008 food crisis, many with the explicit intention of fostering country ownership, multisectoral action, and harmonization among international partners. These bear some resemblance to the failed multisectoral nutrition planning initiatives that followed the 1974 world food crisis, raising the question of whether the current initiatives are doomed to experience the same fate. This paper explores these questions in one country by focusing on the policy sustainability of Bolivia's Zero Malnutrition Program (ZM), a multisectoral initiative that appeared at its initiation to be buttressed by political support and strengthened by design features that differed in important ways from similar efforts of the 1970s. Retrospective and prospective data collected through an action research and grounded methodology revealed, however, that the real struggle in Bolivia came after ZM was launched. ZM champions made undeniable progress in the first 2 years of the program with health-sector interventions, but they underestimated the challenges of building and sustaining the commitment of high-level political leaders, mid-level bureaucrats, and local-level implementers in the majority of other sectors. These initial experiences from Bolivia hold important lessons for several global initiatives to scale up nutrition actions, which are being launched in great haste and so far have given scant attention to strategies for managing the nutrition policy process and strengthening the capacities for implementation.

The management of conflict in nutrition policy formulation: choosing growth-monitoring indicators in the context of dual burden.

We argue in this paper that a shared desire to find a solution to malnutrition and agreement at a broad level concerning priority, evidence-based interventions are important but not sufficient conditions for effective policy development. This paper illustrates this point, and draws out general implications, through a detailed analysis of a case in which conflict emerged when committed nutrition policy actors began discussing the details of program design and implementation. The case involves one country's effort to select "the best" anthropometric indicator for use in its national child growth-monitoring program. In this case the interested parties approached this deceptively simple decision for different reasons, using different sources and standards of evidence and focusing their attention on opposite, but equally critical, operational considerations, while being heavily influenced by global, national, and interorganizational events and relationships. We suggest that actors seeking to translate political commitment for nutrition into effective action should recognize the technical and sociopolitical complexity of seemingly simple decisions related to intervention design and employ more systematic, intentional, and inclusive decision-making procedures. Without attention to such practical matters, the current window of opportunity to reduce malnutrition on a global scale may quickly close.

A Systematic Review of the Measurement of Sustainable Diets.

Sustainability has become an integral consideration of the dietary guidelines of many countries in recent decades. However, a lack of clear metrics and a shared approach to measuring the multiple components of sustainable diets has hindered progress toward generating the evidence needed to ensure the credibility of new guidelines. We performed a systematic literature review of empirical research studies on sustainable diets to identify the components of sustainability that were measured and the methods applied to do so. Two independent reviewers systematically searched 30 databases and other sources with the use of a uniform set of search terms and a priori exclusion criteria. In total, 113 empirical studies were included in the final review. Nearly all of the studies were focused on high-income countries. Although there was substantial heterogeneity in the components of sustainability measured, the estimated greenhouse gas emissions (GHGEs) of various dietary patterns were by far most commonly measured (n = 71 studies). Estimating the GHGEs of foods through various stages of production, use, and recycling with the use of the Life Cycle Assessment approach was the most common method applied to measure the environmental impacts of diets (n = 49 studies). Many components of sustainable diets identified in existing conceptual frameworks are disproportionately underrepresented in the empirical literature, as are studies that examine consumer demand for sustainable dietary alternatives. The emphasis in the literature on high-income countries also overlooks the production and dietary alternatives most relevant to low- and middle-income countries. We propose 3 methodological and measurement approaches that would both improve the global relevance of our understanding of sustainable diets and attend more completely to the existing multidimensional, multiscale conceptual framing of sustainable diets.

Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative.

Undernutrition is the single largest contributor to the global burden of disease and can be addressed through a number of highly efficacious interventions. Undernutrition generally has not received commensurate attention in policy agendas at global and national levels, however, and implementing these efficacious interventions at a national scale has proven difficult. This paper reports on the findings from studies in Bangladesh, Bolivia, Guatemala, Peru and Vietnam which sought to identify the challenges in the policy process and ways to overcome them, notably with respect to commitment, agenda setting, policy formulation and implementation. Data were collected through participant observation, documents and interviews. Data collection, analysis and synthesis were guided by published conceptual frameworks for understanding malnutrition, commitment, agenda setting and implementation capacities. The experiences in these countries provide several insights for future efforts: (a) high-level political attention to nutrition can be generated in a number of ways, but the generation of political commitment and system commitment requires sustained efforts from policy entrepreneurs and champions; (b) mid-level actors from ministries and external partners had great difficulty translating political windows of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional views of undernutrition and disagreements over interventions, ownership, roles and responsibilities; and (c) the pace and quality of implementation was severely constrained in most cases by weaknesses in human and organizational capacities from national to frontline levels. These findings deepen our understanding of the factors that can influence commitment, agenda setting, policy formulation and implementation. They also confirm and extend upon the growing recognition that the heavy investment to identify efficacious nutrition interventions is unlikely to reduce the burden of undernutrition unless or until these systemic capacity constraints are addressed, with an emphasis initially on strategic and management capacities.