The "Fill the Nutrient Gap" analysis: An approach to strengthen nutrition situation analysis and decision making towards multisectoral policies and systems change.

Improved nutrition situation analysis can increase the understanding of the likely magnitude and main causes of the nutrient gap among a particular target group, for example, children under 2 or pregnant and lactating women, in a particular context. The World Food Programme, with input from University of California Davis, International Food Policy Research Institute, Epicentre, Harvard University, Mahidol University, Save the Children, and UNICEF, has developed a framework for strengthened nutrition situation analysis and decision making called the "Fill the Nutrient Gap" (FNG), which aims to support identification of strategies to increase availability, access, and choice of nutritious foods, to ultimately improve nutrient intake. The FNG engages stakeholders from different sectors throughout the analytical process to provide input and discuss findings to collectively identify and prioritize context-specific strategies. The FNG analysis contributes to better understanding the nutrition situation because it (a) focuses on the dietary intake side of the malnutrition framework and analyses in-depth the nutrient intake of different target groups; (b) linear programming is used in combination with review of secondary data to characterize barriers to nutrient intake, in particular to understand the availability, cost and affordability of nutritious diets for households and target groups with higher nutritional needs, and model potential interventions to improve them; (c) it links the nutrition situation analysis to decision making by providing an evidence base for decision makers to inform their strategies; (d) it facilitates multisectoral discussion on barriers to nutrient intake and enables a prioritization of context-specific strategies (both nutrition specific and sensitive) to improve the nutrition situation across food, health, and social protection systems.

Prevention of acute malnutrition: distribution of special nutritious foods and cash, and addressing underlying causes--what to recommend when, where, for whom, and how.

Acute malnutrition is associated with increased morbidity and mortality risk. When episodes are prolonged or frequent, acute malnutrition is also associated with poor growth and development, which contributes to stunting Nutrition-specific and nutrition-sensitive strategies to prevent undernutrition during the first 1,000 days from conception to 24 months of age can reduce the risks of wasting, stunting, and micronutrient deficiencies. Under circumstances that exacerbate the underlying causes of undernutrition and increase the incidence of wasting, such as food insecurity related to lean seasons or emergencies, or increased incidence of illness, such as diarrhea or measles, additional efforts are required to prevent and treat wasting. Special nutritious foods directly meet the increased nutrient requirements of children at risk for wasting; assistance to vulnerable households, in the form of cash or food, enables households to better meet the food, health, and other needs of household members and may increase resilience; water, sanitation, and hygiene (WASH) and health interventions help prevent and address illness and hence reduce wasting risk. The contributions of specific interventions to reducing the incidence of wasting are difficult to assess under emergency conditions, due to ethical constraints and to the fact that multiple strategies are implemented at the same time. However, pragmatic studies under real-life circumstances, using different designs, e.g., including a group receiving "best possible" treatment, can provide evidence about what works, to what extent, at what cost, and under which circumstances. Programs should address the most important causes in given contexts, be feasible to implement at scale, and assess implementation, coverage, and outcomes.

Impact of a homestead gardening program on household food security and empowerment of women in Bangladesh.

This paper assesses the additional benefits of a homestead gardening program designed to control vitamin A deficiency in Bangladesh. In February and March 2002, data were collected on the food security and social status of women from 2,160 households of active and former participants in the gardening program and from control groups in order to assess the impact and sustainability of the program. The proportions of active and former-participant households that gardened year-round were fivefold and threefold, respectively, higher than that of the control group (78% and 50% vs. 15%). In a three-month period, the households of active participants produced a median of 135 kg and consumed a median of 85 kg of vegetables, while the control households produced a median of 46 kg and consumed a median of 38 kg (p <.001). About 64% of the active-participant households generated a median garden income of 347 taka (US$1 = 51 taka), which was spent mainly on food, and 25% of the control households generated 200 taka in the same period (p < .001). The garden production and income levels of formerly participating households three years after withdrawal of program support were much higher than those of the control households, illustrating the sustainability of the program and its ability to increase household food security. Significantly more women in active- and former-participant households than in control households perceived that they had increased their economic contribution to their households since the time the program was launched in their subdistricts (> 85% vs. 52%). Similar results were found for the level of influence gained by women on household decision-making. These results highlight the multiple benefits that homestead gardening programs can bring and demonstrate that these benefits should be considered when selecting nutritional and development approaches targeting poor households.

Educating and training a workforce for nutrition in a post-2015 world.

Nearly all countries in the world today are burdened with malnutrition, manifesting as undernutrition, micronutrient deficiencies, and/or overweight and obesity. Despite some progress, efforts to alleviate malnutrition are hampered by a shortage in number, skills, and geographic coverage, of a workforce for nutrition. Here, we report the findings of the Castel Gandolfo workshop, a convening of experts from diverse fields in March 2014 to consider how to develop the capacity of a global cadre of nutrition professionals for the post-2015 development era. Workshop participants identified several requirements for developing a workforce for nutrition, including an ability to work as part of a multisectoral team; communication, advocacy, and leadership skills to engage decision makers; and a set of technical skills to address future challenges for nutrition. Other opportunities were highlighted that could immediately contribute to capacity development, including the creation of a consortium to link global North and South universities, online training modules for middle managers, and practical, hands-on experiences for frontline nutrition workers. Institutional and organizational support is needed to enable workshop recommendations on education and training to be effectively implemented and sustained. The findings from the Castel Gandolfo workshop can contribute to the delivery of successful nutrition-relevant actions in the face of mounting external pressures and informing and attaining the forthcoming Sustainable Development Goals.

