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PR, IFPRI3; OA; 2 Promoting Healthy Diets and Nutrition for all, Nutrition, Diets, and Health (NDH); Food and Nutrition Policy, We write in response to the commentary by Gupta et al. (2023) on small-quantity lipid-based nutrient supplements (SQ-LNS) for infants and young children 6 to 24 months of age, which was prompted by the recent brief guidance note from UNICEF (2023) explaining when, why and how SQ-LNS are being prioritized as part of their package of preventive actions to combat early childhood malnutrition. The UNICEF document was disseminated shortly after publication of a correspondence in Nature Food (Aguayo et al. 2023), authored by nutrition leaders from several organizations, that summarized the evidence on the benefits of SQ-LNS and called for this intervention to be scaled up and integrated into programs for populations in which child undernutrition is prevalent and dietary quality is very poor.

PR, IFPRI3; ISI; Cross-cutting gender theme; 2 Promoting Healthy Diets and Nutrition for all, Development Strategies and Governance (DSG); Transformation Strategies; Nutrition, Diets, and Health (NDH); Food and Nutrition Policy, The 21st Century has been marked by increased volatility in food prices, with global price spikes in 2007-08, 2010-11, and again in 2021-22. The impact of food inflation on the risk of child undernutrition is not well understood, however. This study explores the potential impacts of food inflation on wasting and stunting among 1.27 million pre-school children from 44 developing countries. On average, a 5 percent increase in the real price of food increases the risk of wasting by 9 percent and severe wasting by 14 percent. These risks apply to young infants, suggesting a prenatal pathway, as well as to older children who typically experience a deterioration in diet quality in the wake of food inflation. Male children and children from poor and rural landless households are more severely impacted. Food inflation during pregnancy and the first year after birth also increases the risk of stunting for children 2-5 years of age. This evidence provides a strong rationale for interventions to prevent food inflation and mitigate its impacts on vulnerable children and their mothers.

Non-PR, IFPRI4; Food Security Portal, Development Strategies and Governance (DSG); Transformation Strategies; Nutrition, Diets, and Health (NDH); Food and Nutrition Policy, Frequent food crises with spiking prices have become the new normal in the 21st century, bringing urgency to the task of understanding their nutritional impacts on poor and food insecure populations. In a new analysis of 1.27 million children in 44 low- and middle-income countries (LMICs), we show that exposure to food inflation in the womb and first years of life is associated with greater risks of child wasting in the short run and stunting in the long run. Food inflation also poses larger wasting risks for children of poor and landless rural households, exacerbating existing inequalities. These results show the urgency of policies focused on improving maternal and young child nutrition, and the importance of broadening actions to reduce food price volatility and boost access to nutritious foods.

PR, IFPRI3; ISI; DCA; Capacity Strengthening; 2 Promoting Healthy Diets and Nutrition for all; CRP4, Nutrition, Diets, and Health (NDH); Poverty, Gender, and Inclusion (PGI); Food and Nutrition Policy; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Nutrition-sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition- and gender-sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2−4 years in Burkina Faso. A 3-year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15−49 years with an index child aged 2−4 years. We assessed the effects 1.5-years (WASH substudy) and 3-years (endline) post-intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH-livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04−0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03−0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock-related risks and improve livestock-hygiene-related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.

PR, IFPRI3; 2 Promoting Healthy Diets and Nutrition for all; Advancing Research on Nutrition and Agriculture (ARENA), Foresight and Policy Modeling (FPM); Development Strategies and Governance (DSG); Transformation Strategies; Nutrition, Diets, and Health (NDH); Food and Nutrition Policy, Suboptimal diets are the most important preventable risk factor for the global burden of non-communicable diseases. The EAT-Lancet reference diet was therefore developed as a benchmark for gauging divergence from healthy eating standards. However, no previous research has comprehensively explored how and why this divergence exists in poorer countries undergoing nutrition transitions. This study therefore analyzes dietary patterns and drivers of the demand for nutritious foods using nationally representative household surveys from Ethiopia, Kenya, Tanzania, and Uganda. We show how barriers to dietary convergence stem from combinations of poverty, high relative food prices and weak preferences for some specific healthy foods. The article concludes by discussing interventions for strengthening consumer demand for healthy diets in Africa.

PR, IFPRI3; ISI; 2 Promoting Healthy Diets and Nutrition for all, PHND, Background: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNS) reduce child wasting and stunting. There is little information regarding effects on severe wasting or stunting. Objective: We aimed to identify the effect of SQ-LNS on prevalence of severe wasting (weight-for-length z-score < -3) and severe stunting (length-for-age z-score < -3). Methods: We conducted a two-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNS provided to children 6 to 24 mo of age. We generated study-specific and subgroup estimates of SQ-LNS vs. control and pooled the estimates using fixed-effects models. We used random effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.

