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Bangladesh is urbanizing rapidly, facing challenges of malnutrition, low coverage and poor quality of urban nutrition services.

Adolescence is a critical period of physical and psychological development, especially for girls, because poor nutrition can affect their wellbeing as well as that of their children. We aimed to assess the feasibility and impact of a package of nutrition education interventions delivered through public primary schools on the diets of adolescent girls in Ethiopia.

Alive & Thrive supported the Government of Burkina Faso to strengthen the provision of iron and folic acid (IFA) supplementation and interpersonal counseling on maternal nutrition and breastfeeding through antenatal care (ANC) services and community-based contacts in 2 regions.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22–47%), and maternal factors (15–30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households.

We use a randomized controlled trial in rural Bangladesh to compare two models of delivering nutrition content jointly to husbands and wives: deploying female nutrition workers versus mostly male agriculture extension workers. Both approaches increased nutrition knowledge of men and women, household and individual diet quality, and women’s empowerment. Intervention effects on agriculture and nutrition knowledge, agricultural production diversity, dietary diversity, women’s empowerment, and gender parity do not significantly differ between models where nutrition workers versus agriculture extension workers provide the training. The exception is in an attitudes score, where results indicate same-sex agents may affect scores differently than opposite-sex agents. Our results suggest opposite-sex agents may not necessarily be less effective in providing training. In South Asia, where agricultural extension systems and the pipeline to those systems are male-dominated, training men to deliver nutrition messages may offer a temporary solution to the shortage of female extension workers and offer opportunities to scale promote nutrition-sensitive agriculture. [ABSTRACT FROM AUTHOR]

A growing body of evidence indicates that agricultural development programs can potentially improve production diversity and diet quality of poor rural households; however, less is known about which aspects of program design are effective in diverse contexts and feasible to implement at scale. We address this issue through an evaluation of the Agriculture, Gender, and Nutrition Linkages (ANGeL) project. ANGeL is a randomized controlled trial testing what combination of trainings focused on agricultural production, nutrition behavior change communication, and gender sensitization were most effective in improving production diversity and diet quality among rural farm households in Bangladesh. We find that trainings focused on agriculture improved production diversity in terms of greater production of fruits and vegetables grown on the homestead, eggs, dairy, and fish; adding trainings on nutrition and gender did not significantly change these impacts. Trainings focused on both agriculture and nutrition showed the largest impacts on diet quality, with evidence indicating that households in this arm also significantly increased consumption out of homestead production for fruits and vegetables, eggs, dairy, and fish. Findings indicate that agricultural training that promotes production of diverse, high-value, nutrient-rich foods can increase production diversity, and this can improve diet quality, but diet quality impacts are larger when agricultural training is combined with nutrition training. Relative to treatments combining agriculture and nutrition training, we find no significant impact of adding the gender sensitization on our measures of production diversity or diet quality. [ABSTRACT FROM AUTHOR]

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 LancetSeries 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.

13 years after the first LancetSeries on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.

Despite improvements over the last decade or more, India still accounts for a large proportion of the global prevalence of maternal and child undernutrition. We use a cluster-randomized controlled design and two waves of panel data on more than 2000 households from Bihar to analyse the impact on diet quality and anthropometry of a health and nutrition intervention delivered through an at-scale women's self-help group (SHGs) platform. We find that the intervention had small but significant impacts on women and children's dietary diversity, with the main impacts coming from an increase in the consumption of fruits and vegetables and dairy, however, it had no impact on women's body mass index. We identify several potential pathways to impact. To the extent that SHGs can effect broad-based social change, their current reach to millions of women makes them a powerful platform for accelerating improvements in maternal and child health and nutrition outcomes. [ABSTRACT FROM AUTHOR]

Adolescent pregnancy and child undernutrition are major social and public health concerns. We aimed to examine associations between adolescent pregnancy and child undernutrition in India, where one in five adolescents live, and one in three of the world's stunted children.

In this review, the influence of seasonal variation on undernutrition during the first 1000 days of life of life in rural South Asia is conceptualized using a modified framework developed under the “Tackling the Agriculture and Nutrition Disconnect in India” project. Evidence for the existence and extent of seasonality is summarized from 14 studies reporting on six proximal determinants of undernutrition. A limited number of studies examine seasonal variation in risk factors for this age group. All available studies, however, report a compelling finding of significant seasonal variation for at least one determinant of undernutrition. Research to clarify mechanisms for potentially adverse effects of seasonal variation on health and nutritional status during the first 1000 days of life is needed.

