Elsevier

The Lancet

Volume 382, Issue 9891, 10–16 August 2013, Pages 536-551
The Lancet

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

https://doi.org/10.1016/S0140-6736(13)60843-0Get rights and content

Summary

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 women's 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 women's 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.

Introduction

The food system is threatened by food and oil price volatility, diversion of resources from production of food to biofuels, climate change and related water shortages, persistent conflicts and emergencies, and natural disasters affecting agriculture production and yields.1, 2, 3, 4 These challenges are compounded by changes in demand for food that are brought about by growing populations, increasing incomes, and urbanisation—shifts that raise concerns about diet quality and food safety, while threatening water, land, and other finite natural resources.5, 6, 7, 8 In view of these challenges, protection of nutrition, let alone acceleration of progress, will entail more than bringing nutrition-specific interventions to scale. It will require a new and more aggressive focus on coupling effective nutrition-specific interventions (ie, those that address the immediate determinants of nutrition) with nutrition-sensitive programmes that address the underlying causes of undernutrition (panel 19, 10).

Nutrition-sensitive programmes draw on complementary sectors such as agriculture, health, social protection, early child development, education, and water and sanitation to affect the underlying determinants of nutrition, including poverty; food insecurity; scarcity of access to adequate care resources; and to health, water, and sanitation services.11 Key features that make programmes in these sectors potentially nutrition-sensitive are: they address crucial underlying determinants of nutrition; they are often implemented at large scale and can be effective at reaching poor populations12 who have high malnutrition rates; and they can be leveraged to serve as delivery platforms for nutrition-specific interventions. Nutrition-sensitive programmes might therefore help to accelerate progress in improving nutrition by enhancing the household and community environment in which children develop and grow, and by increasing the effectiveness, coverage, and scale of nutrition-specific interventions.

Key messages

  • Nutrition-sensitive interventions and programmes in agriculture, social safety nets, early child development, and education have enormous potential to enhance the scale and effectiveness of nutrition-specific interventions; improving nutrition can also help nutrition-sensitive programmes achieve their own goals.

  • Targeted agricultural programmes and social safety nets can have a large role in mitigation of potentially negative effects of global changes and man-made and environmental shocks, in supporting livelihoods, food security, diet quality, and women's empowerment, and in achieving scale and high coverage of nutritionally at-risk households and individuals.

  • Evidence of the effectiveness of targeted agricultural programmes on maternal and child nutrition, with the exception of vitamin A, is limited; strengthening of nutrition goals and actions and rigorous effectiveness assessments are needed.

  • The feasibility and effectiveness of biofortified vitamin A-rich orange sweet potato for increasing maternal and child vitamin A intake and status has been shown; evidence of the effectiveness of biofortification continues to grow for other micronutrient and crop combinations.

  • Social safety nets are a powerful poverty reduction instrument, but their potential to benefit maternal and child nutrition and development is yet to be unleashed; to do so, programme nutrition goals and interventions, and quality of services need to be strengthened.

  • Combinations of nutrition and early child development interventions can have additive or synergistic effects on child development, and in some cases, nutrition outcomes. Integration of stimulation and nutrition interventions makes sense programmatically and could save cost and enhance benefits for both nutrition and development outcomes.

  • Parental schooling is consistently associated with improved nutrition outcomes and schools provide an opportunity, so far untapped, to include nutrition in school curricula for prevention and treatment of undernutrition or obesity.

  • Maternal depression is an important determinant of suboptimum caregiving and health-seeking behaviours and is associated with poor nutrition and child development outcomes; interventions to address this problem should be integrated in nutrition-sensitive programmes.

  • Nutrition-sensitive programmes offer a unique opportunity to reach girls during preconception and possibly to achieve scale, either through school-linked conditions and interventions or home-based programmes.

  • The nutrition-sensitivity of programmes can be enhanced by improving targeting; using conditions; integrating strong nutrition goals and actions; and focusing on improving women's physical and mental health, nutrition, time allocation, and empowerment.

Nutrition-sensitive programmes can help protect poor populations from the negative consequences of global food security threats and mitigate the effects of financial, weather-related, and man-made shocks (eg, conflicts). Such shocks make poor populations increasingly vulnerable to undernutrition, as shown by food and fuel price crises in the past 6 years,4 and documented effects of conflicts on morbidity and mortality among affected populations.13, 14 Climate change and the expected increased frequency of droughts and flooding are likely to reduce food availability and dietary diversity, and increase rates of infectious diseases such as diarrhoea or malaria.15 Under these circumstances, nutrition-sensitive programmes can help to protect the assets and welfare of poor people and their investments in the health, nutrition, and development of their children.