Macro shocks and micro outcomes: child nutrition during Indonesia's crisis.

A survey of households in rural Java is used to assess the nutritional impact of Indonesia's drought and financial crisis of 1997/1998. A time-age-cohort decomposition reveals significant nutritional impacts. However, child weight-for-age (WAZ) remained constant throughout the crisis, despite rapid increases in food prices and the consequent household consumption shock. The evidence is consistent with the hypothesis that within households, mothers buffered children's caloric intake, resulting in increased maternal wasting. However, reductions in the consumption of high-quality foods further resulted in increased prevalence of anemia for both mothers and children. The combined effects were particularly severe for cohorts conceived and weaned during the crisis.

Process indicators for monitoring and evaluating vitamin A programs.

Vitamin A deficiency disorders (VADD) are a major public health problem in many parts of the world and one of the leading underlying causes of childhood mortality. Therefore, VADD control programs can contribute to reaching the international development goal of reducing childhood mortality by two thirds by the year 2015. Although economic development leads to greater food consumption of animal products (the most bioavailable source of vitamin A), other strategies, such as high dose vitamin A capsule supplementation, fortification and food production programs have been developed to tackle the VADD problem independent of economic development efforts. In this article, we discuss the essential role of process indicators in monitoring and fine-tuning VADD control and prevention programs toward ensuring that such programs will be more effective and cost-effective.

Association of household rice expenditure with child nutritional status indicates a role for macroeconomic food policy in combating malnutrition.

Macroeconomic food policies have the potential to reduce malnutrition by improving access to food, a determinant of nutritional status. However, very little is understood about the mechanisms and the magnitude of the effects of macroeconomic food policies such as food price policies on nutritional status. Data collected by the Nutritional Surveillance Project on a total of 81,337 children aged 6-59 mo in rural Bangladesh between 1992 and 2000 were used to examine how changes in rice price affect child underweight. Rice consumption per capita declined only slightly during the period but rice expenditure per capita varied widely due to fluctuations in rice price. Rice expenditure was positively correlated with the percentage of underweight children (r = 0.91, P = 0.001). Households were found to spend more on nonrice foods as their rice expenditure declined, and nonrice expenditure per capita was negatively correlated with the percentage of underweight children (r = -0.91, P = 0.001). Expenditure on nonrice foods per capita increased with the frequency with which nonrice foods were consumed (P < 0.05) and with the diversity of the diet (P < 0.001). The findings suggest that the percentage of underweight children declined when rice expenditure fell because households were able to spend more on nonrice foods and thereby increase the quantity and quality of their diet. We hypothesize that macroeconomic food policies that keep the price of food staples low can contribute toward reducing child underweight.

The high prevalence of low hemoglobin concentration among Indonesian infants aged 3-5 months is related to maternal anemia.

Iron deficiency anemia among young children is a large health problem. However, there is little information about the prevalence of anemia among young infants because it has been assumed that normal, breast-fed infants have adequate iron stores until 4-6 mo of age. We analyzed cross-sectional data from the HKI/GOI Nutrition and Health Surveillance System in rural Java, Indonesia from Sept. 1999 to Feb. 2001 for hemoglobin (Hb) of 3- to 5-mo-old breast-fed infants (n = 990) and related factors. The prevalence of Hb < 90 g/L was 13.4%, < 100 g/L, 37%, and < 110 g/L, 71%. Multiple logistic regression analysis revealed that normal birth weight infants (>2500 g) of anemic mothers (Hb < 120 g/L) had an odds ratio (OR) [95% confidence interval (CI)] of 1.81 [1.34-2.43] to have a low Hb (< 100 g/L) compared with infants of nonanemic mothers with a normal birth weight. Infants of nonanemic mothers but with low birth weight had an OR of 1.15 [0.61-2.16], and those with low birth weight and anemic mothers of 3.68 [1.69-8.02]. Other risk factors included stunting (OR 1.70 [0.97-2.95]), a young mother (<20 y, OR 1.54 [0.95-2.49]), lower maternal education and living in West Java or East Java. Considering that maternal postpartum Hb reflects Hb during pregnancy, that anemia among mothers in this population is due mainly to iron deficiency, and that children born to anemic mothers are at higher risk of a low Hb, we hypothesize that low infant Hb in this population is due to iron deficiency. Intervention studies in iron deficient populations should test this hypothesis.

Integrating strategies for combating vitamin A deficiency: successes in Asia.

Indonesia and Bangladesh were among the first countries to distribute vitamin A capsules (VAC) to underfives in the early 1970s. Since then, VAC coverage has increased very much. In Indonesia, VAC are now distributed to underfives in two special months. In Cambodia, VAC distribution started less than a decade ago and coverage is yet <50%. After being linked to National Immunization Days, it is now linked to Immunization Outreach, which seems a good strategy. Because VAC are only distributed to underfives and postpartum women, and because coverage is usually around 50-80%, other strategies are implemented simultaneously. Recent HKI-evaluations found that promotion of dark-green leafy vegetables and eggs in Indonesia increased their consumption and improved vitamin A status. In Bangladesh, underfives and women of households with a homestead garden and/or poultry had a lower risk of vitamin A deficiency. The HKI Homestead Food Production Program aims at improving homestead food production activities in order to increase production and consumption of vitamin A-rich foods. Food fortification in Indonesia reaches large parts of the population, while coverage is related to socio-economic status and urban/rural location. The successes in Asia emphasize the need for multiple strategies and integration with other health and agricultural programs.