08 Sep 2015

Nutrition Country Profile (2014) Submissions

Global Nutrition Report

The Global Nutrition Report put out a call for submissions on the 2014 Nutrition Country Profiles earlier this year. In this call, we asked those of you who are working in-country to write a brief case study on your respective Nutrition Country Profile, outlining the story the profile tells and reflecting on how closely it relates to the reality you face. We also asked you to include suggestions on how we can make the profiles more useful for your work. For full details on the call for submissions, click here.

Below are the submissions we received. They have been reviewed by the Global Nutrition Report team and in some cases refined or commented on in collaboration with the submission authors.

The opinions stated in the submissions are purely those of the submission authors and do not necessarily reflect the views of the Global Nutrition Report team or the Report's authors.

  1. Kenya – David Hong (One Acre Fund)

Collaborating with farmers to improve nutrition at scale: A case study of orange-fleshed sweet potatoes (OFSP) in Kenya

In Kenya, a country where 43 percent of the population lives in extreme poverty and many cannot afford nutritious food, there is an overwhelming need for nutrition interventions that work at scale[i]. According to the Global Nutrition Report’s Kenya Country Profile, 35 percent of children under five are stunted, which is nearly 2.5 million children[ii]. An estimated 84 percent of Kenyan preschool children suffer from a Vitamin A deficiency, which is crucial for eye and reproductive health[iii]. One Acre Fund, a social enterprise in East Africa, uses country-level data from the GNR as a baseline to measure progress on nutrition indicators across our program. In 2013, we sought to increase OFSP adoption and nutrition impact for 60,000 farmers in Western Kenya.

OFSP is high in nutritional content and is an important source of β-carotene). With just 125 grams of fresh orange-fleshed sweet potato root, preschool children can meet their daily Vitamin A needs. OFSP are also drought resistant[iv] and are already locally grown and accepted. Our main challenge was to scale the supply of OFSP vines. Sweet potato breeding programs are highly limited in Sub-Saharan Africa and we learned that there were no suppliers large enough to meet our demand[v]. Through the efforts of agronomic and logistical staff, hundreds of casual laborers, and a 100 acre plot of leased land, we were able to conduct one of largest OFSP multiplication efforts ever in East Africa.

With a successful supply of vines, the next hurdle was to drive widespread farmer adoption. Because maize is the region’s main staple crop, many farmers are not interested in growing alternative staple crops, despite the risk of diseases like MLND. To address this challenge, our staff executed created a social marketing campaign to increase awareness of OFSP, educated field officers, demonstrated planting techniques with farmers, conducted focus groups, and implemented planting surveys. We added OFSP vines into our core product offering for 2013 and hired more trucks to deliver the large bags of vines to farmers’ doorsteps.

As a result, over 90 percent of farmers adopted OFSP and 93 percent followed the recommendations outlined in our storage and planting trainings. Even though our techniques were more time-consuming than traditional practices, 73 percent of farmers preferred the new methods and believed they were an improvement. Post-harvest surveys showed that farmers were happy with the new sweet potato package and that on average, farmers who adopted OFSP earned $55 of additional income versus those that did not. For many farmers, this additional impact represented 25 percent of total farm profits.

To achieve food and nutrition security, development organizations must understand the connections between poverty, undernutrition, and smallholder farmer behavior. As an organization that is built for scale and expansion, we were able to leverage these strengths to multiply OFSP vines to a unprecedented level – anything less would have blunted our impact. By listening to farmers, we were able to improve nutrition, increase incomes, and build resilience for thousands of smallholder farmers in Western Kenya.

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[i] World Bank. World Development Indicators 2015.

[ii] International Food Policy and Research Institute (IFPRI). 2014 Nutrition Country Profile: Kenya. Global Nutrition Report. 2014.

[iii] International Food Policy and Research Institute (IFPRI). 2014 Nutrition Country Profile: Kenya. Global Nutrition Report. 2014.

[iv] Low, J et al. A Food-Based Approach Introducing Orange-Fleshed Sweet Potatoes Increase Vitamin A Intake and Serum Retinol Concentrations in Young Children in Rural Mozambique. The Journal of Nutrition. 2007.

[v] International Potato Center. Unleashing the potential of sweetpotato in Sub-Saharan Africa: Current challenges and way forward. 2009.

