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Public investment in agriculture

Enhance productivity

Attract private investment

Reduce poverty and hunger

* Stunting linked to hunger/malnutrition and poverty – resolved by providing sustainable source of food and income for these individuals

Sustainability can be achieved by attracting investments instead of simply providing financial/food aid

Address nutritional needs of girls pregnant & lactating women, and older individuals

Current studies and reports highlight the need for more investment in nutrition, however is insufficient for action to be taken

Knowledge gaps about what areas need to be financed and how much needs to be put into the cause

Information available only on expanding the coverage of nutrition interventions, but no estimates on how the goals can be met

Not focused on stunting, but on a few consequences of undernutrition

Nutrition Specific Interventions

Direct:

public provision of complementary foods

prophylactic zinc supplementation for children

complementary feeding education

Indirect: reduce the risk of pre-term birth and the risk of a child being born small-for-gestational age -> reduce stunting risk factors

multiple micronutrient supplementation in pregnancy

balanced energy-protein supplementation for pregnant women

intermittent preventive treatment of malaria (IPTp) for pregnant women

Indirect: lower the incidence of diarrhoea

breastfeeding promotion

vitamin A supplementation

Government commitment to reducing incidence of childhood stunting
- ensuring equality, supporting equity and reducing discrimination in communities would allow for at-risk individuals to receive community support and government support -> economic status and accessibility

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Global prevalence:

In 2017, close to 151 million children under five have stunted growth.

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Percentages of stunting globally has decreased from 2012 to 2017 but are still far from the 2025 and 2030 targets.

Target for 2025: requires 40% reduction in the number of children under five who are stunted.

Target for 2030: requires 50% reduction in the number of children under five who are stunted.

Prevalence of stunting has decreased in Africa, Asia, Latin America and the Caribbean. However, prevalence of stunting has increased in Oceania.

58.7 million were stunted in 2017 in Africa, 83.6 million in Asia, 5.1 million in Latin America and the Caribbean in 0.5 million in Oceania.

73 countries have a child stunting prevalence of ≥ 20%, contributing to the global child stunting prevalence

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Wasting and underweight: Potential solutions

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Wasting and underweight: Potential solutions

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Addressing the burden of wasting will require a multipronged approach, including prevention in infancy and early childhood, early identification before children develop medical complications, and treatment of affected children, particularly those with severe wasting. In order to meet the global targets set, country implementation has to be scaled up, investments for nutrition need to be increased and enhanced policy coherence is required.
Policy making/ Political

1. The Nutrition Decade:

encourages governments to set country-specific SMART commitments for urgent investment, action and collaboration at national level.

provides countries with mechanisms e.g. Action Networks for sharing good practices, illustrating  successes and challenges, promoting improved coordination and building political momentum to scale up global action.

2. Policies, programmes and strategies to support breastfeeding as a norm, support children’s right to a healthy diet, including access to diverse, nutritious, safe and age-appropriate foods

3. Implement national health plans and UHC roadmaps to:

increase health care access to population

expand the package of quality health services and essential health services in fragile and conflict affected settings

reduce out of pocket payments

School

1. More nutrition intervention programmes among school-age children above  programmes for preschool children as schools are increasingly being recognized as an effective platform for providing nutrition and health interventions to school-age children and adolescents.

2. Promoting good nutrition and health in school settings improves the growth and development of children and reduce risk factors for non-communicable diseases. In addition, SDG2 highlights the importance of nutrition for adolescent girls.

School nutrition programmes to provide:

1. nutritious meals or snacks

2. micronutrient supplements

3. nutrition information, education and counselling

School feeding programmes to:

1. help prevent hunger

2. increase school enrolment

3. reduce absenteeism

4. improve learning outcomes

Deworming and micronutrient supplementation are linked to:

1. better nutrition and learning

Water, hygiene and sanitation

1. Water, hygiene and sanitation programmes need to ensure access to safe drinking water and sanitation facilities.

Social

1. Social protection and safety net programmes need to ensure access to healthy diets for children and families left behind by mainstream development.

2. Provision of prevention rations of specialized nutritious food or cash-based transfers

Medical

1. Improved growth monitoring and promotion, for instance by vaccination services and during child health and nutrition days, could help identify children at risk of severe wasting and at risk of morbidity and mortality, such as those who are moderately wasted and those in need of treatment.

