Six policy and program briefs follow. The first describes the impressive efforts that Nepal has undertaken to
address micronutrient deficiencies, despite being a very poor country. The second discusses an effort in
Kenya to launch a flour fortification effort in an exceptionally short period of time, despite many years of not
having done so previously. The third brief illustrates the long-term impact of nutrition supplementation. It
reviews the findings of a study on Guatemala that examined the long-term impact of improved nutrition on
the stature, intellectual abilities, and wages of adults. The fourth discusses South Korea’s efforts to encourage
the maintenance of traditional diets. The fifth reviews a program in Brazil for encouraging physical activity.
The last examines efforts by Finland to reduce salt consumption.
Nepal Addresses Micronutrient Deficiencies
Many Nepali families lack the income needed to consistently buy nutrient-rich foods. Many families also lack
the knowledge of a healthy diet needed to ensure their children are well nourished. These issues have resulted
in high rates of undernutrition and micronutrient deficiencies, particularly in women and children.111
In the 1990s, for example, more than half of the under-5 children in Nepal were stunted.111,112 In addition,
nearly 75 percent of pregnant women and over half of all children were anemic. The coverage of nutritional
programs was low. Many pregnant women did not receive iron and folic acid supplements,111 and there was
little fortification of food.
Policy and Program Briefs 211

In addition.113 Nepal has demonstrated that it is possible for a country with limited finances to carry out cost-effective programs to address micronutrient deficiencies with substantial results. The Micronutrient Initiative has also helped the government to pilot a vitamin A supplementation program for newborns. efforts were undertaken to increase the availability of zinc in the private sector. the government initiated the National Anemia Control Strategy and Iron Intensification Program in 2003. however. Nepal saw a decrease in mortality of children under the age of 5 from 142 per 1.113 Community health worker volunteers (CHWV). UNICEF. NGOs. and the Micronutrient Initiative. the delivery of zinc in the public and private sectors. play an important role in implementing these programs. on nutrition topics such as the importance of eating nutrient-rich foods and micronutrient supplements. community volunteers. and has helped to strengthen the monitoring and reporting system for zinc usage and the zinc supply chain. and Nepal’s development partners have led to a number of successes. effective spread of knowledge about the importance of micronutrients. good hygiene habits. there was also 95 percent coverage of vitamin A supplementation among children.000 in 1990 to 51 per 1. African countries have fortified salt with iodine and have even made salt fortification a requirement. The usage of zinc had increased from less than 1 percent in 2005 to nearly 16 percent in 2008. In addition. among other programs.114 By 2009. This is despite the substantial nutritional gaps in Africa that could be addressed at least partly through fortification.114 The collaborative efforts of the government. the United States Agency for International Development (USAID) and the Ministry of Health collaborated to integrate zinc into the national diarrhea management plan. particularly women. Rapid Results Initiative for Food Fortification in Kenya For many years. with support from WHO. and diarrhea.000 in 2009. the use of community health worker volunteers. However. In 2006. Nepal has become a leader in addressing micronutrient deficiencies.4 percent of caregivers provided zinc during any bout of diarrhea in the previous 2 weeks. Linked with these efforts.111 Linked to these efforts on micronutrient supplementation. recording the children or women who receive the supplements. and reduce morbidity and mortality from measles. More recently. and careful program supervision and monitoring. pneumonia. They administer the needed supplements in their communities. over 80 percent of pregnant women were receiving iron and folic acid supplements.115 Until recently. This has been achieved in Nepal largely through strong political support. progress on food fortification in the Africa region has been relatively slow and in 2011 there were no requirements in the region for the fortification of other foods. maternal care. in addition to deworming services. A monitoring system was established to identify pregnant women as soon as possible and to ensure that women fully participate in the recommended services. and 67 percent correctly taking zinc for the recommended 10 full days. and breastfeeding. To increase the use of both oral rehydration therapy (ORT) and zinc when treating diarrheal disease. only 0. the CHWVs spend time educating parents. with 85 percent of users correctly taking zinc and oral rehydration salts together. public and private sector programs to increase the use of zinc reached 65 percent of the population by 2009. It has also been assisted by close collaboration with a number of Nepal’s development partners. Kenya was among the countries that had successfully fortified salt but had not fortified other staple foods. and fortified foods. The failure to move on fortification stemmed at least partly from difficulty in getting the public and private sectors to work together on fortification.113 Vitamin A tablets are being distributed to children twice a year to help enhance children’s immunity. and anemia had dropped 35 percent among these women. This program provides iron supplements for pregnant women distributed by female community health volunteers. these parties must . To address anemia. prevent night blindness. USAID has supported training for private sector healthcare providers. Additionally. By 2009.112 The Micronutrient Initiative has also helped the government to improve popular knowledge and awareness about zinc through local radio advertising. In order for fortification to succeed. usually women who live in the community.114 Nongovernmental organizations (NGOs) have played an important role in addressing issues related to micronutrient deficiencies by helping to train CHWVs to perform the tasks mentioned previously.