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2. Mozambique – Erin Homiak (Concern Worldwide)

Addressing Gender Inequality to Accelerate Improved Nutritional Outcomes: Reflections from Mozambique

Mozambique represents one of the many paradoxes of underdevelopment – a country where almost 43% (2011) of children under five suffer from chronic malnutrition[i]despite vast areas of bio-diverse and fertile land and its production of an array of fruits, vegetables, tubers, nuts, and even nutrient-dense foods like avocados and noni. This implies that access to food is not the only factor that impacts nutrition. If nutrition indicators are to improve, nutrition cannot only be addressed from a health perspective but rather the social determinants of health must be addressed as well as, issues of gender equality appear most prominent.

In response to some of these challenges, Mozambique has established the Technical Secretariat for Food Security and Nutrition (SETSAN), a unit housed within the Ministry of Agriculture. The steps being taken by this coordinating body are guided by Mozambique’s National Multi-sectorial Action Plan to reduce Chronic Under-nutrition (PAMRDC)[ii].

Despite the multi-sectorial nature of the PAMRDC framework, distal factors related to malnutrition remain a significant challenge. Factors including poor health conditions, poverty (with a GDP per capita of $1,012 in 2013), lack of water and sanitation (where only 8% of the population had access to piped water in 2012), poor infrastructure, gender inequality (scoring 0.657 out of 1.0 on the Gender Inequality Index in 2013)[iii], and a lack of education around nutrition that can challenge traditional practices[iv].

Indeed, if one looks at the 2014 Mozambique’s Nutrition Country Profile[v], it is not easy to identify the root causes of malnutrition just by looking at nutritional status indicators that show only 43 percent of infants under 6 months are exclusively breastfeed and that only 13 percent of children under two are receiving an acceptable diet[vi]. The profile highlights factors which contribute to malnutrition that go beyond simple health and nutrition indices. Factors like low female secondary school enrollment (24%), sociocultural factors influencing early marriage, and gender inequality (ranked 146 out of 193) appear as underlying social determinants of health.

A very large portion of the population in Mozambique is illiterate and there is a high rate of school dropout. The literacy rate among females in Mozambique is 42.8% compared to 70.8% for males, a striking contrast[vii]. The stark contrast between the level of literacy among men and women is representative of gender inequality and sheds light on the socio-economic disadvantage that Mozambican women have due to their education deficit. This calls for an investment in gender-specific public health and educational programming.

Much is presently being done on a small scale to address the gender gap across sectors. The Country Profile highlights the depth of this gap and should be used as a call for action to scale up the response to gender in all sectors. However, without underscoring the need to address gender and associated sociocultural practices as distal factors implicated in nutrition, the current pattern is likely to remain highly resistant to change.

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[i] Global Nutrition Report, “2014 Nutrition Country Profile: Mozambique,” http://www.globalnutritionreport.org/files/2014/12/gnr14_cp_mozambique.pdf, (February 17, 2015).

[ii] Multisectoral Action Plan for the Reduction of Chronic Undernutrition in Mozambique 2011- 2015 (2020) (Maputo: Department of Nutrition, 2010).

[iii] Global Nutrition Report.

[iv] Concern Worldwide, Barrier Analysis Report: Linking Agribusiness and Nutrition in Mozambique LAN (Manica Province: Unpublished Data, 2014).

[v] Global Nutrition Report.

[vi] Global Nutrition Report.

[vii] Central Intelligence Agency, “The World Factbook,” https://www.cia.gov/library/publications/the-world-factbook/geos/mz.html, (March 10, 2014).

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3. Nigeria – Oluwatoyin Oyekenu for the WINN programme

Optimal breastfeeding practices are essential for child survival and it is estimated that 11.6 per cent of all child deaths globally are attributable to suboptimal breastfeeding[i]. Early initiation and exclusive breastfeeding for six months is not only essential for child survival, it has also been shown to increase a child’s IQ by three points and decreases the risk of maternal haemorrhage. Timely introduction of appropriate complementary foods, including feeding children at least four times a day with foods from at least four food groups has been shown to reduce both stunting and underweight[ii].

Infant and young child feeding is an area in which Nigeria, especially the Northern part, is lagging behind and where investments could lead to substantial improvements in child survival. According to the Nigeria country profile from the 2014 Global Nutrition Report, rates of exclusive breastfeeding for the first six months are very low, with only 15 per cent of infants exclusively breastfed[iii].

