Marie T. Ruel

Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?

Acceleration of progress in nutrition will require effective, large-scale nutrition-sensitive programmes that address key underlying determinants of nutrition and enhance the coverage and effectiveness of nutrition-specific interventions. We reviewed evidence of nutritional effects of programmes in four sectors--agriculture, social safety nets, early child development, and schooling. The need for investments to boost agricultural production, keep prices low, and increase incomes is undisputable; targeted agricultural programmes can complement these investments by supporting livelihoods, enhancing access to diverse diets in poor populations, and fostering womens empowerment. However, evidence of the nutritional effect of agricultural programmes is inconclusive--except for vitamin A from biofortification of orange sweet potatoes--largely because of poor quality evaluations. Social safety nets currently provide cash or food transfers to a billion poor people and victims of shocks (eg, natural disasters). Individual studies show some effects on younger children exposed for longer durations, but weaknesses in nutrition goals and actions, and poor service quality probably explain the scarcity of overall nutritional benefits. Combined early child development and nutrition interventions show promising additive or synergistic effects on child development--and in some cases nutrition--and could lead to substantial gains in cost, efficiency, and effectiveness, but these programmes have yet to be tested at scale. Parental schooling is strongly associated with child nutrition, and the effectiveness of emerging school nutrition education programmes needs to be tested. Many of the programmes reviewed were not originally designed to improve nutrition yet have great potential to do so. Ways to enhance programme nutrition-sensitivity include: improve targeting; use conditions to stimulate participation; strengthen nutrition goals and actions; and optimise womens nutrition, time, physical and mental health, and empowerment. Nutrition-sensitive programmes can help scale up nutrition-specific interventions and create a stimulating environment in which young children can grow and develop to their full potential.

Are Determinants of Rural and Urban Food Security and Nutritional Status Different? Some Insights from Mozambique

Undernutrition of children 0-60 months old in Mozambique is much higher in rural than in urban areas. Food security is about the same, although substantial regional differences exist. Given these outcomes, we hypothesized that the determinants of food security and nutritional status in rural and urban areas of Mozambique would differ as well. Yet we find that the determinants of food insecurity and malnutrition, and the magnitudes of their effects, are very nearly the same. The difference in observed outcomes appears primarily due to differences in the levels of critical determinants rather than in the nature of the determinants themselves.

Good Care Practices Can Mitigate the Negative Effects of Poverty and Low Maternal Schooling on Children’s Nutritional Status: Evidence from Accra

This study uses data from a representative survey of households with preschoolers in Accra, Ghana to (1) examine the importance of care practices for childrens height-for-age z-scores (HAZ); and (2) identify subgroups of children for whom good maternal care practices may be particularly important. Good caregiving practices related to child feeding and use of preventive health services were a strong determinant of childrens HAZ, specially among children from the two lower income terciles and children whose mothers had less than secondary schooling. In this population, good care practices could compensate for the negative effects of poverty and low maternal schooling on childrens HAZ. Thus, effective targeting of specific education messages to improve child feeding practices and use of preventive health care could have a major impact on reducing childhood malnutrition in Accra.

Working Women in an Urban Setting: Traders, Vendors and Food Security in Accra

Data collected from a 1997 household survey carried out in Accra, Ghana, are used to look at the crucial role that women play as income earners and in securing access to food in urban areas. The high number of female-headed households and the large percent of working women in the sample provide a good backdrop for looking at how women earn and spend income differently than men in an urban area. Livelihood strategies for both men and women are predominantly labor based and dependent on social networks. For all households in the sample, food is still the single most important item in the total budget. Yet, important and striking differences between men and womens livelihoods and expenditure patterns exist. Compared to men, women are less likely to be employed as wage earners, and more likely to work as street food vendors or petty traders. Women earn lower incomes, but tend to allocate more of their budget to basic goods for themselves and their children, while men spend more on entertainment for themselves only. Despite lower incomes and additional demands on their time as housewives and mothers, female-headed households, petty traders, and street food vendors have the largest percentage of food secure households. This paper explores differences in income, expenditure, and consumption patterns in an effort to answer this question, and suggests ways that urban planners and policymakers can address special concerns of working women in urban areas.

