Nutrition at the World Food Programme - Food and ... Nutrition at the World Food Programme 2012 Nutrition Policy The Nutrition Policy was approved by the WFP Executive Board in February

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Nutrition at the World Food ProgrammeProgramming for Nutrition-SpecificInterventions

December 2012

© WFP 2012

All rights reserved. Reproduction and dissemination of material in this information product for

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Special thanks to:

Solutions for hidden hunger

Table of Contents

Programming for Nutrition-Specific Interventions

Introduction 2

WFP Nutrition Policy 4

Nutrition Terminology 6

Treating Moderate Acute Malnutrition 9

Preventing Acute Malnutrition 14

Preventing Chronic Malnutrition- Stunting 18

Addressing Micronutrient Deficiencies 25

Monitoring and Evaluation Logic Models 30

Nutrition Product Sheet 34

1

WFP’s nutrition response is based on a thoroughunderstanding of the nutrition situation, in order todeliver the most appropriate response. This entailsidentifying who is suffering from undernutrition,what type of undernutrition, when undernutrition isoccurring, where undernutrition is occurring, andwhy undernutrition is occurring. This also entailsunderstanding the nutrient gap and access to

nutrients. WFP uses an expanded version of theUNICEF conceptual framework on the causes ofmalnutrition to guide information gathering, tofacilitate identification of possible causes of thenutrition situation, to understand the relationshipbetween immediate and underlying causes ofmalnutrition as well as basic determinants, and todesign the most appropriate responses.1

2 Nutrition at the World Food Programme

Introduction

Nutritional Status/Mortality

Natural Physical Human Economic

Social Capital/Assets

Individual Food Intake

Household Food Production, Income Generating Activities, Exchange,

Loans, Savings, Transfers

Health Status/Disease

Household Access to Food

Social and Care Environment

Access to Health Care & Health Environment

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Context

Food Availability/Markets

Political, Economical, Institutional, Security, Social, Cultural, Gender Environment

Agro-ecological Conditions/Climate

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LivelihoodStrategies

LivelihoodAssets

Food and Nutrition Security Conceptual Framework

1. WFP’s operational focus is on the left side of this conceptual framework, i.e. on improving household access to food andindividual dietary intake of sufficient food and nutrients.

The immediate causes of undernutrition areinadequate dietary intake and disease. Theframework also shows that many factors in additionto nutrient intake or consumption of special foodsare important for nutritional status. For example,clean water, health care and hygiene, good caringpractices, maternal education, household foodsecurity and economic development are allimportant for good nutrition.

WFP aims to address within a comprehensiveresponse the Individual Food Intake and theHousehold Access to Food. Without adequatenutrients, a child’s bone and muscle growth may notbe adequate to gain in height/length, immunesystem performance may be undermined making thechild more susceptible to disease, and braindevelopment may be particularly affected. Thenutrients required for optimal growth anddevelopment are diverse, including essential aminoacids, macro-minerals (e.g. calcium, phosphorus,magnesium), and micronutrients (vitamins,minerals). As a rule of thumb, a diet that consistslargely of plant-source foods (e.g. cereals, vegetables,fruits), with virtually no animal-source foods (milkproducts, fish, meat, eggs) or fortified foods, doesnot provide all these required nutrients for a youngchild’s growth, health and development.

WFP works in partnership with governments insupport of national priorities. A core component ofthe way in which WFP designs and delivers nutritionprogramming is capacity development to design,implement, and support national policy andprogramming for reducing undernutrition inpartnership with UN sister agencies, NGOs, theprivate sector, and academia. WFP’s efforts innutrition are focused on improving availability andaccess to adequate complementary foods to ensurethat nutrient needs are met, which means that wherenecessary specific nutrient-dense foods may be used.In addition to meeting nutrient needs, and usingspecialized nutritious foods where necessary, WFPsupports a multisectoral response to undernutrition

which includes disease prevention, promotion ofoptimal breastfeeding practices, and good hygiene.

The primary intent of this booklet is to assist in thedesign of nutrition-specific programmes in WFPcountry offices, but may also serve as a resource fortraining or advocacy activities. The followingsections offer introductions to acute malnutrition,chronic malnutrition and micronutrient deficienciesand summarize evidence around WFP’s nutrition-specific interventions. The booklet also includesinformation to support WFP staff in applying thecurrent evidence base to programme design,implementation, monitoring and evaluationactivities.

For more information, please [email protected].

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Saving lives has always been a WFP priority,particularly in emergencies. Because of their highnutritional needs and vulnerability, children are atparticular risk of stunting and even death whenaccess to a diet that meets all their nutrient needs islacking. Poor nutrition for pregnant women cancause mortality but can also impede foetal growth,resulting in low birthweight and increasing the riskthat children’s growth will be stunted.Undernutrition weakens the immune system andincreases the risk and severity of infections. One-third of all child deaths are related toundernutrition, which kills a child every ten seconds.Wasting and stunting are responsible forapproximately 20 percent of childhood mortality,and micronutrient deficiencies in non-wasted, non-stunted children another 8–10 percent. More childdeaths and disability2 in children younger than fiveyears of age are attributable to stunting andmicronutrient deficiencies – with nearly all thisburden due to deficiencies of vitamin A and zinc –than to severe acute malnutrition because they affectmany more children and reduce productivity andquality of life.3

Not only does undernutrition kill, it also preventschildren from growing up to live productive lives.Children without access to an adequate diet duringthe first 1,000 days between conception and 2 yearsof age suffer irreversible, long-term consequencessuch as impaired physical and cognitivedevelopment. They are also at higher risk of chronicconditions such as cardiovascular disease, obesity

and diabetes later in life. Stunting holds backdevelopment, so preventing it can protect andimprove the livelihoods of entire societies.

Treating and preventing undernutrition is thereforevery important in both emergency and non-emergency settings, to reduce mortality and toprotect and improve livelihoods. The Lancet medicaljournal has indicated that if undernutrition can beovercome – especially during the first 1,000 days –not only can lives be saved, but children can alsogrow up to realize their full potential.

Undernutrition has many causes, so efforts to tackleit must be multi-disciplinary, engaging diversestakeholders in line with national priorities. Basedon its mandate and comparative advantage, WFPcan help to ensure physical and economic access to anutritious, acceptable and age-appropriate diet forthose who lack it. While reaching more than 90million beneficiaries every year – many of themchildren – and meeting both their caloric andnutrient needs, WFP can also have an indirectimpact on the lives of many more people byadvocating for comprehensive solutions anddeveloping the capacity of governments and otherpartners to include food-based components in theirstrategies for tackling undernutrition.


2012 Nutrition Policy

The Nutrition Policy was approved by the WFP Executive Board

in February 2012. It encompasses the previous policies on

nutrition topics and sets the way forward for WFP to engage in

nutrition by outlining nutrition-specific and nutrition-sensitive

programmes. The new policy demonstrates WFP’s commitment

to addressing undernutrition and describes different areas

where WFP will focus its efforts.

2. Disability-adjusted life-years (DALYs) refer to the sum of years of potential life lost due to premature mortality and the years of productive life lost due todisability (WHO). While disease may not always lead to death, it reduces productivity and quality of life.

3. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M. What works? Interventionsfor maternal and child undernutrition and survival. Lancet 2008; 371:417-40.

WFP will continue to improve its internal processesand capacity to support food-based solutions whereappropriate. It will leverage its expanded toolbox –which now includes a greater variety of speciallyformulated, nutritious food products, and cash andvoucher distribution – ensuring that all toolscontribute to the achievement of nutritionobjectives.

WFP will also expand its focus on research, assistpartners in developing improved and more cost-effective products, and ensure an adequate supply tomeet growing demand for these products.Undernutrition is a complex, multi-faceted problem,and responses need to include many diverse actors.WFP’s contribution is essential: in a context ofpoverty, the right food, at the right place at the righttime is a prerequisite for a successful response.

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WFP’s mission in nutrition is focused on itscomparative strengths related to food:

… to work with partners to fight

undernutrition by ensuring physical and

economic access to a nutritious and age-

appropriate diet for those who lack it and

to support households and communities in

utilizing food adequately. WFP ensures

access to the right food, at the right place,

at the right time.

WFP will strive to accomplish this mission bydesigning and supporting the implementation ofprogrammes and operations in the five areas coveredby its policy framework:

1. treating moderate acute malnutrition (wasting);

2. preventing acute malnutrition (wasting);

3. preventing chronic malnutrition (stunting);

4. addressing micronutrient deficiencies amongvulnerable people, to reduce mortality and improvethe health of all groups, through fortification;

5. strengthening the focus on nutrition in programmeswithout a primary nutrition objective and, wherepossible, linking vulnerable groups to theseprogrammes.

General Nutrition Terms:

Malnutrition: Occurs when the nutrient and energyintake does not meet or exceeds an individual’srequirements to maintain growth, immunity andorgan function. Malnutrition is a general term andcovers both undernutrition and overnutrition(overweight/obesity).

Undernutrition: The consequence of an insufficientintake of energy, protein and/or micronutrients,poor absorption or rapid loss of nutrients due toillness or increased energy expenditure.Undernutrition encompasses low birth weight,stunting, wasting, underweight and micronutrientdeficiencies.

Undernourishment: Food intake that isinsufficient to meet dietary energy requirementscontinuously, which is reported on an annual basisby the Food and Agriculture Organization of theUnited Nations (FAO) as an indicator for the firstMillennium Development Goal (MDG) which aimsto halve the prevalence of undernourishment in thedeveloping world by 2015.4 Undernourishment is notassessed at the individual level.

Nutrient gap: The difference between nutrientrequirements and nutrient intake. While diets maybe adequate in terms of energy (kcals), they may stillbe inadequate in terms of nutrients, leavingindividuals at risk of undernutrition. Nutrient gapanalysis can be a critical step in developing WFPprogramming that is appropriate to the context.

Micronutrient deficiency: A lack or shortage of amicronutrient (also called vitamins or minerals).Micronutrients are essential components of enzymesand hormones and are therefore key in bodily

processes, immunity, proper growth and metabolismof an individual. Micronutrient deficiencies oftenoccur simultaneously and can arise due to lack ofintake, absorption, or utilization of one or morevitamins or minerals. It is referred to as hiddenhunger because a large percentage of the populationmay be deficient without showing any clinicalsymptoms or signs of deficiency.

Growth failure: The condition where an individualis shorter and/or thinner than their well-nourishedcounterparts and where the individual does not meether/his growth potential. Growth may fail due todeficiencies of various micronutrients, energy,protein and/or macro-minerals.

Nutrition Situation AssessmentTerms:

Acute malnutrition: Acute malnutrition, alsoknown as wasting, develops as a result of recentrapid weight loss or a failure to gain weight. Inchildren, it is assessed through the nutritional indexof weight-for-height (WFH) or mid-upper armcircumference (MUAC). Acute malnutrition is alsoassessed using the clinical signs of visible wastingand nutritional oedema. In adults, wasting isassessed through MUAC or Body Mass Index (BMI).In pregnant and lactating5 women (PLW), wastingcan be assessed through MUAC. The degree of acutemalnutrition of an individual is classified as eithermoderate (MAM) or severe (SAM) according tospecific cut-offs and reference standards. At thepopulation level, acute malnutrition is categorized inthree ways:

• Global acute malnutrition (GAM):represents the proportion of children 6-59


Nutrition Terminology

4. The 2012 State of Food Insecurity in the World report presents new estimates from 1990-2012, reflecting key improvements in data and FAO’smethodology. For more information on the revised methodology, see http://www.fao.org/publications/sofi/en/

5. Please note that "breastfeeding" or "nursing" are the preferred terms for “lactating” when communicating with the media or non-specialists.

months in the population classified with MAM +SAM according to their weight-for-height(WFH) (Z-score), and/or nutritional oedema.6

GAM is an indicator of acute malnutrition in apopulation, and is used to assess the severity ofthe situation.

• Moderate acute malnutrition (MAM):represents the proportion of children 6-59months in the population who are classifiedwith WFH ≥-3 and < -2 (Z-score).

• Severe acute malnutrition (SAM):represents the proportion of children 6-59months in the population who are classifiedWFH <-3 (Z-score) and/or presence ofnutritional oedema.

Nutritional oedema: Nutritional oedema indicatesa serious type of acute malnutrition in whichnutritional deficiencies lead to swelling of limbs(feet, hands) due to retention of fluids. Children withnutritional oedema are automatically classified withsevere acute malnutrition (SAM), and often requiretherapeutic feeding and medical treatment torecover. Also known as bilateral oedema.

