NUTRITION IS AN ECONOMIC ISSUE

This is the knockdown statistic from the Global Nutrition Report: 1 in 3 people on the planet are malnourished and every country is now struggling with malnutrition in some form, ranging from underweight to obesity. There are few development challenges that can make this claim.

The costs of an increasing burden of malnutrition are enormous, impeding not only population health improvements but economic growth and development. Poor nutrition causes a massive burden of death and disability in the world according to the Global Burden of Disease, with nutritional deficiencies responsible for 680,000 deaths every year and 50 million years lived with disability. The Copenhagen Consensus reports that this burden of death and disability squanders as much as 11% of GNP in Asia and Africa as a result of lives lost, less learning in school, less earning in the workplace, and days lost to illness. Failing to act on malnutrition is currently costing high, middle and low income governments billions of dollars in healthcare costs that are rising steeply, despite the fact that investing in nutrition can deliver big benefits. According to the Copenhagen Consensus, every $1 invested in reducing child malnutrition can save up to $166. Nutrition is an economic issue.

YOUNG WOMEN HOLD THE KEY TO NUTRITION ADVANCES

Death and disability from malnutrition are concentrated among women of reproductive age (15-49 years) and children under five. 40% (260,000) of all nutrition deaths and 56% (28 million) of years lived with disability due to nutritional deficiencies are among women and children in these age groups. The leading cause of these deaths is protein-energy malnutrition which accounts for 90% (226,000) of nutrition deaths among children under five and 34% (14,000) among women of reproductive age. Iron-deficiency anemia is the other major cause of nutrition-related death and disability among women, responsible for 60% (25,000) of all nutrition deaths and an enormous 80% (9 million) of all years lived with disability due to nutritional deficiencies among women aged 15 to 49. Further, the Lancet Maternal and Child Nutrition Series reported that more than 160 million children under five are “stunted” and at greater risk of death especially from infectious diseases, while those who survive face impaired health, educational and economic performance that can last a lifetime.

Three quarters of all nutrition deaths among young women and children under five are in just ten countries, including India, Nigeria, Democratic Republic of Congo, Ethiopia, Niger, Mali, Tanzania, Chad, Kenya and Angola. Not surprisingly these are the countries struggling with very large populations of malnourished women, especially in India where half of all women aged 15 to 49 (150 million) are anemic and, according to recent research by Diane Coffey, almost half of all women enter pregnancy underweight. Many western and central African countries are also struggling with anemia prevalence rates of 50%.

The world needs an all out assault on anemia among women of reproductive age. Anemic and underweight women are not only at greater risk of death and disability from pregnancy and childbirth, but are more likely to give birth to low birth weight babies, who in turn have a higher risk of death and disability.  It is alarming that among the countries with the highest anemia prevalence, deaths are actually rising. According to the Global Burden of Disease since 1990, anemia deaths among women 15 to 49 years have risen by 33% in India, 48% in Nigeria, 92% in Afghanistan and 140% in Mozambique. Not surprisingly, only four of the 185 countries assessed in the Global Nutrition Report are reducing anemia among younger women at the required 5.2% per year, including Burundi, Kenya, Viet Nam and Vanuatu. Of all World Health Assembly nutrition targets, reducing anemia among women of reproductive age is the most off target.

At the other end of the spectrum is obesity which now affects many more women (375 million) than men (266 million), and contributes to the high and rising burden of death and disability from non-communicable diseases in many low and middle-income countries (Lancet, 2016). Indeed many of these countries are now struggling with what is called a “double burden” of malnutrition.

As the major providers of nutritious food for their children and families, women of reproductive age also exert a profound influence on the nutritional status of families, communities and future generations, especially in countries where women are wholly responsible for family food preparation. In recognition of women’s leadership role in family nutrition, efforts to improve mothers’ agency to provide nutritious foods and to create a healthy home environment, in a way that doesn’t impede female labor force participation, should be at the center of nutrition policies and programs. In this context, the ability of women to breastfeed for up to two years after birth and to cook meals that do not contribute to the dangerously high levels of household air pollution should be special priorities. There needs to be a wider recognition that reducing current levels of malnutrition, and arresting its intergenerational cycle, depends on the actions of women of reproductive age.

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REDUCING MATERNAL MALNUTRITION: A NEW DEVELOPMENT PRIORITY

As the burden of nutrition-related death and disability is concentrated among women of reproductive age and their children, and in recognition of the critical role women play in determining the nutritional status of populations, national nutrition strategies should focus on improving the nutritional status of women of reproductive age and on strengthening their capacity to provide nutritious diets for themselves, their children and their extended families.  Accordingly, countries should set targets for halving underweight and anemia among women 15-49 years by 2020 and for eliminating both by 2030. 

To achieve these goals, all nutrition stakeholders should work together to simultaneously increase the supply of foods and supplements designed to meet the special nutritional needs of women, especially during pregnancy, and encourage their use by educating women, by providing cash transfers conditional on their use, by offering nutritious foods and supplements as incentives for healthy behaviors (e.g. childhood vaccination, prenatal care visits), and by making foods and supplements available at the places women frequent daily (e.g. schools, workplaces and shops).

Urgent action on the consumption of iron-folic acid supplements and iron-fortified staple foods is required, alongside protein-energy foods and supplements especially for adolescent girls and pregnant women in the countries where iron-deficiency prevalence and deaths are highest.  Women should be encouraged to use these products through a mix of education and cash and non-cash incentives, which the World Bank concludes can improve nutrition, especially when delivered directly to women. Incentives can include cash directly to mothers or rewards such as mobile phone minutes, energy subsidies, access to job information, educational supplies for children, or other rewards valued by specific populations.  Another model is to link food rewards to compliance with other health and related programs. For example, the Poverty Action Lab in India found that when women were offered a food reward (lentils) upon completion of their child’s vaccination schedule, full vaccine coverage went up substantially.

