Nutrition at the World Food Programme the Immediate Causes of Undernutrition Are Inadequate Dietary Intake and Disease

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This document is available online at wfp.org/policy-resources Table of Contents

Programming for Nutrition-Specific Interventions

Introduction 2 WFP Nutrition Policy 4 Nutrition Terminology 6 Treating Moderate Acute Malnutrition 9 Preventing Acute Malnutrition 14 Preventing Chronic Malnutrition- Stunting 18 Addressing Micronutrient Deficiencies 25

Monitoring and Evaluation Logic Models 30 Updated Nutrition Product Sheet 34

1 Introduction

WFP’s nutrition response is based on a thorough nutrients. WFP uses an expanded version of the understanding of the nutrition situation, in order to UNICEF conceptual framework on the causes of deliver the most appropriate response. This entails malnutrition to guide information gathering, to identifying who is suffering from undernutrition, facilitate identification of possible causes of the what type of undernutrition, when undernutrition is nutrition situation, to understand the relationship occurring, where undernutrition is occurring, and between immediate and underlying causes of why undernutrition is occurring. This also entails malnutrition as well as basic determinants, and to understanding the nutrient gap and access to design the most appropriate responses. 1

Food and Nutrition Security Conceptual Framework l

Nutritional Status/ e

Mortality v e l

l a u d i v i d n I

Individual Food Health Status/ S Intake Disease D R A Z A H

D Livelihood N

A Outcomes

S Context l K

Household Access Social and Care Access to Health Care & e C v

O to Food Environment Health Environment Food e l H

Availability/ d

l o O Markets h T

e E Political, s R u U Economical, o S Institutional, H O

P Security, X Household Food Production, Livelihood

E Social, Income Generating Activities, Exchange, Strategies Cultural, Loans, Savings, Transfers Gender Environment

/ d Agro-ecological y l t i o

Conditions/ l n h e u Climate e v s e m

l Natural u m o o

Physical Human Economic H

Social Capital/Assets C Livelihood Assets

1. WFP’s operational focus is on the left side of this conceptual framework, i.e. on improving household access to food and individual dietary intake of sufficient food and nutrients.

2 Nutrition at the World Food Programme The immediate causes of undernutrition are inadequate dietary intake and disease. The framework also shows that many factors in addition to nutrient intake or consumption of special foods are important for nutritional status. For example, clean water, health care and hygiene, good caring practices, maternal education, household food security and economic development are all important for good nutrition.

WFP aims to address within a comprehensive response the Individual Food Intake and the Household Access to Food. Without adequate nutrients, a child’s bone and muscle growth may not be adequate to gain in height/length, immune system performance may be undermined making the child more susceptible to disease, and brain development may be particularly affected. The

nutrients required for optimal growth and a z o d

development are diverse, including essential amino n e M acids, macro-minerals (e.g. calcium, phosphorus, r o t c

magnesium), and micronutrients (vitamins, i V / minerals). As a rule of thumb, a diet that consists P F largely of plant-source foods (e.g. cereals, vegetables, W fruits), with virtually no animal-source foods (milk products, fish, meat, eggs) or fortified foods, does which includes disease prevention, promotion of not provide all these required nutrients for a young optimal breastfeeding practices, and good hygiene. child’s growth, health and development. The primary intent of this booklet is to assist in the WFP works in partnership with governments in design of nutrition-specific programmes in WFP support of national priorities. A core component of country offices, but may also serve as a resource for the way in which WFP designs and delivers nutrition training or advocacy activities. The following programming is capacity development to design, sections offer introductions to acute malnutrition, implement, and support national policy and chronic malnutrition and micronutrient deficiencies programming for reducing undernutrition in and summarize evidence around WFP’s nutrition- partnership with UN sister agencies, NGOs, the specific interventions. The booklet also includes private sector, and academia. WFP’s efforts in information to support WFP staff in applying the nutrition are focused on improving availability and current evidence base to programme design, access to adequate complementary foods to ensure implementation, monitoring and evaluation that nutrient needs are met, which means that where activities. necessary specific nutrient-dense foods may be used. In addition to meeting nutrient needs, and using For more information, please contact specialized nutritious foods where necessary, WFP [email protected]. supports a multisectoral response to undernutrition

3 2012 Nutrition Policy

The Nutrition Policy was approved by the WFP Executive Board in February 2012. It encompasses the previous policies on nutrition topics and sets the way forward for WFP to engage in nutrition by outlining nutrition-specific and nutrition-sensitive programmes. The new policy demonstrates WFP’s commitment to addressing undernutrition and describes different areas where WFP will focus its efforts.

Saving lives has always been a WFP priority, and diabetes later in life. Stunting holds back particularly in emergencies. Because of their high development, so preventing it can protect and nutritional needs and vulnerability, children are at improve the livelihoods of entire societies. particular risk of stunting and even death when access to a diet that meets all their nutrient needs is Treating and preventing undernutrition is therefore lacking. Poor nutrition for pregnant women can very important in both emergency and non- cause mortality but can also impede foetal growth, emergency settings, to reduce mortality and to resulting in low birthweight and increasing the risk protect and improve livelihoods. The Lancet medical that children’s growth will be stunted. journal has indicated that if undernutrition can be Undernutrition weakens the immune system and overcome – especially during the first 1,000 days – increases the risk and severity of infections. One- not only can lives be saved, but children can also third of all child deaths are related to grow up to realize their full potential. undernutrition, which kills a child every ten seconds. Wasting and stunting are responsible for Undernutrition has many causes, so efforts to tackle approximately 20 percent of childhood mortality, it must be multi-disciplinary, engaging diverse and micronutrient deficiencies in non-wasted, non- stakeholders in line with national priorities. Based stunted children another 8–10 percent. More child on its mandate and comparative advantage, WFP deaths and disability 2 in children younger than five can help to ensure physical and economic access to a years of age are attributable to stunting and nutritious, acceptable and age-appropriate diet for micronutrient deficiencies – with nearly all this those who lack it. While reaching more than 90 burden due to deficiencies of vitamin A and zinc – million beneficiaries every year – many of them than to severe acute malnutrition because they affect children – and meeting both their caloric and many more children and reduce productivity and nutrient needs, WFP can also have an indirect quality of life. 3 impact on the lives of many more people by advocating for comprehensive solutions and Not only does undernutrition kill, it also prevents developing the capacity of governments and other children from growing up to live productive lives. partners to include food-based components in their Children without access to an adequate diet during strategies for tackling undernutrition. the first 1,000 days between conception and 2 years of age suffer irreversible, long-term consequences such as impaired physical and cognitive development. They are also at higher risk of chronic conditions such as cardiovascular disease, obesity

2. Disability-adjusted life-years (DALYs) refer to the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability (WHO). While disease may not always lead to death, it reduces productivity and quality of life. 3. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371:417-40.

4 Nutrition at the World Food Programme WFP’s mission in nutrition is focused on its 1. treating moderate acute malnutrition (wasting); comparative strengths related to food: 2. preventing acute malnutrition (wasting); … to work with partners to fight undernutrition by ensuring physical and 3. preventing chronic malnutrition (stunting); economic access to a nutritious and age- appropriate diet for those who lack it and 4. addressing micronutrient deficiencies among to support households and communities in vulnerable people, to reduce mortality and improve utilizing food adequately. WFP ensures the health of all groups, through fortification; access to the right food, at the right place, at the right time. 5. strengthening the focus on nutrition in programmes without a primary nutrition objective and, where WFP will strive to accomplish this mission by possible, linking vulnerable groups to these designing and supporting the implementation of programmes. programmes and operations in the five areas covered by its policy framework:

WFP will continue to improve its internal processes WFP will also expand its focus on research, assist and capacity to support food-based solutions where partners in developing improved and more cost- appropriate. It will leverage its expanded toolbox – effective products, and ensure an adequate supply to which now includes a greater variety of specially meet growing demand for these products. formulated, nutritious food products, and cash and Undernutrition is a complex, multi-faceted problem, voucher distribution – ensuring that all tools and responses need to include many diverse actors. contribute to the achievement of nutrition WFP’s contribution is essential: in a context of objectives. poverty, the right food, at the right place at the right time is a prerequisite for a successful response.

5 Nutrition Terminology

General Nutrition Terms: processes, immunity, proper growth and metabolism of an individual. Micronutrient deficiencies often Malnutrition: Occurs when the nutrient and energy occur simultaneously and can arise due to lack of intake does not meet or exceeds an individual’s intake, absorption, or utilization of one or more requirements to maintain growth, immunity and vitamins or minerals. It is referred to as hidden organ function. Malnutrition is a general term and hunger because a large percentage of the population covers both undernutrition and overnutrition may be deficient without showing any clinical (overweight/obesity). symptoms or signs of deficiency.

Growth failure: Undernutrition: The consequence of an insufficient The condition where an individual intake of energy, protein and/or micronutrients, is shorter and/or thinner than their well-nourished poor absorption or rapid loss of nutrients due to counterparts and where the individual does not meet illness or increased energy expenditure. her/his growth potential. Growth may fail due to Undernutrition encompasses low birth weight, deficiencies of various micronutrients, energy, stunting, wasting, underweight and micronutrient protein and/or macro-minerals. deficiencies. Nutrition Situation Assessment Undernourishment: Food intake that is Terms: insufficient to meet dietary energy requirements continuously, which is reported on an annual basis Acute malnutrition: by the Food and Agriculture Organization of the Acute malnutrition, also United Nations (FAO) as an indicator for the first known as wasting, develops as a result of recent Millennium Development Goal (MDG) which aims rapid weight loss or a failure to gain weight. In to halve the prevalence of undernourishment in the children, it is assessed through the nutritional index developing world by 2015. 4 Undernourishment is not of weight-for-height (WFH) or mid-upper arm assessed at the individual level. circumference (MUAC). Acute malnutrition is also assessed using the clinical signs of visible wasting Nutrient gap: The difference between nutrient and nutritional oedema. In adults, wasting is requirements and nutrient intake. While diets may assessed through MUAC or Body Mass Index (BMI). 5 be adequate in terms of energy (kcals), they may still In pregnant and lactating women (PLW), wasting be inadequate in terms of nutrients, leaving can be assessed through MUAC. The degree of acute individuals at risk of undernutrition. Nutrient gap malnutrition of an individual is classified as either analysis can be a critical step in developing WFP moderate (MAM) or severe (SAM) according to programming that is appropriate to the context. specific cut-offs and reference standards. At the population level, acute malnutrition is categorized in Micronutrient deficiency: A lack or shortage of a three ways: micronutrient (also called vitamins or minerals). Micronutrients are essential components of enzymes • Global acute malnutrition (GAM): and hormones and are therefore key in bodily represents the proportion of children 6-59

4. The 2012 State of Food Insecurity in the World report presents new estimates from 1990-2012, reflecting key improvements in data and FAO’s methodology. For more information on the revised methodology, see http://www.fao.org/publications/sofi/en/ 5. Please note that "breastfeeding" or "nursing" are the preferred terms for “lactating” when communicating with the media or non-specialists.

6 Nutrition at the World Food Programme months in the population classified with MAM + Ready-to-Use foods (RUF): is the existing SAM according to their weight-for-height generic term that refers to foods that do not need to (WFH) (Z-score), and/or nutritional oedema. 6 be prepared, cooked, or mixed with water. RUFs GAM is an indicator of acute malnutrition in a used in nutrition programmes are generally made population, and is used to assess the severity of with peanuts, sugar, milk powder, vegetable oils, and the situation. vitamins and minerals, though they may be made with chickpeas or other commodities. The package • Moderate acute malnutrition (MAM): can be opened and the food can be eaten directly. represents the proportion of children 6-59 RUFs do not require water or cooking, and have low months in the population who are classified moisture content, so the risk of contamination is with WFH ≥-3 and < -2 (Z-score). low.