Food companies felt that the government would not create and monitor food standards and the government felt that food companies would not willingly fortify foods. To help overcome these barriers.collaborate. The private sector is responsible for producing and selling the fortified foods.116 Initially. the KNFFA leadership decided to collaborate with the Micronutrient Initiative (MI) and the Rapid Results Institute (RRI) to produce a fortified CHAPTER 8 Nutrition and Global Health 212 .116 The Kenyan National Food Fortification Alliance (KNFFA) was established to mobilize food companies and government organizations to fortify foods. the process proved to be slow and little progress was made. because both play an important role in food fortification. The public sector is responsible for food safety.

By the end of the 130 days.2 more years of school than the other women. met international standards for vitamin A fortification in edible oils. between 2002 and 2004—25 years after the nutrition supplementation ended—researchers. there was no significant relationship between the type of supplement taken and the amount of school completed. compared to the boys who received fresco in the original study. the Institute of Nutrition of Central America and Panama (INCAP) initiated the first phase of a study on nutrition supplementation and child development among 2. scored higher on both tests as adults than those who received fresco. adult intellectual functioning. 1977. measured through their wages. water supply. In order to move ahead on a fortification program. and February 28. such as food companies and government organizations. Kenya was able to meet its goal and achieve in a very short amount of time what it had not been able to do at all previously. such as the Tamil Nadu Nutrition Project. fortification standards. compared to the other group. One such study was done for a program in Guatemala.116 As a result of the initiative. Some of those programs. the InterAmerican Series Test was used. such as quality standards and standard enforcement. which can be put on a product to show that it meets standards. have been evaluated carefully. a fortification certification process. goals were set: in 130 days. a training meeting was held for stakeholders. it was found that receiving the atole supplement was positively related for both men and women to higher adult intellectual functioning. three brands of oil. As part of this effort. education. Additionally. and a fortification logo. However. There was no significant increase in economic productivity in women who received one supplement.117 The study followed the cohort of children over time and compared the effects of the nutritional supplement on schooling.116 The Kenya Bureau of Standards monitors food fortification standards and the Ministry of Health now regulates the certification process. Incaparina (a protein mixture). Researchers randomly assigned one of two treatments to each of the children. food in 100 days or less. the stakeholders were brought together to address concerns surrounding food fortification. after controlling for the number of years of school completed.116 Through this effort. Children who had received the supplement of protein and energy. Second. This supplement consisted of dry skim milk. In two villages. fresco did not provide fat or protein and offered only minimal energy. child birthweight. and to invite participation in the project. and related social investments.118 . as described in this section. children were offered a dietary supplement called “atole” that provided protein and energy. children were offered a supplement called “fresco. However. and sugar. Childhood Nutrition Supplementation and Adult Productivity in Guatemala A number of countries have undertaken efforts to provide supplementary food to undernourished children. Among men. particularly in poor women and children in low-income countries. atole. The Raven Progressive Matrices Test was used to determine cognitive development. During this time. The RRI is a nonprofit organization that focuses on helping countries achieve rapid and sustainable results in key areas of health. and which of the supplements was given in the INCAP nutrition intervention. The MI is a nonprofit organization based in Canada that is the leading global agency focusing exclusively on addressing micronutrient deficiencies. Boys who were under the age of 3 when they first received atole had 46 percent higher wages as adults. a fortified food certification process would be developed and three brands of edible oils would be fortified with vitamin A.117 In order to measure literacy and reading comprehension. were developed.” Unlike atole. women who received atole completed 1.117 Researchers also examined the relationship between economic productivity of individuals. there has been increased collaboration and trust between the public and private sectors. Both supplements were equally fortified with micronutrients before being distributed twice daily from a central location in each village. or 15 percent of the edible oil market. In the other two villages.448 of those who participated in the original study as children. In four Guatemalan villages between March 1. and individual productivity. in collaboration with Emory University.53 Overall. surveyed 1. 1969. very rarely has anyone followed for more than 2 decades the children who participated in a supplementary feeding program in order to gauge long-term program impact in adulthood.392 children who were under the age of 7.115. laying the foundation for future fortification of additional staple foods.

a larger head circumference. women who had received atole as children were found to have babies. their offspring had greater height-for-age and weight-for-age. Additionally. The protein.119 Overall. especially sons.However. Compared to those who received fresco.and energy-based atole nutritional supplement resulted in Policy and Program Briefs 213 . with a higher birthweight. a girl’s involvement in the INCAP intervention positively affected her offspring. and a greater height at birth. this study has helped to shed light on the value of nutritional supplementation among children.

