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Approaches that work

For nutrition to improve, many factors are necessary. A recent study by the United Nations, which confirmed that there is no one formula to follow, had this is to say about some of the factors that are essential:

Nutrition and economic growth: Most countries in which nutrition has improved over the last two decades also enjoyed relatively high rates of economic growth over a sustained period. Where economic growth has resulted in increased household income and resource access for the poor, the nutritional pay-off has been large. In Indonesia, for example, economic growth from 1976 to 1986 was accompanied by a 50 per cent rise in the income of the poorest 40 per cent of the people. Improvements in nutrition were relatively constant throughout the economic boom, although they could have been even better.

But while economic growth must be understood as a frequent contributor to nutrition improvement, it is not a necessary condition for it.

Nutrition and the status of women: Where nutrition improvement has lagged behind economic growth, social discrimination against women is common. The high rates of child malnutrition and low birthweight in much of South Asia are blamed by some experts on such factors as women's poor access to education and low levels of participation in the paid workforce, compared with other regions. In Thailand, where nutrition has improved remarkably in the last two decades, women's rates of literacy and participation in the labour force are high, and women have a strong place in social and household-level decision-making.

Nutrition and social-sector spending: Investments in health, education, sanitation and other social sectors — especially with an emphasis on access of women and girls to these services and resources — are among the most important policy tools for improving nutrition. Evidence comes from Zimbabwe, where explicit policies were followed to redress the lack of access of many communities to basic services after independence in 1980.

Actions that concentrate on nutrition improvement may have a more rapid and focused effect. A number of these more direct approaches that have worked are described below.

In villages in the Iringa region of Tanzania, a seemingly modest process began in the early 1980s when villagers, many of them in poor and remote areas, began to track the weight of their children. With financial support from the Government of Italy and day-to-day technical support from UNICEF, the Child Survival and Development Programme eventually reached more than half the population of Tanzania. Severe malnutrition virtually disappeared, and mild and moderate malnutrition was greatly reduced, saving the lives of thousands of children. A major feature of the programme was community-based growth monitoring, which helped people understand the problems that cause malnutrition and take actions to solve them — called the triple A' approach. The programme did not increase the production or availability of basic food, therefore the success achieved suggests that an overall lack of food at the household level was not the major cause of malnutrition in young children and pregnant women in the villages.

In Thailand, another success story

On the other side of the globe, Thailand has improved the nutrition of millions of its children through a combination of approaches, aided by a booming economy. According to the Government, malnutrition of under-five children fell from about 51 per cent in 1982 (measured as a proportion of underweight children) to about 19 per cent in 1990, and severe malnutrition virtually disappeared during that period.

A number of policy and programme measures contributed to reducing both malnutrition and poverty. Targeted to poorer regions, these included school lunch programmes, surveillance of basic minimum needs' indicators, village-level planning to ensure that priority needs were met, rural job creation and support for small-scale food producers.

Protecting, promoting and supporting breastfeeding

Virtually all programmes that have reduced malnutrition have focused on improvements in infant feeding, especially the protection, promotion and support of breastfeeding. Inappropriate advertising and promotion by manufacturers of breastmilk substitutes — mostly infant formula — have been a central challenge in this regard.

In 1981, the World Health Assembly, comprising the health ministers of almost all countries, adopted the International Code of Marketing of Breastmilk Substitutes. Drafted by WHO, UNICEF, NGOs and representatives of the infant food industry, the Code establishes minimum standards to regulate marketing practices, stipulating in particular that health facilities must never be involved in the promotion of breastmilk substitutes and that free samples should not be provided to pregnant women or new mothers.

Progress has been relatively slow in translating the Code's minimum provisions into national laws. As of September 1997, only 17 countries had approved laws that put them into full compliance with the Code. Training and development of model legislation are now accelerating action in this area.

To help support breastfeeding, UNICEF and WHO in 1991 began an intensive effort to transform practices in maternity hospitals. The Baby-Friendly Hospital Initiative (BFHI), as the effort is called, has, in just six years, helped transform over 12,700 hospitals in 114 countries into centres of support for good infant feeding.

Tackling specific nutritional deficiencies

It is impossible to separate protein-energy malnutrition from vitamin and mineral deficiencies, and reductions in overall malnutrition have usually been achieved by addressing both micronutrient and protein-energy deficiencies. But progress has been more rapid in reducing some deficiencies than others.

Grains of salt: Reducing iodine deficiency disorders

The reduction in iodine deficiency, the world's most important cause of preventable mental retardation, is a major global success story. Of the countries that had iodine deficiency problems in 1990, 26 now iodize over 90 per cent of their edible salt. Another 14 countries iodize between 75 and 90 per cent of their salt. It is estimated that up until 1990, about 40 million children born each year were at some risk of mental impairment caused by iodine deficiency in their mothers' diets. By 1997, that figure was probably closer to 28 million. The number of children born each year with cretinism is difficult to estimate — but in 1990 it was on the order of 120,000. It is probably about half that now.

Capitalizing on vitamin A's benefits

Although the value of vitamin A for protecting children against blindness has been known for decades, vitamin A's amazing ability to strengthen resistance to infection and reduce the chances of children dying has only recently won general acceptance by the scientific and medical establishment.

Several approaches exist to prevent vitamin A deficiency that can be highly effective if applied in complementary ways. These include supplements (commonly administered in capsule form), fortification of food and improving diet through gardening or other methods.

By mid-1997, the policy of providing children with periodic high-dose supplements was adopted in all but 3 of the 38 countries where clinical vitamin A deficiency still existed — and in all but 13 of the additional 40 countries with documented subclinical deficiency.