Chronic malnutrition: Chronic malnutrition isalso referred to as stunting and develops as a resultof inadequate nutrition or repeated infections orboth; typically, during the critical window ofopportunity of the first 1,000 days from conceptionto two years of age. It is measured by the nutritionalindex of height-for-age (HAZ) and is manifested by achild being too short for his or her age. Unlikewasting, the development of stunting is a slowcumulative process that may not be evidentimmediately. Chronic malnutrition cannot generallybe reversed, only prevented.

Nutrition Product Terms:

Specialized nutritious foods7: Refers to the rangeof specialized food products and supplements thatprovide varying levels of energy, micronutrients, andmacronutrients necessary for growth and health inorder to prevent or treat undernutrition. Specializednutritious foods are often defined or categorised asfollows:

Ready-to-Use foods (RUF): is the existinggeneric term that refers to foods that do not need tobe prepared, cooked, or mixed with water. RUFsused in nutrition programmes are generally madewith peanuts, sugar, milk powder, vegetable oils, andvitamins and minerals, though they may be madewith chickpeas or other commodities. The packagecan be opened and the food can be eaten directly.RUFs do not require water or cooking, and have lowmoisture content, so the risk of contamination islow.

• Ready-to-Use Therapeutic Food (RUTF) isan energy-dense mineral and vitamin-enrichedRUF, specifically designed to treat SAM withoutmedical complications at the community level.RUTF is given over a period of approximatelyeight weeks until the child recovers. Duringtreatment, the child will need no other foodsother than breastmilk.

• Ready-to-Use Supplementary Food(RUSF) is a type of RUF that is specificallydesigned for the treatment of moderate acutemalnutrition in children 6-59 months of age.RUSFs are fortified with micronutrients andcontain essential fatty acids and quality proteinto ensure a child’s nutritional needs are met.

Lipid-based nutrient supplement (LNS) is aterm used to describe a product, i.e., a lipid-basedspread or paste. They have different formulationsand dosages and can be used for different purposes.They can generally be grouped into three categories.They are described as LNS Small Quantity, LNSMedium Quantity, and LNS Large Quantity (same asRUSF) in order to indicate the amount of productthat is used. Current available LNS products areready-to-use foods (RUF).

Fortified blended foods (FBFs)8 are a mixture ofcereals and other ingredients (such as soya beans orpulses) that have been milled, blended, pre-cookedby extrusion or roasting, and fortified with a premixand with a wide range of vitamins and minerals. Inorder to overcome constraints with earlierformulations (bulky, poor absorption, incompleterange of vitamins and minerals), FBFs have beenimproved and now include a more comprehensivevitamin and mineral profile and some ingredients

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6. MUAC can be used to identify children to enrol in nutrition programming (cut-offs are established) and to present a degree of the problem, but thresholdsto signal the severity of the nutrition situation have not been established.

7. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Otherproducts may be approved for use in future.

8. WFP has renamed its range of fortified blended foods as follows: CSB+=Super Cereal-CSB; CSB++=Super Cereal Plus-CSB; WSB+=Super Cereal-WSB;WSB++=Super Cereal Plus-WSB, RSB+=Super Cereal-RSB; RSB++=Super Cereal Plus-RSB.

are specially processed to decrease the anti-nutrientproperties. In addition, some improved FBFs usedfor treatment of moderate acute malnutrition(MAM) in children 6-59 months also include milk.

Micronutrient powders (MNPs) are a mix ofmultiple micronutrients used in programmes toprevent micronutrient deficiencies (MNDs) amongchildren 6-59 months, and are also increasingly toprevent MNDs among school-age children through

school feeding programmes. MNPs are distributed insmall sachets that are added to solid or semi-solidfoods after preparation and prior to consumption.MNPs are tasteless, odourless and easily dissolvablein most warm foods. MNPs do not provide energy,but do provide the complete FAO/WHOrecommended daily intake (1 RecommendedNutrient Intake (RNI)) of each micronutrient perdose. Most countries use the 15 micronutrientformulation.


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What is acute malnutrition?

At the individual level, acute malnutrition (wasting)refers to a form of malnutrition that reflects recentweight loss. The effects of acute malnutrition arereversible with treatment. Individuals often appearvery thin. Acute malnutrition is assessed throughweight-for-height or mid-upper arm circumference(MUAC) in children, with MUAC for pregnant andlactating women (PLW), and by Body Mass Index(BMI) for adults. The individual is then classified asoverweight/obese, normal, with moderate acutemalnutrition (MAM), or severe acute malnutrition(SAM) based on specific cut-offs for interpretation ofanthropometric measures. Acute malnutrition is alsoassessed through the presence of nutritional oedema(swelling due to excess fluid retention on both sidesof the body which indicates severe acutemalnutrition).

Nutritional status at the population level isestimated based on the proportion (prevalence) ofglobal acute malnutrition (GAM) in children 6-59months in the population. The prevalence of GAMrefers to the proportion of all of the childrenclassified with MAM plus all of the childrenclassified with SAM. GAM is often used as a proxyindicator for the severity of a crisis. Other membersof the household may be affected in addition tochildren 6-59 months. Prevalence of GAM shouldalways be interpreted for programming in light of

the broader context, taking into account aggravatingand risk factors.

Why should WFP engage in thetreatment of moderate acutemalnutrition?

• Acute malnutrition is a major risk factor for childmortality. A child with MAM is up to three timesas likely to die as a well-nourished child. A childwith SAM is nine times as likely to die as a well-nourished child. While the immediate risk ofmortality is higher for a child with SAM than withMAM, the total number of children affected byMAM is much greater, and therefore absolutemortality is higher for MAM than SAM. [1-3]

• As of 2011, it was estimated 8 percent of childrenunder five worldwide had moderate and severeacute malnutrition. This figure translates intoover 52 million children under five. [4]

• SAM treatment requires very strong linkages withmedical screening and services. By reachingchildren before they develop SAM, treatment ofMAM can help to ease the burden on alreadyoverstretched health systems in most developingcountries. If there are no programmes to treatMAM in an emergency, the prevalence of SAMoften increases, which puts additional strain onavailable health system and on programmes tomanage SAM.

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TreatingModerate Acute Malnutrition

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WFP Nutrition-specific pillar 1:

To treat moderate acute malnutrition – wasting –particularly among children aged 6–59 months, pregnantand lactating women, and malnourished people intreatment for HIV and tuberculosis.1

What is WFP’s nutrition-specificprogramming to treat moderateacute malnutrition?

• What: Targeted supplementary feedingprogrammes (TSFP)

• Why: There are five objectives of targeted SFPs,specifically (i) to rehabilitate individuals withMAM from specific target groups, (ii) to preventindividuals with MAM from developing SAM, (iii)to prevent mortality associated with MAM, (iv) toprovide follow-up support for individuals whohave been treated for SAM to prevent a relapseand (v) to prevent deterioration of maternalnutritional status and subsequent poor birthweight.

• Who: Admission depends on whether or not theindividual has MAM. Target groups for TSFPinclude: children 6-59 months of age with MAM,PLW9 with MAM (up to six months after givingbirth), malnourished individuals (children 5-19,women, and men) on Anti-retroviral Therapy(ART) and/or Direct Observed Treatment Short-course (DOTS) treatment (for people living withHIV and TB). The specific target groups that areincluded will depend on country level nutritionsituation analysis. The number of plannedbeneficiaries is calculated based on the prevalenceof MAM in the population, the estimated numberof new cases of malnutrition in that target groupover the duration of the project (incidence), andthe expected coverage of the programme.

• How: TSFPs provide a specialized nutritious foodto individuals on a regular basis according tospecific admission and discharge criteria based onnutritional status. Discharge criteria should bereached within a reasonable amount of time(generally three to four months).10 TSFPs includescreening for medical conditions that may needfurther treatment, routine health-relatedinterventions (supplementation with vitamin A,deworming) and nutrition education programmesfor caregivers to promote healthy behaviour.Individual recovery is monitored biweekly.Individuals who meet the discharge criteria areconsidered recovered. If their nutritional status

deteriorates or stays the same, individuals areoften referred to SAM treatment or to medicalservices to address underlying illnesses. WFPshould implement programmes to treat MAMaccording to national guidelines for MAMtreatment, but if these guidelines are out of datein relation to international standards, WFP shouldadvocate with partners and the government toundertake a process to update the guidelines.

• What specialized nutrition foods to provide:

The specific specialized nutritious food used willdepend on the context and target group. Optionsinclude11:

- For children 6-59 months: Large QuantityLipid-based nutrient supplements (LNS)(Plumpy’sup, AchaMum, and eeZeeRUSF) andimproved fortified blended food (Super CerealPlus)

- For PLW and malnourished individuals onART/DOTS treatment: fortified blended food(FBF) (Super Cereal) with oil and sugar addedat the distribution site

• Where/When: Treatment of MAM is onecomponent of the larger community-basedmanagement of acute malnutrition (CMAM)framework, the recommended response to acutemalnutrition. Treatment of MAM can beimplemented in both emergency and developmentcontexts (i.e., Strategic Objectives 1, 3 and 4)12. Inemergencies, the context –as well as pre-existingGAM levels and other indicators of vulnerability –should guide when a TSFP is part of theemergency nutrition response. TSFPs arecommonly established in countries, provinces ordistricts where GAM prevalence is at least 10percent among children aged 6–59 months, orwhere GAM is 5–9 percent but aggravating factorsexist. Programmes are generally run the wholeyear, though an individual will only participate inthe programme for a specific period of time.


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9. In the case of children under 6 months with MAM, the mother as opposed to the child is admitted into the programme, and exclusive breastfeeding ispromoted. The mother is discharged once the child reaches 6 months and then the child is enrolled in the programme if they have MAM.

10. Recent research has shown shorter recovery times with specialized nutritious foods. [5-8]11. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Other

products may be approved for use in future. 12. Largely in EMOP: Emergency Operations and PRRO: Protracted Relief and Recovery Operations, but also possible in CP: Country Programme or DEV:

Development programmes if there is an SO3.

What is new in WFP’s approach tothe treatment of moderate acutemalnutrition?

I. Decision-making tool and evolving

guidance: There have been significant changesto programming for nutrition in emergenciesover the past years including the development ofnew specialized nutritious foods and newevidence on programming to prevent acutemalnutrition. TSFPs are no longer the soleresponse to the management of MAM in anemergency response. The Global NutritionCluster (GNC) convened a MAM Working Groupunder the leadership of WFP to develop adecision-making tool for MAM programmingdesign (including prevention, treatment, andmonitoring) in emergencies13. The tool isintended as an interim operational guidancewhile further normative guidance is developed.For the non-emergency context, WFP now workson engagement in protocol development orrevision, providing technical andimplementation support where MAMprogrammes are operating and supporting theuse of new specialized nutritious foods.

II. New specialized nutritious foods: Inresponse to increased understanding of thenutrient needs for children with MAM14, newspecialized nutritious foods have been

developed. The nutrients in specializednutritious foods are more easily absorbed (feweranti-nutrients), contain animal proteins (whichhave been found to be superior than plantproteins in terms of recovery from acutemalnutrition), and have an improvedmicronutrient profile. WHO has developed atechnical note that serves as a reference forrecommendations on the composition ofsupplementary foods used to treat children withMAM. Treatment costs using the new productsare not significantly greater than thoseassociated with previous products, though thecost per metric ton may be somewhat higher,because they are often more effective andduration of treatment is often shorter. WFP hasdeveloped a product sheet for the specializednutritious foods currently in use entitled: TheRight Food at the Right Time. This documentincludes information on each food and rationsize indicated for each nutrition intervention andtarget group; as well as information on shelf lifeand other characteristics.

III. WFP is working to improve overall monitoringand evaluation for TSFPs, including dataquality, data analysis, data aggregation,interpretation and use. TSFP performanceindicators (e.g. recovery, default, death, non-response) are now WFP corporate indicators fortreatment of MAM. One area of collaboration isbetween WFP, Save the Children-UK, and other

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13. The decision tool is available from http://www.unicef.org/nutritioncluster/files/MAM_DecisionTool_July_2012_with_Cover.pdf14. The 2012 WHO technical note on supplementary foods for the management of moderate acute malnutrition in infants and children 6-59 months of age

can be accessed from http://apps.who.int/iris/bitstream/10665/75836/1/9789241504423_eng.pdf

Community OutreachMAM treatment

Services to prevent undernutrition

SAM outpatient

SAM inpatient

CMAM Framework:As agreed in the WFP-UNICEF Global MOU

partners to pilot a Minimum Reporting Package(MRP) to improve the monitoring, evaluationand reporting of TSFP.

How do we know that WFP’sapproach to the treatment ofmoderate acute malnutritionworks?