PR, IFPRI4; 2 Promoting Healthy Diets and Nutrition for all, PHND, One of the most significant challenges for food systems today is ensuring that every individual has access to — and consumes — sustainable healthy diets. These are defined as nutritious, healthy (meaning they help prevent disease), safe, affordable, and culturally acceptable diets that support optimal nutrition and health and cause low environmental pressure and impact. The food systems tasked with producing these healthy diets are under significant stress due to environmental and natural resource constraints, as well as climate change. Moreover, the types and amounts of foods we consume — and the way we produce, process, and move these foods — compromise the stability and resilience of natural resources and biodiverse ecosystems and contribute to climate change.

PR, IFPRI3; CRP4; 2 Promoting Healthy Diets and Nutrition for all; ISI, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Background: The Lives Saved Tool (LiST) is a mathematical modelling tool for estimating the survival, health, and nutritional impacts of scaling intervention coverage in low- and middle-income countries (LMICs). Various nutrition interventions are included in LiST and are regularly (and independently) reviewed and updated as new data emerge. This manuscript describes our latest in-depth review of nutrition evidence, focusing on intervention efficacy, appropriate population-affected fractions, and new interventions for potential inclusion in the LiST model. Methods: An external advisory group (EAG) was assembled to review evidence from systematic reviews on intervention-outcome (I-O) pairs for women and children under five years of age. GRADE quality was assigned to each pair based on a LiST-specific checklist to facilitate consistent decisions during the consideration. For existing interventions with new information, the EAG was asked to recommend whether to update the default efficacy values and population-affected fractions. For the new interventions, the EAG decided whether there was sufficient evidence of benefit, and in affirmative cases, information on the efficacy and affected fraction values that could be used. Decisions were based on expert group consensus. Results: Overall, the group reviewed 53 nutrition-related I-O pairs, including 25 existing and 28 new ones. Efficacy and population-affected fractions were updated for seven I-O pairs; three pairs were updated for efficacy estimates only, three were updated for population-affected fractions only; and nine new I-O pairs were added to the model, bringing the total of nutrition-related I-O pairs to 34. Included in the new I-O pairs were two new nutrition interventions added to LIST: zinc fortification and neonatal vitamin A supplementation. Conclusions: For modelling tools like LiST to be useful, it is crucial to update interventions, efficacy and population-affected fractions as new evidence becomes availa

Non-PR, IFPRI1; 2 Promoting Healthy Diets and Nutrition for all, DSGD; PHND, The 21st Century has been marked by increased volatility in food prices, with global price spikes in 2007-08, 2010-11, and again in 2021-22. The impact of food inflation on the risk of child undernutrition is not well understood, however. This study explores the potential impacts of food inflation on wasting and stunting among 1.27 million pre-school children from 44 developing countries. On average, a 5 percent increase in the real price of food increases the risk of wasting by 9 percent and severe wasting by 14 percent. These risks apply to young infants, suggesting a prenatal pathway, as well as to older children who typically experience a deterioration in diet quality in the wake of food inflation. Male children and children from poor and rural landless households are more severely impacted. Food inflation during pregnancy and the first year after birth also increases the risk of stunting for children 2-5 years of age. This evidence provides a strong rationale for interventions to prevent food inflation and mitigate its impacts on vulnerable children and their mothers.

PR, IFPRI3; ISI; 2 Promoting Healthy Diets and Nutrition for all, DSGD; MTID; PHND, Governments, donors and others must step up to protect current and future generations from the devastating effects of malnutrition, as well as to prevent acute food insecurity.

PR, IFPRIOA; IFPRI3; ISI; CRP4; Advancing Research on Nutrition and Agriculture (ARENA); 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH; DSGD, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), In low and middle income countries macroeconomic volatility is common, and severe negative economic shocks can substantially increase poverty and food insecurity. Less well understood are the implications of these contractions for child acute malnutrition (wasting), a major risk factor for under-5 mortality. This study explores the nutritional impacts of economic growth shocks over 1990–2018 by linking wasting outcomes collected for 1.256 million children from 52 countries to lagged annual changes in economic growth. Estimates suggest that a 10% annual decline in national income increases moderate/severe wasting prevalence by 14.4–17.8%. An exploration of possible mechanisms suggests negative economic shocks may increase risks of inadequate dietary diversity among children. Applying these results to the latest economic growth estimates for 2020 suggests that COVID-19 could put an additional 9.4 million preschoolers at risk of wasting, net of the effects of preventative policy actions.