• Severe acute malnutrition (SAM): • Ready-to-Use Therapeutic Food (RUTF) is represents the proportion of children 6-59 an energy-dense mineral and vitamin-enriched months in the population who are classified RUF, specifically designed to treat SAM without WFH <-3 (Z-score) and/or presence of medical complications at the community level. nutritional oedema. RUTF is given over a period of approximately eight weeks until the child recovers. During Nutritional oedema: Nutritional oedema indicates treatment, the child will need no other foods a serious type of acute malnutrition in which other than breastmilk. nutritional deficiencies lead to swelling of limbs (feet, hands) due to retention of fluids. Children with • Ready-to-Use Supplementary Food nutritional oedema are automatically classified with (RUSF) is a type of RUF that is specifically severe acute malnutrition (SAM), and often require designed for the treatment of moderate acute therapeutic feeding and medical treatment to malnutrition in children 6-59 months of age. recover. Also known as bilateral oedema. RUSFs are fortified with micronutrients and contain essential fatty acids and quality protein Chronic malnutrition: Chronic malnutrition is to ensure a child’s nutritional needs are met. also referred to as stunting and develops as a result of inadequate nutrition or repeated infections or Lipid-based nutrient supplement (LNS) is a both; typically, during the critical window of term used to describe a product, i.e., a lipid-based opportunity of the first 1,000 days from conception spread or paste. They have different formulations to two years of age. It is measured by the nutritional and dosages and can be used for different purposes. index of height-for-age (HAZ) and is manifested by a They can generally be grouped into three categories. child being too short for his or her age. Unlike They are described as LNS Small Quantity, LNS wasting, the development of stunting is a slow Medium Quantity, and LNS Large Quantity (same as cumulative process that may not be evident RUSF) in order to indicate the amount of product immediately. Chronic malnutrition cannot generally that is used. Current available LNS products are be reversed, only prevented. ready-to-use foods (RUF).

Fortified blended foods (FBFs) 8 are a mixture of Nutrition Product Terms: cereals and other ingredients (such as soya beans or pulses) that have been milled, blended, pre-cooked Specialized nutritious foods 7: Refers to the range by extrusion or roasting, and fortified with a premix of specialized food products and supplements that and with a wide range of vitamins and minerals. In provide varying levels of energy, micronutrients, and order to overcome constraints with earlier macronutrients necessary for growth and health in formulations (bulky, poor absorption, incomplete order to prevent or treat undernutrition. Specialized range of vitamins and minerals), FBFs have been nutritious foods are often defined or categorised as improved and now include a more comprehensive follows: vitamin and mineral profile and some ingredients

6. MUAC can be used to identify children to enrol in nutrition programming (cut-offs are established) and to present a degree of the problem, but thresholds to signal the severity of the nutrition situation have not been established. 7. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Other products may be approved for use in future. 8. WFP has renamed its range of fortified blended foods as follows: CSB+=Super Cereal-CSB; CSB++=Super Cereal Plus-CSB; WSB+=Super Cereal-WSB; WSB++=Super Cereal Plus-WSB, RSB+=Super Cereal-RSB; RSB++=Super Cereal Plus-RSB.

7 are specially processed to decrease the anti-nutrient school feeding programmes. MNPs are distributed in properties. In addition, some improved FBFs used small sachets that are added to solid or semi-solid for treatment of moderate acute malnutrition foods after preparation and prior to consumption. (MAM) in children 6-59 months also include milk. MNPs are tasteless, odourless and easily dissolvable in most warm foods. MNPs do not provide energy, Micronutrient powders (MNPs) are a mix of but do provide the complete FAO/WHO multiple micronutrients used in programmes to recommended daily intake (1 Recommended prevent micronutrient deficiencies (MNDs) among Nutrient Intake (RNI)) of each micronutrient per children 6-59 months, and are also increasingly to dose. Most countries use the 15 micronutrient prevent MNDs among school-age children through formulation. s e y a H

n o n n a h S / P F W s e y a H n o n n a h S / P F W

8 Nutrition at the World Food Programme Treating Moderate Acute Malnutrition T r e a t i n g

M o d e r

WFP Nutrition-specific pillar 1: a t e

To treat moderate acute malnutrition – wasting – c u t

particularly among children aged 6–59 months, pregnant e

and lactating women, and malnourished people in M a l

treatment for HIV and tuberculosis. n u t r i t i o n

1What is acute malnutrition? the broader context, taking into account aggravating and risk factors. At the individual level, acute malnutrition (wasting) Why should WFP engage in the refers to a form of malnutrition that reflects recent treatment of moderate acute weight loss. The effects of acute malnutrition are malnutrition? reversible with treatment. Individuals often appear very thin. Acute malnutrition is assessed through weight-for-height or mid-upper arm circumference • Acute malnutrition is a major risk factor for child (MUAC) in children, with MUAC for pregnant and mortality. A child with MAM is up to three times lactating women (PLW), and by Body Mass Index as likely to die as a well-nourished child. A child (BMI) for adults. The individual is then classified as with SAM is nine times as likely to die as a well- overweight/obese, normal, with moderate acute nourished child. While the immediate risk of malnutrition (MAM), or severe acute malnutrition mortality is higher for a child with SAM than with (SAM) based on specific cut-offs for interpretation of MAM, the total number of children affected by anthropometric measures. Acute malnutrition is also MAM is much greater, and therefore absolute assessed through the presence of nutritional oedema mortality is higher for MAM than SAM. [1-3] (swelling due to excess fluid retention on both sides of the body which indicates severe acute • As of 2011, it was estimated 8 percent of children malnutrition). under five worldwide had moderate and severe acute malnutrition. This figure translates into Nutritional status at the population level is over 52 million children under five. [4] estimated based on the proportion (prevalence) of global acute malnutrition (GAM) in children 6-59 • SAM treatment requires very strong linkages with months in the population. The prevalence of GAM medical screening and services. By reaching refers to the proportion of all of the children children before they develop SAM, treatment of classified with MAM plus all of the children MAM can help to ease the burden on already classified with SAM. GAM is often used as a proxy overstretched health systems in most developing indicator for the severity of a crisis. Other members countries. If there are no programmes to treat of the household may be affected in addition to MAM in an emergency, the prevalence of SAM children 6-59 months. Prevalence of GAM should often increases, which puts additional strain on always be interpreted for programming in light of available health system and on programmes to manage SAM.

9 What is WFP’s nutrition-specific deteriorates or stays the same, individuals are programming to treat moderate often referred to SAM treatment or to medical acute malnutrition? services to address underlying illnesses. WFP should implement programmes to treat MAM • What: Targeted supplementary feeding according to national guidelines for MAM programmes (TSFP) treatment, but if these guidelines are out of date T r in relation to international standards, WFP should e a Why: t • There are five objectives of targeted SFPs, advocate with partners and the government to i n g specifically (i) to rehabilitate individuals with undertake a process to update the guidelines.

o MAM from specific target groups, (ii) to prevent d What specialized nutrition foods to provide: e individuals with MAM from developing SAM, (iii) • r a t The specific specialized nutritious food used will

e to prevent mortality associated with MAM, (iv) to

A provide follow-up support for individuals who depend on the context and target group. Options c

u 11 t have been treated for SAM to prevent a relapse include : e

M and (v) to prevent deterioration of maternal a l n nutritional status and subsequent poor birth - For children 6-59 months: Large Quantity u t Lipid-based nutrient supplements (LNS) r weight. i t i

o (Plumpy’sup, AchaMum, and eeZeeRUSF) and n • Who: Admission depends on whether or not the improved fortified blended food (Super Cereal individual has MAM. Target groups for TSFP Plus ) include: children 6-59 months of age with MAM, PLW 9 with MAM (up to six months after giving - For PLW and malnourished individuals on birth), malnourished individuals (children 5-19, ART/DOTS treatment: fortified blended food women, and men) on Anti-retroviral Therapy (FBF) (Super Cereal) with oil and sugar added (ART) and/or Direct Observed Treatment Short- at the distribution site course (DOTS) treatment (for people living with Where/When: HIV and TB). The specific target groups that are • Treatment of MAM is one included will depend on country level nutrition component of the larger community-based situation analysis. The number of planned management of acute malnutrition (CMAM) beneficiaries is calculated based on the prevalence framework, the recommended response to acute of MAM in the population, the estimated number malnutrition. Treatment of MAM can be of new cases of malnutrition in that target group implemented in both emergency and development 12 over the duration of the project (incidence), and contexts (i.e., Strategic Objectives 1, 3 and 4) . In the expected coverage of the programme. emergencies, the context –as well as pre-existing GAM levels and other indicators of vulnerability – • How: TSFPs provide a specialized nutritious food should guide when a TSFP is part of the to individuals on a regular basis according to emergency nutrition response. TSFPs are specific admission and discharge criteria based on commonly established in countries, provinces or nutritional status. Discharge criteria should be districts where GAM prevalence is at least 10 reached within a reasonable amount of time percent among children aged 6–59 months, or (generally three to four months). 10 TSFPs include where GAM is 5–9 percent but aggravating factors screening for medical conditions that may need exist. Programmes are generally run the whole further treatment, routine health-related year, though an individual will only participate in interventions (supplementation with vitamin A, the programme for a specific period of time. deworming) and nutrition education programmes for caregivers to promote healthy behaviour. Individual recovery is monitored biweekly. Individuals who meet the discharge criteria are considered recovered. If their nutritional status

9. In the case of children under 6 months with MAM, the mother as opposed to the child is admitted into the programme, and exclusive breastfeeding is promoted. The mother is discharged once the child reaches 6 months and then the child is enrolled in the programme if they have MAM. 10. Recent research has shown shorter recovery times with specialized nutritious foods. [5-8] 11. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Other products may be approved for use in future. 12. Largely in EMOP: Emergency Operations and PRRO: Protracted Relief and Recovery Operations, but also possible in CP: Country Programme or DEV: Development programmes if there is an SO3.

10 Nutrition at the World Food Programme CMAM Framework: As agreed in the Services to prevent WFP-UNICEF Global MOU undernutrition

SAM T r

outpatient e a t i Community n g

Outreach M

MAM treatment o d e r

SAM a t

inpatient e

A c u t e

M a l n u t r i t i o n

developed. The nutrients in specialized What is new in WFP’s approach to nutritious foods are more easily absorbed (fewer the treatment of moderate acute anti-nutrients), contain animal proteins (which malnutrition? have been found to be superior than plant proteins in terms of recovery from acute I. Decision-making tool and evolving malnutrition), and have an improved guidance: There have been significant changes micronutrient profile. WHO has developed a to programming for nutrition in emergencies technical note that serves as a reference for over the past years including the development of recommendations on the composition of new specialized nutritious foods and new supplementary foods used to treat children with evidence on programming to prevent acute MAM. Treatment costs using the new products malnutrition. TSFPs are no longer the sole are not significantly greater than those response to the management of MAM in an associated with previous products, though the emergency response. The Global Nutrition cost per metric ton may be somewhat higher, Cluster (GNC) convened a MAM Working Group because they are often more effective and under the leadership of WFP to develop a duration of treatment is often shorter. WFP has decision-making tool for MAM programming developed a product sheet for the specialized design (including prevention, treatment, and nutritious foods currently in use entitled: The monitoring) in emergencies 13 . The tool is Right Food at the Right Time. This document intended as an interim operational guidance includes information on each food and ration while further normative guidance is developed. size indicated for each nutrition intervention and For the non-emergency context, WFP now works target group; as well as information on shelf life on engagement in protocol development or and other characteristics. revision, providing technical and implementation support where MAM III. WFP is working to improve overall monitoring programmes are operating and supporting the and evaluation for TSFPs, including data use of new specialized nutritious foods. quality, data analysis, data aggregation, interpretation and use. TSFP performance II. New specialized nutritious foods: In indicators (e.g. recovery, default, death, non- response to increased understanding of the response) are now WFP corporate indicators for nutrient needs for children with MAM 14 , new treatment of MAM. One area of collaboration is specialized nutritious foods have been between WFP, Save the Children-UK, and other

13. The decision tool is available from http://www.unicef.org/nutritioncluster/files/MAM_DecisionTool_July_2012_with_Cover.pdf 14. The 2012 WHO technical note on supplementary foods for the management of moderate acute malnutrition in infants and children 6-59 months of age can be accessed from http://apps.who.int/iris/bitstream/10665/75836/1/9789241504423_eng.pdf

11 partners to pilot a Minimum Reporting Package How does the treatment of (MRP) to improve the monitoring, evaluation moderate acute malnutrition and reporting of TSFP. relate to WFP’s other nutrition- specific programming?