A recent cost benefit analysis of TSFPs in 3 countriesfound that programme costs were almost entirelyoffset by the immediate benefits of the programme(return on investment), with additional valuecreated through enabling beneficiaries to lead alonger and more productive life.

Recent research shows that TSFP can result in highrecovery rates, in particular with use of the newspecialized nutritious foods. For example:

• A study in Malawi showed that in a food-insecure setting, infants and children receivingsupplementary feeding for 12 weeks with lipid-based nutrient supplement (LNS) or maize-soyaflour fortified blended food (FBF) showedrecovery from MAM of 93 percent and 75percent respectively. [5]

• The new formulation of Corn Soya Blend (SuperCereal Plus (CSB++)) was shown to be equallyeffective as Large Quantity LNS/Ready-to-usesupplementary food (RUSF) (peanut and soya-based supplementary food) in the treatment ofMAM in Malawi. [6]

• The new specialized nutritious foods have betterresults than the previous formulation of CornSoya Blend (CSB):

- In Malawi, children receiving LNS showedsignificantly higher recovery rates (80percent) after only eight weeks of treatment,compared to the previous formulation of CSB(72 percent). [7]

- In Niger, children receiving LNS showedhigher weight gain, higher recovery rates (79percent versus 64 percent), a shorter lengthof stay and lower transfer rates compared tothe previous formulation of CSB. [8]

How does the treatment ofmoderate acute malnutritionrelate to WFP’s other nutrition-specific programming?

• Relation to addressing micronutrient

deficiency disorders: The specialized nutritiousfoods used in the treatment of MAM containadequate micronutrients to meet micronutrientrequirements without additional use ofMicronutrient Powders (MNPs). Routinesupplementation of vitamin A at admission, andtreatment of anaemia with iron/folate whereappropriate, are part of routine medical care inTSFP and also address specific micronutrientintake shortfalls for individuals with MAM.

• Relation to general food distribution (GFD):

Depending on the context, TSFPs may take placewhere GFDs or other food security interventionsare being provided to food-insecure households.Overall impact of the TSFP may be limited ifhousehold food insecurity is not addressed at thesame time.

Who are the key partners in thetreatment of moderate acutemalnutrition?

Key partners in the treatment of MAM include thegovernment, UN agencies, and NGO partners. Thegovernment has the overall responsibility for thewelfare of its population. WFP is the lead UnitedNations agency responsible for treatment andprevention of MAM. WFP coordinates with UNICEF(the lead agency for treatment of SAM) regardinglinks between treatment of MAM and SAM.Furthermore, in emergencies, WFP works under theInter-Agency Standing Committee (IASC) GlobalNutrition Cluster. In the context of nutrition needsof refugees, asylum seekers, returnees and, in somecircumstances, internally displaced persons, WFPcoordinates with UNHCR as the lead agency.Additionally, WFP works with a variety of NGOpartners in distribution and monitoring activities.WFP also collaborates with a range of UN agenciesand NGO partners to ensure that the underlyingcauses of undernutrition are addressed, includingimprovements in care practices, health, water andsanitation, and food security.


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References

1. Black RE, et al. Maternal and Child Undernutrition: Global and regional exposures and health consequences. The Lancet2008; 371: 243-260.

2. Pelletier DL, et al. Epidemiological Evidence for a Potentiating Effect of Malnutrition on Child Mortality. American Journal ofPublic Health 1993; 83: 1130-1133.

3. Habicht JP, et al. Malnutrition Kills Directly, Not Indirectly. The Lancet 2008; 371: 1749-1750.

4. UNICEF, WHO, The World Bank (2012). UNICEF, WHO, World Bank Joint Child Malnutrition Estimates. (UNICEF, NewYork; WHO, Geneva; The World Bank, Washington DC)

5. Phuka J, Thakwalakwa C, Maleta K, et, al. Supplementary feeding with fortified spread among moderately underweight 6-18month-old rural Malawian Children. Maternal and Child Nutrition 2009, 5:159-170.

6. LaGrone LN, et al. A novel fortified blended flour, corn-soy blend “plus-plus,” is not inferior to lipid based ready to usesupplementary foods for the treatment of moderate acute malnutrition in Malawian children. American Journal of ClinicalNutrition 2012; 95(1): 212-9.

7. Matilsky DK, Maleta K, Castleman T, Manary M. Supplementary feeding with fortified spreads results in higher recovery ratesthat with corn-soy blend in moderately wasted children. Journal of Nutrition 2009; 139(4): 773-778.

8. Nackers F, et al. Effectiveness of ready-to-use therapeutic food compared to a corn/soy-blend-based pre-mix for the treatmentof childhood moderate acute malnutrition in Niger. Journal of Tropical Pediatrics 2010; 56(6):407-13.

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What is acute malnutrition?

At the individual level, acute malnutrition (wasting)refers to a form of malnutrition that reflects recentweight loss. The effects of acute malnutrition arereversible with treatment. Individuals often appearvery thin. Acute malnutrition is assessed throughweight-for-height or mid-upper arm circumference(MUAC) in children, and MUAC for pregnant andlactating women (PLW), and Body Mass Index(BMI) for adults. The individual is then classified asoverweight/obese, normal, with moderate acutemalnutrition (MAM), or with severe acutemalnutrition (SAM) based on specific cut-offs forinterpretation of anthropometric measures. Acutemalnutrition is also assessed through the presence ofnutritional oedema (swelling due to excess fluidretention on both sides of the body which indicatessevere acute malnutrition).

Nutritional status at the population level is assessedthrough the prevalence of global acute malnutrition(GAM) among children 6-59 months in thepopulation. The prevalence of GAM refers to theproportion of all of the children classified with MAMplus all of the children classified with SAM. GAM isoften used as a proxy indicator for the severity of acrisis. Other members of the household may beaffected in addition to children 6-59 months.Prevalence of GAM should always be interpreted forprogramming in light of the broader context, takinginto account aggravating or risk factors.

Why should WFP engage inprevention of acute malnutrition?

• Acute malnutrition is a major risk factor for childmortality. A child with MAM is three to four timesas likely to die as a well-nourished child. A childwith SAM is nine times as likely to die as a well-nourished child. While the immediate risk ofmortality is higher for a child with SAM than withMAM, the total number of children affected byMAM is much greater, and therefore absolutemortality is higher for MAM than SAM. [1-3]

• As of 2011, it was estimated 8 percent of childrenunder five worldwide had moderate and severeacute malnutrition. This figure translates intoover 52 million children under five. [4]

• Prevalence of MAM can double during the leanseason when food availability is low ahead of thenext harvest. The lean season also often coincideswith a rainy season which brings an increase inthe incidence of both acute respiratory infectionsas well as episodes of diarrhoeal disease. Thecombination of reduced caloric intake and anincrease in morbidity can result in a sharpincrease in the prevalence of acute malnutrition inchildren. These increases can be even greater inemergencies. Prevention can mitigate the increaseand the associated risks related to mortality,morbidity and overall child development.


PreventingAcute Malnutrition

2WFP Nutrition-specific pillar 2:

To prevent acute malnutrition, particularly amongchildren aged 6–23 months (sometimes 6–59months in sudden-onset emergencies) and pregnantand lactating women.

• SAM treatment requires strong linkages withmedical screening and services. By reachingchildren before they develop SAM, prevention ofacute malnutrition can help to ease the burden onalready overstretched health systems in mostdeveloping countries.

• Preventing acute malnutrition has the potential toreduce child mortality and morbidity, and alsoreflects WFP’s focus on the window of opportunityby targeting children 6-23 months of age and PLW.

What is WFP’s nutrition-specificprogramming to prevent acutemalnutrition?

• What: Blanket Supplementary FeedingProgrammes (BSFP)15

• Why: To prevent nutritional deterioration andrelated mortality in vulnerable populations andhigh risk groups.

• Who: The target group will depend on thecontext, however the default target group ischildren 6-23 months of age. The prevalence ofacute malnutrition is often higher in this agegroup. They have an increased risk of mortality,and a tendency to deteriorate more quickly thanolder children. When the food security situation isextremely severe or when coverage and quality forthe treatment of MAM is limited, the age groupfor children can be extended to 6-35 months or 6-59 months of age. Where prevalence of lowbirthweight or prevalence of undernutritionamong women of reproductive age is high, and thecrisis is likely to impact infant and young childfeeding practices and where resources andcapacity are not limiting, PLW should also beincluded in the BSFP. The number of plannedbeneficiaries is calculated based on the estimatednumber of individuals in the specific target groupin the specific geographic area of programmingand an estimate of programme coverage.

• How: BSFPs provide a specialized nutritious foodto all individuals in the selected target group on aregular basis. Admission into the programme doesnot depend on nutritional status, and individuals

participate for a specific period of time (generally3-6 months). Programme delivery can becommunity-based with a separate independentdistribution, or it can be linked to a general fooddistribution or other platform when appropriate.WFP implements programmes to prevent acutemalnutrition in line with national guidelines, butif these guidelines are out of date in relation tointernational standards, WFP advocates with thegovernment and partners to undertake a processto update the guidelines.

• What to provide: The specific specializednutritious food used will depend on the contextand target group. Options include16:- For children 6-23 months: Medium Quantity

lipid-based nutrient supplements (Plumpy’doz,eeZeeCup, WawaMum) or fortified blendedfoods (Super Cereal Plus)

- For PLW: fortified blended food (Super Cereal)plus oil and sugar

• When/Where: BSFPs can be implemented inboth emergency and transition contexts (i.e.,Strategic Objectives 1 and 3)17. BSFPs are part ofthe standard response to prevent acutemalnutrition in young children in an emergency,particularly an emergency that impacts on foodavailability or where the prevalence of acutemalnutrition and micronutrient deficiencies(MNDs) are already high prior to the emergency.BSFPs are also recommended when wastingincreases seasonally in a predictable manner,usually during the agricultural lean season. BSFPscan also be considered when access toprogrammes to treat MAM and SAM is low.BSFPs are generally implemented during specificparts of the year, and are not generally in placethe whole year.

What is new in WFP’s approach toprevent acute malnutrition?

I. Decision-making tool and evolving

guidance: There have been significant changesto programming for nutrition in emergenciesover the past years including the development ofnew specialized nutritious foods and newevidence on programming to prevent acute

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15. Evidence is being compiled on alternative responses and as it becomes available WFP may expand its programming options.16. Please refer to the Nutrition Product Sheet The Right Food at the Right Time for more information on specialized nutritious foods currently in use. Other

products may be approved for use in future.17. Largely in EMOP: Emergency Operations and PRRO: Protracted Relief and Recovery Operations, but also possible in CP: Country Programme or DEV:

Development programmes if there is a Strategic Objective 3.

malnutrition. As a result of these changes, TSFPsare no longer the sole response to themanagement of MAM in an emergency response.The Global Nutrition Cluster (GNC) convened aMAM Working Group under the leadership ofWFP to develop a decision-making tool for MAMprogramming design (including prevention,treatment, and monitoring) in emergencies. Thetool is intended as an interim operationalguidance while further normative guidance isdeveloped.18

II. New specialized nutritious foods: Inresponse to increased understanding of thenutrient needs for children, new specializednutritious foods have been developed. Thenutrients in these specialized nutritious foodsare more easily absorbed (fewer anti-nutrients),contain animal proteins (which have been foundto be superior to plant proteins in terms ofrecovery from acute malnutrition), and a morewell developed micronutrient profile. Productsfor the prevention of acute malnutrition arenutrient dense and contain fewer kilocaloriesthan products for treatment of MAM. WFP hasdeveloped a product sheet for the specializednutritious foods currently in use called: TheRight Food at the Right Time. This documentincludes information on each food and rationsize indicated for each nutrition intervention andtarget group; as well as information on productcost, shelf life and other characteristics.

III. There are a number of studies on-going tomeasure the impact of BSFPs. In addition,efforts are under way within WFP to strengthenthe framework for monitoring andevaluation of indicators and the analysis ofBSFP programming.

How do we know that WFP’sapproach to prevention of acutemalnutrition works?

