75103 Improving Nutrition Through Multisectoral Approaches Agriculture and Rural Development This guidance brief calls on Bank TTLs to take action on the following fronts: • Incorporate nutrition sensitive analysis and activities into the design of Agriculture and Environmental Services (AES) projects, as well as in the food-security policy dialogue. • During the project, periodically measure the progress of activities affecting nutrition using relevant output and outcome indicators (e.g. food consumption indicators) at a minimum at baseline, mid-term and project completion. • Ensure that agriculture projects and policies do not unintentionally harm nutrition. What is nutrition sensitive agriculture? Nutrition sensitive agriculture aims to maximize the impact of nutrition outcomes for the poor, while minimizing the unintended negative nutritional consequences of agricultural interventions and policies on the poor, especially women and young children. It is agriculture with a nutrition lens, and should not detract from the sector’s own goals. The agriculture sector is best placed to influence food production and the consumption of nutritious foods necessary for healthy and active lives. AES projects may also affect water quality, disease occurrence, food safety, and women’s time use (which, in turn, affects child care practices) – each of which are important for nutrition. Improving Nutrition Through Multisectoral Approaches Principles for Nutrition Sensitive Agriculture 1. Invest in women: safeguard and strengthen the capacity of women to provide for the food security, health, and nutrition of their families. Increase access to and year-round availability of high-nutrient 2. content food. Improve nutrition knowledge among rural households to enhance 3. dietary diversity. Incorporate explicit nutrition objectives and indicators into 4. agricultural project and policy design. Malnutrition is poor nutritional status caused by nutritional deficiency (undernutrition) or excess Examples of (overnutrition). This guidance brief focuses on undernutrition, which results from inadequate nutrition sensitive agriculture: quantity and/or quality of food, disease, and inadequate care/feeding practices, and that is Dietary diversity promotion, manifest in the form of low height-for-age (stunting), low weight-for-age (underweight), low weight-for- e.g., backyard gardens, horticulture, height (wasting), and/or micronutrient deficiencies pulses, livestock, dairy, fish, and healthy (also referred to as “hidden hunger�). indigenous foods, with nutrition/ Consequences of undernutrition home economics extension services; • Single largest cause of child deaths. Undernutrition contributes to at least 35% of biofortification, food fortification, e.g., child deaths globally. cereals, vegetable oils, • Lost human capital. Individuals undernourished as children have poorer cognitive development, milk, market-based food products; lower school attainment and IQ, and lower women-focused agriculture. productivity and income as adults. They are also more likely to have undernourished children, perpetuating poverty. • Lost economic growth. Undernutrition costs an estimated 2-3% of GDP in many low-income countries. • Irreversible damage during the “first 1,000 days�. Vitamin and mineral deficiencies experienced during pregnancy and the first two years of life will have severe and often irreversible consequences to a child’s development. • Important for all. Everybody affects nutritional outcomes of the “first 1,000 days�, e.g. girls (who will become mothers), adult caretakers (who care for and feed infants), and adults (who provide for their families). Undernutrition also diminishes an adult worker’s productivity by exacerbating disease or through chronic fatigue and reduced work capacity in the case of iron deficiency anemia. Improving Nutrition Through Multisectoral Approaches Agriculture and Rural Development Agriculture affects nutrition outcomes to varying degrees through several pathways. Evidence to date has shown that among the five main pathways, household consumption and women’s empowerment (including women’s control of economic resources) are the two linked most closely to nutritional status, and yield the greatest results in decreasing malnutrition. Pathways linking agriculture to nutrition Pathway Strength of pathway 1. Increase macroeconomic Modest effect. Doubling per capita agricultural income is associated with an growth overall approximately 15-21% decline in stunting on average, which would result in very slow and uneven progress in reducing undernutrition. 2. Increase access to food Modest effect. Of the countries meeting the MDG1 target to halve hunger, fewer by higher production and than one-third are on track to meet the MDG1 target to halve undernutrition, decreased food prices demonstrating the limited translation of national-level grain availability to nutritional improvements. 3. Increase household Variable effects. On average, income poverty and undernutrition are correlated, income through selling but increases in household income do not necessarily lead to improved agricultural products nutritional status of its most vulnerable members. Increasing women’s income has stronger positive effects on nutritional status. Existing empirical evidence shows commercialization based on cash crops has limited nutritional effects on vulnerable individuals in producer households. 4. Increase nutrient dense Some evidence. The best evidence to date is found from increasing small- food production for scale production of nutrient-dense foods. Nutrition education enhances dietary household consumption consumption and the potential for consumer demand. 5. Empower women Strong evidence. Over 50% of the reduction in child underweight from 1970- through targeted 1995 is attributable to improvements in women’s status. In agricultural activities, agricultural interventions increasing women’s discretionary income and reducing women’s time and labor constraints appear to be especially important to improve nutrition. Client demand for nutrition-sensitive agriculture There is increasing attention to addressing undernutrition through agriculture that will likely raise client demand. Important initiatives include: • The Scaling Up Nutrition (SUN) global movement, with attention to multisectoral action. • The Zero Hunger Challenge launched by the UN Secretary General to end hunger and malnutrition within our lifetimes • Development of country CAADP plans (Comprehensive African Agriculture Development Programme) that include nutrition in Pillar 3 (Food Supply and Hunger). • CGIAR research program (CRP-4), Agriculture for Improved Nutrition and Health (A4NH). • Nutrition mainstreaming as a FAO corporate priority. • Multiple development partners have recently developed agriculture-nutrition guidance and tools. Improving Nutrition Through Multisectoral Approaches Improving Nutrition Through Multisectoral Approaches Homestead food production in South Asia: Improving food security and nutrition through multiple pathways Homestead food production projects in Bangladesh — implemented by Helen Keller International and partner CSOs—have resulted in higher vitamin A status, increased women’s income, and increased energy intakes for vulnerable household members. These projects achieved positive nutrition results with a combination of increased year-round food availability and nutrition education. Households with homestead gardens— sometimes complemented with small-scale animal husbandry—grew a greater variety and Brazil’s biofortification program: amount of foods, many of which provided From farm to fork vitamin A and other micronutrients. Nutrition education, and the fact that women managed EMBRAPA Food Technology of the Brazilian the gardens and were the primary decision- Agricultural Research Corporation—under makers about their use, helped to ensure the Brazil’s Ministry of Agriculture, Livestock, and foods were consumed. Women also used Food Supply—is leading the BioFORT project. income from selling the gardens’ produce to Its goal is to increase the vitamin and mineral purchase other nutrient-dense foods such as content of foods that are already part of the lentils and animal-source foods. The homestead Brazilian population’s diet and to promote their food production model has helped millions of consumption by the population and in school people in vulnerable populations to improve meals. The foods selected for biofortification year-round food security. across 11 regions of Brazil include maize, sweet potato, pumpkin, wheat, cowpea, cassava, beans, and rice. Each is bred using conventional breeding practices to produce varieties with higher nutritional content and equivalent or better agronomic qualities, including yield. The state of Sergipe has one of the lowest Human Development Index scores in the country. The daily energy and micronutrient consumption is inadequate among schoolchildren and teenagers. Sergipe was selected as a test site to pioneer the integration of biofortified crops into the school feeding system. The use of high vitamin A cassava and sweet potato, high iron and zinc cowpea, and common bean are being tested in school meals to help students increase their intake of calories and essential micronutrients. Other project teams are developing and testing commercial products with biofortified varieties, such as breads, snacks, and meals of precooked instant soups and porridges. The R&D effort also tests different preparation and packaging solutions to ensure the preservation of micronutrients. Improving Nutrition Through Multisectoral Approaches Agriculture and Rural Development Do no harm considerations During the design phase, AES project teams can assess potential harms and develop mitigation strategies appropriate for the context. Monitoring for potential harmful impacts during project implementation also will provide information important for triggering mitigation strategies. Agricultural productivity, focused primarily on staple grains, does not necessarily reduce undernutrition. Policies that strongly favor staple grains over other crops or foods may skew the balance from nutritious foods, e.g., horticulture, pulses, livestock, dairy, fish, and healthy indigenous foods. These foods do not receive preferential treatment such as subsidies for staple grains, and basic agricultural research/education exclusively focused on staple grains. Further unintended negative consequences caused by AES projects include the following: Nutrition-sensitive agriculture in practice Observed negative impacts Possible mitigation measures Irrigation projects may increase • Include analysis of hydrophilic vector-borne diseases in hydrophilic vector-borne disease, e.g., environmental safeguard analysis; ensure mitigation measures malaria, schistosomiasis, and Japanese are established encephalitis Animal husbandry projects may • Strengthen mitigation measures and risk management increase the risk of zoonotic diseases framework for zoonotic infections in program design Reduction in women’s access to • During project social or gender analysis, determine who is resources if projects shift production benefiting from intervention activities and develop strategies to toward male-dominated crops ensure equitable intra-household access to resources • Include women’s time use in project gender analysis to Reduction in women’s time available determine women’s labor time requirement for child care, impacting child health and nutritional status • Introduce timesaving technologies for tasks commonly performed by women • Promote production and consumption of micronutrient-rich Production increase/price reduction in crops calorie-dense foods may unfavorably alter dietary quality and contribute to • Include food consumption indicators in project’s Results obesity and chronic diseases Framework to monitor consumption trends which could affect likelihood of obesity and chronic disease Improving Nutrition Through Multisectoral Approaches Improving Nutrition Through Multisectoral Approaches Incorporate indicators in AES to monitor nutrition Because of the agriculture sector’s strong role in validated as a measure for calorie and nutrient addressing dietary constraints to good nutrition, adequacy of the diet. These scores are being food consumption indicators are central measures used in WHO, FAO, and USAID Feed the Future of nutrition-relevant impact for AES projects. projects. Anthropometry and biochemical measures are • Food Consumption Score is a composite score important if a project goal is to decrease stunting, based on dietary diversity, food frequency, and underweight, or vitamin and mineral deficiency the nutrient content of different food groups rates, and if sufficient sample sizes permit consumed by the household. It has been validated adequate power. For most AES projects, using against per capita calorie consumption and asset food consumption indicators is a practical option and wealth indices. The score is being used by to provide relevant information about nutrition- WFP in their surveillance activities. related impacts. Suggested food consumption • Months of Adequate Household Food indicators include: Provisioning indicator measures household food • Simple, project-specific indicators based on accessibility throughout the past year, and reflects project interventions, e.g., number of days the the seasonality aspect of food security. It has been previous week when any amount of X (nutritious incorporated as a standard impact indicator in all food) was consumed. Africare’s food security programs. • Dietary Diversity Scores consist of a simple count • Household Hunger Scale is a measure of the of the different food groups that a household or degree of household food insecurity over a recall an individual has consumed over a given period period of four weeks. It has a strong relationship of time (usually 24 hours). The household dietary with household income and wealth scores, and is diversity score reflects the food access dimension being used by FAO and USAID Feed the Future of food security, while individual scores have been projects. THE WORLD BANK Improving Nutrition Through Multisectoral Approaches