How do we know that WFP’s • Relation to addressing micronutrient T approach to the treatment of deficiency disorders: r

e The specialized nutritious a moderate acute malnutrition t foods used in the treatment of MAM contain i n works? g adequate micronutrients to meet micronutrient

o requirements without additional use of d e A recent cost benefit analysis of TSFPs in 3 countries Micronutrient Powders (MNPs). Routine r a t found that programme costs were almost entirely

e supplementation of vitamin A at admission, and

A offset by the immediate benefits of the programme treatment of anaemia with iron/folate where c u t (return on investment), with additional value appropriate, are part of routine medical care in e

M created through enabling beneficiaries to lead a TSFP and also address specific micronutrient a l n longer and more productive life. intake shortfalls for individuals with MAM. u t r i t Relation to general food distribution (GFD): i Recent research shows that TSFP can result in high o • n recovery rates, in particular with use of the new Depending on the context, TSFPs may take place specialized nutritious foods. For example: where GFDs or other food security interventions are being provided to food-insecure households. • A study in Malawi showed that in a food- Overall impact of the TSFP may be limited if insecure setting, infants and children receiving household food insecurity is not addressed at the supplementary feeding for 12 weeks with lipid- same time. based nutrient supplement (LNS) or maize-soya flour fortified blended food (FBF) showed recovery from MAM of 93 percent and 75 Who are the key partners in the percent respectively. [5] treatment of moderate acute malnutrition? • The new formulation of Corn Soya Blend (Super Cereal Plus (CSB++)) was shown to be equally Key partners in the treatment of MAM include the effective as Large Quantity LNS/Ready-to-use government, UN agencies, and NGO partners. The supplementary food (RUSF) (peanut and soya- government has the overall responsibility for the based supplementary food) in the treatment of welfare of its population. WFP is the lead United MAM in Malawi . [6] Nations agency responsible for treatment and prevention of MAM. WFP coordinates with UNICEF • The new specialized nutritious foods have better (the lead agency for treatment of SAM) regarding results than the previous formulation of Corn links between treatment of MAM and SAM. Soya Blend (CSB): Furthermore, in emergencies, WFP works under the Inter-Agency Standing Committee (IASC) Global - In Malawi , children receiving LNS showed Nutrition Cluster. In the context of nutrition needs significantly higher recovery rates (80 of refugees, asylum seekers, returnees and, in some percent) after only eight weeks of treatment, circumstances, internally displaced persons, WFP compared to the previous formulation of CSB coordinates with UNHCR as the lead agency. (72 percent). [7] Additionally, WFP works with a variety of NGO - In Niger , children receiving LNS showed partners in distribution and monitoring activities. higher weight gain, higher recovery rates (79 WFP also collaborates with a range of UN agencies percent versus 64 percent), a shorter length and NGO partners to ensure that the underlying of stay and lower transfer rates compared to causes of undernutrition are addressed, including the previous formulation of CSB. [8] improvements in care practices, health, water and sanitation, and food security.

12 Nutrition at the World Food Programme References

1. Black RE, et al. Maternal and Child Undernutrition: Global and regional exposures and health consequences. The Lancet 2008; 371: 243-260.

2. Pelletier DL, et al. Epidemiological Evidence for a Potentiating Effect of Malnutrition on Child Mortality. American Journal of Public Health 1993; 83: 1130-1133. T r

3. Habicht JP, et al. Malnutrition Kills Directly, Not Indirectly. The Lancet 2008; 371: 1749-1750. e a t i

4. UNICEF, WHO, The World Bank (2012). UNICEF, WHO, World Bank Joint Child Malnutrition Estimates. (UNICEF, New n g

York; WHO, Geneva; The World Bank, Washington DC) M o

5. Phuka J, Thakwalakwa C, Maleta K, et, al. Supplementary feeding with fortified spread among moderately underweight 6-18 d e

month-old rural Malawian Children. Maternal and Child Nutrition 2009, 5:159-170. r a t e

6. LaGrone LN, et al. A novel fortified blended flour, corn-soy blend “plus-plus,” is not inferior to lipid based ready to use A c

supplementary foods for the treatment of moderate acute malnutrition in Malawian children. American Journal of Clinical u t

Nutrition 2012; 95(1): 212-9. e

7. Matilsky DK, Maleta K, Castleman T, Manary M. Supplementary feeding with fortified spreads results in higher recovery rates a l n

that with corn-soy blend in moderately wasted children. Journal of Nutrition 2009; 139(4): 773-778. u t r i 8. Nackers F, et al. Effectiveness of ready-to-use therapeutic food compared to a corn/soy-blend-based pre-mix for the treatment t i o

of childhood moderate acute malnutrition in Niger. Journal of Tropical Pediatrics 2010; 56(6):407-13. n l a m a J

d a j m A / P F W

13 Preventing Acute Malnutrition

WFP Nutrition-specific pillar 2:

To prevent acute malnutrition, particularly among children aged 6–23 months (sometimes 6–59 months in sudden-onset emergencies) and pregnant and lactating women.

2What is acute malnutrition? Why should WFP engage in prevention of acute malnutrition? At the individual level, acute malnutrition (wasting) refers to a form of malnutrition that reflects recent • Acute malnutrition is a major risk factor for child weight loss. The effects of acute malnutrition are mortality. A child with MAM is three to four times reversible with treatment. Individuals often appear as likely to die as a well-nourished child. A child very thin. Acute malnutrition is assessed through with SAM is nine times as likely to die as a well- weight-for-height or mid-upper arm circumference nourished child. While the immediate risk of (MUAC) in children, and MUAC for pregnant and mortality is higher for a child with SAM than with lactating women (PLW), and Body Mass Index MAM, the total number of children affected by (BMI) for adults. The individual is then classified as MAM is much greater, and therefore absolute overweight/obese, normal, with moderate acute mortality is higher for MAM than SAM. [1-3] malnutrition (MAM), or with severe acute malnutrition (SAM) based on specific cut-offs for • As of 2011, it was estimated 8 percent of children interpretation of anthropometric measures. Acute under five worldwide had moderate and severe malnutrition is also assessed through the presence of acute malnutrition. This figure translates into nutritional oedema (swelling due to excess fluid over 52 million children under five. [4] retention on both sides of the body which indicates severe acute malnutrition). • Prevalence of MAM can double during the lean season when food availability is low ahead of the Nutritional status at the population level is assessed next harvest. The lean season also often coincides through the prevalence of global acute malnutrition with a rainy season which brings an increase in (GAM) among children 6-59 months in the the incidence of both acute respiratory infections population. The prevalence of GAM refers to the as well as episodes of diarrhoeal disease. The proportion of all of the children classified with MAM combination of reduced caloric intake and an plus all of the children classified with SAM. GAM is increase in morbidity can result in a sharp often used as a proxy indicator for the severity of a increase in the prevalence of acute malnutrition in crisis. Other members of the household may be children. These increases can be even greater in affected in addition to children 6-59 months. emergencies. Prevention can mitigate the increase Prevalence of GAM should always be interpreted for and the associated risks related to mortality, programming in light of the broader context, taking morbidity and overall child development. into account aggravating or risk factors.

14 Nutrition at the World Food Programme • SAM treatment requires strong linkages with participate for a specific period of time (generally medical screening and services. By reaching 3-6 months). Programme delivery can be children before they develop SAM, prevention of community-based with a separate independent acute malnutrition can help to ease the burden on distribution, or it can be linked to a general food already overstretched health systems in most distribution or other platform when appropriate. developing countries. WFP implements programmes to prevent acute malnutrition in line with national guidelines, but

• Preventing acute malnutrition has the potential to if these guidelines are out of date in relation to P r e

reduce child mortality and morbidity, and also international standards, WFP advocates with the v e n

reflects WFP’s focus on the window of opportunity government and partners to undertake a process t i n

by targeting children 6-23 months of age and PLW. to update the guidelines. g

A c u

What to provide: t

• The specific specialized e

What is WFP’s nutrition-specific nutritious food used will depend on the context M a

16 l programming to prevent acute and target group. Options include : n u malnutrition? t - For children 6-23 months: Medium Quantity r i t i lipid-based nutrient supplements (Plumpy’doz, o n • What: Blanket Supplementary Feeding eeZeeCup, WawaMum) or fortified blended Programmes (BSFP) 15 foods (Super Cereal Plus ) - For PLW: fortified blended food (Super Cereal) • Why : To prevent nutritional deterioration and plus oil and sugar related mortality in vulnerable populations and high risk groups. • When/Where: BSFPs can be implemented in both emergency and transition contexts (i.e., • Who: The target group will depend on the Strategic Objectives 1 and 3) 17 . BSFPs are part of context, however the default target group is the standard response to prevent acute children 6-23 months of age. The prevalence of malnutrition in young children in an emergency, acute malnutrition is often higher in this age particularly an emergency that impacts on food group. They have an increased risk of mortality, availability or where the prevalence of acute and a tendency to deteriorate more quickly than malnutrition and micronutrient deficiencies older children. When the food security situation is (MNDs) are already high prior to the emergency. extremely severe or when coverage and quality for BSFPs are also recommended when wasting the treatment of MAM is limited, the age group increases seasonally in a predictable manner, for children can be extended to 6-35 months or 6- usually during the agricultural lean season. BSFPs 59 months of age. Where prevalence of low can also be considered when access to birthweight or prevalence of undernutrition programmes to treat MAM and SAM is low. among women of reproductive age is high, and the BSFPs are generally implemented during specific crisis is likely to impact infant and young child parts of the year, and are not generally in place feeding practices and where resources and the whole year. capacity are not limiting, PLW should also be included in the BSFP. The number of planned beneficiaries is calculated based on the estimated What is new in WFP’s approach to number of individuals in the specific target group prevent acute malnutrition? in the specific geographic area of programming and an estimate of programme coverage. I. Decision-making tool and evolving guidance: There have been significant changes • How: BSFPs provide a specialized nutritious food to programming for nutrition in emergencies to all individuals in the selected target group on a over the past years including the development of regular basis. Admission into the programme does new specialized nutritious foods and new not depend on nutritional status, and individuals evidence on programming to prevent acute

15. Evidence is being compiled on alternative responses and as it becomes available WFP may expand its programming options. 16. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Other products may be approved for use in future. 17. Largely in EMOP: Emergency Operations and PRRO: Protracted Relief and Recovery Operations, but also possible in CP: Country Programme or DEV: Development programmes if there is a Strategic Objective 3.

15 malnutrition. As a result of these changes, TSFPs • In Niger , provision of RUTF for three months to are no longer the sole response to the non-malnourished children resulted in a management of MAM in an emergency response. significant reduction in the incidence of MAM and The Global Nutrition Cluster (GNC) convened a SAM compared to children who did not receive MAM Working Group under the leadership of the intervention. [6] WFP to develop a decision-making tool for MAM programming design (including prevention, • Another study in Niger showed provision of LNS

P treatment, and monitoring) in emergencies. The (Plumpy’doz) for six months reduced the r e v tool is intended as an interim operational incidence of SAM in a large population of children e n

t guidance while further normative guidance is 6-36 months of age. [7] i n 18 g developed.

c • In South Darfur, Sudan there was no observed u

t New specialized nutritious foods: e II. In increase in GAM during the acute hunger period,

M response to increased understanding of the where a four-month prevention programme was a l n nutrient needs for children, new specialized implemented using either LNS (Plumpy’doz) or u t r nutritious foods have been developed. The improved CSB (oil, sugar, DSM). [8] i t i o nutrients in these specialized nutritious foods n are more easily absorbed (fewer anti-nutrients), • In Haiti following the nutrition response to the contain animal proteins (which have been found 2010 earthquake where a large scale BSFP to be superior to plant proteins in terms of targeting children 6-23 months and PLW was recovery from acute malnutrition), and a more implemented, WFP observed no difference in the well developed micronutrient profile. Products prevalence of GAM after the crisis compared to for the prevention of acute malnutrition are pre-crisis levels. [9] nutrient dense and contain fewer kilocalories than products for treatment of MAM. WFP has • A recent evaluation of a WFP programme to developed a product sheet for the specialized prevent acute malnutrition during the lean season nutritious foods currently in use called: The in Sudan suggests that caseloads of SAM children Right Food at the Right Time. This document can be kept low. [10] includes information on each food and ration size indicated for each nutrition intervention and • WFP also has significant operational learning of target group; as well as information on product programming to prevent MAM in emergencies. In cost, shelf life and other characteristics. Haiti, Niger, Pakistan and the Horn of Africa , WFP addressed the needs of more than 4 III. There are a number of studies on-going to million children. measure the impact of BSFPs. In addition, efforts are under way within WFP to strengthen the framework for monitoring and How does prevention of acute evaluation of indicators and the analysis of malnutrition relate to WFP’s other BSFP programming. nutrition-specific programming?