• In Haiti, a fortified blended food (FBF) was givento all children 6-23 months for prevention and tochildren 6-59 months for treatment. At the end ofthe intervention, there was a lower prevalence ofacute malnutrition among children in thepreventive group compared to the prevalence inthe population of children who had access totreatment of undernutrition when required. [5]

• In Niger, provision of RUTF for three months tonon-malnourished children resulted in asignificant reduction in the incidence of MAM andSAM compared to children who did not receivethe intervention. [6]

• Another study in Niger showed provision of LNS(Plumpy’doz) for six months reduced theincidence of SAM in a large population of children6-36 months of age. [7]

• In South Darfur, Sudan there was no observedincrease in GAM during the acute hunger period,where a four-month prevention programme wasimplemented using either LNS (Plumpy’doz) orimproved CSB (oil, sugar, DSM). [8]

• In Haiti following the nutrition response to the2010 earthquake where a large scale BSFPtargeting children 6-23 months and PLW wasimplemented, WFP observed no difference in theprevalence of GAM after the crisis compared topre-crisis levels. [9]

• A recent evaluation of a WFP programme toprevent acute malnutrition during the lean seasonin Sudan suggests that caseloads of SAM childrencan be kept low. [10]

• WFP also has significant operational learning ofprogramming to prevent MAM in emergencies. InHaiti, Niger, Pakistan and the Horn ofAfrica, WFP addressed the needs of more than 4million children.

How does prevention of acutemalnutrition relate to WFP’s othernutrition-specific programming?

• Relation to nutrition-specific programming:

The specialized nutritious foods used in theprevention of acute malnutrition are alsorecommended for use to improve nutrient intakeas one element of comprehensive programmes toprevent stunting. Both programmes use the same“blanket” distribution approach (e.g. not targetedby nutritional status). These two programmeapproaches however differ in terms of duration aswell as other aspects of programme design.


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18. The decision tool is available from http://www.unicef.org/nutritioncluster/files/MAM_DecisionTool_July_2012_with_Cover.pdf


Nutrition interventions will be more effective ifthey are linked to interventions that addresshousehold food insecurity.

Who are the key partners in theprevention of acute malnutrition?

Key partners in the prevention of acute malnutritioninclude national governments, UN agencies, andNGO partners. The government has the overallresponsibility for the welfare of its population. WFPis the lead UN agency responsible for treatment ofMAM and prevention of acute malnutrition. WFPcoordinates with UNICEF (the lead agency fortreatment of SAM) regarding links betweentreatment of MAM and SAM. Furthermore, inemergencies, WFP works under the Inter-AgencyStanding Committee (IASC) Global Nutrition Cluster

and needs to take a lead role with UNICEF foremergency nutrition response. In the context ofnutrition needs of refugees, asylum seekers,returnees and, in some circumstances, internallydisplaced persons, WFP coordinates with UNHCR asthe lead agency. Additionally, WFP works with avariety of NGO partners in distribution andmonitoring activities. WFP also collaborates with arange of UN agencies and NGO partners to ensurethat the underlying causes of undernutrition areaddressed, including improvements in carepractices, health, water and sanitation, and foodsecurity. Depending on the context and capacity,BSFPs can provide a point of contact with thepopulation for other supportive measures to preventacute malnutrition (such as education on infant andyoung child feeding (IYCF) practices anddeworming) as well as screening and referral fortreatment of SAM and MAM.

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References

1. Black RE, et al. Maternal and Child Undernutrition: Global and regional exposures and health consequences. The Lancet 2008; 371:243-260.

2. Pelletier DL, et al. Epidemiological Evidence for a Potentiating Effect of Malnutrition on Child Mortality. American Journal of PublicHealth 1993; 83: 1130-1133.

3. Habicht JP, et al. Malnutrition Kills Directly, Not Indirectly. The Lancet 2008; 371: 1749-1750.

4. UNICEF, WHO, The World Bank (2012). UNICEF, WHO, World Bank Joint Child Malnutrition Estimates. (UNICEF, New York;WHO, Geneva; The World Bank, Washington DC)

5. Ruel MT, et al. Age-based preventive targeting of food assistance and behaviour change and communication for reduction ofchildhood undernutrition in Haiti: a cluster randomised trial. The Lancet 2008; 371: 588-595.

6. Isanaka S, Nombela N, Dijibo A, et al. Effect of preventive supplementation with ready-to-use therapeutic food on the nutritionalstatus, mortality, and morbidity of children aged 6 to 60 months in Niger: a cluster randomized trial. Journal of the AmericanMedical Association 2009; 301(3): 277-285.

7. Defourny I, Minetti A, Harczi G, Doyon S, Shepherd S, Tectonidis M, Bradol J, Golden H. A large-scale distribution of milk-basedfortified spreads: Evidence for a new approach in regions with high burden of acute malnutrition. PLoS ONE 2009; 4(5): e5455.

8. Boyd E, Talley L., et al. Prevention of Acute Malnutrition during the Lean Season: A Comparison of a Ready to Use SupplementaryFood and an Improved Dry Ration, South Darfur, Sudan. Under review.

9. WFP. Evidence-based Programming: Treatment and Prevention of Acute Malnutrition. PowerPoint, 2011.

10. Acharya P, Kenefick E. Improving Blanket Supplementary Feeding (BSFP) Efficiency in Sudan. ENN Field Exchange 2012; 42: 59-61.

What is stunting?

At the individual level, stunting (chronicundernutrition) refers to the failure to growadequately in length or height in relation to age. [1]Though stunting is defined as being short for one’sage19, it is also a reflection of a larger problem thatincludes inadequacy to attain optimal cognitivedevelopment. Stunting is also associated with highermorbidity and mortality. Stunting largely occursduring the 1,000 days from conception until twoyears of age, and therefore must be prevented duringthis short window of opportunity. [2, 3] Stunting isassessed through the measure of height-for-age.Individuals can be classified with moderate or severestunting according to specific cut-offs. Howevergiven that stunting cannot generally be reversed ortreated, individual classification is not used fortargeting.

At the population level, prevalence of stunting refersto the proportion (prevalence) of children 6-59months who are classified with moderate and severestunting. The overall prevalence of stunting at thepopulation level is used as the basis of programmingdecisions as it gives an indication of the likelihoodthat a child under 2 years of age in a givenpopulation is not receiving adequate nutrition to

reach optimal growth and development. Sincestunting accumulates over time, it is helpful to lookat the proportion of stunting among children underand above 2 years of age, which reflects the age atwhich growth failure has accumulated. Theproportion of stunting among infants and youngchildren is often lower compared to older children.Stunting often goes unrecognized in children wholive in communities where short stature is socommon that it seems normal. [4, 7]

Stunting has multiple causes. An analysis of maindeterminants of stunting is needed, including theidentification of shortfalls in nutrient access and thenutrient gap for children 6-24 months and pregnantand lactating women (PLW) to understand whatbarriers exist. The effects of stunting areintergenerational and efforts to address chronicundernutrition must adopt a lifecycle approach.From conception to 2 years of age, limited access torequired nutrients, inadequate breastfeeding andpoor complementary feeding and care practicesundermine child growth. Stunting can be aggravatedby repeated episodes of infections and illness,especially diarrhoea. Adolescent girls who areundernourished may not be prepared for a healthypregnancy. If a woman’s nutrient intake duringpregnancy is inadequate, there is further risk thather child will be born with low birth weight. Low


PreventingChronic Malnutrition – Stunting


To prevent chronic malnutrition – stunting andmicronutrient deficiencies – particularly among childrenaged 6–23 months and pregnant and lactating women.

19. Height-for-age <-2 SD of the WHO Child Growth Median Standards of the reference population of the same age and sex is the cut-off for classifyingstunting in a child under five years of age.

birth weight infants have less chance of survival andexperience poor health throughout their lifetime.Underlying these direct causes of stunting arepoverty and its social and economic determinants atthe household, community and country levels, suchas food insecurity, lack of access to water andsanitation services, lack of women’s education, andlow family incomes. [2, 3, 5]

Why should WFP engage in theprevention of stunting?

• Stunting and micronutrient deficiencies areassociated with increased morbidity andmortality. Stunting accounts for 15 percent andmicronutrient deficiencies for 10 percent of childmortality. More child deaths and disability-adjusted life-years (DALYs) in children under fiveare attributable to stunting and micronutrientdeficiencies mainly due to deficiencies of vitaminA and zinc than to severe acute malnutrition(SAM) because they affect many more children [2,6, 12].

• In 2011, it was estimated that 165 million childrenwere stunted. More than 90 percent of the world’sstunted children live in Africa and Asia. Whilethere has been progress at the global level, with adecrease in the prevalence of childhood stuntingfrom 39.7 percent in 1990 to 26 percent in 2010,there is still much work to be done. [7]

• Stunting is also associated with reduced physicaland cognitive capacity for life. Longitudinalstudies have shown that early childhood stuntinghas implications for cognition, educationalachievement, and worker productivity/adultwages, with a negative impact of gross domesticproduct (GDP). [4, 5, 8, 9] The 2008 LancetSeries on Maternal and Child Undernutritionreported that height-for-age at 2 years of age wasthe best predictor of human capital. [10]

• Stunting has also been linked to poor health laterin life. A child that is stunted and then gainsweight later in childhood has an increased risk ofnutrition-related chronic diseases such asdiabetes, hypertension and coronary heartdisease. [3, 5]

• The effects of stunting are intergenerational:infants born to women20 who were stunted aresmaller than infants born to better-nourishedwomen. [4] Maternal stunting is consistentlyassociated with an elevated risk of perinatalmortality related to obstructed labour and birthasphyxia due to a narrower pelvis in short women.[11, 12]

What is WFP’s nutritionprogramming to prevent stunting?

• What: There are three elements to acomprehensive portfolio of programmes toprevent stunting, specifically, in areas with highlevels of stunting: (i) complementary feedingthrough the provision of specialized nutritiousfoods for children 6-23 months and pregnant andlactating women (PLW) along with behaviourchange communication (BCC) activities topromote appropriate infant and young childfeeding (IYCF) practices21 and hygiene; (ii)promotion of activities that can impact nutritionindirectly, most often through addressing theunderlying causes of undernutrition acrossmultiple sectors (nutrition-sensitiveinterventions); and (iii) strengthening thecapacity of national governments to assess,identify, design, deliver, monitor and evaluateintersectoral programming that directly andindirectly prevent stunting. BCC and monitoringand evaluation (M&E) activities are afundamental part of all interventions.

• Why: To prevent stunting in children under 24months of age and to promote the nutritionalstatus of adolescents and women in theirreproductive years in order to: (i) address theintergenerational cycle of undernutrition; (ii)bring about a positive impact in health, educationand productivity during the life cycle; and (iii)support social and economic development atcountry level.

• Who: The priority target groups reflect thosemost vulnerable to undernutrition throughaddressing the 1,000 days window ofopportunity22: children 6-23 months and PLW, aswell as adolescent girls when possible.Complementary feeding interventions must

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20. A woman who is less than 145 cm or 4’7” is considered to be stunted.21. Including exclusive breastfeeding up to 6 months of life, continued breastfeeding to two years and timely and appropriate complementary feeding such

as use of specialized nutritious foods plus other nutritious family foods from 6 months up to the first two years. 22. From conception to the first two years of life. 23. From birth until 6 months of age, infants should be exclusively breastfed.

ensure that children aged 6–23 months23 andPLW get the nutrients they need, irrespective oftheir nutritional status. Where the contextsuggests the need and resources allow, adolescentgirls may be included in order to ensure adequatenutrient status of women prior to conceptionand/or in the first trimester. The number ofplanned beneficiaries is based on the estimatednumber of individuals of the specific target groupsin the geographic area of operation and anestimate of programme coverage. Beneficiariescan often be identified and reached throughexisting health systems or social protectionmechanisms. As this intervention is preventativeand designed to prevent a predictable shortfall inmeeting nutrition needs, targeting is not based onindividual nutritional status but based on riskfactors, which may be geographic or socio-economic (low socioeconomic status or areas withhigh or very high prevalence of stunting andmicronutrient deficiencies, mainly anaemia). WFPwill work with governments to leverage existingprogrammes for reaching those at the highest riskof stunting. Nutrition-sensitive programming andcapacity development interventions to preventstunting can impact infant and young child,adolescent and adult nutrition.

• How: The activities depend on the specificcomponents of the prevention of stuntingportfolio and alignment with government nationalnutrition policies and plans. For (i)complementary feeding, specialized nutritiousfoods are recommended for a minimum of sixmonths during a one year cycle. Research is on-going to define the optimal duration of theseinterventions. Specialized nutritious foods withBCC can be delivered through differentmechanisms, including the health sector, andsocial protection programmes, among others.WFP activities should be complemented byhealth, water and sanitation, and agriculturalactivities implemented by partners. For (ii)nutrition-sensitive programming, WFP canimprove household food security and increase theaccess and availability of nutritious foods, as wellas minimizing barriers to optimal nutritionpractices and behaviours for vulnerablepopulations through several programmes andmodalities. These include school feeding(especially if adolescent girls can be reached),promotion of livelihoods and livelihood assets

through food for work (FFW) and purchase forprogress (P4P), as well as increased access tofortified foods for PLW and children 6-23 monthsthrough cash and voucher (C&V) initiatives. Foodand C&V transfers targeting poor people are oftenimplemented through social protection and safetynet programmes (especially where there isgovernment interest and, ultimately, possiblefunding around social protection programmes).For (iii) improving government capacity toprevent stunting, WFP should strengthen thetechnical and managerial capacity of humanresources, strategic partnerships, supporting thenutrient gap analysis for children under two yearsof age and PLW. WFP should also supportadvocacy, policy dialogue, local production offoods, and monitoring and evaluation.