Women's self-help groups (SHGs) have increasingly been used as a vehicle for social, political, and economic empowerment as well as a platform for service delivery. Although a growing body of literature shows evidence of positive impacts of SHGs on various measures of empowerment, our understanding of ways in which SHGs improve awareness and use of public services is limited. To fill this knowledge gap, this paper first examines how SHG membership is associated with political participation, awareness, and use of government entitlement schemes. It further examines the effect of SHG membership on various measures of social networks and mobility. Using data collected in 2015 across five Indian states and matching methods to correct for endogeneity of SHG membership, we find that SHG members are more politically engaged. We also find that SHG members are not only more likely to know of certain public entitlements than non-members, they are significantly more likely to avail of a greater number of public entitlement schemes. Additionally, SHG members have wider social networks and greater mobility as compared to non-members. Our results suggest that SHGs have the potential to increase their members' ability to hold public entities accountable and demand what is rightfully theirs. An important insight, however, is that the SHGs themselves cannot be expected to increase knowledge of public entitlement schemes in absence of a deliberate effort to do so by an external agency. [ABSTRACT FROM AUTHOR]

Improving the nutritional status of women and children in South Asia remains a high public health and development priority. Women's groups are emerging as platforms for delivering health- and nutrition-oriented programs and addressing gender and livelihoods challenges. We propose a framework outlining pathways through which women's group participation may facilitate improvements in nutrition. Evidence is summarized from 36 studies reporting on 24 nutritional indicators across infant and young child feeding (IYCF) practices, intake/diet, and anthropometry. Our findings suggest that women's group-based programs explicitly triggering behavior change pathways are most successful in improving nutrition outcomes, with strongest evidence for IYCF practices. Future investigators should link process and impact evaluations to better understand the pathways from women's group participation to nutritional impact.

Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.

Changes in the immediate, underlying and basic determinants of nutritional status at the community- and household-level are a logical and empirical prerequisite to reducing high levels of undernutrition in high burden countries. This paper considers these factors directly from the perspective of community members and frontline workers interviewed in six countries in South Asia and sub-Saharan Africa. In each country, in-depth interviews were conducted with mothers, other community members and health workers to understand changes in health and nutrition practices, nutrition-specific interventions, underlying drivers and nutrition-sensitive interventions, and life conditions. Overall, the need for basic improvements in livelihood opportunities and infrastructure are solidly underscored. Nutrition-specific and -sensitive changes represented in most cases by deliberate government or NGO supported community interventions are rolling out at a mixed and uneven pace, but are having some significant impacts where solidly implemented. The synthesis presented here provides an invaluable source of information for understanding how community-level change occurred against a wider backdrop of national level progress.

The Indian state of Odisha has made significant strides to address health and nutrition in the last 25 years. We used public data, policy and program documents, published literature, and interviews with program and policy decision-makers, development partners, civil society members (n=29) and community members (n=45) to analyze these changes. Factors that contributed to scale up of health and nutrition interventions and the food security program included overarching policy support, financing at the national and state level, leadership across sectors from government to civil society and development partners, capacity and stability of tenure of bureaucrats, and state innovations in service delivery interventions. Barriers that may impede further progress include lack of sanitation, low levels of women's education, early marriage in girls, livelihood distress, and uneven progress across social groups.

The Indian state of Odisha has made significant strides to address health and nutrition in the last 25 years. We used public data, policy and program documents, published literature, and interviews (n=75) with program and policy decision-makers, representatives from development partners, and civil society and community members to analyze these changes. Factors that contributed to scale up of health and nutrition interventions and the food security program included overarching policy support, financing at the national and state level, leadership across sectors from government to civil society and development partners, capacity and stability of tenure of bureaucrats, and state innovations in service delivery interventions. Barriers that may impede further progress include lack of sanitation, low levels of women's education, early marriage in girls, livelihood distress, and uneven progress across social groups.

