Overview_of_Nutrition_Situation_in_Southeast_Asia.pdf

Overview of the Nutrition Situation in Seven Countries in Southeast Asia

Camila Chaparro, Lesley Oot, and Kavita Sethuraman

April 2014

FANTA III

F O O D A N D N U T R I T I O N

T E C H N I C A L A S S I S TA N C E

Burma (Myanmar)

Vietnam

Timor Leste

The Philippines

Laos

Indonesia

Cambodia

Food and Nutrition Technical Assistance III Project (FANTA) 1825 Connecticut Avenue, NW Washington, DC 20009 T: 202-884-8000 fantamail@fhi360.org www.fantaproject.org

This report is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID) and USAID Bureau for Asia under terms of Cooperative Agreement No. AID‐OAA‐A‐12‐00005, through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360.

The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.

The intended purpose of this report is to provide a broad overview of the status of nutrition in Burma, Cambodia, Indonesia, Laos, the Philippines, Timor Leste, and Vietnam in order to inform potential US‐ supported efforts. To view more information about USAID’s Global Health and Feed the Future (FTF) initiatives and their extensive nutrition contributions, please visit: www.usaid.gov/what‐we‐do/global‐ health/nutrition.

Recommended Citation

Chaparro, C.; Oot, L.; and Sethuraman, K. 2014.

Overview of the Nutrition Situation in Seven Countries in Southeast Asia. Washington, DC: FHI 360/FANTA.

Contact Information

Food and Nutrition Technical Assistance III Project

(FANTA)

FHI 360

1825 Connecticut Avenue, NW Washington, DC 20009‐5721 T 202‐884‐8000 F 202‐884‐8432 fantamail@fhi360.org www.fantaproject.org

Overview of the Nutrition Situation in Seven Countries in Southeast Asia iii

Contents

1 Introduction

2 Background

Causes of Malnutrition of Particular Concern in Asia Preventing and Treating Malnutrition Effectively U.S. Government Efforts to Reduce Malnutrition and USAID’s Investments in Nutrition in Asia ... 16

3 Nutritional Status in Burma, Cambodia, Indonesia, Laos, the Philippines, Timor Leste, and Vietnam

Low Birth Weight, Under-5 Mortality, Stunting, Underweight, and Wasting Among Children Maternal Underweight, Short Stature, and Overweight/Obesity Anemia Micronutrient Deficiencies: Vitamin A and Iodine

4 Potential Underlying and Proximate Contributors to Nutritional Status in Southeast Asia

Immediate Underlying Basic Causes

5 Overall Nutrition Priorities for Seven Countries in Southeast Asia

Priority 1: Wasting and Stunting Among Children Priority 2: Nutrition of Women of Reproductive Age and Low Birth Weight Priority 3: Anemia and Micronutrient Deficiencies Priority 4: Nutrition Governance

6 Recommendations for Southeast Asia

Country Data Sources

References

Appendix 1. Methods

Appendix 2. Additional Data

Appendix 3. Glossary of Terms

LIST OF TABLES

Table 1. Number of Children Under 5 Affected by Malnutrition Table 2. Characteristics of Women of Reproductive Age (15–49 Years): Education, Employment and Empowerment, Fertility, Health Care Access and Utilization, and Child Health Vaccination Coverage and Illness

Table 3. Country Characteristics: Population, Economy, Development, Household, and Community Characteristics

Table A.1. Nutritional Status of Children Under 2 and Children Under 5 Table A.2. Nutritional Status of Women of Reproductive Age iv

LIST OF FIGURES

Figure 1. Evidence-Based Interventions to Improve Maternal and Child Nutrition Figure 2. Incidence (%) of Low Birth Weight Figure 3. Trends in the Incidence (%) of LBW for Countries with Repeated National Estimates, 2000 to 2012 Figure 4. Neonatal, Infant, and Under-5 Mortality Rates (per 1,000 Live Births) Figure 5. Stunting Prevalence (%) by Maternal Education Levels, Cambodia and Timor Leste Figure 6. Stunting Prevalence of Children Under 5 by Wealth Index Figure 7. Trends in the Prevalence (%) of Stunting, Underweight, and Wasting Among Children

Under 5, 2000 to 2012 (Based on Repeated National Estimates) Figure 8. Prevalence (%) of Anemia Among Children Under 5 and Children Under 2 Figure 9. Prevalence of Anemia Among Women of Reproductive Age by Physiological Status

According to Nationally-Representative Data Figure 10. Trends in Anemia Prevalence (%) Among Non-Pregnant Women of Reproductive Age

(15–49 Years) for Countries with Available Data from Repeated National Surveys Figure 11. Estimated Prevalence (%) of Vitamin A Deficiency Among Preschool-Age Children Figure 12. Breastfeeding Practices (%) Figure 13. Complementary Feeding Practices (%) v

Abbreviations and Acronyms

AG/NRM agriculture/natural resource management

ARI acute respiratory infections

BMI body mass index

DHS Demographic and Health Surveys dL decilitre(s)

ENA Essential Nutrition Actions

FANTA Food and Nutrition Technical Assistance III Project

FAO Food and Agriculture Organization of the United Nations g gram(s)