• What to provide: WFP’s efforts in nutrition arefocused on supporting the governments toimprove availability and access of timely andadequate complementary foods (from 6 months),in addition to encouraging continuedbreastfeeding, improved feeding practices andpromoting the use of nutritious local foods, toensure that the nutrient needs of young childrenand other vulnerable groups are met. This meansthat where access and availability issues exist,specific nutrient-dense products may be used. Thetype of food used in complementary feedinginterventions will depend on the nutrient gap inthe diet, the context and target group. [13] Thecommodity should also take into considerationcultural practices and preferences. Optionsinclude24:- For children 6-23 months: Medium Quantity

lipid-based nutrient supplements (LNS) such asPlumpy’doz, eeZeeCup, WawaMum andNutributter; micronutrient powders (MNP) tobe used as home fortification, and fortifiedblended foods (Super Cereal Plus)

- For PLW: fortified blended food (Super Cereal)plus oil and sugar

• Where/when: Currently, complementaryfeeding interventions for the prevention ofstunting can be incorporated into PRRO, CP andDEV programmes25. WFP has committed toinitiating programmes to prevent stunting incountries where the prevalence of stunting is atleast 30 percent, or at a lower thresholdestablished in national policies or programmes, or


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25. PRRO: Protracted Relief and Recovery Operations; CP: Country Programme; DEV: Development programmes.

in high-risk situations. Within countries, WFPprevention of stunting programmes should betargeted to areas with high stunting rates, highpoverty and high food insecurity. Whileprevention of stunting may not be an explicitstrategic objective of emergency programming,emergency nutrition programmes need to bedeveloped with the understanding that nutritionalneeds that are not met during the emergency mayhave negative impacts on stunting andmicronutrient deficiencies. Complementaryfeeding interventions to prevent stunting can bein place the whole year round, as opposed toseasonal blanket supplementary feedingprogrammes (BSFP) for the prevention of acutemalnutrition.

How is WFP’s approach toprevention of stunting differentthan before?

• Improved situation analysis: WFP is in theprocess of strengthening its nutrition situationanalysis capacity, in particular around thenutrient gap (especially of children under 2 yearsof age and PLW), i.e. the difference betweennutrient intake and nutrient needs (both inquality and in quantity). The Cost of Diet (COD)tool helps identify the gap between the incomes offamilies and the local cost of a nutritious diet. TheCOD tool calculates the minimum amount ofmoney a family will have to spend to meet itsenergy, protein, fat and micronutrientrequirements using locally available foods.Understanding the nutrient gap is essential toensure that appropriate programmes using theright food at the right time are developed toaddress the nutrient shortfalls that contribute tostunting.

• New specialized nutritious foods: Newspecialized nutritious foods have been developedto deliver the appropriate quantity and quality ofnutrients in order to more precisely address thenutrient gap of target groups. Macronutrients andenergy are needed, but most importantlymicronutrients and macro-minerals, essentialamino acids, essential fatty acids and animalproteins (milk) are also required as they arecritical for linear growth.

• The comprehensive model for the

prevention of stunting: WFP has been layingthe foundation to address stunting over the lastdecade, by promoting government capacity andsupporting household food security andfortification of staple foods and condiments. Withthe increasing recognition of the role of food anddietary intake in the prevention of stunting, inparticular with the Lancet review in 2008, WFPhas integrated a comprehensive approach basedon recent innovations into its portfolio of stuntingprogramming in order to contribute to bringabout sustainable changes in stunting worldwide,though further efforts in terms of evidence andguidance are required.

• Further development of the evidence base

and strengthened monitoring and

evaluation (M&E): WFP is in the process ofstrategically gathering lessons learned on specificaspects of its current prevention of stuntingprogrammes. In addition, WFP is supporting twonew large-scale multi-year programmes in Malawiand Mozambique to comprehensively addressstunting, which will feed into more knowledge ontargeting, type of foods, delivery channels,identification mechanisms and complementaryactivities and the development of a common M&Eframework that could then be mainstreamedthroughout other programmes in other countries.[14] WFP is also engaging in operational researchin other priority countries in addition to variouscollaborations with academia and researchinstitutions to strengthen the evidence base forprevention of stunting around effectiveness on theutilization/consumption of specialized nutritiousfoods, i.e. the Right food at the Right time.

How do we know that WFP’sapproach to the prevention ofstunting works?

There is evidence that complementary feedinginterventions using specialized nutritious foods ontheir own can prevent stunting, for example:

• A longitudinal and long-term follow-up study(1969 and 1977, 1988-1989, and, 2002-2004) inGuatemala highlighted positive short and longterm health, education and productivity impactsof complementary food supplements (which

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26. The findings relate to male wages only.

included a substantial amount of dried skimmilk) when given during first three years of life:i.e. greater growth in height, better learningcapacity and reading/intelligence scores;increased productivity, 46 percent greaterwages26, and the next generation of childrenwith higher birthweight and headcircumference. [3, 8, 9] This is the mostconvincing worldwide evidence of the role ofnutritious foods in reducing the impact ofchildhood stunting, and it was used by the 2008Lancet Series on Maternal and ChildUndernutrition.

• In Malawi, 12 months of complementaryfeeding intervention using a Medium QuantityLNS had a positive impact on stunting byreducing the incidence of severe stunting whencompared to no intervention. [15]

• In Algeria, provision of a LNS was shown toinduce catch-up growth and reduce anaemia inchildren up to six years. [18]

• In Nepal, from 2008-2010, WFP developed alarge-scale intervention through the distributionof micronutrient powders (MNP) which resultedin a reduction of anaemia, and a contributed toa significant relative decrease of 40 percent ofstunting prevalence in children 6-59 months.[19]

• In Bangladesh, WFP also developed a large-scale MNP intervention for children 6-59months (August 2008-January 2009). Amongchildren in the intervention area, those whoconsumed at least 75 percent of therecommended micronutrient powder had alower prevalence of stunting than those whoconsumed less than 75 percent of the MNPs[20]27

• Recent reviews have found that complementary

feeding support, both with and withoutnutrition education, can result in gains in heightand reduced stunting. [2, 21, 22].

There is also significant evidence for the use ofspecialized nutritious foods to prevent stunting

through nationwide comprehensive social protectionprogrammes in:

• Mexico (“Oportunidades” formerly known as“Progresa” National Social ProtectionConditional Cash Transfer Programme, 1988-2006). In poor, rural communities, distributionof special nutritious foods to children 6-23months and PLW in addition to nutrition-sensitive programming that includedimprovements in education and access to publicservices in combination had an impact onstunting reduction. [23-25]

• Brazil (“Bolsa Familia” National SocialProtection-Conditional Cash TransferProgramme, 1996-2006, 2003-2006) wherechanges in macroeconomic and social policies aswell as maternal schooling and increasedpurchasing power contributed to improvedquality and quantity of nutrient intake andreduced stunting by 50 percent. [26-28]

• Chile has demonstrated one of the largestimpacts on stunting reduction; it is one of thefew countries worldwide that has reached the“normal” expected proportion of children of lowstature for age (2.3 percent). It has a well-established long-term national nutrition policyand programmes which include special fortifiedcomplementary foods for children 6-59 monthsand PLW and intersectoral interventions, whichare currently integrated into a nation-widesocial protection system “Chile Solidario”. [29,30]

• Experiences in South East Asia and SouthAmerica show that stunting can be reducedsubstantially within a decade when bothunderlying28 and basic or structural29 causes ofundernutrition are also addressed. [31]Nutrition-specific programming can build uponthese positive changes to the underlying andbasic causes of undernutrition to help acceleratereduction in the prevalence of stunting.


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27. The decrease in stunting in both Nepal and Bangladesh suggest that other micronutrients in the MNP formulation (zinc in particular) may have had apositive impact on child health and development. This area is being explored as part of current operational research on prevention of stunting andprevention of MNDs.

28. Underlying causes: inadequate access to nutritious foods, inappropriate care practices, and insufficient/poor health services and environment.29. Basic causes: poverty, inequality, women education and empowerment, access to land, among others.

How does prevention of stuntingrelate to WFP’s other nutritionprogramming?

• Relation to nutrition-specific programming:

There is a range of specialized nutritious foodsthat can be used to prevent several forms ofundernutrition. Micronutrient Powders (MNPs)and Nutributter can be used in complementaryfeeding interventions for the prevention ofstunting depending on whether there is a gap inenergy intake that needs to be addressed at thesame time.

• Relation to nutrition-sensitive

programming: By definition, the comprehensiveprogramme to prevent stunting makes linkageswith nutrition-sensitive programming. Asmentioned previously, WFP can improvehousehold food security and increase the accessand availability of specialized nutritious foods.

Who are the key partners in theprevention of stunting?

WFP recognizes that efforts to sustainably addressstunting must be based in country leadership andownership, in line with national priorities and that itmust engage multiple stakeholders and sectors. Insupport of national governments WFPs partnersrange from UN agencies i.e. UNICEF, WHO andFAO; NGOs, private sector, academia and researchinstitutions and the communities themselves. WFPis also engaged in the global multi-stakeholdermovement Scaling Up Nutrition (SUN), [31]; thecountry-led approach Renewed Efforts for EndingChild Hunger and Undernutrition (REACH), and theGlobal Health Initiative (GHI). They aim to scale upproven and effective interventions to achieve asustainable reduction of undernutrition, prioritizingthe 1,000 days window of opportunity period.

23

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References

1. WHO, WHO child growth standards methods and development: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. 2006, Geneva: World Health Organization.

2. Bhutta ZA, Ahmed T, Black R, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M.Maternal and child undernutrition 3.What works? Interventions for maternal and child undernutrition and survival. Lancet 2008;371: 417–40

3. Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition: global and regional exposures and health consequences.The Lancet 2008; 371: 243-60.

4. Alive&Thrive. Insight: Why stunting matters. A&T Technical Brief 2010 Sep;(2)

5. Victoria, C G, et al. Maternal and child undernutrition: consequences for adult health and human capital. The Lancet 2008; 371: 340– 357.

6. UNICEF. Tracking progress on child and maternal nutrition. A survival and development priority. New York, 2009

7. UNICEF, WHO, The World Bank (2012). UNICEF, WHO, World Bank Joint Child Malnutrition Estimates. (UNICEF, New York;WHO, Geneva; The World Bank, Washington DC)

8. Mercedes de Onis, Monika Blössner, Elaine Borghi. Prevalence and trends of stunting among pre-school children, 1990–2020Public Health Nutrition 2012; 15:142-8.

9. Martorell R, et al. History and design of the INCAP longitudinal study (1969-77) and its follow ups (1988-89). J Nutr 1995 Apr;125(4 suppl):1027S-41S.

10. Hoddinott J, Maluccio J, Behrman J, Flores R, Martorell R. Effect of a nutrition intervention during early childhood on economicproductivity in Guatemalan adults. Maternal and Child Undernutrition. The Lancet 2008; 371: 411–16.

11. Kramer MS, Olivier M, McLean FH, Willis DM, Usher RH. Impact of intrauterine growth retardation and body proportionality onfetal and neonatal outcome. Pediatrics 1990 Nov; 86(5):707-13.

12. Lee AC, Darmstadt GL, Khatry SK, LeClerq SC, Shrestha SR, Christian P. Maternal-fetal disproportion and birth asphyxia in ruralSarlahi, Nepal. Arch Pediatr Adolesc Med 2009 Jul;163(7):616-23

13. WFP Nutrition Policy. WFP/EB.1/2012/5-A, January 2012, available on WFP’s Website (http://executiveboard.wfp.org).

14. de Pee S, Bloem MW. Current and potential role of specially formulated foods and food supplements for preventing malnutritionamong 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59 month-old children. Food Nutr Bull2009 Sep; 30 : S434-63

15. Phuka J C et al. Post intervention growth of Malawian children who received 12mo dietary complementation with a lipid-basednutrient supplement or maize-soy flour. Am J Clin Nutr 2009;89:382-90

16. Ruel M, Menon P, Habicht JP, Loechl C, Bergeron G, Pelto G et al. Age-based preventive targeting of food assistance and behaviourchange and communication for reduction of childhood undernutrition in Haiti: a cluster randomized trial. The Lancet 2008; 371:588-95.