Background: There is global consensus that a strong policy response is essential for addressing the dual burden of malnutrition. However, policy makers in low- and middle-income countries may perceive a conflict between food supply policies to combat persistent undernutrition and more recent recommendations for policies addressing rising rates of diet-related noncommunicable diseases (NCDs).Objective: This article explores the potential to use policy space analysisto identify food supply policy opportunities for addressing both undernutrition and diet-related NCDs and to support improved policy coherence.Methods: We conducted an exploratory policy space analysis to identify opportunities and constraints for integrated nutrition policy with respect to the food supply in India, where a dual burden of malnutrition has been well documented. We conducted a review of food supply policies and 27 key informant interviews (16 with stakeholders active in India’s national nutrition policy space, and 11 with policy makers and experts in food supply policy).Results: The analysis suggests several opportunities for an integrated food supply policy agenda, including targeting common foods of concern (such as highly processed foods) and foods that present common benefits (such as fruits and vegetables), and scaling up existing small-scale policy initiatives that support the availability of nutrient-rich foods. Challenges include policy inertia and competing priorities within the economic sector.Conclusion: This scoping study indicates that the policy space analysis framework used here can help to identify specific, contextually appropriate policy options and strategies for strengthening public health nutrition policy within sectors responsible for food supply policy.

Despite consensus on actions to improve nutrition globally, less is known about how to operationalize the right mix of actions—nutrition-specific and nutrition-sensitive—equitably, at scale, in different contexts. This review draws on a large scaling-up literature search and 4 case studies of large-scale nutrition programs with proven impact to synthesize critical elements for impact at scale. Nine elements emerged as central: 1) having a clear vision or goal for impact; 2) intervention characteristics; 3) an enabling organizational context for scaling up; 4) establishing drivers such as catalysts, champions, systemwide ownership, and incentives; 5) choosing contextually relevant strategies and pathways for scaling up, 6) building operational and strategic capacities; 7) ensuring adequacy, stability, and flexibility of financing; 8) ensuring adequate governance structures and systems; and 9) embedding mechanisms for monitoring, learning, and accountability. Translating current political commitment to large-scale impact on nutrition will require robust attention to these elements.

Background Translating national policies and guidelines into effective action at the subnational level (e.g., province or region) is a prerequisite for ensuring an impact on nutrition. In several countries, including Vietnam, the focus of this paper, this process is affected by the quality of the decentralized process of planning and action.Objective This study examined how provincial planning processes for nutrition occurred in Vietnam during 2009 and 2010. Key goals were to understand variability in processes across provinces, identify factors that influenced the process, and assess the usefulness of the process for individuals involved in planning and action.Methods A qualitative case-study methodology was used. Data were drawn from interviews with 51 government officials in eight provinces.Results The study found little variability in the planning process among these eight provinces, probably due to a planning process that was predominantly a fiscal exercise within the confines of a largely centralized structure. Respondents were almost unanimous about the main barriers: a top-down approach to planning, limited human capacity for effective planning at subnational levels, and difficulty in integrating actions from multiple sectors. Provincial-level actors were deeply dissatisfied with the nature of their role in the process.Conclusions Despite the rhetoric to the contrary, too much power is probably still retained at the central level. A strategic multiyear approach is needed to strengthen the provincial planning process and address many of the key barriers identified in this study.

Background The evidence base on the impact of large-scale infant and young child feeding (IYCF) and nutrition programs is limited, partly due to the challenges of rigorously evaluating complex programs including multiple interventions.Objectives To describe the process used to design Alive & Thrive's impact evaluations in the three target countries and discuss the feasibility of developing contextually relevant designs adapted to the country-specific programmatic context.Methods The evaluation designs for Alive & Thrive needed to address several challenges. These included the selection of intervention components to evaluate rigorously; the identification of appropriate comparison groups in the context of rapidly scaling-up programs; the choice of impact indicators; addressing measurement challenges related to evaluating the impact of interventions targeted during the first 2 years of life on stunting; and developing methods and tools to assess implementation, utilization, and program impact pathways within evolving program portfolios.Results In Bangladesh and Vietnam, cluster-randomized probability designs are used for the impact evaluations; in Ethiopia, the impact evaluation uses an adequacy design. In all three countries, repeated cross-sectional surveys, 4 years apart, are used to measure impact, and appropriate age groups are sampled separately to capture change in the main impact indicators. In addition, theory-driven process evaluations are used to study factors that facilitate or prevent achievement of impact and scale.Conclusions We conclude that robust impact and process evaluations of complex, large-scale nutrition programs are feasible, but that early implementer—evaluator engagement and shared vision and motivation to establishing meaningful evaluations are essential.