The rates are even lower in the five states in Northern Nigeria where with Working to Improve Nutrition in Northern Nigeria (WINNN) programme operates; the baseline survey conducted in Jigawa, Katsina, Kebbi, and Zamfara states found only 6 per cent of women exclusively breastfeed for six months. For children 6-23 months nationally, only 10 per cent receive a minimum acceptable diet. Again in the north, rates are even lower, with only 5 per cent of children 6 to 23 months receiving a minimum acceptable diet in the four states included in the WINNN programme baseline survey. The Global Nutrition Report highlights low female enrolment in secondary school, 41 per cent, a key underlying factor influencing mother’s knowledge of best child feeding practices. However, this figure perhaps hides the stark reality in the North, where 86 per cent of mothers had no formal education and only 4.5 per cent of mothers had completed any secondary school[iv].

Working to Improve Nutrition in Northern Nigeria (WINNN) is a 6-year project funded by the Department for International Development (DFID), which began in September 2011. The aim is to reduce mortality by decreasing the incidence and prevalence of under nutrition of 6.2 million children under the age of 5 in 5 Northern Nigerian states: Jigawa, Katsina, Kebbi, Yobe and Zamfara.

The WINNN programme aims to improve infant and young child feeding practices through a number of evidence-based interventions including community support groups and counselling of pregnant women,mothers and/or caregivers with young children in health facilities. The Global Nutrition Report Nigeria profile highlights that Nigeria has implemented partial maternity protection, a key factor in women having the time to feed their children optimally- however this is not likely to benefit women in the North where only 1 per cent of women engage in formal paid employment.

Operational research has sought to increase the effectiveness of the WINNN programme, as well as government nutrition programmes throughout Nigeria, and has specifically identified several actions to improve the programme including:

  1. Improving supervision and support for community health workers delivering the counselling
  2. Prioritizing a small number of contexts specific actions in the counselling rather than a whole package of best practices
  3. Continue to build on the example of using healthy children who have been exclusively breastfed to demonstrate the effectiveness of the practice and reinforce the messages.

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[i] Black, Robert E, Cesar G Victora, Susan P Walker, Zulfiqar A Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, et al. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet, June. doi:10.1016/S0140-6736(13)60937-X.

[ii] Bhutta, Zulfiqar A, Jai K Das, Arjumand Rizvi, Michelle F Gaffey, Neff Walker, Susan Horton, Patrick Webb, Anna Lartey, and Robert E Black. 2013. “Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?” The Lancet, June. doi:10.1016/S0140-6736(13)60996-4.

[iii] 2014 Nutrition Country Profile: Nigeria. 2015. Accessed March 16. http://www.globalnutritionreport.org/files/2014/12/gnr14_cp_nigeria.pdf.

[iv] Visram, Aly, Paul Jasper, Lucie Moore, and Femi Adegoke. 2014. ORIE Nigeria: Quantitative Impact Evaluation- Baseline Report. http://www.heart-resources.org/assignment/orie-nigeria-quantitative-impact-evaluation-baseline-report/.

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4. Philippines – Melinda Gill (Indep) and Lincoln Lau (University of Toronto)

The overall prevalence of undernutrition in the Philippines has not improved significantly over the past decade, with under-5 wasting at 8% (WHA target is < 5%) and stunting relatively stable at 30% (WHA target is a 40% fall by 2025) (GNR 2014).

Underpinning these findings are significant variations in the geographic distribution of undernutrition. For example, the prevalence of under-5 stunting is 13% among the richest urban quintile compared with 45% among the rural poor (FNRI-DOST 2014). Determinants of undernutrition, such as lower levels of female education, exposure to open defecation, higher total fertility rates and reduced access to health care, are also more prevalent in rural areas (Philippines DHS 2013). Furthermore, whilst GDP continues to grow (the highest in Asia in the past year), there has been no reduction in poverty incidence over the past few years (Albert, 2014). Income inequality remains relatively high with a Gini index (2000) of 46 (GNR 2014). This is similarly unchanged over the past decade, except in rural areas where it has been increasing (NEDA-UNDP 2014). Figure 1 uses government data to demonstrate the correlation between stunting prevalence (FNRI-DOST 2012) and the percentage of the population in the lowest wealth quintile (Philippines DHS 2013) across the Philippine’s 17 regions.