17. IFPRI. Timing is everything. Preventing child undernutrition, IFPRI 2008.

18. Lopriore C et al. Spread fortified with vitamins and minerals induces catch-up growth and eradicates severe anemia in stuntedrefugee children aged 3-6 y. Am J Clin Nutr 2004;80:973-81

19. de Pee S et al. Assessing the impact of micronutrient intervention programs implemented under special circumstances-MeetingReport. Food Nutr Bul 2011; 32(1): 255-302.

20. Rah JH, de Pee S, Halati S, Parveen M, Mehjabeen SS, Steiger G, Bloem MW, Kraemer K. Provision of micronutrient powder inresponse to the Cyclone Sidr emergency in Bangladesh: cross-sectional assessment at the end of the intervention. Food Nutr Bull2011; 32:276–84.

21. Dewey K.G. et al. Systematic review and meta-analysis of home fortification of complementary food. Maternal and child nutrition.Blackwell Publishing Ltd, 2009.

22. Imdad, A, M Yakoub, Z Bhutta. Impact of maternal education about complementary feeding and provision of complementary foodson child growth in developing countries. BMC Public Health 2011: 11 (Suppl 3) 1-14.

23. Rivera J, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, andnutrition (Progresa) on rates of growth and anemia in infants and young children: A randomized effectiveness study. Journal of theAmerican Medical Association 2004; 291 (21): 2563-70

24. Presidencia de la Republica de Mexico-Algunos derechos reservados, 2010. Oportunidades (online) available at:http://www.oportunidades.gob.mx/Portal/wb/Web/english.

25. Fernald LCH et al. The Importance of Cash in Conditional Cash Transfer Programs for Child Health, Growth and Development: AnAnalysis of Mexico’s Oportunidades. Lancet. 2008 March 8; 371(9615): 828–837

26. Monteiro C A et al. Causes for the decline in child under-nutrition in Brazil, 1996-2007. Rev Saude Publica 2009;43(1)

27. Lindert K. “Brazil Bolsa Familia program: Scaling up cash transfers for the poor”. MfDR Principles in Action: Sourcebook onEmerging Good Practices, The World Bank pp67-74.

28. Paes-Sousa R et al. Effects of a conditional cash transfer programme on child nutrition in Brazil. Bull World Health Organ 2011;89:496–503.

29. Monckeberg, F. Nutrition in Chile, Past, present and future, 2008

30. La desnutricion infantil en Chile. Informe Ministerio de Salud, 2008.

31. Scaling- up nutrition. Progress report from countries and their partners in the movement to Scale Up Nutrition (SUN): UN, SUN:2011


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What is micronutrient deficiency?

Micronutrients (vitamins and minerals), althoughonly needed in small amounts, are as essential asmacronutrients (protein, fat, and carbohydrates) forensuring the life and health of an individual.Micronutrient deficiencies (MNDs) often result frominadequate dietary consumption, and infectiousdiseases which decrease the absorption of nutrientswhile at the same time increasing individualnutritional requirements. Underlying these directcauses, inadequate health care and sanitation, poorinfant and young child feeding practices, andhousehold food insecurity contribute to MNDs,influencing intake and illness at the individual level.

MNDs of particular concern include vitamin Adeficiency, iodine deficiency disorders, irondeficiency anaemia, and zinc deficiency. Even mildto moderate deficiencies of micronutrient havenegative effects on well-being, such as poorintellectual development, poor vision, suboptimalgrowth and morbidity. For example, zinc deficiencyalone has been shown to increase the risk ofdiarrhoea in young children by 33 percent,pneumonia by 69 percent, and malaria by 56percent. [1] Adequate intake of vitamin A amongchildren under five years can reduce mortality due toinfectious diseases (most notably measles,diarrhoea, and malaria) by approximately 23-35percent.

At the population level, information on theprevalence of MNDs may be assessed through anutrition survey, though this information is notalways available when planning for a newintervention. Proxy information should therefore beused to estimate the nutrient gap and the need formicronutrients, including existing data on MNDprevalence, stunting prevalence, and on risk factorssuch as dietary intake, complementary feedingpractices and household food insecurity.

Why Should WFP engage inaddressing MNDs?

• Micronutrient deficiencies represent a largelyinvisible but devastating form of malnutrition thataffects 2 billion people worldwide. People withMNDs may not show specific signs of deficiency,and may not be aware of their deficiency. Thisphenomenon is often referred to as “HiddenHunger”. • An estimated 190 million (33 percent) of

preschool-age children and 19 million (15percent) of pregnant women are vitamin Adeficient.

• Iron deficiency which contributes to anaemiaaffects about 25 percent of the world’spopulation, most of them children of preschool-age and women.

Addressing MicronutrientDeficiencies


To address micronutrient deficiencies among vulnerablepeople – children aged 6-59 months and pregnant andlactating women – especially to reduce the risk of mortalityduring emergencies and to improve health, throughfortification.

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• Iodine deficiency still affects millions ofpeople, despite programmes of Universal SaltIodization. [2]

• Zinc, iron, and vitamin A deficiencies are in thetop ten causes of death through disease indeveloping countries.

• With rising food prices and climate change, it islikely that an increasing proportion of the world’spopulation will develop MNDs.

• Cost-effective, evidence-based strategies toaddress MNDs are available. The 2008Copenhagen Consensus ranked micronutrientsupplements for children (vitamin A and zinc) asfirst among all development interventions interms of spending priorities based on benefit-costratios.

• WFP operates in many of the most food-insecurecontexts where MNDs are also common. WFP hasthe infrastructure, opportunity, and comparativeadvantage to address MNDs.

There are several ways to address MNDs, including:

• Home fortification (also known as point-of-usefortification) to increase micronutrient intake ofspecific groups. This is a particularly effectivemethod for children 6-23 months since it isgenerally difficult for them to meet their highnutrient intake needs due to their small stomachsize and intake of complementary foods that areoften not adequate in terms of micronutrientcontent.

• General fortification (adding one or morenutrients during processing) of staple foods andcondiments, which offers the possibility ofincreasing micronutrient intake and improvingthe quality of the daily diet of the generalpopulation, including that of adolescent girls andpregnant and lactating women (PLW), in a cost-effective and sustainable manner. In addition todistributing fortified food commodities in foodsecurity operations, WFP and private partnerswork with governments to establish the generalfortification of staple goods and condiments andto introduce innovations such as fortified rice.

• Education to promote a more diverse food

basket in areas where foods with sufficientmacronutrients and micronutrients are availableand accessible. Diets that are heavily plant-basedand contain few animal-source or fortified foods

are often unlikely to meet the nutrient needs ofchildren 6-23 months.

• Supplementation (distribution of concentrateddoses in pill, capsule or drop form) for specificmicronutrients for specific groups, such asvitamin A for children 6-59 months, postnatalvitamin A supplementation, and in rare instancesiodised oil capsules for children 6-59 months.While there is an on-going discussion on eithercontinuing the use of iron folate or switching tomultiple micronutrient capsules (MMC) by PLW,the latter which provide more nutrients are thepreferred option, especially when obstetricservices are available because MMCsupplementation can increase birth weight whichmay cause obstetric complications among shortwomen. When PLW are malnourished, it is alsoimportant to ensure that their other nutrientneeds (calories, and fatty acids) are met.Supplementation is generally administeredthrough health programmes.

• Promotion of public health measures, suchas deworming, and assuring adequate water andsanitation, in order to reduce illness and thereforeincrease absorption of nutrients.

What is WFP’s nutrition-specificresponse to addressing MNDs?

• What: Home fortification with MicronutrientPowder (MNP) or Small Quantity lipid-basednutrient supplement (LNS)

• Why: To improve the quality of the diet and thusnutrient intake for nutritionally vulnerable groupsto the point where the combination of the existingdiet and the home fortificant meets the dailyRecommended Nutrient Intake (RNI) for allnutrients. Improvement of nutrient intake andinfant and young child feeding (IYCF) practices ultimately aims to contribute toimprovements in micronutrient status andtherefore promote growth, development andhealth of target groups.

• Who: Children 6-23 months, and in the case ofhigh prevalence of MNDs, children 6-59 months,are the primary target group. Secondary targetgroups consist of school-age children, adolescents,and adults. Inclusion in the programme is notbased on assessment of micronutrient statusamong the target group. Caseload is calculatedbased on the number of individuals in the specific

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target group in the geographic area of activity andan estimate of programme coverage.

• How: Provision of a home fortificant toindividuals from the target group on a regularbasis for a specific period of time, generally 6-18months. In addition, education on the use of thehome fortificants and positive health andnutrition practices is provided. There are twooptions for home fortificants30: - Nutributter (Small Quantity lipid-based

nutrient supplement (LNS)) for children 6-23 months

- Micronutrient powder (MNP) for children 6-59 months, or other target groups

Nutributter provides both micronutrients andmacro-minerals, essential fatty and amino acids,while MNPs provide only micronutrients. As aprinciple, the frequency and duration of use shouldbe such that it contributes an adequate quantity ofthe required micronutrients. WFP uses the standardWFP-UNICEF-WHO formulation for MNPscontaining 15 micronutrients. [13] The process ofdesigning local packaging for MNPs andimplementing the behaviour change communicationstrategy for the home fortificant at country level areboth parts of home fortification programming.

Where/When: Home fortification is recommendedwhere the micronutrient requirements of children 6-23 months are not met in the typical diet, i.e.where appropriate complementary foods withsufficient macronutrients is locally available andaffordable but lacking in micronutrients. Homefortification with MNPs should also be considered inschool feeding programmes where school meals arepredominantly composed of unprocessed locallyavailable ingredients, as micronutrient content isalmost always inadequate. Home fortification can beimplemented in both emergencies and developmentcontexts (EMOP/PRRO/DEV or CP)31. Programmesare generally run the whole year round, thoughindividuals only participate for a specific period of time.

How is WFP’s response toaddressing MNDs with homefortification different than before?

• New specialized nutritious foods and

operational evidence of effectiveness: MNPswere developed as a way to provide iron and othernutrients required for treating anaemia, becauseiron and folic acid tablets cannot be swallowed byyoung children and syrups are bulky, stain teethand are more easily over-dosed. The strategy ofhome fortification with MNPs appeared to be wellaccepted by beneficiaries, and able to achieve highcoverage. Its impact on nutritional anaemia hasbeen proven [3-6]. As a result, MNPs areincreasingly used for prevention of MNDs and arecomposed of a wider range of micronutrients. Inaddition, Nutributter, a Small Quantity LNS, wasdeveloped to deliver micronutrients as well asmacro-minerals (calcium, magnesium,phosphorus) essential fatty acids and amino acidsrequired for growth. Operational research in theuse and effectiveness of Small Quanity LNS inaddressing MNDs is on-going but indicates that itis a promising option.

How do we know that WFP’sapproach to addressing MNDswith home fortification works?

• MNPs have been proven to have a positive impacton nutritional anaemia. Given that individualsoften have more than one MND, MNPs areassumed to have a positive impact on other MNDsas well. MNPs have also been shown in certaincontexts to have contributed to a positive impacton stunting, for example with long term useamong refugees in Nepal. [7-8] In the same study,MNPs also appeared to have a positive impact onmorbidity associated with diarrhoea. The decreasein both stunting and diarrhoea suggest that othermicronutrients in the formulation (zinc inparticular) may have had a positive impact onchild health and development. However, at thisstage it is unknown if these positive benefits canbe directly attributed to the use of MNP or/andother possible factors such as improved childfeeding practices because of the introduction ofMNP. Future, large-scale, multiple-year MNPprogrammes will need to confirm these benefits.


31. EMOP: Emergency Operations; PRRO: Protracted Recovery and Relief Operations; CP: Country Programme; DEV: Development programmes

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• The positive impact of LNS on MNDs, lineargrowth, and motor development has been proven.[9-11]

In a relatively short time, since initial pilots in 2008,WFP has built strong technical and operationalexpertise in distributing MNPs with various partnersin emergencies, refugee and development settings.[7] Programmes in Bangladesh, eastern Nepal,Kenya, Philippines, Dominican Republic, Colombiaand Haiti have targeted various groups includingchildren under five years of age, PLW, and refugees.School-age children have been reached with MNPthrough school feeding in Tanzania, Cambodia,Ghana, Madagascar and Afghanistan. AdditionalMNP programs are underway in Indonesia, Niger,Mali and Cote d’Ivoire. The provision of MNP tochildren aged 6-59 months and school-age childrenin different settings within regular WFPprogramming scaled up from 350,000 in 2010 tomore than 2 million children in 2012. Thisconsiderable experience has translated into stronganalysis, enhanced programme design and improveddelivery tools, including a toolkit to guide successfulimplementation of large-scale MNP programmes.WFP endeavours to develop the same experience,evidence, and tools for home fortification with LNSin the near term.