Hb hemoglobin

IYCF infant and young child feeding

L liter(s)

LBW low birth weight

MCHN maternal and child health and nutrition

MDG Millennium Development Goal

MICS Multiple Indicator Cluster Surveys

SHOUHARDO Strengthening Household Abilities for Responding to Development Opportunities

SUN Scaling Up Nutrition ug microgram(s)

US$ United States dollars

USAID U.S. Agency for International Development

UNSCN United Nations System Standing Committee on Nutrition

USG U.S. Government

WASH water, sanitation, and hygiene

WFP World Food Programme

WHO World Health Organization

1 Introduction

In the last 5 years interest in addressing malnutrition among young children—particularly those under 2 years of age—and pregnant and lactating women has undergone a global resurgence. The increased attention to this neglected area of maternal, newborn, and child health was supported by analyses in 2008 (Black et al.) quantifying the immense contribution of undernutrition to child mortality—recent analyses estimate that approximately 45% of childhood deaths in 2011 were caused by undernutrition (Black et al. 2013). Analyses also describe the long-term negative and frequently irreversible effects of undernutrition in early life for current and future generations, including impaired cognitive development, lower attained schooling, lower economic productivity, lower birth weight of offspring, and potentially increased risk of certain chronic disease in adult life (Victora et al.

2008). Action to tackle this neglected area was supported by outlining a set of interventions that were known to be not only effective at reducing undernutrition (Bhutta et al. 2008) but also highly cost-effective (Copenhagen Consensus 2012). Since then, there has been an increased commitment by countries, donors, and international agencies to focus on effective interventions during the opportune window to intervene to prevent malnutrition—during the “first 1,000 days,” from pregnancy through the first 2 years of life— when interventions will have a high return. Initiating and maintaining effective national action to reduce undernutrition, however, has proved challenging in many settings, and will be helped by multisectoral approaches with strong political commitment and effective coordination mechanisms that deal with underlying causes (such as income poverty or gender inequity) in addition to providing evidence-based nutrition-specific interventions.

USAID Focus Countries in Southeast Asia

Discussed in this Report

Burma (Myanmar)

Cambodia

Indonesia

Laos

Philippines

Timor Leste

Vietnam

Tackling malnutrition in Asia is critical for several reasons:

Asia leads other world regions with not only the highest percentage of children under 5 who are underweight or wasted (21.9% and 11.2% respectively, as of 2011), but given the population density across the region, it is also home to the greatest total number of children under 5 who are stunted, wasted, or underweight (103.5 million, 39.2 million, and 76.6 million respectively, as of 20111) (Black et al. 2013) o Of the five subregions in Asia, Southeast Asia2 has the second highest prevalence and total number of children who are stunted (29.4%, 15.6 million), wasted (9.4%, 5.0 million) and underweight (18.3%, 9.7 million) (Black et al. 2013).

The burden of malnutrition in this region alone is likely to hold the world back from achieving Millennium Development Goal (MDG) targets and potentially the new global 2025 targets for nutrition

Maternal undernutrition—including short stature and low body mass index (BMI)—is a critical and neglected problem throughout parts of Asia, contributing to high rates of low birth weight

1 The countries included in Asia for these estimates are as defined by the United Nations for regions and subregions (see http://unstats.un.org/unsd/methods/m49/m49regin.htm. These estimates exclude Japan but include both India and China.

2 Southeast Asia (as defined by the United Nations) includes Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, Timor-Leste, and Vietnam.

(LBW) and intrauterine growth restriction in many countries, which top other world regions in terms of both percentages and absolute number of live births affected (Black et al. 2008)

Asia encompasses a diverse range of geography, cultural, religious, and ethnic groups, as well as varying levels of political stability, economic development, and urbanization. Understanding the current nutrition situation as well as the potential causes of malnutrition in different countries of Asia is crucial for supporting country-specific and country-led programs and policies to effectively address this pervasive problem.

The U.S. Agency for International Development (USAID) works with 31 countries in Asia, seven of which are discussed in this report, representing the Southeast region of Asia: Burma (Myanmar), Cambodia, Indonesia, Laos, the Philippines, Timor Leste, and Vietnam. Four of these seven focus countries (Burma, Indonesia, the Philippines, and Vietnam) belong to the 20 countries with the highest burden of malnutrition which constitute 80% of the world’s undernourished children (Bryce et al. 2008).

These seven selected countries will serve to provide a snapshot of the nutrition situation in a portion of the Southeast Asian region where malnutrition is highly prevalent and identify potential causes experienced in this part of the world, which are likely shared among many countries in Southeast Asia with similar characteristics.

USAID has articulated its goals for reducing malnutrition globally (see Box 1), and with increased nutrition-specific interventions and nutrition-sensitive activities, USAID hopes to reduce stunting by 20% in the next 5 years. The U.S. Government (USG) has doubled its funding for nutrition and tripled its funding for agriculture since 2008, which includes US$1 billion in nutrition-specific interventions and US$9 billion in nutrition-sensitive activities for the fiscal years 2012–2014 (The White House 2013).