Is Dietary Diversity an Indicator of Food Security or Dietary Quality? A Review of Measurement Issues and Research Needs:

We discuss food-consumption patterns in Central West Africa from 1961 to 2000 and some implications for combating malnutrition. The availability of food in the region improved in the 1960s, declined sharply in the 1970s and the early 1980s, and has shown a modest positive trend since the mid-1980s. Notwithstanding obvious progress over the past decades and in the region as a whole, food availability today remains below the required levels for large parts of the population and appears unstable over time, particularly in the Sahelian zone. On average, diets in this zone contain fewer than 2,200 kcal, compared with almost 2,500 kcal in the coastal zone. Conversely, protein deficiency is more common in the coastal zone, where a typical diet contains only 45 g of protein, compared with 60 g in the Sahelian zone. Furthermore, consumption is showing a dietary shift toward cereals, while yield growth lags far behind population growth. The associated import dependency and pressure on land seem to gain significance regardless of the region’s agro-ecological capacity to increase and to substitute cereal imports for locally produced food. Moreover, food consumption appears responsive to income changes (calorie-income elasticity ranges from 0.25 to 0.62), while, in turn, it has a significant impact on nutritional outcomes (stuntingcalorie elasticity of –1.42). We conclude that combating malnutrition requires first broad-spectrum income growth, and next specific policies that promote the yield and the contribution to diets of nutritious food produced within the region.Dietary diversity is usually measured using a simple count of foods or food groups over a given reference period. Our overview however revealed that studies in developed and developing countries have used a variety of food and food-group classification systems different numbers of foods and food groups and varying reference period lengths (ranging from 1 to 15 days). Research should be conducted to validate and compare indicators based on different methodological approaches. It would also be useful to continue to explore whether indicators based on food groups (a simpler approach) perform as well as those based on single foods in predicting outcomes of interest. (excerpt)

Socio-economic differentials in child stunting are consistently larger in urban than rural areas

Iron deficiency is the world’s most common nutritional disorder and is predominantly responsible for anaemia in human populations. Its management and control involve iron supplementation and fortification of foods and, in developing countries, the control of parasitic infections as well. It is also important to formulate foodbased strategies to improve the bioavailability of dietary iron, for example, by promoting culturally acceptable changes in food choices, processing, and preservation. These require sound scientific data from nutritional research and the participation of women scientists who are familiar with the local and sociocultural preferences of the target communities. Research has shown that the major effects of processing on iron availability are associated with the separation, dehulling, and cooking procedures. The magnitude of losses varies with the food type and processing technique. Blanching and homogenization of vegetables may account for up to 28% and 40% of soluble iron loss, respectively. Moreover, the traditional practice of adding kanwa (an alkaline salt) to soften beans and to impart a green colour to vegetables during cooking results in reduced iron availability. In contrast, germination and fermentation have been shown to enhance the availability of iron from foods. Thus, traditional-food processing methods, such as fermentation, should be encouraged, actively promoted, and preserved.Urban-rural comparisons of childhood undernutrition suggest that urban populations are better-off than rural populations. However, these comparisons could mask the large differentials that exist among socioeconomic groups in urban areas. Data from the Demographic and Health Surveys (DHS) for 11 countries from three regions were used to test the hypothesis that intra-urban differentials in child stunting were greater than intra-rural differentials, and that the prevalence of stunting among the urban and the rural poor was equally high. A socioeconomic status (SES) index based on household assets, housing quality, and availability of services was created separately for rural and urban areas of each country, using principal components analysis. In most countries, stunting in the poorest urban quintile was almost on par with that of poor rural dwellers. Thus, malnutrition in urban areas continues to be of concern, and effective targeting of nutrition programs to the poorest segments of the urban population will be critical to their success and cost-effectiveness.