Given the gender dynamics within families, care needs to be taken to ensure that special foods meant for women actually reach them, via special labelling, custom formulations that cannot be taken by children, and/or consumption on site at schools or workplaces. Programs that incentivize fathers to prioritize the nutritional status of their wives and daughters should also be explored. For example, analysis by Rohini Pande and Seema Jayachandran suggests that the lower nutritional status of women in India starts very early in life. Their study revealed that first born children in India are actually taller than firstborn African children and that stunting emerges within Indian families only after the arrival of the first son. This suggests that India will never end child malnutrition without broader shifts in parental attitudes towards daughters.

Incentives should also be provided to enable women to breastfeed in hospital, at home and at work and to transition to cooking methods that do not create the high levels of indoor air pollution that are contributing to a massive burden of death and disability (household air pollution is the third leading risk factor for disease burden globally). WHO acknowledges that early and exclusive breastfeeding has the single largest impact on newborn and child mortality of any preventive intervention, and most of the countries that have reduced child deaths by two-thirds since 1990 have exclusive breastfeeding rates above 50%, including Bangladesh, Bolivia, Cambodia, Egypt, Eritrea, Ethiopia, Madagascar, Malawi, Mongolia, Nepal, Peru, Rwanda, and Uruguay. The University of Sheffield is conducting trials to test whether cash payments for breastfeeding can lift rates well above the currently low levels and there needs to be much more experimentation with new approaches to enable breastfeeding (e.g. low cost breast pumps, paid leave, human milk banks, employer rewards). Incentives are also being tested to encourage the use of clean energy including by enticing husbands and fathers to purchase new cookstoves by including phone rechargers and the like. 

It is important that nutritional foods and supplements are accessible to women in the course of their daily lives and do not add any further inconvenience. The recent work by GAIN and Alive & Thrive to encourage large employers of young women in Bangladesh and Viet Nam to educate women about nutrition and provide nutritious foods and breastfeeding support at work is one example of how to reach women without asking them to incur additional costs. Another way is to deliver foods and supplements alongside other services (e.g. polio campaigns, prenatal visits and medicine distribution). For example,  the Clinton Health Access Initiative, the Children’s Investment Fund Foundation, Nutriset, the Government of Nigeria and UNICEF recently collaborated on a campaign in Nigeria where children received nutritional supplements alongside their malaria medicines, protecting them against the double scourge of malaria and malnutrition at a particularly vulnerable time of the year.   

All of these investments in improving the nutritional status of women of reproductive age will bear fruit for children’s nutritional status. The Global Nutrition Report estimates that 70% of the recent reduction in childhood stunting in Bangladesh is due to advances in education, incomes, sanitation and contraception, most of it targeted to women 15 to 49 years.

SUPPORT THE REAL CHAMPIONS OF NUTRITION: MOTHERS

The Sustainable Development Goals aim to “end” hunger and all forms of malnutrition by 2030 and achieve the World Health Assembly targets of a 40% reduction in child stunting, a 50% reduction in anemia among women aged 15-49, a 30% reduction in low birth weight babies, a 5% ceiling on the proportion of children who are wasted and a freeze on the number of overweight children under five. The targets also aim to increase rates of exclusive breastfeeding to at least 50%.

The United Nations, its agencies and partners should affirm that prioritizing the nutritional needs of women of reproductive age will accelerate achievement of all six targets and support the focus on women 15 to 49 years as the key to achieving the new Sustainable Development Goals. The UN should encourage all development partners with a stake in meeting these goals to increase investments in high-impact interventions with a proven track record of improving women’s own nutritional status and their capacity to reduce childhood malnutrition, with priority given to the largest populations of malnourished women.

Full engagement of the private sector is required to achieve these goals as food is a private market transaction in all but the most fragile of humanitarian settings. The makers, distributors, advertisers and sellers of the vast majority of foods that people consume are profit-seeking individuals and companies. Not only do companies provide food, but they are also in steady dialogue with consumers through their marketing channels which are becoming ever more sophisticated with rapid income growth and urbanization occurring everywhere alongside rising consumption of processed foods. The degree to which those committed to achieving the new global nutrition goals can influence the exchange of information and food between food and beverage companies and populations of women 15 to 49 years will largely determine their achievement.

The UN should also lead the charge in a data revolution that would fill the unacceptable gaps in our knowledge of the nutritional status of women of reproductive age at national and sub-national levels. The world urgently needs information on the nutritional status of women, down to state and district levels, especially in the countries with the largest numbers of nutrition-related deaths. It should be as simple as visiting a website to find out the numbers of women aged 15 to 24 in the districts of Uttar Pradesh, India who are underweight, or the numbers of pregnant women with diabetes in Western Nyanza Province, Kenya, or the areas within Kano State Nigeria with the lowest early and exclusive breastfeeding rates.

A final note. There is often talk of the need for nutrition champions among government and development leaders. But the real champions of nutrition are the hundreds of millions of disempowered women who are responsible for feeding future generations under the most challenging of conditions. It is often these women, mostly mothers, who shoulder the burden of farming, shopping, cooking and feeding families when they themselves are often struggling with poor nutrition, low levels of education and severe restrictions in their ability to earn an income and make financial decisions. Enabling these women to take the actions necessary to safeguard their own nutrition and that of their children can unlock the next wave of nutrition advances.