Given the number of children affected by stunting in Asia and the fact that the majority of the world’s undernourished children are in this region, USAID has the opportunity to expand nutrition investments and better leverage existing investments in these seven countries to have a greater impact on reducing not only the regional burden of malnutrition but also the global burden, while also fulfilling its objectives of reducing malnutrition by 20 to 30% globally. The main goals of this report are to:

Discuss potential causes and drivers of malnutrition, as well as solutions, in general and specific to the Asian region

Describe the current nutrition situation of children under 5 years of age (with specific emphasis on children under 2) and women of reproductive age (adolescents and pregnant and lactating women when data permit) in the selected countries

Provide an overview of current programs and policies that are directed at improving nutrition (including both preventative and curative measures) among these vulnerable groups in each country

Provide recommendations for prioritizing and increasing investments in nutrition and better leveraging existing investments for greater impact on reducing malnutrition

This report first presents causes of malnutrition of concern in Asia, potential solutions, and current global and USG efforts to reduce it (Section 2). Next, regional analysis is provided in Section 3 that compares data on nutrition status and trends across and within the seven countries of focus in this report (see Appendix 1 for methods used). From this analysis, potential causes of malnutrition are identified in Section 4 followed by priorities to address these causes (Sections 5 and 6) and recommendations for USAID (Section 7). This report also includes separate individual nutrition profiles for each country consisting of an overview of programs and policies that address nutrition for young children and women of reproductive age, data on nutrition status and trends, priority nutrition problems and their probable causes, and recommendations for dealing with them effectively.

Box 1. USAID’s Strategic Approach to Nutrition: Improving Nutrition for Women and Young

Children

Good nutrition is central to successful development. USAID’s strategic approach to nutrition focuses on:

Preventing malnutrition through a comprehensive package of maternal, infant, and young child nutrition programs

Combating micronutrient deficiencies with targeted supplementation to vulnerable groups and food fortification

Managing moderate or severe acute malnutrition through community‐based programs

Providing nutritional care and support for people living with HIV

Improving nutritional outcomes in food security programs

By 2015, USAID’s nutrition programs will have reduced malnutrition by 20 to 30% in 17 priority

Feed the Future and Global Health Initiative countries.

Source: USAID 2013

2 Background

Causes of Malnutrition of Particular Concern in Asia

This section discusses determinants of malnutrition among pregnant and lactating women and young children in Asia and several important risk factors that are particularly relevant to this region.

Dietary intake. Both dietary quantity (total amount of energy consumed) and quality (dietary diversity and intake of specific nutrients) are of concern in Asia. Traditionally vegetarian diets in some countries, low intake of micronutrient-rich foods (particularly meat and animal source foods, but also certain vegetables and fruits), high intake of compounds that inhibit absorption of key nutrients such as iron and zinc, and monotonous diets based largely on staple grains such as rice are considered prime contributors to micronutrient deficiencies and anemia in Asia. Micronutrient deficiencies of particular concern in Asia include iron, zinc, vitamin A, iodine, and calcium deficiencies.

Low birth weight and maternal nutritional status. LBW in developing countries is primarily due to intrauterine growth restriction rather than premature birth and is both a cause and consequence of maternal and child malnutrition. Asia leads other world regions in both the percentage of children who are born with LBW (18% for Asia overall, ranging from 5.9% in East Asia to 27% in South and Central Asia [Black et al. 2008]) as well as the total absolute number of live births suffering from this condition. The prevalence and total number of infants born “small for gestational age,” indicating some level of fetal growth restriction, is much higher—approximately 30% in Asia overall, ranging from a low of 6.8% in East Asia to a high of 44.6% in South Asia (Black et al. 2013).

Infants who are born with LBW are at greater risk of death during the neonatal period (particularly due to birth asphyxia and infections, including sepsis, pneumonia, and diarrhea) (Black et al. 2008). Compared to its other global regions, the World Health Organization’s (WHO’s) Southeast Asia and Western Pacific regions have the highest percentages (52% and 54%, respectively) of mortality for children under 5 years of age attributable to neonatal deaths (Liu et al. 2012) 3.

Long-term consequences of LBW and intrauterine growth restriction are also apparent, including increased risk of underweight and stunting in childhood. Girls who do not grow adequately during childhood nor catch-up during adolescence, reach their childbearing years with short stature, which can contribute to the risk of LBW in their offspring (Han et al. 2012) thus continuing the intergenerational transmission of malnutrition. Maternal short stature is also associated with increased risk of complications during delivery due to smaller pelvic size. If a girl becomes pregnant during adolescence, further height gain is prevented, and by 6 months postpartum, previously pregnant adolescents have lower BMI, fat mass, and mid-upper arm circumference as compared to their nulligravida peers (Rah et al. 2008).

Maternal underweight has also been shown to increase the risk of LBW and premature birth (Han et al.

2011), as do other nutritional deficiencies, particularly of micronutrients such as iron. Asia has some of the highest rates of maternal malnutrition in the world; in South Asia in particular, the rates of maternal malnutrition (in terms of short stature and underweight, reflecting both chronic energy deficiency as well as micronutrient deficiencies) range from 10 to 40% of women of reproductive age and are considered critical to address (Ahmed et al. 2012). Gender inequity, in terms of access to food, health care, income, 3 The WHO Western Pacific region includes 37 countries, including four countries in this report: Laos, the Philippines, Vietnam, and Cambodia. Burma, Indonesia, and Timor Leste are part of the WHO Southeast Asia region.

education, and decision-making power (discussed later in more detail), is thought to be a primary cause of maternal malnutrition in Asia (ibid).