121 A transition in the cause of death from communicable to noncommunicable diseases is estimated to have occurred in South Korea around 1970. higher literacy rates and cognitive development among men and women.126 . provided nutrition education through seminars and obesity camps. the daily per capita intake of fruits in South Korea increased significantly during the economic transition period. This study further supports the premise that some forms of food supplementation in the early years of life can affect the remaining years of life in substantial and positive ways. and offered nutrition information for citizens on its website.2 percent in 1998.125 Through this initiative. South Korea has demonstrated the potential for effective public/private collaboration in the pursuit of a healthy diet.6 percent of total fat consumed in 1970 to 48.120 The association also provided a variety of traditional menus to elementary schools. Vegetable consumption in South Korea was among the highest in Asia in 1998.9 grams in 1969 to 41. compared with 1940 for the United States and 1950 for Japan. the proportion of fat-derived energy was still significantly lower than in other Asian countries. It also held lectures for parents.120 Obesity rates in Korea today remain among the lowest in the Organisation for Economic Co-operation and Development (OECD). aided nutrition services at local health centers. more than a tenfold increase from the 18. the country was able to adapt its message to contemporary society and successfully retain its traditional diet.5 grams in 1998.121 Furthermore.124 In addition. high- vegetable traditional diet through its economic and nutrition transition.120 Kimchi remained the most consumed food after rice. Brazil: The Agita São Paulo Program Uses Physical Activity to Promote Health Starting in the 1970s.120 Obesity rates in South Korea in 1998 remained quite low. 30 percent of the population is overweight. found to be largely due to government programs encouraging the retention of the traditional South Korean diet. higher employment wages for men. along with letters about preserving traditional dietary culture to students’ homes. and was typically accompanied by vegetables.5 grams of fruits were consumed daily per capita.120 The Korea Dietetic Association (KDA).120 Daily per capita fat intake in South Korea more than doubled from 16. By 1990. however. a 1998 dietary evaluation found that South Korea had lower than expected levels of fat intake (by 16. Based on its level of economic development. Using a combination of information dissemination and provision of skills. and offspring with a higher birthweight.7 percentage points) and obesity prevalence. resulting in lifestyle changes promoting obesity and overweight. at 4 percent of the adult population.3 percent of the adult Brazilian population led a sedentary lifestyle.7 percent for men and 3. Brazil began experiencing rapid economic growth and major socioeconomic shifts. as opposed to a Western style. accounting for approximately 40 percent of the total vegetable intake. 197. the majority of meat consumed was cooked in a Korean style. These rates were much lower than Western and other Asian countries. preventing the spread of obesity. 69. especially after the country hosted the Olympics in 1988. the increase was especially rapid in the 1990s. in part due to a traditional cooking style involving small amounts of oil. fast-food restaurants in particular were popular among the younger generation.122 Unlike other Asian countries.120 The KDA also monitored food and nutrition advertising disseminated through mass media and organized national nutrition campaigns. However. and animal fat increased from 30.9 grams consumed in 1970.123 The combination of these efforts led to a retention of the traditional Korean diet and subsequent positive health outcomes. In 1998. a private organization. at 1.0 percent for women. comprising around 20 percent of total food consumption (280 grams daily per capita). and OECD projections indicate that rates of overweight will increase by a further 5 percent within 10 years. including the rapid introduction of a more Western diet.120 However. South Korea maintained many of the aspects of its low-fat.120 This growth was accompanied by changes in lifestyle. South Korea’s Promotion of and Adherence to a Traditional Diet South Korea’s economy grew rapidly after its recovery from the Korean War (1950–1953).

daily activities such as walking to and from CHAPTER 8 Nutrition and Global Health 214 . the Agita São Paulo Program was launched in 1996 to address São Paulo’s growing problem of obesity and overweight. The goal was to convince the population that this physical activity could come from routine. The program concentrated on feasible.127 School children.After 2 years of preparatory consultation with the Pan-American Health Organization and other international agencies. low.or no-cost ways to achieve at least 30 minutes of moderate-intensity physical activity per day. the workforce. and the elderly were the main targets. most days of the week. The objective was to increase the level of knowledge among the São Paulo population about the importance of physical activity by 50 percent and the level of actual physical activity by 20 percent over a period of 10 years.