How does WFP’s nutrition-specificresponse to addressing MNDswith home fortification relate toother types of WFP programming?

• Relation to other nutrition-specific

programmes: The specialized nutritious foodsused in the treatment and prevention of MAM aredesigned to provide all of the requiredmicronutrients to beneficiaries. MNPs andNutributter are not distributed in theseprogrammes. MNPs and Nutributter are,however, two of several specialized nutritiousfoods that may be used to improve nutrient intakeas one component of comprehensive programmesto prevent stunting.

• Relation to fortification: WFP collaborateswith the government and the private sector inmany countries, where fortified staple foods suchas maize or wheat flour or oil are not yet available,or national fortification guidelines are not yet inline with current WHO guidance or nationalstandards on food fortification.

• Relation to school feeding: Where theprevalence of MNDs have reached public healthsignificance, and where the nutrient gap analysisshows that it is appropriate, MNPs can, and havebeen, used in school feeding programmes toincrease the micronutrient content of local schoolmeals. Reduction of iron and zinc deficiencieshave been observed in school-age children inSouth Africa given MNPs with low doses of highlyabsorbable iron and zinc. [12] Other options toimprove micronutrient content in school feedinginterventions include provision of fortified foodsor high energy biscuits.


WFP distributes food commodities that arefortified, including oil fortified with vitamins Aand D, iodized salt, and fortified maize meal,wheat flour and fortified blended foods (FBF).MNPs and Nutributter can be distributed with theGFD to specifically address the highmicronutrient needs of young children, whenthere is limited capacity or access to other, moretargeted, distribution channels to reach thenutritionally vulnerable group.

• Relation to treatment of severe acute

malnutrition (SAM): Home fortification is notincluded in the treatment of SAM since allrequired macronutrients and micronutrients aresupplied through therapeutic products speciallyformulated to meet the nutrient needs of childrenwith SAM.

How does WFP’s programming toaddress MNDs with homefortification relate to the work ofpartners?

Key partners in addressing MNDs include nationalgovernments, UN agencies, and NGO partners. Thegovernment has the overall responsibility for thewelfare of its population. WFP and UNICEFcollaborate in the design, implementation andevaluation of home-fortification programs andjointly advocate to address micronutrientdeficiencies. UNHCR and WFP jointly implementand monitor micronutrient interventions involvingthe provision of MNPs and lipid-based nutrientsupplements in refugee settings.

WFP is also part of the Home Fortification TechnicalAdvisory Group (a community of stakeholdersincluding members of public, private, academic, andnon-governmental organisations) which in 2011

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developed technical programme guidance on the useof MNPs to address MNDs in order to harmonisehome fortification programming. [13] Members ofthis group include WFP, UNICEF, MicronutrientInitiative, Global Alliance for Improved Nutrition,Helen Keller International, Sprinkles Global HealthInitiative, U.S. Centers for Disease Control and

Prevention, Sight and Life and UC Davis.WFP collaborates with the government as well as theprivate sector around supporting local fortificationcapacity. In addition, WFP coordinates with partnersand the government around supplementation,promotion of public health measures, and nutritioneducation to improve nutrient intake. A

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References

1. Caulfield et al. 2004. Zinc Deficiency. Comparative Quantification of Health Risks, World Health Organization. Pp. 256-79

2. UNICEF. 2009. Tracking Progress on Child and Maternal Nutrition: A survival and development priority

3. Menon P, Ruel MT, Loechl CU, Arimond M, Habicht J-P, Pelto G, Michaud L. Micronutrient sprinkles reduce anemia among 9- to24-mo old children when delivered through an integrated health and nutrition program in rural Haiti. J Nutr 2007; 137: 1023-30

4. De Pee S, Moench-Pfanner R, Martini E, Zlotkin S, Darnton-Hill I, Bloem MW. Home fortification in emergency response andtransition programming: Experiences in Aceh and Nias, Indonesia. Food Nutr Bull 2007; 28: 189-197

5. De-Regil LM, Suchdev PS, Vist GE, Walleser S, Peña-Rosas JP. Home fortification of foods with multiple micronutrient powders forhealth and nutrition in children under two years of age. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.:CD008959

6. WHO. 2011. Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age.

7. Rah JH, de Pee S, Kraemer K, Steiger G, Bloem MW, Spiegel P, Wilkinson C, Bilukha O. Program experience with micronutrientpowders and current evidence. J Nutr 2012; 142: 1915-1965

8. Bilukha O, Howard C, Wilkinson C, Bamrah S, Husain F. Effects of multimicronutrient home fortification on anemia and growth inBhutanese refugee children. Food Nutr Bull. 2011 Sep;32(3):264-76.

9. Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A & Dewey KG. Randomized comparison of 3 types of micronutrientsupplements for home fortification of complementary foods in Ghana: effects on growth and motor development. American Journalof Clinical Nutrition 2007; 86: 412–420

10. Phuka J.C., Maleta K., Thakwalakwa C., Cheung Y.B., Briend A., Manary M. et al. Complementary feeding with fortified spread andincidence of severe stunting in 6- to 18-month-old rural Malawians. Archives of Pediatric and Adolescent Medicine 2008; 162: 629–626

11. Phuka J.C., Maleta K., Thakwalakwa C., Cheung Y.B., Briend A., Manary M. et al. Post intervention growth of Malawian childrenwho received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. American Journal ofClinical Nutrition 2009; 89: 382–390.

12. Troesch B, et al. A Micronutrient Powder with Low Doses of Highly Absorbable Iron and Zinc Reduces Iron and Zinc Deficiency andImproves Weight-For-Age Z-Scores in South African Children. Journal of Nutrition 2010.

13. Home Fortification Technical Advisory Group (HF-TAG). Programmatic Guidance Brief on Use of Micronutrient Powders (MNP) forHome Fortification.2011. http://hftag.gainhealth.org/resources/programmatic-guidance-brief-use-micronutrient-powders-mnp-home-fortification

Monitoring and evaluation (M&E) are closely linkedand mutually supportive. Monitoring is the routinetracking of data on inputs, outputs and outcomeswithin programme operations. The informationcollected allows WFP to assess progress towardsstated objectives, as well as identify whether anyaspects of the operation need adjustment.Evaluation is the process of using data to ascertainthe effectiveness, impact, efficiency, relevance andsustainability of an operation.

An indicator is a quantitative or qualitative factoror variable that provides a simple and reliable meansto measure achievement or to reflect the changesconnected with a WFP operation. In the resultschain (below), indicators for each of the elements areused to measure performance.32

Monitoring focuses on the appropriate and timelyprovision and use of project resources focusingprimarily on inputs, activities, outputs, andoutcomes; evaluation focuses on whether theexpected impacts were achieved. In addition to themore immediate role that M&E plays in measuringprogress towards objectives, an effective M&Esystem will ultimately improve the quality ofactivities; improve management-oriented decisionmaking; improve accountability to donors, partners,host governments and beneficiary communities; andimprove WFP and partners’ ability to conductevidence-based advocacy.

M&E for WFP Nutrition

A new approach to M&E for nutrition has thefollowing objectives: 1) ensure a smooth scaling-upof nutritional interventions; 2) ensure populations

most in need are covered/have access to theinterventions; 3) increase appropriate utilization ofthe nutrition interventions, including consumptionof sufficient quantities of the rations; and 4)measure how the nutrition programme hascontributed to preventing malnutrition andsubsequently, morbidity and mortality.

The approach has several different components: 1) alogical pathway 2) indicator frameworks thatmeasure each step in the logical pathway and 3) datamanagement and reporting. The approach helps tomeasure results as well as to explain how the projectis working and the expected and unexpected resultsobtained. This approach is being developed fordifferent pillars of nutrition programming, as shownon the following pages.

Monitoring & Evaluation – Logic Models

Activities

Actions taken or work performed through which inputs are mobilized to produce specific outputs

Outputs

The products, capital goods and services which result from a WFP operation

Outcomes

Beneficiary and population-level changes in knowledge, practices and attitudes resulting from the intervention

Impacts

The positive and negative, intended or unintended long-term results produced by a WFP operation, either directly or indirectly

Inputs

The financial, human, and material resources required to implement the WFP operation

32. WFP, 2011. The M&E Guide for HIV and TB Programming.


Definitions adapted from M&E Knowledge Base, WFPgo

31

Activities

Policies, production, delivery, quality, & behaviour change com

munication

Outputs

Access & coverage

Outcom

esKnow

ledge, appropiate use, increased intake

Impacts

Impact on status and

function in target population

Inputs

Policies

● Product compliance w

ith national

regulations● D

evelopment of and adherence to

clear and harm

onized product

guidelines & distribution m

odalities

Production &

Supply● D


Q

C/QA at level of production

● Setup of procurement processes

● Establishment of transport chain to

the country w

arehouse● Setup of traceability of product

shelf life

Quality

● Identification of optimal products for

the nutrition interventions

● Develop a supply chain Q

C/QA

system

● Setup of adequate storage facilities

Delivery

● Developm

ent of delivery system to

the target beneficiaries

● Training of agents charged with the

distribution of products to target

beneficiaries

Behaviour C

hangeC

omm

unication● Engagem

ent of government, other key

stakeholders and cooperation partners

● Developm

ent & im

plementation of

intervention strategy for inform

ation,

education & com

munication am

ong

target groups ● Inclusion of adequate IYCF BCC

messages

Availability of the appropriate nutrition intervention for the target beneficiaries

Coverage of target population w

ith intervention

Access to or presencenutrition interventionin com

munities

Acceptability of the nutrition intervention

Adequate system

s in place to identify and target the population in need, including robust referral system

s

Distribution

agents have know

ledge & m

otivation to adequately distribute to &

inform

target population

Target populationuses fortified food appropriately

Increased consum

ption of and adherence to the nutrition intervention by the clearly identified target population

Decreased

mortality &

morbidity

Improved

nutritionalstatus

Improved

development,

performance

& productivity

Target population is clearly identified & know

s, dem

ands,accepts the nutrition intervention

MANAGEMENT, COORDINATING MECHANISMS BETWEEN WFP AND IMPLEMENTING PARTNERS/OTHER PARTNERS, RESOURCES, STAFFING, LOGISTICS

Other interventions:

• Health services

• Safe water

• Vaccination• D

eworm

ing• H

ygiene practices• Adequate breastfeeding

EFFECTIV

E PR

OJEC

T MA

NA

GEM

ENT &

MO

NITO

RIN

G A

ND

EVA

LUA

TION

Abbreviations: IYCF= infant and young child feeding, BCC= behaviour change communication, QC/QA= quality control/quality assuranceSource: Adapted from CDC/WHO, 2011

Logical pathway for Treating and Preventing Acute Malnutrition


Activities


munication

Outputs

Access & coverage

Outcom

esKnow

ledge, appropiate use, increased intake

Impacts

Impact on status and

function in target population

Inputs

Policies &

Research

Included under a separate logical m

odel

Effective Supply and Quality

Specialised Foods• D


Q

C/QA at level of production

• Set up of procurement processes

• Establishment of transport chain

• Setup of traceability of product

shelf life and product quality• D

evelop a supply chain QC/Q

A

system• Setup of adequate storage facilities

Delivery

• Developm

ent /strengthening of

delivery system to the target

beneficiaries

• Training of health staff charged with

the distribution of products to target

beneficiaries

Dem

and and Use

• Engagement of governm

ent, other key

stakeholders and cooperation partners• Identification of optim

al products for

the nutrition interventions• D

evelopment &

implem

entation of

intervention strategy for information,

education &

comm

unication among

target groups

• Inclusion of adequate IYCF BCC

messages

Quality, safe

foods available at distribution sites

Health staff

appropriately distribute to &

inform

target beneficiaries

Effective m

essaging and counselling on products and IYCF delivered product use, nutrition

Target com

munities are

mobilised/inform

ed of the nutrition intervention

Timely

beneficiary access to the nutrition intervention

Target beneficiaries are identified and registered in the program

Right product distributed tim

ely in sufficient quantity/quality to target groups

Health staff are

trained on project delivery

Health staff,

comm

unity leaders, peer groups, etc., are trained according to BCC strategy

High program

coverage and adherence of target beneficiaries

Higher quality,

more

nutritionally dense diet in children aged 6-24 m

onths

Improved

recovery from

MAM

in pregnant and lactating w

omen

Reduced prevalence of stunting in children under tw

o

Reduced iron deficiency anaem

ia among

children and pregnant and lactating w

omen

Target beneficiaries use nutritional supplem

ents appropriately

Sharing of nutritional supplem

ent

Mothers/

caregivers retain and follow

nutrition prom

otion m

essages (product use, feeding practices, hygiene and breastfeeding)