Breastfeeding practices. Breastfeeding is the cornerstone of good infant nutrition, and although breastfeeding of long duration is fairly universal throughout Asia, early initiation of breastfeeding (within the first hour of birth) and exclusive breastfeeding through the first 6 months of life are not common in many countries of the region (Lutter et al. 2011). Delaying initiation of breastfeeding and introducing other liquids prior to 6 months of age (including pre-lacteal feeds) increases the risk of disease and death:

in one study from south India, delaying the initiation of breastfeeding past the first 24 hours increased the risk of death by 78% (Garcia et al. 2011).

Complementary feeding practices. The complementary feeding period, when food and liquids other than breast milk are introduced to the infant’s diet, constitutes a high-risk period for development of malnutrition and disease, particularly diarrhea. Inadequate complementary feeding practices have been identified as a major cause of malnutrition globally, particularly in Asia. Many aspects of complementary feeding are inadequate—the timing of introduction of solid/semi-solid food, the frequency of feeding, the choice of foods, and the way in which they are prepared. Recent analyses of complementary feeding practices in Indonesia, showed that only a little over half of children under 2 (53%) were receiving enough meals for their age per day, although dietary diversity was higher (68%) than that seen in other South Asian countries examined (Ng et al. 2012).

Disease; unhealthy environments; water, sanitation, and hygiene; and access to health care.

Of diseases, globally and in Asia, diarrheal diseases affect the greatest number of individuals— approximately 1.25 billion people in WHO’s Western Pacific region according to estimates from 2004 (WHO 2008)—followed by pneumonia and other lower respiratory infections—affecting 46 million in WHO’s Western Pacific region as of 2004 (ibid). Young children, particularly those between 6–23 months of age, have a particularly high incidence of acute respiratory infections (ARI) (which include both lower and upper respiratory infections), diarrhea, and fever (a potential indicator of malaria).

Pneumonia, diarrhea, and malaria represent the three leading causes of mortality in children under 5 globally (Liu et al. 2012). In WHO’s Southeast Asia region, pneumonia accounts for 22% of under-5 deaths; diarrhea accounts for 11%, and malaria accounts for 1% (ibid).

Mortality from diarrhea has decreased in recent decades, most likely due to improved case management including use of oral rehydration therapy and improved counseling on feeding during illness (Jamison et

al. 2006). Handwashing with soap, providing access to safe water (including household treatment of water for drinking), and appropriate sanitation services to dispose of solid waste will all contribute to reductions in diarrheal morbidity as human feces are the primary source of diarrheal pathogens (ibid). Handwashing has the most consistent preventive effect across populations (Cairncross et al. 2010). In an analysis of determinants of maternal and child malnutrition, sanitation, particularly pit latrine use, had a much higher positive effect on nutrition outcomes in South Asia than in sub-Saharan Africa or Latin America and the Caribbean (Smith et al. 2003). Exclusive breastfeeding and improved complementary feeding practices (including preventing contamination of complementary foods as well as providing nutritionally adequate foods before, during, and after illness) are also essential in reducing diarrhea incidence (Jamison et al.

2006). Rotavirus and measles vaccinations also prevent diarrhea (ibid).

Viral infections are responsible for 40–50% of pneumonia cases in children under 5 in developing countries (Jamison et al. 2006). Two preventative strategies are widespread vaccination against viral and bacterial causes of lower respiratory infections and effective case management including early detection (ibid). ARIs are also impacted by high levels of pollution in many settings, including indoor pollution created by poor housing, overcrowding, and use of organic fuel for cooking (Bhutta et al. 2004). Lower-emission stoves and/or clean fuel help to reduce ARIs (WHO/UNICEF 2013).

Reductions in morbidity and mortality from disease in many countries in Asia are hampered by inadequate access to or utilization of health services. In many areas, particularly those that are rural or remote, health care facilities may be sparse requiring traveling long distances for care, and families may not utilize care when children become sick. Where facilities exist, they are frequently understaffed and under-resourced, lack supplies and equipment, and the cost of services can make them inaccessible to certain segments of the population. In addition, the quality and availability of nutrition services is particularly limited in some countries, which may limit the impact that nutrition interventions can have on disease.