PR, IFPRI3; ISI; GAAP; CRP4; G Cross-cutting gender theme; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

Non-PR, IFPRI4; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; DGO; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), In a pair of commentaries published in The Lancet in August 2020, we and our colleagues in the Standing Together for Nutrition Consortium (STfN) and the leaders of four UN agencies called for immediate action to address the escalating problems of child malnutrition and excess mortality triggered by the COVID-19 pandemic (Fore et al. 2020; Headey et al. 2020). Although child mortality from the virus itself is low compared to other age groups, the social, economic, and health systems crises it has prompted pose a serious threat to young children’s nutrition, health, and survival in low- and middle-income countries (LMICs).

PR, IFPRI3; ISI; DCA; 2 Promoting Healthy Diets and Nutrition for all; CRP4, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

PR, IFPRI3; CRP4; 2 Promoting Healthy Diets and Nutrition for all; IFPRIOA; ISI; DCA, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Little is known about the impact of food-assisted maternal and child health programs (FA-MCHN) on child wasting. We assessed the impact of Tubaramure, a FA-MCHN program in Burundi, on child (0 to 24 months) wasting and the differential impacts by socio-economic characteristics and age. The program targeted women and their children during the first 1000 days and included 1) food rations, 2) strengthening and promotion of use of health services, and 3) behavior change communication (BCC).

PR, IFPRI3; CRP4; 2 Promoting Healthy Diets and Nutrition for all; ISI; DCA, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Background: Simple proxy indicators are needed to assess and monitor micronutrient intake adequacy of vulnerable populations. Standard dichotomous indicators exist for nonpregnant women of reproductive age and 6–23-mo-old children in low-income countries, but not for 24–59-mo-old children or pregnant or breastfeeding women. Objectives: This study aimed to evaluate the performance of 2 standard food group scores (FGSs) and related dichotomous indicators to predict micronutrient adequacy of the diet of rural Burkinabe 24–59-mo-old children and women of reproductive age by physiological status. Methods: A 24-h recall survey was conducted at dry season among 1066 pairs of children and caregivers. Micronutrient adequacy was evaluated by the mean probability of adequacy (MPA) of intake over 11 micronutrients. Proxy indicators were FGS-10 [10 food groups based on the FAO/FHI360 minimum dietary diversity for women (MDD-W) guidelines] and related MDD-W (FGS-10 ≥5); and FGS-7 [7 groups based on the WHO infant and young child (IYC) feeding MDD guidelines] and related MDD-IYC (FGS-7 ≥4). Results: FGS-10 and FGS-7 were similar across children and women (∼3 groups). FGS-10 performed better than FGS-7 to predict MPA in children (Spearman rank correlation = 0.59 compared with 0.50) and women of all 3 physiological statuses (Spearman rank correlation = 0.53–0.55 compared with 0.42–0.52). MDD-W and MDD-IYC performed well in predicting MPA >0.75 in children and MPA >0.6 in nonpregnant nonbreastfeeding (NPNB) women, but a 4-group cutoff for FGS-10 allowed a better balance between sensitivity, specificity, and proportion of correct classification. MPA levels for pregnant and breastfeeding women were too low to assess best cutoff points. Conclusions: MDD-IYC or an adapted MDD-W (FGS-10 ≥4 instead of FGS-10 ≥5) can be extended to 24–59-mo-old children and NPNB women in similar-diet settings. The inadequacy of micronutrient intakes in pregnant and breastfeeding women warrants urgent action

PR, IFPRI3; CRP4; ISI; 2 Promoting Healthy Diets and Nutrition for all, A4NH; MTID; PHND, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Food systems that deliver healthy diets without exceeding the planet’s resources are essential to achieve the worlds’ ambitious development goals. Healthy diets need to be safe, accessible, and affordable for all, including for disadvantaged and nutritionally vulnerable groups such as of smallholder producers, traders, and consumers in low- and middle-income countries. Globally, food systems are experiencing rapid and drastic changes and are failing to fulfil these multiple duties simultaneously. The international community therefore calls for rigorous food systems transformations and policy solutions to support the achievement of healthy diets for all. Most strategies, however, are essentially supply- and market-oriented. Incorporation of a healthy diet perspective in food system transformation is essential to enable food systems to deliver not only on supplying nutritious foods but also on ensuring that consumers have access can afford and desire healthy, sustainable, and culturally acceptable diets. This paper argues that this should be guided by information on diets, dietary trends, consumer motives, and food environment characteristics. Transformational approaches and policies should also take into account the stage of food system development requiring different strategies to ensure healthier diets for consumers. We review current knowledge on drivers of consumer choices at the individual and food environment level with special emphasis on low- and middle income countries, discuss the converging and conflicting objectives that exist among multiple food-system actors, and argue that failure to strengthen synergies and resolve trade-offs may lead to missed opportunities and benefits, or negative unintended consequences in food system outcomes. The paper proposes a menu of promising consumer- and food-environment- oriented policy options to include in the food systems transformation agenda in order to shift LMIC consumer demand towards healthier diets in low- and