industry. implemented.and middle- income countries. Finnish salt intake was estimated to be approximately 12 grams per day (4. reaching 6 million students and 250.00 per person per year.000 teachers. the estimated costs of illness related to a sedentary lifestyle in the state were about $1. representing an investment of less than $0. Partner institutions were also crucial to the program’s success. people who were aware of the program were more likely to be physically active. such as structured fitness programs in gyms or organized sports. but the most popular was “Agita Galera” (“Move. The scientific board consisted of Brazilian and international academics and doctors and provided the program’s scientific foundation. as it was used for conservation of food before other methods were available.0 percent across the states. and carrying out the program’s activities.127 Various evaluations of the program were conducted and found positive effects for both increasing physical activity awareness and physical activity itself. 54.127 Mega-events were intended to reach the majority of cities in São Paolo state and involved at least a million people. recall of the main program objective rose from 9. actions carried out with partner institutions.2 percent of those familiar with the program were physically active in 2002. workers. In contrast.130 In the 1970s.000/QALY (quality- adjusted life year). assessed its implementation. manuals. versus a rate of 31.127 Finland Uses Labels to Reduce Salt Consumption Finland has traditionally had a diet high in salt. more than twice the value recommended by the World Health Organization.800 public schools in the state. and CELAFISCS concluded that the program was a good public health investment. and scientific information to promote physical activity among their employees and the communities they served. These organizations were directly responsible for planning. workers. putting the population at risk for hypertension. nongovernment organizations.128 Agita São Paulo has been a role model for similar local and national programs across Brazil and in other Latin American countries. achieving a cost-effectiveness ratio of less than R$50. the Centers for Disease Control and Prevention.127 Furthermore. and private organizations representing a wide range of sectors.800 mg/day sodium).000. Coordinated by the Studies Center of the Physical Fitness Research Laboratory of São Caetano do Sul (CELAFISCS). reaching 67 percent of the most educated.131 This high intake spurred Finland’s National Nutrition Council to recommend in 1978 steps to reduce salt consumption . Over a 3-year period.127 It was an extremely cost-effective program.000 to $400. The diversity in focus and type of partners encouraged innovation and a greater exchange of ideas for new activities.128 The program was overseen by a scientific board and an executive board. it was largely funded by the São Paulo State Secretariat of Health. and partnerships. Schools received a handbook and poster. they raised awareness of the importance of an active lifestyle through their activities and broad media coverage. advertising tools. stroke.128 The World Health Organization has praised it as a model for other low. Its annual budget ranged from $150. Different mega-events were tailored to promoting specific activities for students. Often coinciding with major cultural or seasonal holidays. Students were also encouraged to prepare their own materials on the subject of physical activity and spread the message of the program in their communities while getting exercise. as well as flyers for students and their families communicating the program’s message. nongovernmental. and it has since spurred an international mega-event celebrated annually to promote worldwide physical activity. Recall increased with socioeconomic status level.5 percent to 24. Each partner used a variety of pamphlets. that each planned. Finally. and the elderly. the program partnered with more than 50 municipalities to establish 50 municipal communities throughout the state.127 The program was structured as a partnership between government. It was celebrated across the 6.13 An analysis supported by the World Bank. organizing. and monitored physical activities in their area. Crowd” or “Active Community Day”).127 The executive board included more than 300 governmental. work or household chores. as opposed to less convenient exercises more likely to cause injury. and academic communities. and the elderly: mega-events.129 The program used three main types of activities to reach its target groups of students. and allowed it to better integrate with the medical community. and coronary heart disease.01 per state inhabitant per year.9 percent for those who were not familiar with the program.

teachers. including health service organizations. which raised both public and government awareness of salt and lower-sodium alterna- tives. media outlets.133 From 1979 to 1982.130 Policy and Program Briefs 215 .132.134 Health education of consumers and training programs for healthcare professionals. nongovernmental organizations. and caterers on how to reduce salt were also important components of the project.nationally. Finnish media aided the effort by releasing numerous reports on the harmful health effects of salt.130 The project was expanded to span the entire country after 3 years. schools. Multiple stakeholders were involved with the project. a community-based intervention to reduce population-wide sodium intake called the North Karelia project was conducted to reduce mortality associated with cardiovascular disease. and the food industry.