Poverty, food security, population density, and land ownership. Malnutrition has long been known to be a consequence of poverty. Poverty is a critical underlying determinant that influences a child’s nutritional status through several pathways: hindering food security and access to diverse and nutritious foods, reducing a child’s ability to receive adequate care, and restricting access to health services and treatment (Black et al. 2008). In turn, malnutrition contributes to poverty, as poor nutrition in utero and early childhood adversely affects cognitive and physical development ultimately leading to reduced human capital and economic productivity, further perpetuating the cycle of poverty. Poverty in Asia is influenced by food security, population densities, and lack of land ownership; all three of which also impact nutritional status. In many parts of Asia, population density is high, limiting the amount of land a household has access to. Increasing landlessness as a result of increasing population pressure on the land is a significant factor in the changing nature of household food security and poverty. In the span of just a generation, population density has resulted in families relying increasingly on off-farm income sources to subsist rather than being able to subsist from the land they own. This transition has meant that poor families are net buyers of food, and not net producers or net sellers of food. As a result, purchasing power and household and individual income levels play an important role in determining how food secure a household is. Further, the need for off-farm income that largely determines purchasing power means that when food prices fluctuate, families pay a higher price for the same amount of staple foods and are less able to afford diverse nutrient-dense foods such as fruits and vegetables. Land ownership laws can also negatively affect land ownership and food access, particularly if they discriminate against women.

Land ownership is also affected by political and civil upheaval, as in Timor Leste, which is recovering from significant conflict in 2006 and has a much longer history of conflict and occupation, and in recent years has not had an effective system to resolve land tenure disputes (IRIN 2011). Finally, climate change (including flooding, land erosion, and rising sea levels) has additional detrimental effects on land ownership in Asian countries affected.

Gender inequality and women’s status. The importance of the education and social status of women relative to men in improving nutritional and health status of children has been documented (Smith et al.

2003). The low status of women in South Asia in particular has been identified as a basic cause of poor maternal and child nutrition and health outcomes (Bhutta et al. 2004). Women of low social status generally have less control over household resources, stricter time constraints, less access to information and health services, poorer mental health, and lower self-esteem (Smith et al. 2003). All of these factors contribute to a woman’s own nutritional status (through her nutritional and care practices for herself, including access to medical care) and worsens her own health outcomes, thus affecting the nutrition and health outcomes of her offspring, both through biological pathways as well as the care she is able to provide to them. In an analysis of three world regions—South Asia, sub-Saharan Africa, and Latin America and the Caribbean—the negative impact of women’s social status on the nutritional status of their children was the strongest in South Asia, and within South Asia, women’s status appeared to be a stronger factor than the other two determinants also identified: urbanization and sanitation (ibid). A recent assessment of mental health and depression among women in both Vietnam and Bangladesh found that not only did depression affect 1 in 3 and 1 in 2 women, respectively, but in both countries it was significantly correlated with greater incidence of ARIs and diarrhea, and with greater levels of stunting in Bangladesh and greater levels of wasting in Vietnam (Nguyen et al. 2013).

Civil and political unrest. Although not prevalent in all countries of Asia, development has been hindered in many countries of the region due to war and political unrest. Of the focus countries in this review, Timor Leste and Indonesia have most recently suffered from political unrest/instability or civil war, while Vietnam and Cambodia have older histories of decades-long conflict and violence. Populations experiencing and recovering from such political instability and/or violence will be inequitably affected, for example, women and children are most severely affected by civil strife and the poor experience particular health and nutrition inequities during the rebuilding period. Destruction of basic services—such as schools—and infrastructure, as well as continued insecurity, prevent access to and utilization of needed services, which negatively impact health and nutrition outcomes, particularly those of women and children.

Governance. The role of government (or lack thereof) is a critical underlying factor contributing to malnutrition. Tackling malnutrition requires that governments demonstrate good “nutrition governance” through: sustained political commitment to improving nutrition that can withstand changes in leadership and other political upheavals; the capability to coordinate actions across different sectors (e.g., health, sanitation, and agriculture) and levels of government (national to local); designating resources for action in nutrition that will be most effective (i.e., reaching those most affected by malnutrition); working effectively with other donors and stakeholders active in the same arena; being accountable to those most vulnerable to nutrition; and providing effective, responsive, and transparent action to address malnutrition issues (Engesveen et al. 2009; Mejia Acosta and Fanzo 2012). Thus it is not surprising that countries with higher levels of government effectiveness, political stability, and rule of law have been shown to have lower rates of malnutrition (Pridmore and Carr-Hill 2010). The strength of a country’s nutrition governance can be partially measured through assessing the presence or absence of concrete plans and policies addressing nutrition, resources dedicated toward action in nutrition, whether nutrition is a component of national development strategies, the priority that is given to nutrition relative to other sectors, the presence of inter-sectoral coordination committees, and regular data collection and monitoring of nutrition indicators (Engesveen et al. 2009). The recently launched Hunger and Nutrition Commitment Index ranks countries on 22 indicators of political commitment to reduce hunger and malnutrition and looks at three areas of government action: (1) policies and programs, (2) legal frameworks, and (3) public expenditures (Lintelo et al. 2013). However, the existence of policies and inter-sectoral coordination committees may not tell the whole story nor be indicative of greater progress in combating malnutrition (Mejia Acosta and Fanzo 2012).

Preventing and Treating Malnutrition Effectively

The 2008 Lancet series on maternal and child undernutrition provided an impetus for the reinvigoration of nutrition efforts and their integration into other sectors. Although nutrition has been on the global development agenda for many years—MDG 1 aims to reduce the proportion of those suffering from hunger by half between 1990 and 2015, and other MDG targets indirectly involve nutrition—the Lancet series analyses provided compelling evidence that not only is undernutrition a serious and neglected public health problem (Black et al. 2008) but that there are effective solutions to address it (Bhutta et al.