Overall, UNICEF estimates that more than half of all young children in countries where vitamin A deficiency is known to be common received high-dose vitamin A capsules in 1996, compared to about one third in 1994, including such large countries as Bangladesh, India, Nigeria and Viet Nam. At roughly 2 cents per capsule and 20 to 25 cents per delivered dose, few other child health or nutrition interventions are as cost-effective in reducing mortality and disability throughout life as vitamin A supplements.

In many countries, vegetable gardens and various food preservation and preparation methods that enhance the vitamin content of diets have been promoted as means of improving vitamin A intake.

Responding to anaemia

Iron deficiency anaemia is probably the most prevalent nutritional problem in the world. Over half the women in developing countries and a large percentage of young children suffer from it, and progress in reducing its prevalence and impact has been slower than might be hoped.

Many countries have adopted policies to ensure that women who seek prenatal care have access to daily iron supplements to help them meet the very high needs of pregnancy and childbirth. UNICEF is a major supplier of iron/folate tablets — a total of 2.7 billion were provided to 122 countries from 1993 to 1996.

Fortifying foods with iron is also an effective means of addressing anaemia. Wheat flour and flour products are the most common vehicles for iron fortification in places where they are widely consumed and centrally processed, particularly in Latin America and the Middle East.

Improving basic health services

The nutritional well-being of children around the world has benefited greatly from the enormous improvements made since 1990 in access to basic health services for children. By 1996, more than 90 per cent of children were immunized in 89 countries and over 80 per cent in another 40 countries, including a 79 per cent global measles immunization rate, protecting children from preventable diseases as well as leaving their vitamin A levels undisturbed.

In addition, over 1 million children are saved each year from death due to dehydration caused by diarrhoea, through the use of oral rehydration therapy (ORT).

An especially important advance has been the revitalization of basic health services through such measures as the Bamako Initiative, launched by African governments in 1987 in response to the rapid deterioration of public health systems in Africa in the 1970s and 1980s, and now operating in other regions.

With WHO and other partners, UNICEF is committed to accelerated action in malaria control, including the use of insecticide-treated bed nets and support for improved drug use in malaria treatment. A combined programme for the prevention of both iron deficiency anaemia — through iron supplementation, fortification and dietary improvement — and parasite-induced anaemia — through malaria control and deworming — is one emerging approach for effectively addressing these age-old problems.

Programmes featuring improved education and information

School-based programmes and non-formal programmes for youth and adults, such as literacy and parent education courses, are useful complements and sometimes a principal vehicle for promoting better nutrition. Schools, teachers and education programmes can also mobilize community participation in many ways, such as through village education committees and parent-teacher associations.

Eight useful lessons

There is no single prescription, but eight points bear noting.

1. Solutions must involve those most directly affected. People who suffer or whose children suffer from malnutrition cannot be passive recipients of programmes. Problems must be assessed with the full and active participation of the families most threatened by nutritional problems and most familiar with their impact and causes.

2. A balance of approaches is necessary. A central challenge for nutrition programmes as well as other development efforts is finding a balance of approaches that work. Processes involving assessment, analysis and action — the triple A' approach — are essential for formulating appropriate bottom-up' solutions, particularly with respect to the ways in which programmes are organized, managed and monitored. But there are some aspects of resolving malnutrition that can be appropriately formulated at higher levels, using more top-down' application of strategies and technologies, based on the scientific knowledge and the most effective technologies available. A combination of top-down and bottom-up actions may be best, as demonstrated by BFHI in promoting breastfeeding, experience with vitamin A supplementation efforts and progress in salt iodization.

3. Nutrition components work better in combination. Malnutrition is the result of many factors, and it has been attacked most effectively in situations in which several sectors and strategies have been brought to bear. Combining improved infant feeding with better household access to food and more accessible health services and sanitation is clearly more effective in reducing malnutrition than any one of these interventions alone. Communication plays a special role in nutrition programmes in arming parents, other caregivers and educators with basic nutrition information, the ability to make informed decisions and the skills and knowledge needed to take action to support improved nutrition in their communities.

4. Progress hinges on continuing research. Gains against malnutrition have depended on relevant research, but more is needed. For example, it took the urging of United Nations agencies and financing from the Government of Canada to ensure that the impact of vitamin A deficiency on mortality was analysed. Also, research institutions, both industry-based and academic, need to include the poor and their day-to-day nutrition problems on the research agenda.

5. Food production is important but not enough. As was demonstrated in Tanzania, nutrition can be improved even in poor communities without increasing overall food availability. Increasing food production, while often necessary, is never enough to ensure nutrition improvement.
6. Everyone has an obligation to child rights. Children have a valid claim to good nutrition, and government agencies and members of society, including parents, have duties to realize this right. All people need to become aware of the nutrition problem, its causes and consequences, possible solutions and their obligation to respect, protect, facilitate and fulfil this right. Advocacy, information, education and training are important strategies to create or increase this awareness.

7. Community and family-based involvement is vital. If they are to care properly for their children, the poor must be recognized as key actors rather than as passive beneficiaries of commodities and services. All available resources, even those controlled outside the community, should be used to support processes within households and the community to improve nutrition.

8. Government policies must reflect the right to nutrition. Some national policies affect nutrition directly, such as salt iodization or immunization programmes. Others, like income and price policies, affect nutrition indirectly. With the ratification of the Convention on the Rights of the Child, governments have the obligation to respect, protect, facilitate and fulfil the rights enshrined in the Convention. All policies should therefore be analysed in terms of their real and potential impact on the right to good nutrition.

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