and magnesium-enriched mineral salts. Building on the momentum from this movement.136 Salt intake was monitored using urinary sodium excretion every 5 years.700 mg/day for women. by more than 10 mm Hg. malnutrition persisted despite considerable investments that had already been undertaken to improve nutrition status. requiring that such foods be labeled with percentage of salt by weight. India Background The Tamil Nadu Integrated Nutrition Project in India is one of the most important efforts ever undertaken to improve nutritional status on a large scale. little attention had been paid to nutrition education for families or to health investments that could complement the investments made in nutrition. ready-made meals. the children who needed assistance most were not getting it. Diastolic blood pressure also decreased substantially.132. One of the best known is the Tamil Nadu Nutrition Project in India. the Finnish Heart Association began putting a “Better Choice” label on low-sodium products. soups and sauces. food that was given to children at feeding centers that was meant to be supplementary to their regular diet often replaced their regular food or was taken home and consumed by family members other than the intended children. This project began in 1980 in the South Indian state of Tamil Nadu. while allowing low sodium foods to carry a “low salt” label.136 There was an 80 percent reduction in death rates from stroke and heart disease among the middle-aged population. 137 Tamil Nadu State. In 1993.900 mg/day for men and 2.132. Moreover. the Ministry of Trade and Industry and the Ministry of Social Affairs and Health implemented salt-labeling legislation for food categories that contribute high amounts of sodium to the diet.135 The legislation required a “high salt content” label on foods with high levels of sodium. the levels of malnutrition in poor women and children in Tamil Nadu were very high at the time the project was conceived. It aimed at improving the nutritional status of poor women and children in the rural areas of the state through a set of well-focused interventions. China has also made considerable progress in the last 10 years in controlling iodine deficiency. and spice mixtures containing salt. Rather. Second.130 This was caused by a combination of consumers choosing lower-sodium products and food companies discontinuing or reformulating their products to avoid high-salt labels through the use of alternatives such as mineral salts.136 CASE STUDIES There are a number of investments in improving nutrition status on a large scale that have made a significant difference to the communities in which they took place. a number of labeling systems were implemented to inform consumers and discourage them from consuming high amounts of sodium. In addition. potassium. studies that had been done on those investments showed that they were not working as planned and were not cost-effective. and the Pansalt logo was used on products with sodium-reduced. First. The form of the food supplement was also difficult for children to eat. contributing to a reduction in overall mortality in Finland and an increase in life expectancy by several years for both men and women. . These specific goals were set for several reasons. By 2002. sausages and other meat products. such as breads.134 It is estimated that these labeling initiatives caused the industry to reduce the salt content of targeted foods by about 20–25 percent. fish products. Third.134 In 2000. butter. mean sodium intake was 3.132.

primary health care. children received food supplements only while they were not growing well. vitamin A supplementation. education of mothers for managing childhood diarrhea.The project design was based on the idea that much of the malnutrition present in Tamil Nadu was because of inappropriate childcare practices. because deficits at an early age often produce irreversible damage to children’s physical and mental development. combined with better childcare practices. supplementary on-site feeding for children who were not growing properly. they identified which children were not growing properly. could return the CHAPTER 8 Nutrition and Global Health 216 . A related innovation of great importance was that supplementary feeding was targeted only to the children identified as faltering. the project included a package of services that were delivered by health and nutrition workers that consisted of nutrition education. The Intervention In line with this approach. rather than just a lack of money to buy food. the project focused considerable attention on nutrition education and efforts to improve care and feeding practices for young children. The intent of this approach was that short-term feeding. project interventions focused on pregnant and lactating women and on children younger than 3 years of age. An important innovation of the project was that it used growth monitoring of the children as a device for mobilizing community action. Together with the community nutrition worker. and the supplementary feeding of a small number of women. They then plotted their weight-for-age on a growth chart. This was done in conjunction with nutrition education for mothers. Thus. In addition. periodic deworming. In addition. Groups of mothers met regularly to weigh their young children.

including: Growth monitoring. and television documentaries to inform consumers and persuade them to switch to iodized salt. China launched the National Iodine Deficiency Disorders Elimination Program. A nationwide public education campaign was launched. 20 percent of children ages 8 to 10 showed signs of goiter. even in the absence of other interventions. Overall. can be a cost-effective way of improving nutritional status. The sale of noniodized salt was banned. through careful evaluation the project was shown to have significantly reduced the levels of malnutrition of the targeted children. iodine deficiency can be simply remedied by adding iodine to salt. was far from simple. The public needed to be made aware of the risk of iodine deficiency. using posters on buses. suggesting that the gains of the project were sustainable. but the health efforts were not fully implemented. The project was also more cost-effective than other investments that had tried to achieve similar aims in India. especially in regions where goiter was so common that it was regarded as normal. The Challenge of Iodine Deficiency Disease in China Background For many years China had the heaviest burden of iodine deficiency in the world. with technical and financial assistance from the donor-funded Iodine Deficiency Disorders Control Project. Nonetheless. child to normal growth. In 1993. Fortunately. Lessons Learned This project was pioneering and revealed some very important lessons. Implementing this in a relatively poor and vast country like China at that time. These improvements also continued over a substantial time. The supply of iodized salt was increased by building 112 new salt iodination factories and enhancing capacity at 55 existing ones. Provincial governors ensured that government education efforts reached even the most remote villages. Women can be organized to participate actively in growth monitoring efforts. Nutrition education can have a permanent and sustainable impact on child care and child feeding practices. and so the government strengthened its resolve to tackle this widespread health risk. The Intervention Scientific evidence linking iodine deficiency to mental impairment was seen by the Chinese government as a threat to its one-child-per-family policy. constituting 40 percent of the global total. and technological assistance was provided to salt producers to adopt iodination. More universal and longer term feeding of children is not necessary to achieve improvements in nutrition. newspaper editorials. Impact The nutrition interventions of the project were largely implemented as planned. however. Salt quality was . Bulk packaging systems were installed to complement 147 new retail packaging centers. with packaging designed to help consumers easily recognize iodized salt. a cheap and universally consumed food. some 400 million people in China were estimated to be at risk of iodine deficiency disorders. This was a major change compared with previous practice in which supplementary feeding was more universal and longer term. coupled with short-term supplementary feeding of children who are faltering. In 1995.