• Relation to nutrition-specific programming: How do we know that WFP’s The specialized nutritious foods used in the approach to prevention of acute prevention of acute malnutrition are also malnutrition works? recommended for use to improve nutrient intake as one element of comprehensive programmes to • In Haiti , a fortified blended food (FBF) was given prevent stunting. Both programmes use the same to all children 6-23 months for prevention and to “blanket” distribution approach (e.g. not targeted children 6-59 months for treatment. At the end of by nutritional status). These two programme the intervention, there was a lower prevalence of approaches however differ in terms of duration as acute malnutrition among children in the well as other aspects of programme design. preventive group compared to the prevalence in the population of children who had access to treatment of undernutrition when required. [5]

18. The decision tool is available from http://www.unicef.org/nutritioncluster/files/MAM_DecisionTool_July_2012_with_Cover.pdf

16 Nutrition at the World Food Programme • Relation to general food distribution (GFD): and needs to take a lead role with UNICEF for Nutrition interventions will be more effective if emergency nutrition response. In the context of they are linked to interventions that address nutrition needs of refugees, asylum seekers, household food insecurity. returnees and, in some circumstances, internally displaced persons, WFP coordinates with UNHCR as the lead agency. Additionally, WFP works with a Who are the key partners in the variety of NGO partners in distribution and prevention of acute malnutrition? monitoring activities. WFP also collaborates with a P r e

range of UN agencies and NGO partners to ensure v e n

Key partners in the prevention of acute malnutrition that the underlying causes of undernutrition are t i n include national governments, UN agencies, and addressed, including improvements in care g

NGO partners. The government has the overall practices, health, water and sanitation, and food c u t responsibility for the welfare of its population. WFP security. Depending on the context and capacity, e is the lead UN agency responsible for treatment of BSFPs can provide a point of contact with the M a l MAM and prevention of acute malnutrition. WFP population for other supportive measures to prevent n u t coordinates with UNICEF (the lead agency for acute malnutrition (such as education on infant and r i t i treatment of SAM) regarding links between young child feeding (IYCF) practices and o n treatment of MAM and SAM. Furthermore, in deworming) as well as screening and referral for emergencies, WFP works under the Inter-Agency treatment of SAM and MAM. Standing Committee (IASC) Global Nutrition Cluster

References

1. Black RE, et al. Maternal and Child Undernutrition: Global and regional exposures and health consequences. The Lancet 2008; 371: 243-260.

2. Pelletier DL, et al. Epidemiological Evidence for a Potentiating Effect of Malnutrition on Child Mortality. American Journal of Public Health 1993; 83: 1130-1133.

3. Habicht JP, et al. Malnutrition Kills Directly, Not Indirectly. The Lancet 2008; 371: 1749-1750.

4. UNICEF, WHO, The World Bank (2012). UNICEF, WHO, World Bank Joint Child Malnutrition Estimates. (UNICEF, New York; WHO, Geneva; The World Bank, Washington DC)

5. Ruel MT, et al. Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial. The Lancet 2008; 371: 588-595.

6. Isanaka S, Nombela N, Dijibo A, et al. Effect of preventive supplementation with ready-to-use therapeutic food on the nutritional status, mortality, and morbidity of children aged 6 to 60 months in Niger: a cluster randomized trial. Journal of the American Medical Association 2009; 301(3): 277-285.

7. Defourny I, Minetti A, Harczi G, Doyon S, Shepherd S, Tectonidis M, Bradol J, Golden H. A large-scale distribution of milk-based fortified spreads: Evidence for a new approach in regions with high burden of acute malnutrition. PLoS ONE 2009; 4(5): e5455.

8. Boyd E, Talley L., et al. Prevention of Acute Malnutrition during the Lean Season: A Comparison of a Ready to Use Supplementary Food and an Improved Dry Ration, South Darfur, Sudan. Under review.

9. WFP. Evidence-based Programming: Treatment and Prevention of Acute Malnutrition. PowerPoint, 2011.

10. Acharya P, Kenefick E. Improving Blanket Supplementary Feeding (BSFP) Efficiency in Sudan. ENN Field Exchange 2012; 42: 59-61.

17 Preventing Chronic Malnutrition – Stunting

WFP Nutrition-specific pillar 3:

To prevent chronic malnutrition – stunting and micronutrient deficiencies – particularly among children aged 6–23 months and pregnant and lactating women.

3What is stunting? reach optimal growth and development. Since stunting accumulates over time, it is helpful to look At the individual level, stunting (chronic at the proportion of stunting among children under undernutrition) refers to the failure to grow and above 2 years of age, which reflects the age at adequately in length or height in relation to age. [1] which growth failure has accumulated. The Though stunting is defined as being short for one’s proportion of stunting among infants and young age 19 , it is also a reflection of a larger problem that children is often lower compared to older children. includes inadequacy to attain optimal cognitive Stunting often goes unrecognized in children who development. Stunting is also associated with higher live in communities where short stature is so morbidity and mortality. Stunting largely occurs common that it seems normal. [4, 7] during the 1,000 days from conception until two years of age, and therefore must be prevented during Stunting has multiple causes. An analysis of main this short window of opportunity. [2, 3] Stunting is determinants of stunting is needed, including the assessed through the measure of height-for-age. identification of shortfalls in nutrient access and the Individuals can be classified with moderate or severe nutrient gap for children 6-24 months and pregnant stunting according to specific cut-offs. However and lactating women (PLW) to understand what given that stunting cannot generally be reversed or barriers exist. The effects of stunting are treated, individual classification is not used for intergenerational and efforts to address chronic targeting. undernutrition must adopt a lifecycle approach. From conception to 2 years of age, limited access to At the population level, prevalence of stunting refers required nutrients, inadequate breastfeeding and to the proportion (prevalence) of children 6-59 poor complementary feeding and care practices months who are classified with moderate and severe undermine child growth. Stunting can be aggravated stunting. The overall prevalence of stunting at the by repeated episodes of infections and illness, population level is used as the basis of programming especially diarrhoea. Adolescent girls who are decisions as it gives an indication of the likelihood undernourished may not be prepared for a healthy that a child under 2 years of age in a given pregnancy. If a woman’s nutrient intake during population is not receiving adequate nutrition to pregnancy is inadequate, there is further risk that her child will be born with low birth weight. Low

19. Height-for-age <-2 SD of the WHO Child Growth Median Standards of the reference population of the same age and sex is the cut-off for classifying stunting in a child under five years of age.

18 Nutrition at the World Food Programme birth weight infants have less chance of survival and • The effects of stunting are intergenerational: experience poor health throughout their lifetime. infants born to women 20 who were stunted are Underlying these direct causes of stunting are smaller than infants born to better-nourished poverty and its social and economic determinants at women. [4] Maternal stunting is consistently the household, community and country levels, such associated with an elevated risk of perinatal as food insecurity, lack of access to water and mortality related to obstructed labour and birth P r e sanitation services, lack of women’s education, and asphyxia due to a narrower pelvis in short women. v e n

low family incomes. [2, 3, 5] [11, 12] t i n g

h r

Why should WFP engage in the What is WFP’s nutrition o n i prevention of stunting? programming to prevent stunting? c

M a l What: n • Stunting and micronutrient deficiencies are • There are three elements to a u t r i

associated with increased morbidity and comprehensive portfolio of programmes to t i o

mortality. Stunting accounts for 15 percent and prevent stunting, specifically, in areas with high n —

micronutrient deficiencies for 10 percent of child levels of stunting: (i) complementary feeding S t u

mortality. More child deaths and disability- through the provision of specialized nutritious n t i adjusted life-years (DALYs) in children under five foods for children 6-23 months and pregnant and n g are attributable to stunting and micronutrient lactating women (PLW) along with behaviour deficiencies mainly due to deficiencies of vitamin change communication (BCC) activities to A and zinc than to severe acute malnutrition promote appropriate infant and young child (SAM) because they affect many more children [2, feeding (IYCF) practices 21 and hygiene; (ii) 6, 12]. promotion of activities that can impact nutrition indirectly, most often through addressing the • In 2011, it was estimated that 165 million children underlying causes of undernutrition across were stunted. More than 90 percent of the world’s multiple sectors (nutrition-sensitive stunted children live in Africa and Asia. While interventions); and (iii) strengthening the there has been progress at the global level, with a capacity of national governments to assess, decrease in the prevalence of childhood stunting identify, design, deliver, monitor and evaluate from 39.7 percent in 1990 to 26 percent in 2010, intersectoral programming that directly and there is still much work to be done. [7] indirectly prevent stunting. BCC and monitoring and evaluation (M&E) activities are a • Stunting is also associated with reduced physical fundamental part of all interventions. and cognitive capacity for life. Longitudinal studies have shown that early childhood stunting • Why: To prevent stunting in children under 24 has implications for cognition, educational months of age and to promote the nutritional achievement, and worker productivity/adult status of adolescents and women in their wages, with a negative impact of gross domestic reproductive years in order to: (i) address the product (GDP). [4, 5, 8, 9] The 2008 Lancet intergenerational cycle of undernutrition; (ii) Series on Maternal and Child Undernutrition bring about a positive impact in health, education reported that height-for-age at 2 years of age was and productivity during the life cycle; and (iii) the best predictor of human capital. [10] support social and economic development at country level. • Stunting has also been linked to poor health later in life. A child that is stunted and then gains • Who: The priority target groups reflect those weight later in childhood has an increased risk of most vulnerable to undernutrition through nutrition-related chronic diseases such as addressing the 1,000 days window of diabetes, hypertension and coronary heart opportunity 22 : children 6-23 months and PLW, as disease. [3, 5] well as adolescent girls when possible. Complementary feeding interventions must

20. A woman who is less than 145 cm or 4’7” is considered to be stunted. 21. Including exclusive breastfeeding up to 6 months of life, continued breastfeeding to two years and timely and appropriate complementary feeding such as use of specialized nutritious foods plus other nutritious family foods from 6 months up to the first two years. 22. From conception to the first two years of life. 23. From birth until 6 months of age, infants should be exclusively breastfed.

19 ensure that children aged 6–23 months 23 and through food for work (FFW) and purchase for PLW get the nutrients they need, irrespective of progress (P4P), as well as increased access to their nutritional status. Where the context fortified foods for PLW and children 6-23 months suggests the need and resources allow, adolescent through cash and voucher (C&V) initiatives. Food girls may be included in order to ensure adequate and C&V transfers targeting poor people are often

P nutrient status of women prior to conception implemented through social protection and safety r e v and/or in the first trimester. The number of net programmes (especially where there is e n

t planned beneficiaries is based on the estimated government interest and, ultimately, possible i n g number of individuals of the specific target groups funding around social protection programmes).