Background Traditionally, impact evaluations have focused primarily on answering what impact programs or interventions have, with less attention to how or why impacts are achieved, or not achieved. The Alive & Thrive initiative, a 6-year program that aims to improve infant and young child feeding (IYCF) practices and reduce stunting in Bangladesh, Ethiopia, and Vietnam, has a specific objective to generate learning on how to achieve and replicate Alive & Thrive's impact.Objective In Alive & Thrive, theory-driven process evaluation methods are the primary mechanism through which data are generated to address this objective. This paper focuses on the different methodological approaches that are being utilized, to answer the critical “how”; questions, and to generate information on the many processes and pathways to program impact.Methods We identify four key principles in our methodological approach that guides all process evaluation activities: 1) developing detailed program impact pathway (PIP) models, 2) linking data collection to PIPs utilizing mixed methods and multiple data sources, 3) linking evaluation activities with program implementation timelines, and 4) engaging with the program implementation and management teams.Results Beginning with the launch of the program, we outline the steps that have been taken in the design and implementation of the process evaluations of Alive & Thrive, and provide examples of how these steps have been operationalized in different country contexts.Conclusions This theory-driven and country- and component-specific approach, centered on careful analysis of PIPs, is intended to generate information on implementation and utilization pathways of Alive & Thrive's interventions, thereby answering the questions of how impacts are achieved, or why not. This evaluation approach is not without challenges, and we highlight some of these key challenges.

In the past 5 years, political discourse about the challenge of undernutrition has increased substantially at national and international levels and has led to stated commitments from many national governments, international organisations, and donors. The Scaling Up Nutrition movement has both driven, and been driven by, this developing momentum. Harmonisation has increased among stakeholders, with regard to their understanding of the main causes of malnutrition and to the various options for addressing it. The main challenges are to enhance and expand the quality and coverage of nutrition-specific interventions, and to maximise the nutrition sensitivity of more distal interventions, such as agriculture, social protection, and water and sanitation. But a crucial third level of action exists, which relates to the environments and processes that underpin and shape political and policy processes. We focus on this neglected level. We address several fundamental questions: how can enabling environments and processes be cultivated, sustained, and ultimately translated into results on the ground? How has high-level political momentum been generated? What needs to happen to turn this momentum into results? How can we ensure that high-quality, well-resourced interventions for nutrition are available to those who need them, and that agriculture, social protection, and water and sanitation systems and programmes are proactively reoriented to support nutrition goals? We use a six-cell framework to discuss the ways in which three domains (knowledge and evidence, politics and governance, and capacity and resources) are pivotal to create and sustain political momentum, and to translate momentum into results in high-burden countries.

Although undernutrition impacts a range of short- and long-term outcomes, nutrition often has low priority on global and national development policy agendas because of overemphasis on technical solutions without adequate consideration of contextual and political factors. An approach is needed for strategic development of nutrition agendas that embraces the contexts influencing policy and program planning and implementation, while addressing salient causes of undernutrition. We describe a simple, comprehensive assessment approach to enable development of sound nutrition strategies and well-grounded effective and appropriate actions for nutrition in a given context. The conceptual framework for this assessment approach incorporates three domains, each essential for defining strategic actions for nutrition: epidemiologic, pertaining to the nutritional situation and the evidence about the efficacy and effectiveness of nutrition interventions; operational, pertaining to coverage, quality, and utilization of nutrition-related interventions and programs as well as capacities, opportunities, and constraints to improving these; and sociopolitical, pertaining to social, political, cultural, and organizational factors at various levels, which may enhance or inhibit efforts to create positive changes in policies and programs. The domains are interlinked, and the sociopolitical domain often underlies the other two domains. Using this framework can reveal important insights for the nutrition policy agenda that were hitherto not considered explicitly in efforts to advance nutrition. This is highlighted in an example from Vietnam and through other papers in this Supplement. Use of this three-domain assessment framework can greatly aid development of feasible and actionable nutrition strategies that are grounded in epidemiologic, operational, and sociopolitical realities.