Figure 1. Relationship between under-5 stunting prevalence and percentage of population living in lowest wealth quintile per region

Philippines Fig 1: Graph - Figure 1. Relationship between under-5 stunting prevalence and percentage of population living in lowest wealth quintile per region

Government health expenditure has fallen and remains low at 2.6% (GNR 2014). Furthermore, devolution of health service provision to each of the Philippine’s 1490 municipalities results in disparities in health financing and spending, service quality and access, and health outcomes which particularly affect poorer municipalities and constituents (WHO 2011). Although expenditure in social protection has increased, particularly through the Philippine government’s largest social welfare program (a conditional cash transfer (CCT) program called Pantawid Pamilyang Pilipino Program or 4Ps which was launched in 2007), experience in other settings suggests that CCT programs do not necessarily improve nutritional outcomes (Ruel and Alderman 2013).

Whilst the Philippine Department of Health has a number of quality nutrition-related programs and policies, including recently established national guidelines on the management of severe and moderate acute malnutrition, closer attention should to be paid to the social determinants of undernutrition to effectively target both nutrition specific and nutrition-sensitive interventions to the most disadvantaged communities and families. Furthermore, creating greater capacity and accountability within the health sector, including enabling the community-based nutrition scholars to collect more accurate and frequent surveillance data, is needed.

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5. Somalia – Nina Dodd (FAO) with comments from the reviewers

Critique of the GNR Somalia Nutrition Profile, 2014

The main objective of the Nutrition Profiles of a Country is to provide summary information for country leaders, development partners, and stakeholders about the extent and causes of malnutrition to inspire action and investment in nutrition to reduce malnutrition.

However for Somalia, sources of nutrition indicators used for GNR country profile are from UNICEF/WHO global databases and not the Food Security and Analysis Unit (FSNAU). Both these agencies depend on FSNAU data for information on nutrition situation in Somalia. The FSNAU seasonal and rapid assessments across most regions and livelihoods zones in Somalia form the basis of a broad range of humanitarian responses/programme interventions by most organisations operational in Somalia. The early warning function of FSNAU has been widely acclaimed as being well-informed and timely, most notably in the lead up to the 2011 declaration of famine in parts of southern Somalia.

Most of the nutrition data reported for Somalia country profile by GNR is outdated e.g. the prevalence of under 5 anthropometry/exclusive breast feeding is reported for 2006 while 2014 prevalence data has also become available.

(Editor’s note: We use the most updated data from the UN/World Bank databases).

There have been a number of promising developments for the Somali economy since 2006. After many years of conflict, the security situation is improving (albeit with occasional setbacks). Even population figures refer to 2012 and not 2014. Estimates of the number of children affected by stunting/underweight calculated based on the 2006 population are of no use since 2014 the population has increased by 50%.Information on the coverage of improved water/sanitation is from 2000 whereas recent information for 2014 is also available from FSNAU and is being used by WASH Cluster.

Child anthropometry data for children <5 suggests information is also available for 0-6 month old infants whereas most anthropometric assessments target 6-59 month old children. Age and gender disaggregated data is not provided which helps to identify who are most at risk for nutrition problems. (Editor’s note: agree this would be useful, but it is a level of detail that is difficult to address in a two page sheet). The international child growth standards/reference (National Centre for Health Statistics/WHO) used to estimate malnutrition is not indicated. (Editor’s note: we use the WHO growth standards, will clarify). There are important differences between the WHO standards and the NCHS reference on prevalence rate of malnutrition which have implications for child health programmes.

Estimates on prevalence of underweight are missing from the country profile. This is an important indicator for the MDGs (Millennium Development Goals) since it is linked to poverty, low levels of education, and poor access to health services. (Editor’s note: the usefulness of underweight is now widely questions, despite it being an MDG indicator. Stunting and wasting have been proposed for the Sustainable Development Goals from 2016 onwards).

Adequate nutrition through appropriate infant and young child feeding (IYCF) during the window of opportunity from pregnancy through to infancy and early childhood is fundamental to the growth, development and survival of children. Somalia country profile has no information on some of the core indicators for IYCF which include: introduction of complementary foods, minimum dietary diversity, minimum meal frequency, and minimum acceptable diet, consumption of iron-rich or iron-fortified foods.