PR, IFPRI3; ISI; CRP4; 2 Promoting Healthy Diets and Nutrition for all; DCA, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Background: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design. Objectives: We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes. Methods: We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6–24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. Results: SQ-LNS provision decreased stunting (length-for-age z score < −2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < −2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < −2) by 18%, acute malnutrition (WLZ < −2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < −2) by 13%, and small head size (head circumference-for-age z score < −2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation. Conclusions: The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. P

PR, IFPRI3; ISI; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Background: Poor birth outcomes are an important global public health problem. Social assistance programs that provide cash or in-kind transfers, such as food or vouchers, hold potential to improve birth outcomes but the evidence on their effectiveness has not been reviewed. Objectives: We systematically reviewed studies that used experimental or quasi-experimental methods to evaluate the impacts of social assistance programs on outcomes in low- and middle-income countries. Methods: The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to assess the certainty of the evidence for birth weight and neonatal mortality (most common outcomes reported). We summarized the evidence on hypothesized nutrition and health pathways of impact. Results: We included 6 evaluations of 4 different cash transfer programs and 1 evaluation of a community-based participatory learning and action program that provided food and cash transfers. The 4 studies that assessed birth weight impacts found significant (P < 0.05) effects ranging from 31 to 578 g. Out of 3 studies that assessed neonatal mortality impacts, 2 found significant effects ranging from 0.6 to 3.1 deaths/1000 live births. The certainty of the evidence for both outcomes was rated as very low due to several methodological limitations. In terms of potential pathways, some studies documented positive effects on maternal diet, antenatal care (ANC) utilization, and delivery in a health facility. Conclusions: Better-designed evaluations are needed to strengthen the evidence base on these programs. Evaluation studies should elucidate underlying mechanisms of impact by including outcomes related to maternal diet, ANC seeking, use of skilled delivery, and women's empowerment in nutrition and health domains. Studies should also assess potential unintended negative consequences of social assistance, such as reduced birth spacing and excess pregnancy weight gain.

PR, IFPRI3; ISI; 2 Promoting Healthy Diets and Nutrition for all; Capacity Strengthening; POSHAN; CRP4, PHND; A4NH; SAR, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Rapid urban expansion has important health implications. This study examines trends and inequalities in undernutrition and overnutrition by gender, residence (rural, urban slum, urban non-slum), and wealth among children and adults in India. We used National Family Health Survey data from 2006 and 2016 (n = 311,182 children 0-5y and 972,192 adults 15-54y in total). We calculated differences, slope index of inequality (SII) and concentration index to examine changes over time and inequalities in outcomes by gender, residence, and wealth quintile. Between 2006 and 2016, child stunting prevalence dropped from 48% to 38%, with no gender differences in trends, whereas child overweight/obesity remained at ~7–8%. In both years, stunting prevalence was higher in rural and urban slum households compared to urban non-slum households. Within-residence, wealth inequalities were large for stunting (SII: -33 to -19 percentage points, pp) and declined over time only in urban non-slum households. Among adults, underweight prevalence decreased by ~13 pp but overweight/obesity doubled (10% to 21%) between 2006 and 2016. Rises in overweight/obesity among women were greater in rural and urban slum than urban non-slum households. Within-residence, wealth inequalities were large for both underweight (SII -35 to -12pp) and overweight/obesity (+16 to +29pp) for adults, with the former being more concentrated among poorer households and the latter among wealthier households. In conclusion, India experienced a rapid decline in child and adult undernutrition between 2006 and 2016 across genders and areas of residence. Of great concern, however, is the doubling of adult overweight/obesity in all areas during this period and the rise in wealth inequalities in both rural and urban slum households. With the second largest urban population globally, India needs to aggressively tackle the multiple burdens of malnutrition, especially among rural and urban slum households and develop actions to maint

PR, IFPRI3; ISI; CRP4; 2 Promoting Healthy Diets and Nutrition for all; POSHAN; Transform Nutrition West Africa, PHND; SAR; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda—now amplified by the COVID-19 crisis.