fortifying salt with iodine cost about 2 to 7 cents per kilogram. technical. and in distribution and sales. Lessons Learned China’s success in reducing iodine deficiency offers valuable lessons for future efforts to reduce other micronutrient deficiencies such as iron and vitamin A through fortification. and goiter rates for children ages 8 to 10 fell from 20. one of several donors. iodine deficiency was reduced dramatically. The Chinese government invested approximately $152 million in the program. The financing strategy was clearly defined from the start. The World Bank. The Impact By 1999. or less than 5 percent of the retail price of salt in most countries. Donor coordination was strong and effective and was managed by the Chinese government and the donors themselves. As a result. both at production.monitored. and sociocultural changes that were needed to do so. because iodine in salt dissipates easily. The government made a firm and long-standing commitment to tackle the problem and brought about administrative.138 Costs and Benefits At the time of these efforts. where the amount of iodine added needs to be just right. legal. compared to 80 percent in 1995.8 percent in 1999. recovering some of this cost by raising the price of iodized salt. and the major players offered mutual support across all activities. deemed the project extremely cost- effective. iodized salt was reaching 94 percent of the country.4 percent in 1995 to 8. reducing the shelf life of iodized salt. The quality of iodized salt also improved markedly. China’s nationally controlled network of production and distribution made licensing and enforcement of legislation easier. The salt industry seized the opportunity of the Case Studies 217 .

salt. Similar arrangements will need to be made to limit sugar. implementation. governments will also need to think creatively about how to ensure that there are government units accountable and responsible for promoting enhanced approaches to nutrition. and ethnicity. and solutions to these problems will need to be carefully tailored to local circumstances. or the sea. Nutrition does not fit neatly into governmental bureaucracies because it touches many government units. Thus. China’s iodination program continues. and education. China is fast approaching the day when iodine deficiency will be unknown throughout its population. First. Legal and finan- cial arrangements need to be made in many countries so that more fortification can take place and the demand for fortified foods will be increased. in which affected people are involved in the design. in the case of nomadic peoples. as noted in the policy brief on Kenya. In addition. governments need to work more effectively with the food industry to improve the way in which foods are fortified and to be sure that processed foods are healthy. Problems of undernutrition are especially severe in South Asia and sub-Saharan Africa.and middle-income countries will have to deal simultaneously with undernutrition and overweight and obesity. A more detailed review of this case is available in Case Studies in Global Health: Millions Saved.139 ADDRESSING FUTURE NUTRITION CHALLENGES As noted earlier. and the dietary risks to good health. and oversight of nutrition activities. for example. About 45 percent of the under-5 child deaths globally are associated with nutritional causes. highly effective solutions are available to deal with a number of critical nutrition issues. such as agriculture. of focusing efforts on community- based action. Through a variety of approaches. almost all low. Thus. with special targeting of resources on areas where the consumption of iodized salt is particularly low. it will have to take a number of steps in a variety of domains. iodination of well or irrigation water. What steps will have to be taken to speed the world’s progress on nutrition? If the world is to do better in nutrition. especially when salt can be obtained cheaply from local salt hills. We have also seen the power in Tamil Nadu. gaining a firmer commercial footing and positioning itself to compete in the international market. and some fats in processed foods. but they are not being implemented sufficiently. health. given its cost advantages. much greater attention needs to be paid by all concerned parties to nutrition as an underlying health issue. policymakers who work both globally and in individual countries need to understand the exceptional importance of nutrition to good health and human productivity and act accordingly. Moreover. dried lakes. Nutritional concerns vary considerably by income group. . or even iodine capsules or injections. the world’s nutritional status still faces critical issues in undernutrition. Improving government policy and action on nutrition will also require a good understanding of the nature of the nutrition problem in different settings. The world will not meet the MDGs that relate to nutrition. gender.and middle-income countries. usually in poor and remote mountainous regions where residents see iodized salt as too costly. the world has made progress in the last several decades in addressing key nutrition problems. Problems of overweight and obesity are growing in many low. Research will be needed to determine the best way to ensure iodine intake in these areas—through price subsidies. Nonetheless. In addition. low-cost. overweight and obesity.investment in eliminating iodine deficiency to restructure and modernize the industry.

