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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.