There is no mention of country nutrition policies, strategies and programmes or legislative provisions which promote child health and nutrition. (Editor’s note: There is some evidence on policies relating to the right to food, legislation on the marketing of breastmilk substitutes, diet related non communicable disease and for SUN countries, data on institutional transformations. Agree it would be good to do more. )

Table 1 shows how the picture of nutrition in Somalia painted by Nutrition Country Profile differs from evidence based data reported by FSNAU which is used by all the humanitarian actors.

(Editor’s note: This is a good takeaway for the GNR team—how can we make the Nutrition Country Profiles more useful for rapidly changing humanitarian contexts?).

The nutrition paradox in Somalia is the low prevalence of stunting with high prevalence of wasting. This is due, in part, to the pastoralist population. The pastoralist lifestyle involves a high intake of animal products which may favour linear growth (height). Estimates for mortality rate for Somalia based on UNICEF indicators are not very useful due to a lack of live birth records and inaccurate records.

IndicatorFSNAU dataGlobal Nutrition Country Profile-2014

Prevalence of Under 5 wasting(6-59 months)

12.9%- in 2014

< 5 yrs

13% -2006 data

Prevalence of Under 5 Stunting (Editor’s note: the difference in values across the two data sets is surprising—need to explore further)(6-59 months)

9.1%- 2014, Low prevalence

< 5 yrs

42% in 2006-Very hIgh

Mortality rates

Based on SMART indicator

SMART surveys calculate U5DR = risk of dying over a period of time of children under 5 years (# of new cases/population under 5/time period)

Conclusion: They are both valid but entirely different indicators that are not comparable. SMART indicators are collected using retrospective survey approaches.

Based on UNICEF indicator

UNICEF indicators = # deaths per # live births (no time period). It is a ratio that measures a risk during a 5 years period of exposure.

Conclusion: They are both valid but entirely different indicators that are not comparable. UNICEF indicator is collected using a different method (not a survey).

Core Indicators of IYCF

Exclusive BF < 6 months) - 5.3% (2009)

Continued BF at 12 months- 47.4% (12.4-84%) -2014

Continued BF at 24 months- 5.7 % (1.7-62.2) 2014

Exclusive BF 9.0 % (2006)

Continued BF at 12 months- 50% -2006

Changes in stunting prevalence over timeTrends are available from 2009-2014Data not availableVitamin A Supplementation61.8%-2014NA

Suggestions for improving country profile

  • The country nutrition profiles should be developed in collaboration with the country. There should be an opportunity to discuss debate and engage on the data for key indicators proposed to be included in the report. (Editor’s note: We do not have the resources to do this for all 193 countries, but we hope this is the beginning of such a process where the data are most controversial)
  • Country profile should provide reliable information. Data should be recent and represent the best and most available statistics available for those indicators at the time of the preparation of the country profile and gathered from a variety of reliable sources. (Editor’s note: Agree—these are the most up to date data in the UNICEF/WHO global databases. The Somalia 2014 data either has not yet been included in the UNICEF/WHO global database for whatever reason)
  • Data should be in the form of automated country profiles and user-defined downloadable data. (Editor’s note: Good idea. We will pursue.)
  • Standard format for indicators should be used for reporting (Editor’s note: we use the standard UNICEF/WHO formats, as far as possible.)
  • Age and gender disaggregated data. (Editor’s note: Not always available, but agree, desirable, but there are only so many data points to get on 2 sides of paper!).
  • Information on evidence based direct Interventions to prevent and treat under nutrition (Nutrition-specific interventions: breastfeeding promotion, vitamin and mineral supplements, and deworming) should be included as it will provide a snapshot of national investments being made in the country to address malnutrition. (Editor’s note: many—but not all--of these are included)
  • Information on existing strategic policy directions will show a country’s unique needs, constraints, capacities, challenges and priorities. Somalia as a SUN country needs to focus on optimal growth of children through reduced levels of wasting (low weight for height) , not stunting. (Editor’s note: At present there is no space for unique policy needs in the profiles. We hope to develop this further.)
  • Include trends on the prevalence of malnutrition as this will allow comparisons to be made over time and demonstrates the changing face of nutrition in the country. (Editor’s note: this is done when possible).