2008). Many of these solutions are also extremely cost-effective, as shown by analysis by the Copenhagen Consensus in 2012, which identified interventions to prevent undernutrition in young children (including micronutrient supplementation, deworming, complementary feeding, and behavior change strategies) as the number one investment to advance global welfare in developing countries due to the very high cost-benefit ratios of these interventions. These “nutrition-specific” interventions (as outlined in Figure 1) tackle the most proximate determinants of malnutrition. Figure 1 also demonstrates the range of target groups that need to be reached to address malnutrition effectively—from adolescents to pregnant women (and women of reproductive age prior to conception) to childhood.

Figure 1. Evidence‐Based Interventions to Improve Maternal and Child Nutrition

Source: Bhutta et al. 2013

Nutrition-specific interventions will work to reduce malnutrition in the short term. However, to achieve long-term reductions in maternal and child malnutrition, improvements in the underlying and basic causes of malnutrition through a multisectoral approach that includes a broader set of “nutrition-sensitive” sectors—such as agriculture, health, family planning, social protection, and education—and addresses the realities of each country will need to occur. (See Box 2 for examples of nutrition-specific and nutrition-sensitive interventions). A recent analysis of nutrition-sensitive interventions and programs in agriculture (homestead food production and bio-fortification), social safety nets (cash or in-kind transfers), early child development, and education (particularly of parents) found that there was enormous potential to enhance the impact of nutrition-specific interventions through these complementary programs (Ruel et al.

2013). However, the effect of these complementary programs on nutrition outcomes is still largely unknown (with a few exceptions) due to programs that didn’t originally take nutrition into account in their design, actions, and goals, as well as poor-quality evaluations. Thus to improve impact on nutrition, nutrition-sensitive programs should aim to:

Improve targeting of beneficiaries based on their nutritional vulnerability (i.e., focused on the 1,000-day window) and geography (based on poverty, location, and level of food insecurity)

Use “conditions” or incentives that address health and nutrition as a requirement for receipt of cash transfers (e.g., conditional cash transfers for education of girls or for delaying first pregnancies)

Include nutrition goals and actions within these programs and ensure that program design and delivery/implementation will effectively address nutrition

Engage women and include interventions to improve women’s health, nutrition, time allocation, and empowerment

Explore ways to serve as a platform for the delivery of nutrition-specific services (e.g., distribution of fortified foods through agriculture or social safety-net programs) (Ruel et al. 2013).

In addition to a multisectoral approach incorporating nutrition-specific and nutrition-sensitive programming, strong nutrition governance is essential. Mechanisms to coordinate efforts across different government sectors and levels of government (national, regional, and local), and providing leadership at the highest level of government, has been shown to be a commonality across countries that have seen significant decreases in malnutrition in recent years (Ruel 2008) (see Box 3 on nutrition governance). As a part of nutrition governance, increasing the participation of communities in decision-making and creating demand for improved nutrition has also been found to be effective (Pridmore and Carr-Hill 2010).

Particularly relevant for certain countries in Asia, finding effective ways to improve the status of women—whether through microfinance directed to women, cash transfers conditional on girls attending school, increasing female representation in government, and/or support for reproductive health and family planning (King et al. 2008)—will be essential for reducing malnutrition. Supporting and cultivating monitoring and evaluation efforts as well as increasing public spending for nutrition and health have also been identified as key actions for supporting reductions in malnutrition (Ruel 2008).

Despite the challenges to reducing malnutrition, examples of effective action in reducing malnutrition exist. At the national level, Thailand has been seen as an example of a country that effectively reduced malnutrition through coordinated, multisectoral efforts led with strong nutrition governance while Vietnam has seen rapid and dramatic reductions in childhood stunting (see Boxes 4 and 5 for a description of the factors credited for success in Thailand and Vietnam).

At a programmatic level, USAID Title II development food assistance programs, which employ a multisectoral approach to reduce malnutrition and improve food security (through activities in agriculture;

maternal and child health and nutrition; water, sanitation and hygiene; and nonagricultural income generation; among others), have been shown to be effective as a whole to reduce child malnutrition, improve some indicators of maternal and child health and nutrition, and increase household access to income and food (van Haeften et al. 2013) (see Box 6 for “lessons learned” from Title II development food assistance programs in terms of improving nutrition outcomes). Box 7 describes the experience of Title II development food assistance programs in Bangladesh and the successful strategies they used to achieve their outcomes. Bangladesh is one of the few country examples where technical sector interventions were evaluated in an integrated manner.

At the global level, the Scaling Up Nutrition (SUN) movement was launched in 2010 with a framework for scaling up nutrition presented at the World Bank and International Monetary Fund annual meetings, followed by a roadmap presented at the United Nations General Assembly. SUN has since evolved into a movement of countries, development partners, international organizations, civil society groups, and businesses, all committed to (1) creating an enabling political environment for country-led scaling up of nutrition involving multiple stakeholders, (2) establishing best practices for scaling up proven interventions, (3) aligning actions around high quality and well-costed country plans, and (4) increasing resources to coherent aligned approaches (Secretariat of the SUN Movement 2012). As of January 2014, over 100 organizations and 45 countries have committed to the SUN movement, including 10 countries in Asia, 3 of which are included in this report (Burma, Indonesia, and Laos).