Non-PR, IFPRI1; CRP4; 2 Promoting Healthy Diets and Nutrition for all, DSGD; PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Suboptimal diets are a major risk factor for avoidable death and disease in low- and middle-income countries. Evidence shows that some foods or food components (e.g., processed red meat, saturated fat, salt, sugar) significantly elevate the risk of noncommunicable diseases and mortality, while others protect health (e.g., vegetables, fruits, pulses, nuts/seeds, fish, whole grains—referred to in this document as “protective foods”). We used household surveys to compare dietary patterns in Ethiopia, Kenya, Tanzania, and Uganda to the EAT-Lancet healthy reference diet and to quantify and explain consumption gaps for nutritious foods. Compared to the EAT-Lancet healthy reference diet, consumption gaps for pulses and nuts/seeds, vegetables, and fruits are large for both poor and rich consumers in rural and urban areas in the four countries studied, while consumption gaps for meat, fish, and eggs and dairy foods are much larger for lower income groups. Food expenditures of most households in these four countries are far too low to allow consumption of the healthy reference diet; animal-source foods and vegetables are the largest cost components of food expenditures, although quantities consumed of both food groups are much lower than the EAT-Lancet healthy reference diet. Income elasticities of demand for pulses and nuts/seeds and vegetables are often low or moderate, suggesting weak consumer preference for these foods, while income elasticities for fruits and animal-source foods are relatively high. Income growth alone will not solve dietary problems in East Africa; in addition to supply-side interventions to improve affordability, special interventions are required to increase consumer demand for underappreciated protective (nutritious) foods such as pulses and nuts/seeds and vegetables.

PR, IFPRI3; CRP4; 2 Promoting Healthy Diets and Nutrition for all; G Cross-cutting gender theme; Advancing Research on Nutrition and Agriculture (ARENA); Ceres2030, DSGD; MTID; PHND; A4NH, CGIAR Research Programs on Agriculture for Nutrition and Health (A4NH), The economic crisis and food and health system disruptions related to the COVID-19 pandemic threaten to exacerbate undernutrition in low- and middle-income countries (LMICs). We developed pessimistic, moderate and optimistic scenarios for 2020–2022 and used three modelling tools (MIRAGRODEP, the Lives Saved Tool and Optima Nutrition) to estimate the impacts of pandemic-induced disruptions on child stunting, wasting and mortality, maternal anaemia and children born to women with a low body mass index (BMI) in 118 LMICs. We estimated the cost of six nutrition interventions to mitigate excess stunting and child mortality due to the pandemic and to maximize alive and non-stunted children, and used the human capital approach to estimate future productivity losses. By 2022, COVID-19-related disruptions could result in an additional 9.3 million wasted children and 2.6 million stunted children, 168,000 additional child deaths, 2.1 million maternal anaemia cases, 2.1 million children born to women with a low BMI and US$29.7 billion in future productivity losses due to excess stunting and child mortality. An additional US$1.2 billion per year will be needed to mitigate these effects by scaling up nutrition interventions. Governments and donors must maintain nutrition as a priority, continue to support resilient systems and ensure the efficient use of new and existing resources.

PR, IFPRI3; ISI; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), The Strategic and Technical Advisory Group of Experts (STAGE) for Maternal, Newborn, Child, Adolescent Health and Nutrition (MNCAHN) which advises the Director-General of WHO, marked its first anniversary in April 2021 as it concluded its third virtual meeting. STAGE has 31 members from all WHO regions and includes the key discipline groups that focus on MNCAHN. STAGE is an independent advisory group that takes a critical look at initiatives and programmes at WHO related to MNCHAN. STAGE provides an opportunity to monitor progress, connect agendas and groups and is a space to facilitate synergies across WHO departments, as well as with other United Nations (UN) agencies.

PR, IFPRI4; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Pre-pandemic, 3 billion people could not afford a healthy diet; that number could rise by 267.6 million due to the pandemic. Food system transformation must support healthy diets and tackle all forms of malnutrition. KEY MESSAGES - Evidence from phone surveys in low- and middle-income countries shows widespread job and income losses and rapid rises in food insecurity due to government measures to contain the pandemic; poorer households, women, and other vulnerable groups are most affected. - Across the globe, the quality of diets deteriorated due to disruptions in supply of fresh, healthy foods, drops in demand for these foods due to unaffordability and perishability, and increased consumption of cheaper sources of calories including starchy staples and ultra-processed foods. - Deteriorations in diet quality could have devastating consequences for the health and nutrition of vulnerable women and children and could increase all forms of malnutrition in the short term and cause lifelong, irreversible development, health, and nutrition damage, reversing decades of progress made so far. - Food system transformation must support healthy diets and by doing so, serve as double duty actions that simultaneously tackle all forms of malnutrition.

PR, IFPRI3; CRP4; 2 Promoting Healthy Diets and Nutrition for all; Food Systems for Healthier Diets; UNFSS, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), The COVID-19 pandemic is affecting food and nutrition security through economic and social systems shocks, food system disruptions and gaps in coverage of essential health and nutrition services. Food systems in low- and middle-income countries must adapt and strengthen food and nutrition security in the wake of COVID-19.