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6. South Africa – Beulah Pretorius (University of Pretoria)

A country profile in a nutshell as it currently presented highlights progress made in combating malnutrition, increasing food supply and also identifies gaps on missing and outdated data. As it is an easy to understand and condensed report, it empowers not only nutritionist and dieticians, but also the government, the business sector, the media and concerned citizens with evidence of the current scale of malnutrition, the measures being taken to combat it, as well as the effectives of current policies and programs, e.g:

  • Data on micronutrient status indicates the effectiveness of intervention programs and policies (e.g. fortification of staple foods) and if there is a need to change vitamin and mineral fortification regulations for the nation’s food supply.
  • Data on overweight and obesity provided a means to track trends and anticipate non-communicable disease risks.
  • Data on raised blood pressure over time can show the effectiveness of the salt and trans-fat regulations as is implemented in South Africa.

The Report can also be seen as a monitoring and evaluation tool to help increase accountability, commitment and progress on reaching the Sustainable Development Goals (SDG’s) which build upon the Millennium Development Goals (MDG’s) and the post 2015 development agenda.

Although studies to determine the nutritional status of the South African population are limited, more recent data is available from the South African National Health and Nutrition (SANHANES-1) report. In future nutrition reports, it might be useful to ascertain that the most recent data is used to fill the existing gaps where new data is available. Data on unemployment will also be useful as this can be seen as a predicting factor for food insecurity in a country.

Studies to determine the nutritional situation of South Africa at a national level is unfortunately limited as only sporadic nationally representative studies have been performed[i]. South Africa is considered an example of a country experiencing a nutrition transition, where under- and over-nutrition increasingly co-exist. This co-existence is often observed within the same household and even within the same individual (due to excessive energy intake with a low intake of essential nutrients)[ii]. The average household income of the poor in South Africa equips many households to procure mainly low cost staple foods such as maize meal porridge and brown bread, with limited added variety. Various studies reporting a dietary diversity score (DDS) <◦4.0 among two out of five South African adults[iii] [iv] [v] [vi]. The number of people living below the food line increased to 32.4% in 2009 from 26.6% in 2006, before dropping to 20.2% of South Africans in 2011[vii].

Although wasting in children is reporting to be low it is increasing[viii]. The most recent data from the South African National Health and Nutrition Survey (SANHANES-I) reported a prevalence of wasting and severe wasting of 2.9% and 0.8%, respectively. At the national level, stunting is by far the most common nutritional disorder, affecting 15.4% of the children with the highest prevalence (>25%) in the younger children (0-3years).Severe stunting was reported in 3.8% of the children. The SANHANES-1 Study also reported underweight and severe underweight of 5.8% and 1.1% respectively. In addition to underweight, the prevalence of overweight in South African is a reality, and increasingly so in children and women[ix]. By comparing the overweight incidence in children among different studies a clear pattern emerged. Overall overweight and obesity prevalence is increasing with the SANHANES-I study reporting a combined overweight and obesity prevalence of 13.5% for children aged 6-14 years. Only 4.2% of women and 12.8% of men were found to be underweight, while more than 60% of the women and 30% of the men were found to be overweight and obese combined. Overweight and obesity incidence increased with age.

Although exact figures for micronutrient deficiencies in all age and gender groups are limited, studies have indicated that many South Africans do not meet their requirements for calcium, iron, zinc, riboflavin, vitamin B6, folate, vitamin C and vitamin A[x]. At national level, the SANHANES-1 data from 2013 indicate that 43.6% of the children under 5 have Vitamin A deficiency, anaemia was present in 10.7% of the children, 33% of the children between 10 and 14 years had no food in the house to eat breakfast and 29.8 % had nothing at home to put in their lunchbox for school.

Numerous factors throughout the food system impact the concentration and bioavailability of nutrients in the diet of a population. Available strategies showing the most promise focus on increasing dietary diversity and reducing food waste and food losses through three main categories: (1) agricultural production strategies, (2) food processing strategies and (3) economic and consumer education strategies[xi] [xii].

[i] The lack of food intake data and the consequences thereof. Van Heerden, I V and Schönfeldt, H C. 1, 2011, South African Journal of Clinical Nutrition, Vol. 24, pp. 10-18.