Undernutrition is the single largest contributor to the burden of disease in developing countries and has documented effects on social and economic development, yet progress in reducing undernutrition remains slow. This paper identifies the range of factors that have influenced the nutrition agenda in developing countries, in order to inform the implementation of three major global initiatives related to undernutrition. Data sources include interviews with nutrition practitioners at the national and international level, written accounts from six African countries, and observations of the policy process in five countries. Data were thematically coded to identify recurrent factors that facilitated or inhibited progress in addressing undernutrition. The data reveal the following: First, societal conditions and catalytic events pose a variety of challenges and opportunities to enlarge and shape the nutrition agenda. Some countries have been successful in using such opportunities, while others have been less successful and there have been some unintended consequences. Second, disagreements over interventions and strategies are an almost universal feature of the nutrition policy process, occur primarily among mid-level actors rather than among politicians or senior administrators, and are primarily the product of structural factors such as organizational mandates, interests, and differences in professional perspectives. Third, many of these structural factors can be molded, aligned, and/or circumvented through strategic action on the part of the mid-level actors to strengthen movement on the nutrition agenda. This evidence that strategic action can redirect and/or overcome the effects of structural factors has important implications for future efforts to advance the nutrition agenda.

Background Optimal feeding of infants and young children in developing countries includes daily feeding of animal-source foods.Objective To evaluate constraints on the availability of animal-source foods at the community level, access to animal-source foods at the household level, and intake of animal-source foods at the individual level among children under 3 years of age in case studies in five developing countries: Mexico, Peru, Haiti, Senegal, and Ethiopia.Methods Data were obtained from published and unpublished research and from program experiences of health and agriculture specialists.Results In Ethiopia, 27% to 51% of case-study chil- dren had consumed an animal-source food on the previous day; from 56% to 87% of children in the other case-study sites had consumed an animal-source food on the previous day. Data on intake of animal-source foods in grams were only available for the Latin American case-study sites, where daily milk intake was high in Mexico and Peru (195 and 180 g/day, respectively) and the intakes of meat, fish, and poultry (MFP) (29.0 and 13.6 g/day) and of egg (18.4 and 4.9 g/day) were low. The conceptual model guiding this work identified more constraining factors at the community and household levels than at the individual level. The most common constraints on feeding animal-source foods to young children were poverty, animal health, and land degradation at the community level; cost of animal-source foods and limited livestock holdings at the household level; and caregivers' perceptions of giving animal-source foods to children at the individual level.Conclusions For program planning, it is useful to simultaneously consider factors that affect community availability of, household access to, and children's intake of animal-source foods. Efforts to overcome individual- level constraints on intake of animal-source foods should be coupled with activities to address community and household constraints.

This research assesses whether fortified cereal blends such as corn-soy blend (CSB) or wheat-soy (WSB) blend can significantly contribute to improving the quality of the diet of infants and young children 6 to 23 months of age. A series of participatory recipe trials was conducted to assess current complementary feeding practices in the Central Plateau of Haiti and to develop new, improved recipes by using a combination of locally available ingredients and foods and donated fortified cereal blends. Our findings show that it is feasible to improve the nutritional quality of complementary foods in poor rural areas of Haiti, using locally available ingredients and fortified cereal blends. Significant improvements in the concentrations of vitamin A could be obtained by including acceptable and affordable amounts of locally available vitamin A-rich foods such as pumpkin or eggs. Only preparations using CSB, however, could achieve the recommended concentrations of iron and zinc in complementary foods, and even this was achievable only for 12- to 23-month-old children. For infants, and especially those between 6 and 8 months of age, the high requirements of 7.7 mg of iron and 1.6 mg of zinc per 100 kcal of complementary foods could not be met, even with a combination of fortified CSB and other locally available, acceptable, and affordable foods. The same was true for the zinc density of complementary foods among 9- to 11-month-old children, which could not be achieved even with fortified CSB. Thus, in this population, fortified cereal blends were key to achieving the recommended iron and zinc densities of complementary foods for children 12 to 23 months of age, but they were not sufficient for infants. Complementary approaches, such as improving the availability, access, and intake of animal-source foods or the use of home fortification techniques (using spreads, sprinkles, or dispersible tablets), are needed to ensure adequate iron and zinc density of complementary foods for infants younger than 12 months in resource-constrained environments such as rural Haiti.