MANAGEMENT, COORDINATING MECHANISMS BETWEEN WFP AND IMPLEMENTING PARTNERS/OTHER PARTNERS, RESOURCES, STAFFING, LOGISTICS

Other interventions:

• Health services

• Safe water

• Vaccination• D

eworm

ing• H

ygiene practices• Adequate breastfeeding

EFFECTIV

E PR

OJEC

T MA

NA

GEM

ENT &

MO

NITO

RIN

G A

ND

EVA

LUA

TION

Abbreviations: IYCF= infant and young child feeding, BCC= behaviour change communication, QC/QA= quality control/quality assuranceSource: Adapted from CDC/WHO, 2011

Logical pathway for Preventing Chronic Malnutrition

33

Activities


munication

OutputsAccess

Knowledge, coverage and appropiate use

Impact on Intake, Status

and Function

Inputs

Policies

• Integrated IYCF/MN

P national plan

of action established• G

overnment approved M

NP

formulation

Production and Supply

• MN

P procured• Training m

aterials printed• Behavior change com

munication

(BCC) m

aterials printed

Delivery

• MN

P integrated into health facility

logistics managem

ent system• Training for m

anagement, providers

& volunteers developed &

im

plemented

• Incentive strategy developed &

im

plemented

Quality

• Internal & external m

onitoring plan

developed & im

plemented

Behavior C

hange Com

munication

(BC

C)

• Stakeholders engaged & advocacy

conducted

• Information, education &

com

munication for behavior change

strategy developed &

implem

ented for

integrated IYCF & M

NP intervention

• BCC materials developed

Availability of M

NPs in country

Access to BCC, IYCF supportive strategies &

M

NPs in

comm

unities

• Imported

M

NPs m

eet

quality

standards &

specifications• D

istributed

MN

Ps meet

quality

standards &

specifications

Providers &

volunteers have know

ledge &

motivation to

adequately distribute M

NP,

deliver IYCF &

MN

P BCC &

solve problems

with m

others &

care takers

Among children

6-23 months:

• Appropriate

use of MN

Ps• Increased

minim

um m

eal

frequency• Increased

minim

um

dietary

diversity

• Increased

minim

um

acceptable diet

Improved intake

& dim

inished loss of vitam

ins & m

inerals am

ong children 6 – 23 m

onths

Decreased

mortality &

m

orbidity am


onths

Improved

nutritional status am


onths

Improved

development,

performance &

productivity am


onths

Coverage of IYCF strategies & M

NP am

ong m

others, caretakers &

children

Mothers,

caretakers &

children know,

demand, accept

& have ability to

appropriately use IYCF strategies &

M

NPs

MANAGEMENT, STAFF, NATIONAL MICRONUTRIENT COALITION, GOVERNMENT & INTERNATIONAL FINANCIAL RESOURCES, FACILITY & COMMUNITY VOLUNTEER INFRASTRUCTURE

Other vitam

in & m

ineral interventions, dew

orming, m

alaria prevention, &

control &

other interventions

EFFECTIV

E PR

OJEC

T MA

NA

GEM

ENT &

MO

NITO

RIN

G A

ND

EVA

LUA

TION

Abbreviations: IYCF= infant and young child feeding, BCC= behaviour change communication, QC/QA= quality control/quality assuranceSource: Adapted from CDC/WHO, 2011. Home Fortification Technical Advisory Group (HF-TAG). A Manual for Developing and ImplementingMonitoring Systems for Home Fortification, 2012.

Logical pathway for Home Fortification


1Also referred to as R

USF. 2

atment of severe acute m

alnutrition (SAM

). 3Super C

ereal is usually m

ixed with 20g oil and 15g sugar before distribution (total est. 989-1176 kcal, 31-38g protein (12-13%

), 16-20g fat (31-32%)). 4C

an vary in different situations and contexts. 5Shelf life indicated is valid for storage at

temperatures less than 30 degrees C

. Ab

breviation

s: LNS =

Lipid-based Nutrient S

upplement, R

USF =

Ready-to-U

se Supplem

entary Food, FBF =

Fortified Blended Food, EFA

= Essential Fatty A

cids, AR

T = A

nti-Retroviral

Therapy (treatment for A

IDS), D

OTS

= D

irectly Observed Treatm

ent (treatment for TB

), RN

I = R

ecomm

ended Nutrient Intakes (FA

O/W

HO

), PDCAAS

= Protein D

igestibility-Corrected A

mino A

cid Score (m

in. 70%), V

&M

=

Vitam

ins and Minerals, m

t = M

etric Ton.

WFP

Specialized N

utritious Foods S

heet

Prog

ramm

e Treatin

g M

oderate A

cute M

alnu

trition (M

AM

)

Gen

eric p

rodu

ct term

Lipid

-based N

utrien

t Su

pp

lemen

t (LNS

) Larg

e Qu

antity (9

2-1

00

g)

1 Fortified

Blen

ded

Foods (FB

F) (2

00

-25

0g

)

Cu

rrent W

FP

nu

trition p

roducts

2 (Peanut-based)

(Peanut-based)

Ach

a Mu

m

(Chickpea-based)

Su

per C

ereal Plu

s

Su

per C

ereal 3

Target

grou

p

Children 6-59 m

onths Children 6-59 m



onths Pregnant and Lactating W

omen

(PLW)

Malnourished individuals on AR

T/D

OTS

Key In

gred

ients

Peanuts, sugar, whey,

vegetable oil, milk, soy

protein, cocoa, V&

M

Peanut, sugar, milk

solids, vegetable oil, V&

M

Chickpeas, vegetable

oil, milk pow

der, sugar, V

&M

, soya lecithin

Corn/w

heat/rice soya, milk pow

der, sugar, oil, V&

M

Corn/w

heat/rice soya, V&M

Daily ration

92g sachet

92g sachet 100g sachet

200g (includes provision for sharing) 200-250g (includes provision for sharing)

Nu

trient p

rofile 500 kcal, 13g protein (10%

), 31g fat (55%).

Contains EFA

, meets

RN

I and PDCAA

S

500 kcal, 13g protein (11%

), 31g fat (56%).

Contains EFA

, meets

RN

I and PDCAA

S

520 kcal, 13g protein (10%

), 29g fat (50%).

Contains EFA

, meets

RN

I and PDCAA

S

787 kcal, 33g protein (17%), 20g fat

(23%). C

ontains EFA, m

eets RN

I and PD

CAA

S

752-939 kcal, 31-38g protein (16%

), 16-20g fat (19%). M

eets RN

I and PDCAA

S

Du

ration of

interven

tion4

60-90 days 60-90 days

60-90 days 60-90 days

PLW: 180 days, AR

T & D

OTS

: 180 days (estim

ated)

Sh

elf life5

24 months

24 months

6 months

12 months

12 months

Packagin

g d

etails Carton: 14.7kg (gross)

and 13.8kg (net) has 150 sachets

Carton: 14.9kg (gross)

and 13.8kg (net) has 150 sachets

Carton: 10.5kg (net)

has 105 sachets Prim

ary: 1.5kg (net) bag; Secondary: 15kg (net) carton has 10

bags; or 18kg sack has 12 bags

25kg (net) bags

35

1All nutrition products address the prevention of micronutrient deficiencies, but sm

all quantity LNS and M

NP do not prevent acute m

alnutrition. 2Super C

ereal is usually mixed w

ith 20g oil and 15g sugar before distribution (total est. 613-989 kcal, 15-31g

protein (10-12%), 8-16g fat (33-41%

)). 3Can vary w

ith different situations, contexts and objectives. 4 Shelf life indicated is valid for storage at tem

peratures less than 30 degrees C. A

bbreviations: LN

S = Lipid-based N

utrient Supplements, RU

SF = R

eady-to-U

se Supplementary Food, FBF =

Fortified Blended Food, MN

P = M

icronutrient Powders, EFA =

Essential Fatty Acids, RNI =

Recomm

ended Nutrient Intakes, PD

CAAS =

Protein Digestibility-C

orrected Amino Acid Score (m

in 70%) V&

M =

Vitamins and M

inerals, m

t = M

etric Ton.

WFP

Specialized N

utritious Foods S

heet

Program

me

Preventing Stunting: All products listed below

can be used for the prevention of stunting

A

ddressing Micronu

trient

Deficien

cies1:

Preven

ting A

cute M

alnu

trition:

Four products specifically for the prevention of acute malnutrition

Generic

product term

Lipid-based Nutrient Supplem

ent (LNS)

Medium

Quantity (20-50g)

Fortified Blended Food (FB

F) (100-200g)

LNS Sm

all Quantity

M

icronutrient P

owders (1g)

Current W

FP

nutrition products

(Peanut-based)

Waw

a Mum

(Chickpea-based)

Super Cereal P

lus Super C

ereal 2 N

utributter®

(Peanut-based) M

icronutrient P

owders (M

NP)

eeZeeC

up

TM

Target group

Children 6-23 months

Children 6-23 m


onths Pregnant and Lactating W

omen



School age children Children older than

6 months

Key Ingredients

Vegetable fat, peanut, sugar, m

ilk powder,

whey, V&

M, cocoa

Chickpeas, vegetable oil, m

ilk powder,

sugar, V&M

Corn/wheat/rice soya,

milk pow

der, sugar, oil, V&

M

Corn/wheat/rice

soya, V&M

Peanuts, vegetable fat, sugar, skim

milk

powder, w

hey, V&M

Vitamins and m

inerals (V&

M)

Vegetable fat,

peanut, sugar, skim

med m

ilk pow

der, V&

M

Daily ration

46g portion (1/7 portion of a pot)

50g sachet 100-200g (200g includes provision for sharing)

100-200g (200g includes provision for sharing)

20g sachet 1g sachet every second day

46g portion (1/7 portion of a pot)

Nutrient profile

247 kcal, 5.9g protein (10%

), 16g fat (58%

). Contains EFA, m

eets RNI and

PDCAAS


), 14.5g fat (50%

). Contains EFA, m

eets RNI and

PDCAAS

394-787 kcal, 16-33g protein (17%

), 10-20g fat (23%

). Contains EFA, m

eets RN

I and PDCAAS

376-752 kcal, 15-31g protein (16%

), 8-16g fat (19%

). M

eets RNI and

PDCAAS


), 7g fat (59%).

Contains EFA, meets

RNI and PD

CAAS

Meets RN

I (N

o energy, fat or protein content)


), 15g fat (56%

). Contains

EFA, m

eets RN

I and PD

CAAS

Duration of

intervention3

90-180 days 90-180 days

90-180 days 90-180 days

180-545 days 180-545 days

90-180 days

Shelf life4

24 months

6 m

onths 12 m

onths 12 m

onths 18 m

onths 24 m

onths M

inimum

12 months

from m

anufacturing date w

hen stored at w

arehouse conditions

Packaging

details Prim

ary packaging: 325g pots. Carton: 12.7kg (gross) and 11.7kg (net) has 36 pots

Carton: 10.5kg (net) has 210 sachets

Primary: 1.5kg (net)

bag; Secondary: 15kg (net) carton has 10 bags; or 18kg sack has 12 bags

25kg (net) bags Carton: 11.95kg (gross) and 10.92kg (net) has 546 sachets

Carton: 14kg (gross) has 240 boxes; 30 sachet in each box. *Packaging varies w

ith supplier

Primary packaging:

325g pots. Carton:

12.7kg (gross) and 11.7kg (net) has 36 pots

Decem

ber 2

012 P

hoto

cre

dits

, front c

over: W

FP/M

ichael H

uggin

s b

ack c

over: W

FP/M

arc

Hofe

r

“Preventing the loss of another generation of children to

malnutrition requires that women and their children must

have adequate access to sufficient nutrition – including the

right nutritional practices such as proper breastfeeding,

adequate hygiene, and nutritious foods as well as, when

required, life-saving micronutrient supplements. The

capacity to contribute to this generation and the next is

in our collective hands.”

Ertharin Cousin, Executive Director

WFP Nutrition

[email protected] www.wfp.org/nutrition

World Food Programme

Via C.G. Viola, 68/70, 00148 Rome, Italy Tel: +39 06 65131

Documents

Nutrition at the World Food Programme - Food and ... Nutrition at the World Food Programme 2012 Nutrition Policy The Nutrition Policy was approved by the WFP Executive Board in February