C h in the geographic area of operation and an For (iii) improving government capacity to r o

n estimate of programme coverage. Beneficiaries prevent stunting, WFP should strengthen the i c

can often be identified and reached through technical and managerial capacity of human M a existing health systems or social protection resources, strategic partnerships, supporting the l n u mechanisms. As this intervention is preventative nutrient gap analysis for children under two years t r i t and designed to prevent a predictable shortfall in of age and PLW. WFP should also support i o n meeting nutrition needs, targeting is not based on advocacy, policy dialogue, local production of —

S individual nutritional status but based on risk foods, and monitoring and evaluation. t u n factors, which may be geographic or socio- t i What to provide: n economic (low socioeconomic status or areas with • WFP’s efforts in nutrition are g high or very high prevalence of stunting and focused on supporting the governments to micronutrient deficiencies, mainly anaemia). WFP improve availability and access of timely and will work with governments to leverage existing adequate complementary foods (from 6 months), programmes for reaching those at the highest risk in addition to encouraging continued of stunting. Nutrition-sensitive programming and breastfeeding, improved feeding practices and capacity development interventions to prevent promoting the use of nutritious local foods, to stunting can impact infant and young child, ensure that the nutrient needs of young children adolescent and adult nutrition. and other vulnerable groups are met. This means that where access and availability issues exist, • How: The activities depend on the specific specific nutrient-dense products may be used. The components of the prevention of stunting type of food used in complementary feeding portfolio and alignment with government national interventions will depend on the nutrient gap in nutrition policies and plans. For (i) the diet, the context and target group. [13] The complementary feeding, specialized nutritious commodity should also take into consideration foods are recommended for a minimum of six cultural practices and preferences. Options months during a one year cycle. Research is on- include 24 : going to define the optimal duration of these - For children 6-23 months: Medium Quantity interventions. Specialized nutritious foods with lipid-based nutrient supplements (LNS) such as BCC can be delivered through different Plumpy’doz, eeZeeCup, WawaMum and mechanisms, including the health sector, and Nutributter; micronutrient powders (MNP) to social protection programmes, among others. be used as home fortification, and fortified WFP activities should be complemented by blended foods (Super Cereal Plus ) health, water and sanitation, and agricultural - For PLW: fortified blended food (Super Cereal) activities implemented by partners. For (ii) plus oil and sugar nutrition-sensitive programming, WFP can improve household food security and increase the • Where/when: Currently, complementary access and availability of nutritious foods, as well feeding interventions for the prevention of as minimizing barriers to optimal nutrition stunting can be incorporated into PRRO, CP and practices and behaviours for vulnerable DEV programmes 25 . WFP has committed to populations through several programmes and initiating programmes to prevent stunting in modalities. These include school feeding countries where the prevalence of stunting is at (especially if adolescent girls can be reached), least 30 percent, or at a lower threshold promotion of livelihoods and livelihood assets established in national policies or programmes, or

24. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Other products may be approved for use in future. 25. PRRO: Protracted Relief and Recovery Operations; CP: Country Programme; DEV: Development programmes.

20 Nutrition at the World Food Programme in high-risk situations. Within countries, WFP • The comprehensive model for the prevention of stunting programmes should be prevention of stunting: WFP has been laying targeted to areas with high stunting rates, high the foundation to address stunting over the last poverty and high food insecurity. While decade, by promoting government capacity and prevention of stunting may not be an explicit supporting household food security and

strategic objective of emergency programming, fortification of staple foods and condiments. With P r e

emergency nutrition programmes need to be the increasing recognition of the role of food and v e n

developed with the understanding that nutritional dietary intake in the prevention of stunting, in t i n

needs that are not met during the emergency may particular with the Lancet review in 2008, WFP g

have negative impacts on stunting and has integrated a comprehensive approach based h r o

micronutrient deficiencies. Complementary on recent innovations into its portfolio of stunting n i c

feeding interventions to prevent stunting can be programming in order to contribute to bring M

in place the whole year round, as opposed to about sustainable changes in stunting worldwide, a l n

seasonal blanket supplementary feeding though further efforts in terms of evidence and u t r i

programmes (BSFP) for the prevention of acute guidance are required. t i o

malnutrition. n Further development of the evidence base — • S t

and strengthened monitoring and u n t

How is WFP’s approach to evaluation (M&E): i WFP is in the process of n g prevention of stunting different strategically gathering lessons learned on specific than before? aspects of its current prevention of stunting programmes. In addition, WFP is supporting two • Improved situation analysis: WFP is in the new large-scale multi-year programmes in Malawi process of strengthening its nutrition situation and Mozambique to comprehensively address analysis capacity, in particular around the stunting, which will feed into more knowledge on nutrient gap (especially of children under 2 years targeting, type of foods, delivery channels, of age and PLW), i.e. the difference between identification mechanisms and complementary nutrient intake and nutrient needs (both in activities and the development of a common M&E quality and in quantity). The Cost of Diet (COD) framework that could then be mainstreamed tool helps identify the gap between the incomes of throughout other programmes in other countries. families and the local cost of a nutritious diet. The [14] WFP is also engaging in operational research COD tool calculates the minimum amount of in other priority countries in addition to various money a family will have to spend to meet its collaborations with academia and research energy, protein, fat and micronutrient institutions to strengthen the evidence base for requirements using locally available foods. prevention of stunting around effectiveness on the Understanding the nutrient gap is essential to utilization/consumption of specialized nutritious ensure that appropriate programmes using the foods, i.e. the Right food at the Right time. right food at the right time are developed to address the nutrient shortfalls that contribute to stunting. How do we know that WFP’s approach to the prevention of • New specialized nutritious foods: New stunting works? specialized nutritious foods have been developed to deliver the appropriate quantity and quality of There is evidence that complementary feeding nutrients in order to more precisely address the interventions using specialized nutritious foods on nutrient gap of target groups. Macronutrients and their own can prevent stunting, for example: energy are needed, but most importantly micronutrients and macro-minerals, essential • A longitudinal and long-term follow-up study amino acids, essential fatty acids and animal (1969 and 1977, 1988-1989, and, 2002-2004) in proteins (milk) are also required as they are Guatemala highlighted positive short and long critical for linear growth. term health, education and productivity impacts of complementary food supplements (which

26. The findings relate to male wages only.

21 included a substantial amount of dried skim through nationwide comprehensive social protection milk) when given during first three years of life: programmes in: i.e. greater growth in height, better learning capacity and reading/intelligence scores; • Mexico (“Oportunidades” formerly known as increased productivity, 46 percent greater “Progresa” National Social Protection 26 P wages , and the next generation of children Conditional Cash Transfer Programme, 1988- r e v with higher birthweight and head 2006). In poor, rural communities, distribution e n

t circumference. [3, 8, 9] This is the most of special nutritious foods to children 6-23 i n g convincing worldwide evidence of the role of months and PLW in addition to nutrition-

C h nutritious foods in reducing the impact of sensitive programming that included r o

n childhood stunting, and it was used by the 2008 improvements in education and access to public i c

Lancet Series on Maternal and Child services in combination had an impact on M a Undernutrition. stunting reduction. [23-25] l n u t r i t • In Malawi , 12 months of complementary • Brazil (“Bolsa Familia” National Social i o n feeding intervention using a Medium Quantity Protection-Conditional Cash Transfer —

S LNS had a positive impact on stunting by Programme, 1996-2006, 2003-2006) where t u n reducing the incidence of severe stunting when changes in macroeconomic and social policies as t i n compared to no intervention. [15] well as maternal schooling and increased g purchasing power contributed to improved • In Algeria , provision of a LNS was shown to quality and quantity of nutrient intake and induce catch-up growth and reduce anaemia in reduced stunting by 50 percent. [26-28] children up to six years. [18] • Chile has demonstrated one of the largest • In Nepal , from 2008-2010, WFP developed a impacts on stunting reduction; it is one of the large-scale intervention through the distribution few countries worldwide that has reached the of micronutrient powders (MNP) which resulted “normal” expected proportion of children of low in a reduction of anaemia, and a contributed to stature for age (2.3 percent). It has a well- a significant relative decrease of 40 percent of established long-term national nutrition policy stunting prevalence in children 6-59 months. and programmes which include special fortified [19] complementary foods for children 6-59 months and PLW and intersectoral interventions, which • In Bangladesh , WFP also developed a large- are currently integrated into a nation-wide scale MNP intervention for children 6-59 social protection system “Chile Solidario”. [29, months (August 2008-January 2009). Among 30] children in the intervention area, those who consumed at least 75 percent of the • Experiences in South East Asia and South recommended micronutrient powder had a America show that stunting can be reduced lower prevalence of stunting than those who substantially within a decade when both consumed less than 75 percent of the MNPs underlying 28 and basic or structural 29 causes of [20] 27 undernutrition are also addressed. [31] Nutrition-specific programming can build upon • Recent reviews have found that complementary these positive changes to the underlying and feeding support, both with and without basic causes of undernutrition to help accelerate nutrition education, can result in gains in height reduction in the prevalence of stunting. and reduced stunting. [2, 21, 22].

There is also significant evidence for the use of specialized nutritious foods to prevent stunting

27. The decrease in stunting in both Nepal and Bangladesh suggest that other micronutrients in the MNP formulation (zinc in particular) may have had a positive impact on child health and development. This area is being explored as part of current operational research on prevention of stunting and prevention of MNDs. 28. Underlying causes: inadequate access to nutritious foods, inappropriate care practices, and insufficient/poor health services and environment. 29. Basic causes: poverty, inequality, women education and empowerment, access to land, among others.

22 Nutrition at the World Food Programme How does prevention of stunting Who are the key partners in the relate to WFP’s other nutrition prevention of stunting? programming? WFP recognizes that efforts to sustainably address • Relation to nutrition-specific programming: stunting must be based in country leadership and P

There is a range of specialized nutritious foods ownership, in line with national priorities and that it r e v

that can be used to prevent several forms of must engage multiple stakeholders and sectors. In e n

undernutrition. Micronutrient Powders (MNPs) support of national governments WFPs partners t i n

and Nutributter can be used in complementary range from UN agencies i.e. UNICEF, WHO and g

feeding interventions for the prevention of FAO; NGOs, private sector, academia and research h r o

stunting depending on whether there is a gap in institutions and the communities themselves. WFP n i c

energy intake that needs to be addressed at the is also engaged in the global multi-stakeholder M a

same time. movement Scaling Up Nutrition (SUN), [31]; the l n u

country-led approach Renewed Efforts for Ending t r

Relation to nutrition-sensitive i t

• Child Hunger and Undernutrition (REACH), and the i o programming: By definition, the comprehensive Global Health Initiative (GHI). They aim to scale up n —

programme to prevent stunting makes linkages proven and effective interventions to achieve a S t u

with nutrition-sensitive programming. As sustainable reduction of undernutrition, prioritizing n t i mentioned previously, WFP can improve the 1,000 days window of opportunity period. n g household food security and increase the access and availability of specialized nutritious foods.

References

1. WHO, WHO child growth standards methods and development: Length/height-for-age, weight-for-age, weight-for-length, weight- for-height and body mass index-for-age. 2006, Geneva: World Health Organization.

2. Bhutta ZA, Ahmed T, Black R, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M. Maternal and child undernutrition 3.What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371: 417–40

3. Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet 2008; 371: 243-60.

4. Alive&Thrive. Insight: Why stunting matters. A&T Technical Brief 2010 Sep;(2)

5. Victoria, C G, et al. Maternal and child undernutrition: consequences for adult health and human capital. The Lancet 2008; 371: 340 – 357.

6. UNICEF. Tracking progress on child and maternal nutrition. A survival and development priority. New York, 2009

7. UNICEF, WHO, The World Bank (2012). UNICEF, WHO, World Bank Joint Child Malnutrition Estimates. (UNICEF, New York; WHO, Geneva; The World Bank, Washington DC)

8. Mercedes de Onis, Monika Blössner, Elaine Borghi. Prevalence and trends of stunting among pre-school children, 1990–2020 Public Health Nutrition 2012; 15:142-8.

9. Martorell R, et al. History and design of the INCAP longitudinal study (1969-77) and its follow ups (1988-89). J Nutr 1995 Apr; 125(4 suppl):1027S-41S.

10. Hoddinott J, Maluccio J, Behrman J, Flores R, Martorell R. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Maternal and Child Undernutrition. The Lancet 2008; 371: 411–16.

11. Kramer MS, Olivier M, McLean FH, Willis DM, Usher RH. Impact of intrauterine growth retardation and body proportionality on fetal and neonatal outcome. Pediatrics 1990 Nov; 86(5):707-13.

12. Lee AC, Darmstadt GL, Khatry SK, LeClerq SC, Shrestha SR, Christian P. Maternal-fetal disproportion and birth asphyxia in rural Sarlahi, Nepal. Arch Pediatr Adolesc Med 2009 Jul;163(7):616-23

13. WFP Nutrition Policy. WFP/EB.1/2012/5-A, January 2012, available on WFP’s Website (http://executiveboard.wfp.org).

14. de Pee S, Bloem MW. Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59 month-old children. Food Nutr Bull 2009 Sep; 30 : S434-63

23 15. Phuka J C et al. Post intervention growth of Malawian children who received 12mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr 2009;89:382-90

16. Ruel M, Menon P, Habicht JP, Loechl C, Bergeron G, Pelto G et al. Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomized trial. The Lancet 2008; 371: 588-95.