[ii] Estimating the burden of disease attributable to excess body weight in South Africa in 2000. Joubert, J, et al., et al. 8, 2007, South African Medical Journal, Vol. 97, pp. 683-690.

[iii] Food variety and dietary diversity as indicators of the dietary adequacy and health status of an elderly population in Sharpeville, South Africa. Oldewage-Theron, W H and Kruger, R. 2008, Journal of Nutrition for the Elderly, Vols. 27(1-2), pp. 101-133.

[iv] Dietary diversity in relation to other household food security indicators. Faber, M, Schwabe, C and Drimie, S. 2009, International Journal of Food Safety, Nutrition and Public Health, Vol. 2(1), pp. 1-15.

[v] How diverse is the diet of adult South Africans? Labadarios, D, Steyn, N P and Nel, J. 2011, Nutrition Journal, Vol. 10(33).

[vi] Shisana, O, et al., et al. South African National Health and Nutrition Examination Survey (SANHANES-I). Cape Town : HSRC Press, 2014.

[vii] StatsSA. Poverty Trends in South Africa - An examination of absolute poverty between 2006 and 2011. Pretoria : Statistics South Africa, 2014. Report No. 03-10-06.

[viii] Anthropometric, vitamin A, iron, and immunisation coverage status in children aged 6–71 months in South Africa. SAVACG. [ed.] (SOUTH AFRICAN VITAMIN A CONSULTATIVE GROUP). 1996, South African Medical Journal, Vol. 86, pp. 354-357.

[ix] NFCS. The National Food Consumption Survey: children aged 1-9 years, South africa, 1999. Pretoria : Department of Health, Nutrition Directorate, 1999.

[x] Executive Summary of the National Food Consumption Survey Fortification Baseline I: South Africa. NFCS-FB-I. Supplement 2, 2008, South African Journal of Clinical Nutrition, Vol. 21(3), pp. 245-300.

[xi] Food system strategies for preventing micronutrient malnutrition. Miller, D D and Welch, R M. 2013, Food Policy, Vol. 42, pp. 115-128.

[xii] From nutrition plus to nutrition driven: How to realise the elusive potential of agriculture for nutrition? Haddad, L. 2013, Food and Nutrition Bulletin, Vol. 34(1), pp. 39-44.

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7. Sri Lanka – Dilka Peiris (World Vision International)

The Global Nutrition Report (GNR) shows Sri Lanka’s optimistic “underlying” outlook: increasing GDP, female secondary school enrolment, and access to drinking water (94%) and improved sanitation (92%).[1] But stunting (15%) and wasting (21%) are “off-course.” Among 123 countries, Sri Lanka ranks third in wasting. The juxtaposed positive “underlying” conditions and poor nutritional status are likely attributable to local variations in poverty, to the poorest having a low share of national consumption, and to rising inequality.[1] A comparison of malnutrition levels across wealth groups is not shown in its country profile, but the National Nutrition and Micronutrient Survey provides this insight on the nature and distribution of malnutrition in Sri Lanka: wealthy people are less stunted and wasted.[1] This, along with data on minimum acceptable diet, could be helpful in a future GNR.

The conflicting indicators have shown World Vision Lanka (WVL) an opportunity for action to accelerate nutritional improvements. WVL integrates a “graduation model” with its nutrition programming, for a sustainable path to better nutrition. This model categorises each household through a Participatory Living Standards Ranking. Public health workers identify underweight children, who are then referred to a Positive Deviance/Hearth programme, which is a ‘nutrition specific” intervention. It identifies positive behaviours in poor families with well-nourished children, facilitates peer learning, and follows up with participants at home. Meanwhile, each household prepares a tailored family development plan including activities to address its specific economic and nutritional needs, e.g., for the “poor” and “poorest of the poor” with malnourished children, plans could include efforts to access nutritious foods. Hence, this is a ‘nutrition sensitive’ programme that aims to “graduate” families to the next ranking through appropriate activities such as savings clubs, technology and skills transfer, business promotion, or access to microfinance, depending on their needs.