PR, IFPRI3; ISI; CRP4, PHND; A4NH, CGIAR Research Programs on Agriculture for Nutrition and Health (A4NH), We thank Saskia Osendarp and colleagues, Mohammad Sorowar Hossain and colleagues, and Christine Stewart and colleagues for their responses to the Lancet Series on the double burden of malnutrition. They make some relevant points that we would like to address here.

Non-PR, IFPRI4; CRP4; 2 Promoting Healthy Diets and Nutrition for all; 3 Building Inclusive and Efficient Markets, Trade Systems, and Food Industry; 5 Strengthening Institutions and Governance; G Cross-cutting gender theme; Urban food systems for better diets, nutrition, and health; UNFSS, PHND; A4NH; DSGD; MTID, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

Non-PR, IFPRI5; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), India’s Covid-19 mitigation efforts should be to prevent child undernutrition now rather than to treat it later.

PR, IFPRI3; CRP4; ISI; HarvestPlus, PHND; A4NH; DGO; HarvestPlus, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), The unprecedented global social and economic crisis triggered by the COVID-19 pandemic poses grave risks to the nutritional status and survival of young children in low-income and middle-income countries (LMICs). Of particular concern is an expected increase in child malnutrition, including wasting, due to steep declines in household incomes, changes in the availability and affordability of nutritious foods, and interruptions to health, nutrition, and social protection services. One in ten deaths among children younger than 5 years in LMICs is attributable to severe wasting because wasted children are at increased risk of mortality from infectious diseases. Before the COVID-19 pandemic, an estimated 47 million children younger than 5 years were moderately or severely wasted, most living in sub-Saharan Africa and south Asia.

Non-PR, IFPRI1; CRP4; 2 Promoting Healthy Diets and Nutrition for all; Advancing Research on Nutrition and Agriculture (ARENA), PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), In developing countries macroeconomic volatility is common, and severe negative economic shocks can substantially increase poverty and food insecurity. Less well understood are the implications of these contractions for child acute malnutrition (wasting), a major risk factor for under-5 mortality. This study explores the nutritional impacts of growth shocks over 1990-2018 by linking wasting outcomes collected for 1.256 million children from 52 countries to lagged annual changes in national income. Difference-in-difference estimates suggest that a 10% annual decline in national income increases moderate/severe (WHZ<-2) and severe wasting (WHZ<-3) by 14 and 22 percent. An exploration of possible mechanisms suggests negative economic shocks increase risks of diarrhea, fever, and maternal underweight prevalence, and reduce child dietary diversity. Applying these results to the predicted economic impacts of COVID-19 suggests that millions of pre-school children are at increased risk of wasting and wasting-related morbidity and mortality unless urgent preventative action is taken.

Non-PR, IFPRI1; CRP4; 1 Fostering Climate-Resilient and Sustainable Food Supply; 2 Promoting Healthy Diets and Nutrition for all; 3 Building Inclusive and Efficient Markets, Trade Systems, and Food Industry; 4 Transforming Agricultural and Rural Economies; UNFSS, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Agriculture holds tremendous potential to improve nutrition. Traditionally, agriculture investments focused on producing enough food to allow people to meet their caloric needs and on generating employment and income. In the last decade, the understanding of how agriculture can contribute to nutrition has shifted from the implicit assumption that increased productivity and income would automatically improve nutrition to the acknowledgement that explicit nutrition goals and actions are needed to improve nutritional outcomes (1–4). This has led to increased commitments and investments in nutrition-sensitive agriculture programs and accompanying research to study these programs’ impact on nutrition outcomes. Guidance on how to make agriculture more nutrition-sensitive was also developed and included recommendations to target the first 1,000 days of a child’s life (from conception to 2 years of age) and to focus on reducing stunting (5–7). These developments coincided with the global commitment to achieve the World Health Assembly target of reducing child stunting by 40 percent by 2025 (8).

Non-PR, IFPRI4; CRP4, PHND; A4NH, CGIAR Research Programs on Agriculture for Nutrition and Health (A4NH), The COVID-19 pandemic has all the makings of a perfect storm for global malnutrition. The crisis will damage the nutritional status of vulnerable groups through multiple mechanisms. We can expect a dangerous decline in dietary quality in low- and middle-income countries (LMICs) stemming from the income losses related to government-mandated shutdowns and de-globalization, as well as from the freezing of food transfer schemes such as school feeding programs and the breakdown of food markets due to both demand shocks and supply constraints. But malnutrition will also increase due to healthcare failures, as already strained healthcare systems are forced to divert resources from a range of nutritionally important functions — including antenatal care, immunization, micronutrient supplementation, and prevention and treatment of childhood diarrhea, infections, and acute malnutrition — toward combating COVID-19.