P 17. IFPRI. Timing is everything. Preventing child undernutrition, IFPRI 2008. r e v

e 18. Lopriore C et al. Spread fortified with vitamins and minerals induces catch-up growth and eradicates severe anemia in stunted n

t refugee children aged 3-6 y. Am J Clin Nutr 2004;80:973-81 i n g

19. de Pee S et al. Assessing the impact of micronutrient intervention programs implemented under special circumstances-Meeting C h Report. Food Nutr Bul 2011; 32(1): 255-302. r o n

i 20. Rah JH, de Pee S, Halati S, Parveen M, Mehjabeen SS, Steiger G, Bloem MW, Kraemer K. Provision of micronutrient powder in c

M response to the Cyclone Sidr emergency in Bangladesh: cross-sectional assessment at the end of the intervention. Food Nutr Bull a

l 2011; 32:276–84. n u t

r 21. Dewey K.G. et al. Systematic review and meta-analysis of home fortification of complementary food. Maternal and child nutrition. i t i Blackwell Publishing Ltd, 2009. o n

— 22. Imdad, A, M Yakoub, Z Bhutta. Impact of maternal education about complementary feeding and provision of complementary foods S t on child growth in developing countries. BMC Public Health 2011: 11 (Suppl 3) 1-14. u n t i 23. Rivera J, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and n g nutrition (Progresa) on rates of growth and anemia in infants and young children: A randomized effectiveness study. Journal of the American Medical Association 2004; 291 (21): 2563-70

25. Fernald LCH et al. The Importance of Cash in Conditional Cash Transfer Programs for Child Health, Growth and Development: An Analysis of Mexico’s Oportunidades. Lancet. 2008 March 8; 371(9615): 828–837

26. Monteiro C A et al. Causes for the decline in child under-nutrition in Brazil, 1996-2007. Rev Saude Publica 2009;43(1)

27. Lindert K. “Brazil Bolsa Familia program: Scaling up cash transfers for the poor”. MfDR Principles in Action: Sourcebook on Emerging Good Practices, The World Bank pp67-74.

28. Paes-Sousa R et al. Effects of a conditional cash transfer programme on child nutrition in Brazil. Bull World Health Organ 2011; 89:496–503.

29. Monckeberg, F. Nutrition in Chile, Past, present and future, 2008

30. La desnutricion infantil en Chile. Informe Ministerio de Salud, 2008.

31. Scaling- up nutrition. Progress report from countries and their partners in the movement to Scale Up Nutrition (SUN): UN, SUN: 2011

24 Nutrition at the World Food Programme Addressing Micronutrient Deficiencies A d d r e s s i n g

M i c

WFP Nutrition-specific pillar 4: r o n u t r i To address micronutrient deficiencies among vulnerable e n t

people – children aged 6-59 months and pregnant and D

lactating women – especially to reduce the risk of mortality e f i during emergencies and to improve health, through c i e

fortification. n c i e s

4What is micronutrient deficiency? At the population level, information on the prevalence of MNDs may be assessed through a Micronutrients (vitamins and minerals), although nutrition survey, though this information is not only needed in small amounts, are as essential as always available when planning for a new macronutrients (protein, fat, and carbohydrates) for intervention. Proxy information should therefore be ensuring the life and health of an individual. used to estimate the nutrient gap and the need for Micronutrient deficiencies (MNDs) often result from micronutrients, including existing data on MND inadequate dietary consumption, and infectious prevalence, stunting prevalence, and on risk factors diseases which decrease the absorption of nutrients such as dietary intake, complementary feeding while at the same time increasing individual practices and household food insecurity. nutritional requirements. Underlying these direct causes, inadequate health care and sanitation, poor Why Should WFP engage in infant and young child feeding practices, and addressing MNDs? household food insecurity contribute to MNDs, influencing intake and illness at the individual level. • Micronutrient deficiencies represent a largely MNDs of particular concern include vitamin A invisible but devastating form of malnutrition that deficiency, iodine deficiency disorders, iron affects 2 billion people worldwide. People with deficiency anaemia, and zinc deficiency. Even mild MNDs may not show specific signs of deficiency, to moderate deficiencies of micronutrient have and may not be aware of their deficiency. This negative effects on well-being, such as poor phenomenon is often referred to as “Hidden intellectual development, poor vision, suboptimal Hunger”. growth and morbidity. For example, zinc deficiency • An estimated 190 million (33 percent) of alone has been shown to increase the risk of preschool-age children and 19 million (15 diarrhoea in young children by 33 percent, percent) of pregnant women are vitamin A pneumonia by 69 percent, and malaria by 56 deficient . percent. [1] Adequate intake of vitamin A among • Iron deficiency which contributes to anaemia children under five years can reduce mortality due to affects about 25 percent of the world’s infectious diseases (most notably measles, population, most of them children of preschool- diarrhoea, and malaria) by approximately 23-35 age and women. percent.

25 • Iodine deficiency still affects millions of are often unlikely to meet the nutrient needs of people, despite programmes of Universal Salt children 6-23 months. Iodization. [2] • Supplementation (distribution of concentrated • Zinc, iron, and vitamin A deficiencies are in the doses in pill, capsule or drop form) for specific top ten causes of death through disease in micronutrients for specific groups, such as A d developing countries. vitamin A for children 6-59 months, postnatal d r e vitamin A supplementation, and in rare instances s s

i • With rising food prices and climate change, it is iodised oil capsules for children 6-59 months. n g

likely that an increasing proportion of the world’s While there is an on-going discussion on either M i

c population will develop MNDs. continuing the use of iron folate or switching to r o multiple micronutrient capsules (MMC) by PLW, n u t • Cost-effective, evidence-based strategies to the latter which provide more nutrients are the r i e

n address MNDs are available. The 2008 preferred option, especially when obstetric t

D Copenhagen Consensus ranked micronutrient services are available because MMC e f supplements for children (vitamin A and zinc) as supplementation can increase birth weight which i c i e first among all development interventions in may cause obstetric complications among short n c

i terms of spending priorities based on benefit-cost women. When PLW are malnourished, it is also e s ratios. important to ensure that their other nutrient needs (calories, and fatty acids) are met. • WFP operates in many of the most food-insecure Supplementation is generally administered contexts where MNDs are also common. WFP has through health programmes. the infrastructure, opportunity, and comparative advantage to address MNDs. • Promotion of public health measures , such as deworming, and assuring adequate water and There are several ways to address MNDs, including: sanitation, in order to reduce illness and therefore increase absorption of nutrients. • Home fortification (also known as point-of-use fortification) to increase micronutrient intake of specific groups. This is a particularly effective What is WFP’s nutrition-specific method for children 6-23 months since it is response to addressing MNDs? generally difficult for them to meet their high nutrient intake needs due to their small stomach • What: Home fortification with Micronutrient size and intake of complementary foods that are Powder (MNP) or Small Quantity lipid-based often not adequate in terms of micronutrient nutrient supplement (LNS) content. • Why: To improve the quality of the diet and thus • General fortification (adding one or more nutrient intake for nutritionally vulnerable groups nutrients during processing) of staple foods and to the point where the combination of the existing condiments, which offers the possibility of diet and the home fortificant meets the daily increasing micronutrient intake and improving Recommended Nutrient Intake (RNI) for all the quality of the daily diet of the general nutrients. Improvement of nutrient intake and population, including that of adolescent girls and infant and young child feeding (IYCF) pregnant and lactating women (PLW), in a cost- practices ultimately aims to contribute to effective and sustainable manner. In addition to improvements in micronutrient status and distributing fortified food commodities in food therefore promote growth, development and security operations, WFP and private partners health of target groups. work with governments to establish the general fortification of staple goods and condiments and • Who: Children 6-23 months, and in the case of to introduce innovations such as fortified rice. high prevalence of MNDs, children 6-59 months, are the primary target group. Secondary target • Education to promote a more diverse food groups consist of school-age children, adolescents, basket in areas where foods with sufficient and adults. Inclusion in the programme is not macronutrients and micronutrients are available based on assessment of micronutrient status and accessible. Diets that are heavily plant-based among the target group. Caseload is calculated and contain few animal-source or fortified foods based on the number of individuals in the specific

26 Nutrition at the World Food Programme target group in the geographic area of activity and How is WFP’s response to an estimate of programme coverage. addressing MNDs with home fortification different than before? • How : Provision of a home fortificant to individuals from the target group on a regular • New specialized nutritious foods and basis for a specific period of time, generally 6-18 operational evidence of effectiveness: MNPs A

months. In addition, education on the use of the were developed as a way to provide iron and other d d r

home fortificants and positive health and nutrients required for treating anaemia, because e s s

nutrition practices is provided. There are two iron and folic acid tablets cannot be swallowed by i 30 n g

options for home fortificants : young children and syrups are bulky, stain teeth M i

- Nutributter (Small Quantity lipid-based and are more easily over-dosed. The strategy of c r nutrient supplement (LNS)) for children o home fortification with MNPs appeared to be well n u

6-23 months t

accepted by beneficiaries, and able to achieve high r i e

- Micronutrient powder (MNP) for children coverage. Its impact on nutritional anaemia has n t

6-59 months, or other target groups been proven [3-6]. As a result, MNPs are D e f

increasingly used for prevention of MNDs and are i c i Nutributter provides both micronutrients and composed of a wider range of micronutrients. In e n c

macro-minerals, essential fatty and amino acids, i

addition, Nutributter, a Small Quantity LNS, was e while MNPs provide only micronutrients. As a developed to deliver micronutrients as well as s principle, the frequency and duration of use should macro-minerals (calcium, magnesium, be such that it contributes an adequate quantity of phosphorus) essential fatty acids and amino acids the required micronutrients. WFP uses the standard required for growth. Operational research in the WFP-UNICEF-WHO formulation for MNPs use and effectiveness of Small Quanity LNS in containing 15 micronutrients. [13] The process of addressing MNDs is on-going but indicates that it designing local packaging for MNPs and is a promising option. implementing the behaviour change communication strategy for the home fortificant at country level are both parts of home fortification programming. How do we know that WFP’s approach to addressing MNDs Where/When: Home fortification is recommended with home fortification works? where the micronutrient requirements of children 6-23 months are not met in the typical diet, i.e. • MNPs have been proven to have a positive impact where appropriate complementary foods with on nutritional anaemia. Given that individuals sufficient macronutrients is locally available and often have more than one MND, MNPs are affordable but lacking in micronutrients. Home assumed to have a positive impact on other MNDs fortification with MNPs should also be considered in as well. MNPs have also been shown in certain school feeding programmes where school meals are contexts to have contributed to a positive impact predominantly composed of unprocessed locally on stunting, for example with long term use available ingredients, as micronutrient content is among refugees in Nepal. [7-8] In the same study, almost always inadequate. Home fortification can be MNPs also appeared to have a positive impact on implemented in both emergencies and development morbidity associated with diarrhoea. The decrease 31 contexts (EMOP/PRRO/DEV or CP) . Programmes in both stunting and diarrhoea suggest that other are generally run the whole year round, though micronutrients in the formulation (zinc in individuals only participate for a specific period particular) may have had a positive impact on of time. child health and development. However, at this stage it is unknown if these positive benefits can be directly attributed to the use of MNP or/and other possible factors such as improved child feeding practices because of the introduction of MNP. Future, large-scale, multiple-year MNP programmes will need to confirm these benefits.

30. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Other products may be approved for use in future. 31. EMOP: Emergency Operations; PRRO: Protracted Recovery and Relief Operations; CP: Country Programme; DEV: Development programmes

27 • The positive impact of LNS on MNDs, linear • Relation to school feeding: Where the growth, and motor development has been proven. prevalence of MNDs have reached public health [9-11] significance, and where the nutrient gap analysis shows that it is appropriate, MNPs can, and have In a relatively short time, since initial pilots in 2008, been, used in school feeding programmes to WFP has built strong technical and operational increase the micronutrient content of local school A d expertise in distributing MNPs with various partners meals. Reduction of iron and zinc deficiencies d r e in emergencies, refugee and development settings. have been observed in school-age children in s s

i [7] Programmes in Bangladesh, eastern Nepal, South Africa given MNPs with low doses of highly n g

Kenya, Philippines, Dominican Republic, Colombia absorbable iron and zinc. [12] Other options to M i

c and Haiti have targeted various groups including improve micronutrient content in school feeding r o children under five years of age, PLW, and refugees. interventions include provision of fortified foods n u t School-age children have been reached with MNP or high energy biscuits. r i e

n through school feeding in Tanzania, Cambodia, t Relation to general food distribution (GFD):

D Ghana, Madagascar and Afghanistan. Additional • e f MNP programs are underway in Indonesia, Niger, WFP distributes food commodities that are i c i e Mali and Cote d’Ivoire. The provision of MNP to fortified, including oil fortified with vitamins A n c

i children aged 6-59 months and school-age children and D, iodized salt, and fortified maize meal, e s in different settings within regular WFP wheat flour and fortified blended foods (FBF). programming scaled up from 350,000 in 2010 to MNPs and Nutributter can be distributed with the more than 2 million children in 2012. This GFD to specifically address the high considerable experience has translated into strong micronutrient needs of young children, when analysis, enhanced programme design and improved there is limited capacity or access to other, more delivery tools, including a toolkit to guide successful targeted, distribution channels to reach the implementation of large-scale MNP programmes. nutritionally vulnerable group. WFP endeavours to develop the same experience, evidence, and tools for home fortification with LNS • Relation to treatment of severe acute in the near term. malnutrition (SAM): Home fortification is not included in the treatment of SAM since all required macronutrients and micronutrients are How does WFP’s nutrition-specific supplied through therapeutic products specially response to addressing MNDs formulated to meet the nutrient needs of children with home fortification relate to with SAM. other types of WFP programming?

• Relation to other nutrition-specific How does WFP’s programming to programmes: The specialized nutritious foods address MNDs with home used in the treatment and prevention of MAM are fortification relate to the work of designed to provide all of the required partners? micronutrients to beneficiaries. MNPs and Nutributter are not distributed in these Key partners in addressing MNDs include national programmes. MNPs and Nutributter are, governments, UN agencies, and NGO partners. The however, two of several specialized nutritious government has the overall responsibility for the foods that may be used to improve nutrient intake welfare of its population. WFP and UNICEF as one component of comprehensive programmes collaborate in the design, implementation and to prevent stunting. evaluation of home-fortification programs and jointly advocate to address micronutrient • Relation to fortification: WFP collaborates deficiencies. UNHCR and WFP jointly implement with the government and the private sector in and monitor micronutrient interventions involving many countries, where fortified staple foods such the provision of MNPs and lipid-based nutrient as maize or wheat flour or oil are not yet available, supplements in refugee settings. or national fortification guidelines are not yet in line with current WHO guidance or national WFP is also part of the Home Fortification Technical standards on food fortification. Advisory Group (a community of stakeholders including members of public, private, academic, and non-governmental organisations) which in 2011

28 Nutrition at the World Food Programme developed technical programme guidance on the use Prevention, Sight and Life and UC Davis. of MNPs to address MNDs in order to harmonise WFP collaborates with the government as well as the home fortification programming. [13] Members of private sector around supporting local fortification this group include WFP, UNICEF, Micronutrient capacity. In addition, WFP coordinates with partners Initiative, Global Alliance for Improved Nutrition, and the government around supplementation, Helen Keller International, Sprinkles Global Health promotion of public health measures, and nutrition A

Initiative, U.S. Centers for Disease Control and education to improve nutrient intake. d d r e s s i n g

M i c r o n u t r i e n t

D e f i c i e n c i e s

References

1. Caulfield et al. 2004. Zinc Deficiency. Comparative Quantification of Health Risks, World Health Organization. Pp. 256-79

2. UNICEF. 2009. Tracking Progress on Child and Maternal Nutrition: A survival and development priority

3. Menon P, Ruel MT, Loechl CU, Arimond M, Habicht J-P, Pelto G, Michaud L. Micronutrient sprinkles reduce anemia among 9- to 24-mo old children when delivered through an integrated health and nutrition program in rural Haiti. J Nutr 2007; 137: 1023-30

4. De Pee S, Moench-Pfanner R, Martini E, Zlotkin S, Darnton-Hill I, Bloem MW. Home fortification in emergency response and transition programming: Experiences in Aceh and Nias, Indonesia. Food Nutr Bull 2007; 28: 189-197

5. De-Regil LM, Suchdev PS, Vist GE, Walleser S, Peña-Rosas JP. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD008959

6. WHO. 2011. Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6– 23 months of age.

7. Rah JH, de Pee S, Kraemer K, Steiger G, Bloem MW, Spiegel P, Wilkinson C, Bilukha O. Program experience with micronutrient powders and current evidence. J Nutr 2012; 142: 1915-1965

8. Bilukha O, Howard C, Wilkinson C, Bamrah S, Husain F. Effects of multimicronutrient home fortification on anemia and growth in Bhutanese refugee children. Food Nutr Bull. 2011 Sep;32(3):264-76.

9. Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A & Dewey KG. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. American Journal of Clinical Nutrition 2007; 86: 412–420

10. Phuka J.C., Maleta K., Thakwalakwa C., Cheung Y.B., Briend A., Manary M. et al. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-month-old rural Malawians. Archives of Pediatric and Adolescent Medicine 2008; 162: 629– 626

11. Phuka J.C., Maleta K., Thakwalakwa C., Cheung Y.B., Briend A., Manary M. et al. Post intervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. American Journal of Clinical Nutrition 2009; 89: 382–390.

12. Troesch B, et al. A Micronutrient Powder with Low Doses of Highly Absorbable Iron and Zinc Reduces Iron and Zinc Deficiency and Improves Weight-For-Age Z-Scores in South African Children. Journal of Nutrition 2010.

13. Home Fortification Technical Advisory Group (HF-TAG). Programmatic Guidance Brief on Use of Micronutrient Powders (MNP) for Home Fortification.2011. http://hftag.gainhealth.org/resources/programmatic-guidance-brief-use-micronutrient-powders-mnp- home-fortification

29 Monitoring & Evaluation – Logic Models

Monitoring and evaluation (M&E) are closely linked An indicator is a quantitative or qualitative factor and mutually supportive. Monitoring is the routine or variable that provides a simple and reliable means tracking of data on inputs, outputs and outcomes to measure achievement or to reflect the changes within programme operations. The information connected with a WFP operation. In the results collected allows WFP to assess progress towards chain (below), indicators for each of the elements are stated objectives, as well as identify whether any used to measure performance. 32 aspects of the operation need adjustment. Evaluation is the process of using data to ascertain the effectiveness, impact, efficiency, relevance and sustainability of an operation.

Inputs Activities Outputs Outcomes Impacts

The financial, human, Actions taken or work The products, capital Beneficiary and The positive and and material resources performed through goods and services population-level negative, intended or required to implement which inputs are which result from a changes in knowledge, unintended long-term the WFP operation mobilized to produce WFP operation practices and attitudes results produced by a specific outputs resulting from the WFP operation, either intervention directly or indirectly

Definitions adapted from M&E Knowledge Base, WFPgo

Monitoring focuses on the appropriate and timely most in need are covered/have access to the provision and use of project resources focusing interventions; 3) increase appropriate utilization of primarily on inputs, activities, outputs, and the nutrition interventions, including consumption outcomes; evaluation focuses on whether the of sufficient quantities of the rations; and 4) expected impacts were achieved. In addition to the measure how the nutrition programme has more immediate role that M&E plays in measuring contributed to preventing malnutrition and progress towards objectives, an effective M&E subsequently, morbidity and mortality. system will ultimately improve the quality of activities; improve management-oriented decision The approach has several different components: 1) a making; improve accountability to donors, partners, logical pathway 2) indicator frameworks that host governments and beneficiary communities; and measure each step in the logical pathway and 3) data improve WFP and partners’ ability to conduct management and reporting. The approach helps to evidence-based advocacy. measure results as well as to explain how the project is working and the expected and unexpected results obtained. This approach is being developed for M&E for WFP Nutrition different pillars of nutrition programming, as shown on the following pages. A new approach to M&E for nutrition has the following objectives: 1) ensure a smooth scaling-up of nutritional in terve ntion s; 2) ensure populations

32. WFP, 2011. The M&E G uide for HIV and T B Programming.

30 Nutrition at the World Food Programme

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c r n n t r i e d p o n c a e

i t e e g v

b n r o n r t o n o h

r n d v n d o p I c a t i t i p e a i r i e e l

t n t t s e e u a a

m t a a

p n r h w n n u s i i e

o t o i l

q c u e p r w t a g e f

c e t e e y a a d a t h e H S V D H A s t s

r t O • • • • • • n a o t c

n c , a i y

t t a e i n n p p c v o i e

& l i d n t

m t d d a y e a c y m I t c e e n i t s m u p i n v v m l o a d d i o i r s I u o o a l t e f o i r r t b o r u e r r f r r t p p c t r v p o o a e

u e e t m m & p I I D d n m s m

Abbreviations: IYCF= infant and young child feeding, BCC= behaviour change communication, QC/QA= quality control/quality assurance Source: Adapted from CDC/WHO, 2011 31 Logical pathway for Preventing Chronic Malnutrition I n

MANAGEMENT, COORDINATING MECHANISMS BETWEEN WFP AND IMPLEMENTING p PARTNERS/OTHER PARTNERS, RESOURCES, STAFFING, LOGISTICS u t s

•

• • D

•

• D

•

• •

m E • P I • S •

• n

P f p o & e e I D I E T D S D S E S D m t e t i s s s Q o b t b d c f o n n d a h h r e l t y h m l e n s

d l e e e d e e e e e e e C i l a u i t a b e c r e e e i t s c c e g t t t v u c n n l e e v v v v c g i a l / d k i e n s u u

a t

n i i l u v t a i c l e r e e e e e e u Q n d f e e a e b e e s e h t p p i v n i

e a s g l l l l f f r p i u v n m i a t h l l s l s d o o o o A a i i f

s e i i i r t

d y e i c c o i o o

s f , g t g e

o p p p p

g i y v s t

c n o e

i i r o m &

n r f f e

a a p

l a

i m m

m e r i a t a

d i o n o S t s a n m A o

s b r r a t

a i

r t e d i t n o o f e y p u R

r i i

o i o d e e u e u u d n

e e

& o n s a

e f n r s l d r r h n n n n d e e p F p

e e t d c s s u n s t o c

a i e

u t t t c

s c v q s e o s

o p e p

U c i

t o

d a p a t h n

o o c t e e m & / o u a

n a u o p l f r e n s o r l t s a f m t y l i f

a a t b

r a

l d i o

e q

g s t e

y f d o h o n i e

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r d m r e a s l u o

a e f n t

g e o m f p e c i v c c

s u r t p

n v a

n i g , p

p e n t h p h y u a e o t s t

c a e e i t t d d

a y r l g d m h

n r n a t o n e t e c r n r o o o

i t e e i p s a t i n o

f f Q q n t d c f h a r i d I a e o

p l

t e

o m m a i a Y c u

u t l e p p e u v u d e r o

r Q n a h g t C a c p

r r a e s c m n h e r a i i s r l a e C o o t o l n r F t i t o t r n g t e i s n l

i o

r i t c d y n u a /

f i g o o c r t f e

y g g B o t , e Q d u a t

n t , e h i n n

t y a e

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r s C u q c c

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m d s

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n c t t f

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h a

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o n y e

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e r t

e ,

s y

F F E C T I V E s a f Q i n e m c T t p q B r s a p t t i c t i d b g l n H H R T a b T n n d e o o i r r e a a i o u o d t c c i r u r i e r e u u m