Although there is much knowledge of what works in nutrition. and without side effects. it is important for all societies to make the health and nutritional well-being of their citizens a national priority. government. if additional cost-effective ways were found for fortifying foods. and inexpensive food supplements were available. micronutrient supplementation.and middle-income countries get a better sense of what works and at what cost to reduce the nutritional risks to good health. very cheaply. It will also be essential that today’s low. and then collaborate with each other and with communities to implement solutions to these problems. there are also other areas in which additional knowledge could fill important gaps. and. if better formulas were available for some of the vitamin and mineral supplements that could be given less frequently. The world needs to continue gathering scientific knowledge about how key nutrition issues can be addressed. plan on how they can best be addressed. It would be very valuable to the world’s nutrition status and health if more easy-to-make. and food fortification Nutrition-sensitive interventions—those interventions that address the underlying determinants of malnutrition. nutritious. One way to do this would be to create partnerships of civil society. as rapidly as possible and in cost-effective ways. and the private sector that can work together to identify nutrition issues. As we consider the measures that can be taken to address key nutritional issues. such as vaccination programs or CHAPTER 8 Nutrition and Global Health 218 . such as promotion of exclusive breastfeeding. Lastly. it is essential to consider interventions in three domains: Nutrition-specific interventions—those interventions that can have a direct impact on nutrition.

Studies have shown that people can improve what they eat.5 This could include. it is very important to improve the control of parasitic infections such as hookworm and to control diarrheal diseases. implementing. and the management of diarrhea. it may be necessary that people receive food supplements like a high-protein. policies. In addition. These problems are also the result of.140 Nutrition education needs to be spread much more widely and in more appropriate ways to promote appropriate breastfeeding and complementary feeding and to help people eat better and more nutritious foods. and how they eat their food by improvements in knowledge. To succeed. To set the foundation for improvements in the nutritional status of poor people in low. Of course. malaria. Conditional cash transfer programs are also being used to promote better nutrition. how they cook them. natural disaster and conflict. even in the absence of improvements in income. resources. which are cash transfers that can be used only to buy certain health and nutrition services or the right to buy certain foods at reduced prices. growth monitoring and promotion programs must be coupled with programs for behavior change communication. Under these circumstances. can also be important to improving nutrition outcomes at low cost. It is especially important that these programs be community- based. and how they consume them. and pregnant and lactating mothers. children. Indonesia. or are compounded by.57 In the last decade or so. and improvements in water supply and sanitation. especially poor infants. and women. appropriate introduction of complementary foods.141 The two-way relationship between infection. Undernutrition It has already been noted that knowledge and behaviors are important determinants of what foods people eat.and middle-income countries. Vitamin A should be given twice per year and should be integrated with child survival and other health services to minimize the cost of distribution. These can be given in capsules or syrups.nutrition programs to enable farmers to increase the yield of crops that they consume ••The enabling environment for nutrition—this concerns laws. doing this will also demand renewed efforts at health education. such as immunization. vitamin A has . how they cook. such as food stamps. disease. and nutrition status has been noted. some people may receive vouchers for food. Alternatively. Some people will simply not eat enough food or enough of the right foods. Additional comments on other measures for addressing undernutrition and overweight and obesity follow. Growth monitoring and promotion programs. largely because of income gaps. mothers who participate in these programs need to understand the importance of child growth and how they can carry out improved feeding and caring practices. Vitamin and mineral supplementation is widespread in the world. like that in Tamil Nadu. as well as others that were carried out in Honduras. especially infants. poor nutritional status reduces immunity to disease. children. high-calorie ready-to-use therapeutic food. and smart cards are increasingly taking the place of food stamps or transfers of cash. for example. such as exclusive breastfeeding. more effective basic health services. taxing sweetened beverages or foods high in fat. At the same time. and monitoring nutrition interventions. and is often used as a way of improving the micronutrient status of large numbers of people. and institutional issues that relate to the approach countries take to nutrition and how effective they are at formulating. and Madagascar. and measles. is not expensive. Many infections and diseases reduce one’s ability to eat or ability to absorb food.