PR, IFPRI4; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

Non-PR, IFPRI5; CRP4; POSHAN, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Growth monitoring (GM) and promotion is a routine part of primary healthcare for children in >80% of countries. In India, 57.5 million children are measured every month by frontline workers to assess their growth and to trigger preventive or curative services. Standard guidance for anthropometry suggests that quality can be compromised by the choice of measurement equipment, placement of equipment, and positioning of children during measurement. Little is known about the quality of measurement processes during GM. We compared child height and weight measurement processes with standards for anthropometry to assess GM quality.

PR, IFPRI3; CRP4; 2 Promoting Healthy Diets and Nutrition for all; IFPRIOA; ISI, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

Non-PR, IFPRI5; CRP4; 2 Promoting Healthy Diets and Nutrition for all; UNFSS, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Good nutrition is integral to human well-being and to humanity’s ability to achieve the Sustainable Development Goals (SDGs). Nutrition permeates almost all the SDGs, both as an outcome as well as an important input into their achievement, especially in terms of strengthening human capital. This paper focuses on the specific relationship of nutrition with SDG11, “Make cities and human settlements inclusive, safe, resilient and sustainable.”

PR, IFPRI3; ISI; CRP4; Alive and Thrive, PHND; A4NH, CGIAR Research Programs on Agriculture for Nutrition and Health (A4NH)

PR, IFPRI3; GAAP; CRP2; CRP4; ISI; PRSSP; Transfer Modality Research Initiative (TMRI), A4NH; PIM; PHND, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH); CGIAR Research Program on Policies, Institutions, and Markets (PIM)

PR, IFPRI3; ISI; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

PR, IFPRI3; Alive and Thrive; CRP4; DCA; 2 Promoting Healthy Diets and Nutrition for all, A4NH; PHND, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Background: The Minimum Dietary Diversity for Women (MMD-W) was validated as a proxy of micronutrient adequacy for non-pregnant women, with proposed data collection being either a list-based or a qualitative open recall method. Few studies have compared the performance of these two methods. Objectives: We compared performance in predicting micronutrient adequacy of food group indicators (FGIs) measured by the list-based and the quantitative open recall method using varying quantity cutoffs. We also examined the agreement between list-based and open recall FGIs.

PR, IFPRI3; CRP4; ISI; 2 Promoting Healthy Diets and Nutrition for all; IFPRIOA, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Evidence on the cost‐effectiveness of multisectoral maternal and child health and nutrition programmes is scarce. We conducted a prospective costing study of two food‐assisted maternal and child health and nutrition programmes targeted to pregnant women and children during the first 1,000 days (pregnancy to 2 years). Each was paired with a cluster‐randomized controlled trial to evaluate impact and compare the optimal quantity and composition of food rations (Guatemala, five treatment arms) and their optimal timing and duration (Burundi, three treatment arms). We calculated the total and per beneficiary cost, conducted cost consequence analyses, and estimated the cost savings from extending the programme for 2 years. In Guatemala, the programme model with the lowest cost per percentage point reduction in stunting provided the full‐size family ration with an individual ration of corn–soy blend or micronutrient powder. Reducing family ration size lowered costs but failed to reduce stunting. In Burundi, providing food assistance for the full 1,000 days led to the lowest cost per percentage point reduction in stunting. Reducing the duration of ration eligibility reduced per beneficiary costs but was less effective. A 2‐year extension could have saved 11% per beneficiary in Guatemala and 18% in Burundi. We found that investments in multisectoral nutrition programmes do not scale linearly. Programmes providing smaller rations or rations for shorter durations, although less expensive per beneficiary, may not provide the necessary dose to improve (biological) outcomes. Lastly, delivering effective programmes for longer periods can generate cost savings by dispersing start‐up costs and lengthening peak operating capacity.