Box 2. Nutrition‐Specific versus Nutrition‐Sensitive Interventions

Nutrition‐specific interventions/programs refer to the immediate, most proximate causes of maternal and child malnutrition, namely dietary intake, feeding and caregiving practices, and infectious disease burden. Interventions that would be considered “nutrition‐specific” include maternal dietary or micronutrient supplementation, promotion of breastfeeding and optimal complementary feeding practices, dietary diversification and micronutrient supplementation for children, fortification, treatment of severe acute malnutrition, and disease prevention and management.

Nutrition‐sensitive interventions/programs address the underlying causes of maternal and child malnutrition—such as food security and access to health services and resources at the maternal, household, and community levels for caregiving—and include specific nutrition goals and actions.

Examples of nutrition‐sensitive interventions or programs include agriculture and food security programs; social safety nets; early child development; women’s empowerment; schooling; water, hygiene, and sanitation; and health and family planning services.

Adapted from Ruel et al. 2013

Box 3. Good Nutrition Governance: What is Needed?

The Institute of Development Studies carried out a six‐country assessment in 2011–2012 to compare the “formulation and implementation of government nutrition strategies” across

Bangladesh, India, Peru, Zambia, Brazil, and Ethiopia (Mejia Acosta and Fanzo 2012)—countries which had all scored “medium” or “strong” on nutrition governance in a previous assessment by

WHO in 2009 (Engesveen et al. 2009). The study found three aspects as key to good nutrition governance: capability to coordinate actions across multiple sectors and government sectors;

accountability to the demands of civil society and other stakeholders to take action to address malnutrition; and responsiveness to ensure that the “window of opportunity” during the first

1,000 days to prevent malnutrition is not missed. In addition, the key findings and policy recommendations as they relate to “how government works best to improve nutrition outcomes”

(Mejia Acosta and Fanzo 2012) are as follows:

1. The executive branch of government should be directly involved in malnutrition reduction policies at the presidential or prime ministerial level. This helps to raise public awareness, coordinate efforts of different government sectors, and protect funding allocations.

2. Establish effective bodies to coordinate nutrition actions across government ministries.

These bodies can facilitate effective funding allocations, monitor progress, and facilitate decision making among other stakeholders. Coordination bodies need to have strong political support and appropriate funding sources.

3. Frame nutrition as an integral part of the national development agenda. A high public profile for nutrition can create greater public awareness and concern and is most effective when nutrition is seen as part of a broader development agenda.

4. Develop a single narrative about the severity of malnutrition. This can help to set clear policy goals.

5. Ensure that local governments have the capacity to deliver nutrition services. Adequate decentralized structures help to deliver nutrition services at the local level.

6. Encourage local ownership of nutrition programs and their outcomes.

7. Support civil society groups to develop social accountability mechanisms.

8. Collect nutrition outcome data at regular intervals, especially in highly dynamic and fragile contexts. Lack of accurate and timely nutrition data can impede formulation of nutrition strategies.

9. Use centralized funding mechanisms to generate greater incentives to cooperate in the design, implementation, and monitoring of nutrition interventions.

10. Governments should create financial mechanisms to protect (earmark) nutrition funding and use it in a transparent way.

Box 4. Malnutrition Reduction in Thailand: Factors for Success

Thailand is frequently cited as a success story in reducing malnutrition, both in Asia and globally.

The prevalence of underweight among children under 5 was reduced from 25% in 1986 to 15% in

1995, a rate of 1.1 percentage points per year which is double what has been seen elsewhere due to general development. While some of the factors contributing to Thailand’s success (outlined below) may be replicable in other countries, one of the primary lessons learned from Thailand’s experience was that identifying strategies that fit Thailand’s particular political, cultural, and administrative environment was crucial. Some of the reasons for Thailand’s success in tackling malnutrition (which mirror many of the conclusions in Box 3 on good nutrition governance) include:

Government commitment to a national nutrition program and multisectoral poverty alleviation strategies

Creating a national consensus that investing in nutrition was important to building the country’s future and communicating this to all levels of society

Multisectoral holistic approach to addressing malnutrition involving the health, education, and agricultural sectors, and particularly close integration of nutrition within health

Targeting the most‐vulnerable population groups and regions (provinces) of the country to ensure the best use of resources

Building community involvement, empowerment, and self‐reliance to establish the idea that

“nutrition was a family and community responsibility not just the Government’s” through:

o The use of community volunteers on a large scale o Community involvement in program planning and implementation o An assessment and monitoring approach—“Basic Minimum Needs” that prioritized nutrition among its indicators—which served as a tool for communities to collect their own data, conduct their own needs assessment, and identify their development priorities, and also provided results at the community level o Local financing mechanisms (which also increased sustainability)

Managing the nutrition sector through multiple committees, rather than one agency, which increased “buy‐in” from multiple stakeholders to the importance of nutrition

Sources: Heaver and Kachondam 2002; Ruel 2008; Tontisirin and Bhattacharjee 2001

Box 5. Reducing Stunting in Vietnam: Factors for Success

Vietnam has seen dramatic declines in childhood stunting unlike many of the other countries in the region. The stunting prevalence of children under 5 has steadily fallen from 43% in 2000 to

36% in 2006, and finally to 23% in 2011. Understanding some of the reasons why Vietnam has been so successful in reducing under‐5 stunting levels may provide some key insights for other countries around the region.