Nutrition-sensitive programmes are likely to affect nutrition through changes in food and non-food prices and income, and through women's empowerment. Panel 216, 17 and figures 118, 19 and 218, 19 show results of analyses of the links between income growth and maternal and child anthropometry and anaemia (appendix p 1). Appendix p 2 summarises evidence regarding the association between women's empowerment and child nutrition.

We review evidence of the nutritional effect of programmes from different sectors, and discuss how such investments could be made more nutrition-sensitive. We selected sectors on the basis of: relevance for nutrition (eg, address crucial underlying determinants of nutrition); availability of assessments of their nutritional effect; high coverage of poor populations; and targeting (programmes are, or could be, targeted to reach nutritionally vulnerable groups). The two sectors that most closely meet these criteria are agriculture and social safety nets. Early child development programmes do not meet the high coverage criteria but they are included because child development and nutrition outcomes share many of the same risk factors, and there is a growing interest in examination of potential integration and synergies in programming and outcomes.20, 21 Schooling is also included, despite failing to meet all criteria, because of the importance of parental education for child nutrition and development. Health, water and sanitation, and family planning are covered in the accompanying report by Zulfiqar Bhutta and colleagues.22 Investments and policies in several other sectors (eg, transportation; communication and information technology; and global food, agriculture, and trade) have the potential to affect nutrition, as do more targeted policies (eg, maternity leave); however, we excluded these sectors because of the absence of assessments of nutritional effects.

Consistent with the Maternal and Child Nutrition Series, we focus on adolescent girls and women, infants, and young children during the first 1000 days of life (period from conception to a child's second birthday). Interventions to improve nutrition and child development during this period have high rates of return because of their importance in enhancing economic productivity later in life23 fostered by a combination of improved health, nutrition, and cognition, which lead to more schooling, higher-paying jobs, and overall enhancement of physical, cognitive, and reproductive performance.24

The programmes we reviewed generally have several objectives, including improving income, food security, women's empowerment, and nutrition. For this reason cost-effectiveness studies cannot be easily applied to assess or rank these programmes. Similarly, although cost–benefit analysis can be used in principle, this analysis needs a common metric for all outputs, generally in monetary terms. However, a conversion of a death averted into monetary values requires an arbitrary assessment of the value of premature deaths averted. Similarly, although equity is usually deemed socially desirable, its value cannot be easily quantified.25 Therefore, the nutrition outcomes in the programmes we discuss cannot be directly compared with those in the accompanying report by Zulfiqar Bhutta and colleagues.22 However, as we explain, the programmes we review are an integral component of an overall strategy to improve global nutrition.

Section snippets

Agriculture

Agriculture systems have a crucial role in provision of food, livelihoods, and income.1 Agriculture is the main occupation of 80% of poor populations in rural areas, including women. In Africa, women account for 70% of agricultural labour and 80% of food processing labour.26, 27 Growing concerns about how to meet the food needs of an estimated global population of 9 billion by 2050 have spurred renewed efforts to boost agriculture production and productivity in the face of increasing threats

Social safety nets

Social safety nets are programmes that distribute transfers to low-income households. These programmes raise income among vulnerable groups and enhance resilience by preventing destitution brought about by loss of assets or reduced investment in human capital during times of crises. Transfers can be in the form of cash or food, although with improved technology for tracking income transfers, cash transfers are increasingly the preferred means to support chronically poor households. Between 0·75

Early child development

Stunting and impaired cognitive development share several of the same risk factors, including deficiencies in protein, energy, and some micronutrients, intrauterine growth retardation, and social and economic conditions, such as maternal depression and poverty.109 Some of the key phases of brain growth and development also encompass the first 1000 days of life, the period of peak susceptibility to nutritional insults. Therefore, some key interventions can protect children from both nutritional

Schooling

Although children are beyond the crucial 1000 days window when they enter school, their schooling experience might be a strong determinant of the nutrition of the next generation. Parental schooling has been consistently associated with child nutritional status, with maternal education often, but not always, having a larger explanatory power than paternal education, controlling for income and schooling choices.124, 125 The positive global trends in schooling are, therefore, encouraging for

Discussion

In 2008, The Lancet Maternal and Child Undernutrition Series included conditional cash transfer programmes and dietary diversification approaches as “general nutrition support strategies”, and noted small positive effects of conditional cash transfers on child anthropometry in three Latin American countries, and an absence of a statistically significant of effect of dietary diversification strategies on child nutrition outcomes.134 In the present series, we discuss evidence regarding the

Conclusions

Nutrition-sensitive programmes hold great promise for supporting nutrition improvements and boosting the scale, coverage, and benefits of nutrition-specific actions. New incentives are needed to support innovations in nutrition-sensitive programmes and unleash their potential to tackle nutrition while also achieving their own goals. New nutrition-sensitive agriculture44 and social safety net programme designs, methods, and packages of interventions are being tested and are strengthening links

References (138)

  • N Petry et al.