PR, IFPRI3; ISI; CRP4, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH)

PR, IFPRI3; ISI; CRP4, PHND; A4NH, 9 pages, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), In Nepal, more than one‐third of children are stunted. Prior studies have shown that women's empowerment in agriculture is associated with child (<2 years) length‐for‐age z ‐scores (LAZ) in Nepal. This study tests whether child dietary diversity (DD) and household water, sanitation, and hygiene (WASH) facilities and practices mediate the associations between women's empowerment and LAZ. With a cross‐sectional dataset of 4,080 households from 240 rural communities across 16 districts of Nepal, we used ordinary least squares regression models to first estimate the associations between women's empowerment and LAZ for children 6 to 24 months (n = 1,402; our previous published analysis included all children <24 months of age), using the Women's Empowerment in Agriculture Index's Five Domains of Empowerment subindex. We used standardized structural equation models to test whether child DD and/or household WASH mediated the association between women's empowerment and child LAZ. Overall, women's empowerment was positively associated with child LAZ (β = 0.24, P = 0.03), as found in our previous analyses. In the mediation analysis, women's empowerment was positively associated with WASH (β = 0.78, P < 0.001), and in turn child LAZ (β = 0.09, P < 0.001). Women's empowerment was not associated with DD, but DD was associated with LAZ (β = 0.06, P = 0.05). Empowered women had better WASH practices than nonempowered women, which translated into higher child LAZ. Child DD was not a mediating factor in the association between women's empowerment and child LAZ. More research is needed to explore other pathways by which women's empowerment may affect child nutrition outcomes.

PR, IFPRI3; Alive and Thrive; CRP4; ISI; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Appropriate infant and young child feeding practices are critical for optimal child growth and development, but in Ethiopia, complementary feeding (CF) practices are very poor. Alive & Thrive (A&T) provided intensive behavior change interventions through 4 platforms: interpersonal communication (IPC), nutrition-sensitive agricultural activities (AG), community mobilization (CM), and mass media (MM). The aim of this study was to evaluate the impact of A&T intensive compared with nonintensive interventions (standard nutrition counseling and agricultural extension service and less intensive CM and MM) on CF practices and knowledge and child anthropometric outcomes.

PR, IFPRI3; CRP4; ISI; GAAP; 2 Promoting Healthy Diets and Nutrition for all; G Cross-cutting gender theme; UNFSS, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Nutrition-sensitive programs in low- and middle-income countries often aim to improve child nutrition outcomes in part by empowering women. Though previous studies have found cross-sectional associations linking women's empowerment and child nutritional status, there is limited empirical evidence supporting the hypothesis that empowering women as part of an intervention will, in turn, improve child nutritional outcomes. We tested this hypothesis using two waves of data from a cluster-randomized controlled trial of a nutrition-sensitive agricultural program in Burkina Faso. With structural equation models, we examined whether four domains of women's empowerment—purchasing decisions, healthcare decisions, family planning decisions, and spousal communication—mediated the program's impact on reducing wasting and increasing hemoglobin among children who were three to 12 months old at the start of the two-year program. We found that improvements in women's empowerment in the domains of spousal communication, purchasing decisions, healthcare decisions, and family planning decisions contributed to the program's impact on reducing wasting with the largest share being attributable to spousal communication. Improvements in women's empowerment did not contribute to the increase in hemoglobin. These findings provide the first evidence from a randomized controlled trial that women's empowerment is a pathway by which a nutrition-sensitive program can improve child wasting. Programs that aim to improve child nutritional status should incorporate interventions designed to empower women.

Non-PR, IFPRI5; POSHAN; CRP4, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Globally, it is recognized that multiple forms of undernutrition exist. Yet, little evidence exists on co-existence of multiple forms of undernutrition or on the potential shared determinants of these manifestations. Therefore, using data from India, we aimed to: 1) estimate the co-occurrence of undernutrition among children (stunting and anemia) and women (underweight and anemia); and 2) identify their shared determinants.

PR, IFPRI3; ISI; CRP4; IFPRIOA; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), Child development is affected by multiple factors throughout pregnancy and childhood. Multisectoral programs addressing these factors may improve children's development.

Non-PR, IFPRI5; CRP4; POSHAN, PHND; A4NH, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), We examined trends and inequities in the double burden of malnutrition among girls, boys, women and men by residence and wealth between 2006 and 2016 in India where 590 million individuals are expected to live in cities by 2030.

Non-PR, IFPRI5; CRP4; 2 Promoting Healthy Diets and Nutrition for all, PHND; A4NH, CGIAR Research Programs on Agriculture for Nutrition and Health (A4NH), Most countries are now experiencing a double burden of malnutrition (DBM), characterized by the coexistence of nutritional deficiencies (underweight, wasting, stunting, micronutrient deficiencies) and overweight/obesity and diet-related non-communicable diseases (obesity/DR-NCDs). Actions to address the two sides of the DBM are typically managed by separate communities, policies, programs, governance structures, and funding streams. Double duty actions, defined as actions that simultaneously address nutritional deficiencies and obesity/DR-NCDs, have been proposed as a win-win solution to tackling malnutrition in all its forms. The objective of the work was to explore opportunities—and make recommendations—for double duty actions to be delivered by programs and policies in key sectors such as health, social protection, education, and agriculture.