Some Urban Facts of Life: Implications for Research and Policy

Abstract This review of recent literature explores the challenges to urban food and nutrition security in the rapidly urbanizing developing world. The premise of the manuscript is that the causes of malnutrition and food insecurity in urban and rural areas are different due primarily to a number of phenomena that are unique to or exacerbated by urban living. These areas include: (a) a greater dependence on cash income; (b) weaker informal safety nets; (c) greater labor force participation of women and its consequences for child care; (d) lifestyle changes, particularly diet and exercise patterns; (e) greater availability of public services, but questionable access by the poor; (f) greater exposure to environmental contamination; and (g) governance by a new, possibly nonexistent, set of property rights. The main focus is on identifying what is different about urban areas, so as to better frame the program and policy responses.

The Food, Fuel, and Financial Crises Affect the Urban and Rural Poor Disproportionately: A Review of the Evidence

The vulnerability of the urban poor to the recent food and fuel price crisis has been widely acknowledged. The unfolding global financial crisis, which brings higher unemployment and underemployment, is likely to further intensify this vulnerability. This paper reviews the evidence concerning the disproportionate vulnerability of the urban compared with the rural poor to these types of shocks. It reviews some of the unique characteristics of urban life that could make the urban poor particularly susceptible to price and financial shocks and summarizes the evidence regarding the disproportionate vulnerability of the urban poor. The focus is on impacts on poverty, food insecurity, and malnutrition. The review shows that although the urban poor are clearly one of the population groups most affected by the current (and previous) crises, the rural poor, landless, and net buyers are in no better position to confront the crisis without significant suffering. The poorest of the poor are the ones who will be most affected, irrespective of the continent, country, or urban or rural area where they live. The magnitude and severity of their suffering depends on their ability to adapt and on the specific nature, extent, and duration of the coping strategies they adopt. A better understanding of how these coping strategies are used and staggered is critical to help design triggers for action that can prevent households from moving to more desperate measures. Using these early coping strategies as early warning indicators could help prevent dramatic losses in welfare.

Does Geographic Targeting of Nutrition Interventions Make Sense in Cities? Evidence from Abidjan and Accra

Although most developing country cities are characterized by pockets of substandard housing and inadequate service provision, it is not known to what degree low incomes and malnutrition are confined to specific neighborhoods. This analysis uses representative household surveys of Abidjan and Accra to quantify small-area clustering in service provision, demographic characteristics, consumption, and nutrition. Both cities showed significant clustering in housing conditions but not in nutrition, while income was clustered in Abidjan, but less so in Accra. This suggests that neighborhood targeting of poverty-alleviation or nutrition interventions in these and similar cities could lead to undercoverage of the truly needy.

Undernutrition, Poor Feeding Practices, and Low Coverage of Key Nutrition Interventions

OBJECTIVE: To estimate the global burden of malnutrition and highlight data on child feeding practices and coverage of key nutrition interventions. METHODS: Linear mixed-effects modeling was used to estimate prevalence rates and numbers of underweight and stunted children according to United Nations region from 1990 to 2010 by using surveys from 147 countries. Indicators of infant and young child feeding practices and intervention coverage were calculated from Demographic and Health Survey data from 46 developing countries between 2002 and 2008. RESULTS: In 2010, globally, an estimated 27% (171 million) of children younger than 5 years were stunted and 16% (104 million) were underweight. Africa and Asia have more severe burdens of undernutrition, but the problem persists in some Latin American countries. Few children in the developing world benefit from optimal breastfeeding and complementary feeding practices. Fewer than half of infants were put to the breast within 1 hour of birth, and 36% of infants younger than 6 months were exclusively breastfed. Fewer than one-third of 6- to 23-month-old children met the minimum criteria for dietary diversity, and only ∼50% received the minimum number of meals. Although effective health-sector–based interventions for tackling childhood undernutrition are known, intervention-coverage data are available for only a small proportion of them and reveal mostly low coverage. CONCLUSIONS: Undernutrition continues to be high and progress toward reaching Millennium Development Goal 1 has been slow. Previously unrecognized extremely poor breastfeeding and complementary feeding practices and lack of comprehensive data on intervention coverage require urgent action to improve child nutrition.