2. Medical and nutritional treatment of severe acute malnutrition needs to be scaled up as part of routine health and nutrition services for children to improve childhood survival.

Require modifications to ensure that health services treat children with wasting until they achieve full recovery from the condition, and that key commodities (e.g. Ready to Use Therapeutic Food) are routinely available and managed as part of national health systems

Maternal

1. Investments in the nutrition of children and adolescents can improve current and future nutrition, while breaking the intergenerational cycle of malnutrition in all its forms

2. Greater emphasis on strengthening systems to establish a continuum of care for adolescent girls, mothers and their children.

3. Improve periconception care, and care during and after pregnancy
4. Feeding habits are equally critical and promoting, protecting and supporting appropriate Infant and young child feeding (IYCF) practices - exclusive breastfeeding during the first six months, followed by continued breastfeeding with adequate complementary feeding up to two years.

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Possible mechanisms for the overweight/obesity

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Possible mechanisms for the overweight/obesity

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1. Psychosocial route from food insecurity to obesity. Anxiety, stress and depression -> binging when food is available , choosing low-cost, energy-dense “comfort foods” rich in fat, sugar and salt. Such foods have been found to have physiological effects that reduce stress in the short term.

2. The stress of living with food insecurity can also have a negative effect on breastfeeding and young child feeding practices, which in turn increases the children’s risk of obesity in adulthood

3. Metabolic adaptations to chronic starvation (store fat more easily as a way to survive). 'Feast-and-famine cycle, increase in body fat, decrease in LBM when food is plentiful -> rapid weight gain.

4. Inexpensive, high-calorie, low nutritious food.

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Wasting and underweight: Possible mechanisms

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Wasting and underweight: Possible mechanisms

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1. Direct: through compromised diets

From poor consumption of food, in terms of quality, quantity and continuity => Insufficient intake of calories, protein, vitamins and minerals

2. Indirect:
a. through inadequate infant and child feeding = Household food insecurity is associated with higher rates of maternal depression and stress in lower-middle-income as well as high-income countries, and this can adversely affect maternal confidence and self-efficacy, initiation and duration of breastfeeding and age-appropriate complementary feeding

b. lack of access to clean water, sanitation and healthcare = increase risk of gastrointestinal infections, diarrhea and infectious disease → interfere with body’s ability to absorb nutrients → wasting & undernutrition results

c. vicious cycle of wasting and infection =

undernutrition increases susceptibility to infection (poor immune system) → poor appetite and intestinal absorption → rapid weight loss → stunting

d. poor access to healthcare =
slows recovery from these illnesses → prolongs illness & malnourished state → wasting & undernutrition

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Global Prevalence of WASTING & UNDERWEIGHT

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Global Prevalence of WASTING & UNDERWEIGHT

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In 2017,
>50 million children under 5  suffered from wasting (7.5% of children) **Asia + Oceania affected the most (1 in 10; 7 in 10 in Asia)

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Link between food access/ insecurity and stunting

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Link between food access/ insecurity and stunting

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Economic

Cost of nutritious foods

Income of households

Lower income (e.g. in Africa) --> lower PP --> lesser choice and diet variety

Less nutritious, more convenient foods more affordable

Accessibility

Transportation network

Transportation facilities

Availability

Ability of country to produce sufficient nutritious food products to feed the population - supply is affected by weather, climate, govt policies (land allocated for agriculture), govt subsidies for agriculture

Ability of country to import sufficient food products - govt policies

Social

Cultural norms/ consumer behaviour

Price vote affects supply of the good/ product

Exclusive breastfeeding protects against child stunting

Household food security

Prioritization of energy over nutrition

Prolonged poor diets → maternal undernutrition → increase risk of low birthweight → increase risk of child stunting.

→ Insufficient intake of calories, protein, vitamins and minerals/ poor diet quality → stunting

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Link between food access/insecurity & overweight/ obesity

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Link between food access/insecurity & overweight/ obesity

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In the context of globalized food markets where the relative cost of foods that are high in fats and sugar is low compared to fresh products such as fruits, vegetables and legumes, the prioritization of cost

Food-insecure families may result in diets high in energy and low in diversity, micronutrients and fibre.

Moderate levels of food insecurity are often associated with diets that are energy-dense yet poor in micronutrients, resource constraints may force people to reduce the nutritional quality of their diets.