Urban–rural comparisons of childhood undernutrition suggest that urban populations are better off than rural populations. However, these comparisons could mask the large differentials that exist between socio-economic groups in urban areas. Data from the Demographic and Health Surveys for 11 countries from three regions were used to test the hypothesis that intra-urban differentials in child stunting are greater than intra-rural differentials, and that the prevalence of stunting among the urban and the rural poor is equally high. A socio-economic status (SES) index based on household assets, housing quality, and availability of services was created separately for rural and urban areas of each country, using principal components analysis. Odds ratios (OR) were computed to estimate the magnitude of differentials in stunting (height-for-age Z scores < −2) between urban and rural areas and between the lowest and highest SES quintiles within areas. The prevalence of stunting was lower in urban than in rural areas for all countries, but rural–urban odds ratios were relatively small (< 3.3). As hypothesized, the gap between low and high SES was markedly larger in urban (median OR, 4) than rural (median OR, 1.8) areas, and differentials were statistically significant (interaction between area and SES in logistic regression) in all but three countries. Within-urban ORs as high as 10 were found in Peru and the Dominican Republic, whereas within-rural ORs were smaller than 3.5, except in Brazil. In most countries, stunting in the poorest urban quintile was almost the same as that among poor rural dwellers. Thus, malnutrition in urban areas continues to be of concern, and effective targeting of nutrition programmes to the poorest segments of the urban population will be critical to their success and cost-effectiveness.

This paper considers the role of caregiving on children's health and development with a special focus on identifying the constraints on effective caregiving in urban areas, and the potential solutions. It uses the extended UNICEF framework for nutrition which suggests that there are six major types of care behaviour: feeding and breast-feeding, food preparation and handling, hygiene behaviour, psycho-social care, care for women and home health practices. To ensure adequate care for the child, the caregiver needs adequate knowledge and education, physical and mental health, autonomy in decision-making, time, and social support from the family and community. This paper describes each of these resources and constraints, and two of the behaviour types (breast-feeding and health care utilization) in the urban areas of eight countries in eastern and southern Africa. It also presents a matrix highlighting critical constraints on caregiving behaviours in urban areas, and potential solutions, and identifies areas where further research is needed.

Childhood stunting and wasting are often portrayed as relatively distinct manifestations of undernutrition. Little is known about how children progress from one manifestation of undernutrition to another as they grow older, nor how intervention strategies need to consider the potential overlap of these manifestations of undernutrition. While much is known about the causes of growth faltering in general, much less is known about which pre-disposing contextual and biological factors cause children to become stunted as opposed to wasted or both. Increasingly, nutrition researchers have tended to focus on one form of malnutrition or the other, lacking an integrated framework for understanding both phenomena. Similarly, some practitioner communities focus on prevention of stunting while others focus on recuperative treatment of wasting. The fragmentation of interests and perspectives on childhood undernutrition has negative consequences for advocacy efforts that aim to bring attention and resources to child nutrition across the globe. It also has serious implications for how children worldwide receive nutrition interventions and services. The symposium aimed to bring together a set of speakers from academic, practice and policy communities to discuss and debate these issues.

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

BackgroundAlive & Thrive Vietnam, a 6-year initiative (2009–2014), has developed and incorporated elements of social franchising into government health services to provide high-quality nutrition counseling services to improve infant and young child feeding practices. One element of franchising that has not yet been implemented is fee for service, which is a potential financing mechanism for sustaining services in the long run.ObjectiveThis research aims to estimate maternal willingness to pay (WTP) for nutrition counseling services and to examine potential factors associated with their WTP.Design and methodsData were drawn from an impact evaluation survey of 2,511 women with a child <2 years old from four provinces in Vietnam. An iterative bidding technique was employed to explore individual WTP. The first bid was defined as VND 20,000 (~US$ 1), which was approximately the level of the actual service cost. Depending on the participant response, the bid increased or decreased. Finally, the respondents were asked about the highest price they would be willing to pay for the service.ResultsOverall, 92.6% of clients reported a need for nutrition counseling services for children <2 years. The WTP rates at bid levels of VND 5,000, 10,000, 20,000, 40,000, and 100,000 were 95.2, 94.4, 90.7, 68.9, and 33.4%, respectively. The mean and median of the maximum WTP were VND 58,500 and 50,000, respectively. In multiple regression models, WTP rates were higher among younger women, the Kinh majority group, and better educated and wealthier women.ConclusionA high demand for nutrition counseling coupled with a WTP by almost all segments of society would potentially cover costs of delivery for nutrition counseling services in Vietnam.