With the support of Government Livelihood Development, Medical, and Agriculture workers, and local authorities, as well as the private sector for market linkages, WVL implements this graduation model with 7,620 households in 16 areas, with approximately 2,500 children in PD/Hearth. The model’s success is due to its tailored and multi-sectoral approach to economic resilience and improved nutrition. https://youtu.be/J7GNMvsoWgc

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8. Timor Leste – Filipe Da Cost (Office of the President)

For Timor –Leste, the Global Nutrition Report (GNR) country profile, provides a comprehensive set of nutrition specific and nutrition sensitive indicators providing a useful resource to plan and develop multi-sector nutrition interventions and programmes. Having a complete set of country specific nutrition and nutrition related data in one document is very valuable; mitigating the time and resources required accessing this data from a range of different sources.

Whilst we acknowledge the difficulties accessing the most recent data in a timely manner through the UN system, it is critical to have the most up-to-date data for the Profiles to be used effectively. Establishing key national GNR focal points in the country to validate and cross check data with local sources prior to publication, could be a way of overcoming this issue in the future. The President’s Office or KONSSANTIL would be willing to take on this important role.

To further improve the country profiles, we also suggest the following changes:

  1. For non-sun countries, such as Timor- Leste, deleting the section on Scaling up Nutrition (SUN) country institutional transformations, 2014 (%) as this section was not useful.
  2. Adding ‘estimated’ where relevant to the Prevalence of adult overweight and obesity (2008) (%) and to the Metabolic risk factors for diet related non communicable diseases, 2008 (%)’ graphs. For Timor- Leste these are only estimates, as we do not have actual prevalence data on these indicators.
  3. Adding the word ‘malnutrition’ to the underlying determinants heading.
  4. Keeping the child and adolescent /adults nutrition data headings consistent. We suggest changing child anthropometry heading to ‘child nutrition status’ to ensure consistency.
  5. Having a trend graph for all the nutrition data (not just stunting).
  6. The micronutrient status of population table is not clear as it also includes data on children under a section labelled ‘adolescents and adults’. We suggest separating micronutrient data between the two sections i.e. adolescents/adults and children.
  7. Adding ‘infant’ to the heading Intervention coverage and child feeding practices and separating these two sections which are quite different.
  8. Adding a map or flag to each profile to identify the country.
  9. Attaching a success story or case study to each profile.

High Level Commitment and Multi-Sector Coordination: A Key to Success in Timor-Leste

Timor Leste Fig 2: Bar chart - Prevalence of undernutrition in women of reproductive age (%)

After years of hardship and occupation, Timor-Leste has achieved significant social and economic improvements since independence in 2002. This progress is underscored in the recent 2013 Food Security and Nutrition Survey (TLFNS) which showed reductions in the prevalence of undernutrition (e.g. stunting and wasting in children and underweight in women of reproductive age) as compared to the 2009 data reflected in the recent Global Nutrition Report.[1] In addition, Timor-Leste has one of the highest rates of early initiation of breastfeeding in the region at 93 percent, and exclusive breastfeeding rates continue to improve.

Nevertheless, food security and dietary diversity remain critical issues, especially in rural areas, where less than 20 percent of children (6-23 months) consume a minimal acceptable diet, leading to high rates of anemia and other micronutrient deficiencies.[1] Evidence[1] shows that improving nutrition in the first 1,000 days[1] leads to optimal physical and cognitive development in children, enhancing future productivity and economic potential—also a national priority.

In response to this, the Government of Timor-Leste has shown real commitment to improving nutrition through the signing of the Comoro Declaration[1], the development of the Strategic Development Plan and the other plans, and is working to realize these commitments through increased budgets, improved coordination through development partner forums, the National Nutrition Working Group, and CPLP[1]. Timor-Leste also established the National Council for Food Security, Sovereignty, and Nutrition (KONSSANTIL), a high level cross-sector coordination committee dedicated to addressing the multiple causes of malnutrition. This government-wide approach is supported by the Office of His Excellency the President of Timor-Leste, and focused on interventions guided by the Zero Hunger Challenge National Action Plan for a Hunger and Malnutrition Free Timor-Leste. The five pillars of the Action Plan[1] galvanize the efforts of multiple ministries to not only address food security and dietary diversity but also undertake activities to improve water, sanitation, and hygiene; family planning, reproductive health; and health and education services.

Although the Action Plan is in early days of implementation, with continued support from His Excellency the President of Timor-Leste and KONSSANTIL, cross-sector activities are being implemented to improve nutrition and food security in the country. By working together, we hope to show the world how a new nation can become a healthy, smart, prosperous nation now, and for generations to come.

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