Food-insecure people are often less likely to have physical access to markets where they can buy nutritious and healthy foods at affordable prices, particularly in high-income countries.

The negative effect of food insecurity on diet quality has been documented in low-, middle- and high-income countries alike.

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Insufficient intake of macro and micronutrients > poor maternal nutrition and health > increased risk of low birthweight > child stunting

- Poor maternal nutrition > limits growth of fetus and increases risk of neonatal death. In the first 1000 days, risk of stunting is closely linked to mother’s health.
--> Pregnancy in adolescence creates competition for nutrients between the still-growing mother and her fetus
--> Closely spaced pregnancies also deplete a mother’s nutrient reserves

- Poor maternal health

--> If mother is infected with malaria, hiv/aids, intestinal worms
--> Hypertension during pregnancy increases risk of low birth weight and preterm delivery

Intergenerational cycle
Girls undernourished at birth > during childhood > Pregnant during adolescence > Overworked during pregnancy > Have Low birth weight babies > Unable to breastfeed optimally

Inadequate breastfeeding
Inadequate breastfeeding > lack of natural growth stimulators in mother's milk > lack of immunoprotection
Breastfeeding should be paired with complementary feeding (cooked cereals, mashed foods, meat, fish, pulses, etc)
Inadequate practices:
- feeding infrequently
- giving excessively diluted foods
- providing insufficient quantities of food and non-responsive feeding
- Should only stop at 2 yrs old

Infections
- Unsafe food and water
Mycotoxins (such as aflatoxin) produced by fungi in food crops > environmental enteric dysfunction, systemic inflammation, immunomodulation, and changes in the hepatic metabolism of micronutrients > inflammation > extensive intestinal damage > poor absorption of nutrients
- Pneumonia, malaria, diarrhoea disease, and intestinal worms severely impact child’s growth
- Experiencing 5 or more diarrhoea episodes before the age of 2 is the main cause of stunting in 25% of affected children

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1. Address climate-risk and environmental issues with improved policies.
2. Education on nutrition and health-sensitive considerations.
3. Climate smart technological advancements → such as crop varieties, water management, climate proof food storage → reducing food insecurity.
4. Climate risk insurance →protects people, businesses and states from the adverse effects of climate variability and extremes
5. Proposals to facilitate and/or place restrictions on the types of foods that can be purchased with food supplement benefits, to provide incentives for buying more healthful foods, and to expand nutrition education efforts

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Link between food access/insecurity and WASTING & UNDERWEIGHT

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Link between food access/insecurity and WASTING & UNDERWEIGHT

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overview: food insecurity → reduction in quantity/quality of food consumed → inability to meet daily dietary requirements → wasting (**low weight-for-height which reflects a reduction or loss of body weight, considered a relevant indicator of acute malnutrition)

1. seasonal variations esp in seasonal countries → harvest seasons, droughts & rains → variations in the food supply

2. humanitarian crisis solutions (i.e. wars) → negatively impact quantity and diversity of foods available → monotonous diets with low nutrient density → constrain child growth

3. cultural and social factors such as women and children being discriminated against during the distribution of food under conditions of scarcity, mothers adjusting food intake to buffer effect of food insecurity on their children, gender inequalities which influence decision-making power and access to food→ Affect the distribution of food and resources within households → Women and children higher risk of undernourishment → poor food access increases the risk of low birth weight in children, which are associated with a higher risk of overweight and obesity later in life

4. food insecurity →  higher cost of nutritious foods, the stress of living with food insecurity, and physiological adaptations to food restriction (contextual factors such as country income level, or urban versus rural area may explain some differences in the observed relationships between food insecurity and nutritional outcomes) → underweight & wasting

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Global Prevalence of Obesity/ overweight

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Global Prevalence of Obesity/ overweight

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1. More than 1 in 8 adults – or more than 672 million – is obese.
2. In 2016, more than 1.9 billion (39%) adults were overweight.
Over 650 million (13.2%) were obese
3. In 2017, 5.6% (38.3 million) of children under 5 years are overweight globally. This is an increase from 5.4% in 2012.

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Global Prevalence of WASTING & UNDERWEIGHT

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Global Prevalence of WASTING & UNDERWEIGHT

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Moderately wasted vs Severely wasted children in 2017