The lack of change in infant and young child feeding (IYCF) indicators (i.e., exclusive breastfeeding has remained constantly low at around 17% for the last 10 years) indicate that the improvement in stunting may come more from improvements in water and sanitation, agricultural growth, and a strong health system. Access to safe drinking water in Vietnam increased from 79% in 2000 to

92% in 2011 while the percent of households using “improved/not shared” toilet/latrine rose from 44% in 2000 to 74% in 2011. Diarrhea prevalence among children under 5 years fell from

11% in 2000 to 7% in 2011; the lowest prevalence in the region. In addition to improved water and sanitation, Vietnam has seen some of the highest rates of agricultural growth in the word

(between 1990 and 2010) at 4% per year. However, this high rate of growth in agriculture is not necessarily linked to a reduction in stunting as Tanzania has seen similar growth (3.8%) over the same time period and has not seen the same reduction in stunting. In Vietnam, increased yields led to a demand for more jobs and a majority of small landholders saw increased yields and profits (factors not present in Tanzania), thus indicating that the type of agricultural growth may be an important factor as well. Lastly, Vietnam has seen continued improvements in their health system, as 92.4% of women gave birth in a health facility in 2011 compared to 63.8% in 2006, which illustrates the high levels at which women and children are able to access health care.

Vietnam’s success illustrates the impact that nutrition‐sensitive interventions, such as improved water and sanitation, access to more and diversified foods from increased agricultural outputs, and increased access to health services, can have on reducing stunting. Vietnam’s success also indicates that rapid change is possible by addressing both the basic and underlying causes of malnutrition. However, this is still only the first step for Vietnam as the stunting prevalence is still very high among ethnic minorities (41% in 2011) and still affects one in five children across the country. In addition, an examination of the stunting prevalence by age indicates that stunting is highest among children 24–35 months and continuously higher in children above the age of 2 than below. Thus, in order for Vietnam to continue its impressive reduction in under‐5 stunting, addressing key nutrition issues such as the extremely low levels of optimal IYCF practices and potential causes of stunting among older children, such as poor dietary diversity and feeding frequency, is critical. In an effort to address some of these concerns, the Government of Vietnam has amended the labor code to allow mothers 6 months of maternity leave, expanded the ban on the advertisement on breast milk substitutes, and a created a revised National Infant and Young

Child Feeding Action Plan.

Sources: Vietnam Multiple Indicator Cluster Survey’s from 2000, 2006, and 2011; Food and Agriculture Organization of the United Nations (FAO) et al. 2012

Box 6. Lessons Learned from USAID Title II Development Food Assistance Programs

The Second Food Aid and Food Security Assessment evaluated changes in and accomplishments of

Title II development food aid (non‐emergency) programs between 2003 and 2009. In total, 101 programs in 28 countries were reviewed including 64 programs in 20 countries in Africa, 14 programs in 3 countries in Asia, and 23 programs in 5 countries in Latin America and the

Caribbean. These programs implemented interventions in a wide‐range of sectors to address food insecurity and malnutrition, including: agriculture and natural resource management (AG/NRM);

maternal and child health and nutrition (MCHN); vulnerable group feeding; HIV; education; water, sanitation, and hygiene; non‐agriculture income generation; infrastructure; and emergency preparedness and disaster management.

Overall, the assessment showed that:

Stunting in children under 5 fell on average 1.32 percentage points per year and underweight fell by 0.63 percentage points per year with delivery of MCHN services in Title II programs. These rates exceeded the secular trends in undernutrition reduction in many of the same countries (based on Demographic and Health Surveys [DHS]).

More than three‐quarters of the programs reporting on household diets and incomes found improvements, including improvements in the months of adequate household food provisions and improvements in markers of household dietary diversity.

Evidence for the effectiveness of integrating interventions across different technical sectors (e.g., AG/NRM and MCHN) is slim however, as few programs reviewed in the assessment measured such effects (e.g., impact on beneficiaries receiving both AG/NRM and MCHN programming). One evaluation that did look at the integrated effects of multiple sectors was in Bangladesh (see

Box 7).

Recommendations for MCHN programming based on findings from projects that saw greater improvements in nutrition include:

Targeting women and children in the first 1,000 days from pregnancy to 2 years of age, focusing on prevention

Providing most or all of the Essential Nutrition Actions (ENA) as well as preventive and curative health services

Coordinating with child health days to ensure greater coverage of health and nutrition services

Improving complementary feeding practices; strategies included prioritizing improving complementary feeding, behavior change with the right message to the right person at the right time based on formative research on maternal dietary and infant and young child feeding

(IYCF) practices, and counseling home visits to improve IYCF

Preventive, conditional supplementary feeding as an essential intervention; programs that provided MCHN…