Fortification can cost as little as 3 to 5 cents per person reached per year. About two-thirds of the world now consumes iodized salt. and for which fortification is inexpensive. and the impact of fortification of salt could be further expanded through its double fortification with iron. fortification in the industrialized countries has contributed greatly to the disappearance of several deficiencies. soy sauce. fortification is a good way to harness the resources of commercial marketing Addressing Future Nutrition Challenges 219 . At the same time. The key to effective fortification is to find a food product that is very widely consumed. These efforts can be expanded. as well as iodine. Unfortunately. Food fortification is practiced in many countries for a number of micronutrients. as we have seen in the China case noted earlier.142 Thus. Multiple vitamin and mineral supplements are also being manufactured. for which there are no technical impediments to fortification. and other products. additional and carefully monitored efforts can be made to provide iron and folate to pregnant women. many different food products can be fortified. The fortification of salt with iodine is a very widespread practice and is very inexpensive. In addition.57 Clearly. margarine. increasingly one could fortify flour. as well as salt. cooking oil. In fact.been given orally to infants and children during national polio immunization days in many countries. these efforts have not worked as well as planned and need to be carefully reviewed and refined to enhance both coverage of supplementation and the extent to which women take the pills they do get. which can be sprinkled on children’s food to fortify it.

national. it may be that the most effective way of reducing iron deficiency in women is to operate an effective program of fortification for iron and folic acid. local. Given its scope. especially in low. as well as the benefit-cost ratio of some nutrition interventions. Even the most expensive nutrition interventions. The latest studies show that young child deaths could be reduced by about 15 percent if the appropriate countries could take to scale a package of nutritional interventions. and public awareness through mass media on diet and physical activity. including obesity. Strategies should include efforts on the international. They can also encourage surveillance. such as rice. Given the difficulties of iron supplementation. These interventions compare favorably in their cost-effectiveness with a range of other health interventions that are cost-effective. Table 8-6 indicates the cost per DALY averted of a number of measures to address undernutrition. In September 2011. networks to enhance the health of the population. monitoring. The aim of this work is to use technologies to improve the nutritional content of foods. yams.91 Overweight and Obesity The obesity epidemic poses a serious global problem. Condom promotion to prevent transmission of HIV has a cost per DALY averted of about $40. identifying key targets for strengthening and shaping primary prevention to reduce risk factors for NCDs. a range of these and related nutrition interventions are cost-effective or have a high ratio of benefits to costs. and the media is also essential. International organizations can have a large impact on obesity by setting global nutrition and physical activity standards. urban planners. and individual levels. Efforts are also under way for biofortification. To address cardiovascular disease . such as food supplements for young children. for example. the evidence suggests that this package would be highly cost-effective at a cost per DALY averted of about $179. healthcare providers. schools.143 The World Health Organization has also done a large amount of work on the subject. it is important to use policy measures across multiple levels to prevent obesity and reverse its trend. including developing best buy cost-effective interventions to address NCDs. or other vegetables. the agricultural sector. the United Nations General Assembly convened a summit on global noncommunicable diseases. The involvement of the food industry. WHO recommends reduced salt intake in food. have a cost-effectiveness that is similar to that of antiretroviral therapy for HIV/AIDS or the use of aspirin to prevent heart disease. and evaluation systems. replacement of trans fat with polyunsaturated fat. including:8 Folic acid supplementation or fortification for pregnant women Balanced energy protein supplementation for pregnant women Calcium supplementation for pregnant women Multiple micronutrient fortification for pregnant women Promotion of appropriate breastfeeding practices Appropriate complementary feeding Supplementation with vitamin A and zinc for children aged 6 to 59 months Appropriate management of severe acute malnutrition Appropriate management of moderate acute malnutrition Moreover. The cost-effectiveness of several vaccines and bednets for malaria control. is around $10 per DALY averted.and middle-income countries.91 In fact. to insure nutrition standards are met and to identify countries where obesity policies are most needed. For diet and physical activity.

In: Semba RD. Nutrition and Health in a Developing World. New Jersey: Humana Press. WHO recommends counseling and multidrug therapy for people with a high risk of developing heart attacks and TABLE 8-6 Cost-Effectiveness and Benefit: Cost Ratios of Selected Nutrition Interventions Cost per DALY Averted: $5–$15 for vitamin A and zinc supplements $40 for community-based management of severe acute malnutrition $50–$150 for behavior change interventions taken to scale $66–$115 for iron fortification $90 for folic acid fortification Benefit: Cost Ratios 6:1 for deworming 8:1 for iron fortification of staples 30:1 for salt iodination 46:1 for folic acid fortification Data from Horton S. eds. . Bloem M. and diabetes. Forthcoming. third edition. 2015. Totowa. Economics of nutritional interventions.