    Stable iron isotope studies in Rwandese women indicate that the common bean has limited potential as a vehicle for iron biofortification

    J Nutr

    (2012)
  • F Afridi

    Child welfare programs and child nutrition: evidence from a mandated school meal program in India

    J Dev Econ

    (2010)
  • AK Osei et al.

    Community level micronutrient fortification of school lunch meals improved vitamin A, folate, and iron status of schoolchildren in Himalayan villages of India

    J Nutr

    (2010)
  • N Schady et al.

    Are cash transfers made to women spent like other sources of income?

    Econ Lett

    (2008)
  • JL Leroy et al.

    Cash and in-kind transfers in poor rural communities in Mexico increase household fruit, vegetable, and micronutrient consumption but also lead to excess energy consumption

    J Nutr

    (2010)
  • JL Leroy et al.

    Cash and in-kind transfers lead to excess weight gain in a population of women with a high prevalence of overweight in rural Mexico

    J Nutr

    (2013)
  • 2011 Global food policy report

    (2012)
  • GC Nelson et al.

    Climate change. Impact on agriculture and costs of adaptation

    (2009)
  • P Webb

    Medium-to long-run implications of high food prices for global nutrition

    J Nutr

    (2010)
  • The state of food insecurity in the world, 2012. Economic growth is necessary but not sufficient to accelerate reduction of hunger and malnutrition

    (2012)
  • Global economic prospects: commodities at the crossroads

    (2009)
  • OECD-FAO. OECD-FAO agricultural outlook, 2012....
  • P Pinstrup-Andersen et al.

    Food policy for developing countries. The role of government in global, national and local food systems

    (2011)
  • Progress report from countries and their partners in the Movement to Scale Up Nutrition

    (2011)
  • M Shekar et al.

    Module A. Introduction

  • RE Black et al.

    Maternal and child undernutrition and overweight in low-income and middle-income countries

    Lancet

    (2013)
  • M Grosh et al.

    For protection and promotion: the design and implementation of effective safety nets

    (2008)
  • H Alderman

    Safety nets can help address the risks to nutrition from increasing climate variability

    J Nutr

    (2010)
  • L Haddad et al.

    Reducing child malnutrition: how far does income growth take us?

    World Bank Econ Rev

    (2003)
  • H Alderman et al.

    Anemia in low-income countries is unlikely to be addressed by economic development without additional programs

    Food Nutr Bull

    (2009)
  • Measure DHS Stat-Compiler

  • Global database on child Growth and malnutrition

    (2012)
  • ZA Bhutta et al.

    Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

    Lancet

    (2013)
  • D Almond et al.

    Killing me softly

    J Econ Perspect

    (2011)
  • J Hoddinott et al.

    The consequences of early childhood growth failure over the life course. IFPRI Discussion Paper 01073

    (2011)
  • H Alderman

    The economic cost of a poor start to life

    J Dev Origins Health Dis

    (2010)
  • The state of food and agriculture, 2010–2011. Women in agriculture. Closing the gender gap for development

  • P Pinstrup-Andersen

    The food system and its interaction with human health nutrition. Leveraging agriculture for improved nutrition in health. 2020 Conference: Leveraging Agriculture for Improving Nutrition and Health. Brief 13

    (2011)
  • J Hoddinott et al.

    Investments to reduce hunger and undernutrition

  • World Bank. World Development Report 2008. Agriculture for development. Washington, DC: The International Bank for...
  • P Pinstrup-Andersen

    Guiding food system policies for better nutrition. Background paper for The State of Food and Agriculture, 2013

    (2013)
  • P Pinstrup-Andersen

    Can agriculture meet future nutrition challenge?

    Eur J Dev Res

    (2013)
  • A Herforth et al.

    Prioritizing nutrition in agricutural and rural development: guiding principles for operational investments. Health, Nutrition, and Population discussion paper

    (2012)
  • Improving nutrition through multisectoral approaches

    (2013)
  • From agriculture to nutrition. Pathways, synergies and outcomes

    (2007)
  • S Gillespie et al.

    The agriculture-nutrition disconnect in India: what do we know? IFPRI Discussion Paper 01187

    (2012)
  • World Development Report 2012. Gender equality and development

    (2011)
  • J Hoddinott

    Agriculture, health, and nutrition: toward conceptualizing the linkages. 2020 Conference: Leveraging Agriculture for Improving Nutrition and Health. Paper 2

    (2012)
  • JL Leroy et al.

    The micronutrient impact of multisectoral programs focusing on nutrition: examples from conditional cash transfer, microcredit with education, and agricultural programs

  • Cited by (0)

    Members listed at end of paper

    View full text