C i e e t a a u a m e s t t o g

P g o o o r r c c m m f e

n n a t t e e d t a a i i C t a d n f g g d o h b e o e i n n g j u r r a R s r i e e n e r r s i l l e l i i e c

m m t e e f s i s t t t i l s r r e e p i v v r t t t s f f l b l y t i

O t c h h

i d a r

i i y t t t g i s f i i e t e e d d e i s y p t o o s a c c

u s t i u u r

m i

r e e J r i , , n n n

e y i n r i i s s n n t , v n t n n a

b e d a a o e E d t

o o t t t t t e / d s e g a

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a a

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t t C a g d t e / o o i

i y a e t y i

l t l f f

c e t u i u f e i r g a h

n n T i f f i

n n e o v e

. n , o s o

a c s A , b y e

f a r

e d

n u t M

l o

a c a t O i r a r

e t

p h r c e y r r y r A

m e s e e e

N u

s A

t & G p

E c o M u v E e t N r a s n b p i I d p c a m E H T n g Y o p e r i r f u e

s f e f e C o o u & n p o t e a t s d d r F n r r r e c l

i s i t m o u u

M t s t f b h a d i i i p c c e o c v u g

e O t t r l i s n t e t l

s a i l i a i t n e i u N a

v r a r a

g t s i g e g I t f e e n e

f o

T r e a s

l o , d e y

t O

n & n

d R

I N G

A N D

E b h p f ( m p b n t s a a s c a n n b c M S T H V e a p a u u o a K d p n r y r r e e u u u h i A o e r e g a e o r r v r p p g n n h p d t t t n a g t o g d e s L c a h m r r r e p p i h r e e e

o r e i i i e d s g e t i f s U o

r t t t i l l n f f r e w i o n p a t o e e n a O i i i u t t i c i i e p o o o

v g c c r A

f l g g r t m m g e e l c l n i e s r i i n n n e e i o o

n a a e

T t o s i

e / e c a u r o d

a a e e

a g w c , r r s n

I u s e d

t f l l g n n i i a n r r

e e

s a i e t e n r t t d o n s s e l

s e m a N y , d

f c g

t s

a ) a

e o s p i d e n p

m i r n o t p a e i k a e t s e

u s e 6 c d r l m n p M I H a , m e h e r u - i

A c o c g e 2 i n t t p l o M r g h r d 4 a s e r i v n e r t

t e

m e e i i i r a

o n n v

d r n n n e

q g o y i

t e a d u

a n

w f t l

a g a t r l

h y o o n l e i i n

s t m m d d y

• • • • • O • n

t A H D V S H f h u a d a y e e e n c f e g a w r e c c I q

l i t o m t

e i i u n n i w h r o n I a a t p m

a n e e s t t a t

m e e i r i e p i o c n v n r

t r r n b v g e

a t o l c t p c s a d p R R i r n a p c c a w e h h t n n r e r e e t e c t u r e e a i i i o f a

i d d t o g l l s a c n i s g v s d d a c e u u n e e t t t a n r r i t m a c c i f e t s s c e e i l n a e

n e e e t : n n n p i g u n e d d g t n a c

d s t

u a c y s i

p i w a

n i e a r n n

a n u m o

o n d d n g o l n m a d

e d o f

r n

e i

o g n n

Abbreviations: IYCF= infant and young child feeding, BCC= behaviour change communication, QC/QA= quality control/quality assurance Source: Adapted from CDC/WHO, 2011

32 Nutrition at the World Food Programme Logical pathway for Home Fortification I n

MANAGEMENT, STAFF, NATIONAL MICRONUTRIENT COALITION, GOVERNMENT & p INTERNATIONAL FINANCIAL RESOURCES, FACILITY & COMMUNITY VOLUNTEER INFRASTRUCTURE u t s

•

D •

• P •

•

• •

B P •

• • ( B

P r o e & e u G f o I I M M S d ( B B T i s I c c I i & i T l o o n o m m o n n C n n B l h r t o o f r l

t a e e C o

N N i l r

i t g r a b a t d t a f i c C v m n c C a a v v m e p p h l v a c e e o C i i P P i e e k i u o i d n s c e n ) C i e v g e t l l a g t r r e

e m

h e e e n u e l t t n u c l y i m m i r i p r v i r ) u r o n i s i n s n m m h a t o g n a l c o a t

a c y r u i a n i , p g

m g o t v a o i a s v t y o m t r t

n l

n e e o e t t

e e p e

i r

t l t

c i

& e o m d f a m n n g C i A i

o e d n d d e d r d e c o u o

c e u e t

o r t t s r n e h

n s a

h r n a r e e a e e a r i I & r a r t I d t v

a e c t t a s Y t x a

, r r n s Y d d t m a

i n

u c e

e l d a i

e o

t a C n n i C s a a e b d t h e m c l r e d t d a n

p o g g F d l g F i l e e t n a d s r i a i

p p i e

e p s u / n g v e S i

f o n g e v & l n a M p h o r e

m s l c e y a

n g v u a e c o t

g C

r r d e a l

l N M o i o e , g e p m o v i

p e

d e d

n o b m t l m

e r P & d e p i n N p m e o h c o t e i e m d

d i e n e t e

v p o o l P e m n n n h i

y e l

d t d m e e m n s

a m i &

a t M a e n v i u &

y l e d i n l t o & v

d t p e t s t m N n s i d u a

o t h , o p i r l

t o e

i d P e r n

u n c e e

r r f i

m p v , a n i n d m a a

c o r c t q g l

c i e e o

c i a h & c i u o

n n l a v a p t a i

n a l t t t t i i

c a l n d i y o e l i

a o y i o n

g e

t d n n n

n y

e r

, s f

F F E C T I V E M c w

s M A

d •

m P • k v a o

o n d r e i v

i N N D I s s s M q s s q M o P o t r l l l e o a m v t p t u h i p t e u t u P P v i v R N r q a N w i a s e i e n l

a i s

i a v p e a n t u m b t d n P O B

P c l c t

l a r l a p o r e b i d i a u i e e d s i s i C i t n

t J t f o k f b d r r i

I y t a r e

t y a i i i l t C E o

m c e m t o e c Y i e s u g

r r c e

r t h a b a

C r

n d

C s y d t e o d y & e & e M s e e t l t

s F u e

h e i e t r o &

d o

o m

n s t & a t & f &

M n

P O t

s s

r s ,

A e

N u A A t c G c p e E s M u s E t N s M A c s I T Y o t c

N r C m & c a P e F t

m s e

s M s

s g i u u O n

i t n e p

o N s i p t

I i B o & e T r C s

t O C i v R , e

N G

A N D

E M

•

u s

•

c m a c & 6 I • & c M C A d c V Y t h a h a

p e s - m o

A m a d m d f m u N o I I I A r o C M h 2 r r e i i r m p n n n v a l l c t i i s e e p t e P L d d o a 3 v e F

i i i h r e t N c c c c h e I n n n t t p q a s U o n e r r v

e t

r r r e r e Y a a

e s P m a e e i i i n r u e e e p a e g r g o m m m r p A C k k t r o

r n n s d e a a a

g s r i f

r a s o e e t y K e a F i p T

c i

a u u u , n s s s , a t e , a M m k r r n

h b

n r y

t I e e e m m m

b c

s s a t n

i t e i o i N o O a e d d d y o &

l l l h c

o g d i e & &

f w t l

n t P c

m s

y w e

r y

e e s g : a d l e

, e p s

p i t n

d e o a

t p

g l

o , p

c i a o t v e e

u r a s g e 6 a & l & I e o m m

s – a m d s p o

n i

2 m r i n o d n o 3 g f

i e v

v r m e c i a s i d h t l o h a s

i n i l e

m n d t d t r h i a

e n s k n s o d i p O n e

I t e r t t m

h e h w e e v e r p o e r v r a

r n

e i m c v n t n a t i i t t

i o t n e n o a i n o d r g n m v , n

F e

I s i & n m u n n , 6 a 6 n d I I D m m a a p p 6

m m n t t c m m m e r e u

& a e a i – – – o o o c o o v r t l c p p

k t a o o o r r

f d r n m n e r 2 2 2 i o t b r r e i r n n n o u e t t l a s o o r 3 3 3 i , i o r i i g g g n a d a c

o l m n v v o

i p S t

s t i m m m n e e e l t c c c i m y

a t e v y a d d r h h h & a

o o o n d a i

l &

e t i i i t

n n n l l l c l

y u s d d d n

e t t t

t s r r r t h h h a

, e e e

& s s s

t n n n u

Abbreviations: IYCF= infant and young child feeding, BCC= behaviour change communication, QC/QA= quality control/quality assurance Source: Adapted from CDC/WHO, 2011. Home Fortification Technical Advisory Group (HF-TAG). A Manual for Developing and Implementing Monitoring Systems for Home Fortification, 2012. 33 P r 1 W m A D P p T S G g K n C i N A D e A n r b i i c r l a r r h u u a e v x e a u o s o b e t o o e o r c t e r y g v c n i e t r g d

l F g r t d u r e e k r r l

. y r e l

r i r I y e f e v

i e w u p v a y t a d

r e

f n P i n , i r O e t l i a c

e g i t

m o n u i a

g r c o h t b t f t n r i r n i t r

t s

n r e o m

2 W t

t a e u i d e S

6 p n 0 g o e i r p n

t o d e g v s t F r t

r n i r o i e

: d n o p

o i l m o P o

e 6 a L e i n 4 f

d N

s n

T i

m t a

l S u r R o a t e n e o

s U c d i f c = a

n l

t t t s

1 m h s L F i

5 s i . e p a g

p 2 n i

d 3 o s t l - O

u s X ( b t i g t P - a r z a p s e S r a e a

\ r

e b d t t C a 6 1 ( 2 C P p 3 v 5 9 ( R C ¶ T L L m u e V

P 1 N e n e r 5 4 0 2 0 a h o N X O m f i a d r e o e o X 0 p g a u S d 0

g 0 - r n i I r n , r e l m a t t 9 t % P n

e i

t g t L r e p o d

1 a V s n s k

a 0 i

t u a r e e f o i e d n N a a a ) n 3 S c - u o n i e I

r t n i n n R t ,

d : c r a c s b s d . t n \ , t n

t i s 8 t h - h

3 , a l T l a P

a r 1

S ¶ h , n c e u

P k i u 6 B e V e y t

1 s b s E u o 4 i H s

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c . ,

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p C 7 S g i

n \ o A d R

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k i t R t n Q ( t e h 5 r h c a r , , o e M e e 9

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s V n s r o U y

o u s n s s F

) m

- 6 a S , t

y o ) .

t . 1

X F m

s 9

0 S = m e e 8 S 0 u n

9 O a

R H d l F -

p A P n e g 1 e 6 2 C ( H

C a P 1 s V 9 5 R ( C o a p d 1 H ) P 1 c o o u n e d 5 4 0 2 0 H & h a o N

7 l Q 1 e r N 1 y l e u a d

0 g 0 - r n = i 6 i W i M I

s l - m a d u D 9 t % o n m

t h t H t o k U t 1 a s n s k

s o a 0 u e r r \ o c e H n a a ) - n , 3 c i u e d i e

d a t e

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s 8 t M n h - h 3 a l X

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h D 6 6 C A (

C h s o l C 1 5 ( R C F R e e ) C 1 B u C W i a

0 2 0 h a h o N A c ,

c l H m F a

0 A h g , s 0 0 - r n i i h 1 i I

v l c t A 9 t % M

= a i

m d 6 g

t o g 3 c h a 1 o k a S k a 0 r -

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X 2

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p o t n u , P 0 e d : a 5 k a d V n

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n % a p t o s

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H f o - i A , w )

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t a K e 3 5

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l k / e s c t ) t H &

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p s c r t P c ( a c g a

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A n n a a

s m i

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s T o v o m n a

m 1

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7 l e s

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d f 2 e l n % e r 0 A o k

t t % t f n ( r

e e b o o s ) p t

F x r r ) a i n

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B s h g R s

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m r

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l t

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l t T n t a e , h u m

m e d t r r i u p n i V 2

1 D M ( P

S C R ( 2 s 7 a r t e s P 1 p i a h r 2 5 0 5 a o N o u O

a r t y e L 6 a a a n i k

0 2 r r p I l o

T n W m g t n

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s r h

a s a e

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e n S t e o l s 2 i b a C s t / t n u d m d a e

h , r 0 l a f A p

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g c i e L i l A 3 n r d n 3

u r e s

a t

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d f

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C c n = a n I s 0 i

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i 3 a M r f s

d t ) i i e y ( d 8 c a t ,

e e a

1 a i p a g u r g D t n l t r 9 r

g , r i a

O g i i o e o c s p % e V l n T e

v s r u T t W

S s & t

i ) o s

o s

o g C . u M = n t o

n r e a . o . m

n l n A y

u e e

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