POLICY BRIEF
Photo: Bart Verweij/World Bank
Malnutrition in the Early Years
3 THINGS TO REMEMBER
In brief Healthy nutrition is vital for young children’s development. What pregnant mothers, babies and toddlers eat and drink has lifelong impacts on their health, brain development and future eating behaviours. Yet millions of young children suffer from malnutrition, which includes being undernourished, obese or lacking key micronutrients. While some policy solutions exist, bolder experimentation and action are needed.
Malnutrition in all its forms can lead to lifelong problems, from poor brain development to chronic health issues Undernutrition is still widespread while obesity is surging, leading to a ‘double burden’ in many countries Policies like fortifying staple foods and encouraging breastfeeding can be effective, but policymakers don’t yet have all the answers
Policy Brief: Malnutrition in the Early Years
2020
What do we know? Malnutrition is affected by several different factors, from diet and lifestyle to our genetic makeup. Nutritional problems in early life are directly connected to long-term issues.
Meanwhile, being overweight in the early years significantly increases the risk of obesity, hypertension, diabetes and other metabolic disorders in later life.6 This transfers across generations: parental obesity makes it more likely that their children will be obese, thus increasing the chances for their children.7
This starts during pregnancy. When pregnant mothers don’t consume enough food or get enough specific micronutrients, like zinc and iron, their children are more likely to develop cognitive delays, attention deficit and psychiatric disorders.1 Following birth, exclusive breastfeeding provides children the vital nutrients they need, and greatly reduces the risks of infections and chronic diseases.2 Stunting, or impaired growth, which is linked to poor early nutrition, hampers children’s cognitive development and long-term health.3
Photo: GAIN/Andrew Suryono
When young children start eating solid foods, diet remains essential. Undernutrition doesn’t just include a lack of calories but the “hidden hunger” of micronutrient deficiencies. This can lead to poor growth, weakened immunity and tissue development, poor health, and risk of death.4 Important nutrients, such as protein, provide the building blocks in the brain for key processes like the growth of cells.5
In numbers
1 in 3
children under five are undernourished or overweight globally8
21%
chance of a severely obese two-year-old having a healthy weight at 359
340 million children under five suffer from micronutrient deficiencies globally10
Policy Brief: Malnutrition in the Early Years
2020
Why does it matter? Malnutrition affects a huge proportion of young children around the world. At least half of children under five suffer from one or more micronutrient deficiencies, and one-third are either undernourished or overweight.11 This is not only hampering young children’s development: it is costing lives. Each year, over 400,000 young children die due to zinc deficiency,12 while more than one million child deaths are attributable to stunting.13 Malnutrition does not affect all children equally: it tends to occur primarily in families confronting poverty, with risk factors like poor feeding practices and inadequate healthcare.14
Economic growth and social interventions have begun to reduce undernutrition in the last two decades, albeit slowly.15 Obesity, however, is increasing at an alarming rate, meaning many countries have the ‘double burden’ of dealing with both undernutrition and overnutrition.16 In Africa, for example, where rates of stunting remain high, the number of obese children under five nearly doubled between 1990 and 2014.17 Obesity’s overall impact on the global economy is already estimated to be $2 trillion, or 2.8% of global GDP – around the same cost to healthcare as smoking or armed conflict.18
KEY ISSUES
Breastfeeding Obesity Poverty Stunting
Policy Brief: Malnutrition in the Early Years
2020
What can policymakers do?
Many countries and institutions are scaling promising interventions with the support of the Scaling Up Nutrition (SUN) movement, a collaboration of 61 countries and four Indian states, along with businesses, UN agencies and international donors.19
Here are some interventions with potential: FORTIFY STAPLE FOODS like flour, rice and salt with micronutrients such as iron, iodine, folic acid and zinc. These products must be regulated, and given support to become competitive.20
Photo: Davidsonluna on Unsplash
ENCOURAGE BREASTFEEDING by giving mothers active support in the community and in the workplace. Read our Breastfeeding Policy Brief to find out how.
In Curitiba, Brazil, the government fixed the price of fresh fruit and vegetables to 40–45% below conventional retail prices for a special group of grocery shops and mobile markets. From 2006 to 2017, the number of people consuming five portions a day of fruit and vegetables rose from 34.8% to 45.5%.21
TAX UNHEALTHY PRODUCTS, like Mexico’s
2014 sugary drinks tax, which reduced purchases by 7.6%.22 However, evidence of its direct impact on obesity has been limited.23 SUBSIDISE HEALTHY FOOD options and improve access. It must be combined with other interventions, though: studies show access alone does not boost healthy eating.24 Integrate support and advice on nutrition and exercise into HEALTH AND EDUCATION SERVICES for young children, such as in health visits, nurseries and childcare centres.
Photo: Photo by Peter de Ruiter
Malnutrition is complex and requires comprehensive action. Importantly, caregivers like parents play a vital role in what and how they feed young children. Supporting them requires action from governments as well as the food industry itself.
Amsterdam is integrating obesity prevention into its home-visiting health system for parents and infants. Midwives and nurses identify risk factors for obesity, such as maternal health, then offer tailored support like dietary advice. The city’s obesity drive cut overweight and obesity in school-age children by 12% from 2012 to 2015, but not yet for under-fives.25
Improve nutritional choices with contextrelevant BEHAVIOURAL CHANGE interventions, from national campaigns to targeted programmes.
Despite these policy ideas, there isn’t yet a definitive set of interventions to deal with all types of malnutrition. In particular, attempts to decrease obesity in young children have achieved mixed results, with the evidence base still unclear.26 More action and experimentation is needed.
Policy Brief: Malnutrition in the Early Years
2020
CASE STUDY
Indonesia
Nutrition games in Indonesia IMPROVING DIETS BY CHANGING BEHAVIOURS
THE PROBLEM: In the East Java region, more than 40% of children under five suffer from malnutrition.27
THE SOLUTION: National TV commercials and targeted interactive “emo-demo” games in communities.
HOW DOES IT WORK? Working with the Indonesian government and the London School of Hygiene and Tropical Medicine, the Global Alliance for Improved Nutrition (GAIN) developed “emo-demos” (“emotional demonstrations”) in targeted communities. These interactive games help mothers associate positive nutritional behaviours, such as breastfeeding, with strong emotions. This was combined with a national mass media campaign, including television and social media, promoting messages like the importance of eating a balanced diet.
"The problem was not knowledge, it was actually behaviour."
Photo: GAIN/Andrew Suryono
- Ravi Menon, Indonesia Country Director at the Global Alliance for Improved Nutrition (GAIN)
THE IMPACT: Exclusive breastfeeding increased by 14%, and 13% more toddlers consumed diverse diets.28 250,000 women have been reached so far.29
Focusing on the East Java region, with a high population of malnourished under-fives, GAIN’s work has focused on five issues: anaemia during pregnancy, low breastfeeding rates, un-diverse diets for young children, unhealthy snacks and poor sanitation. Along with a national mass media campaign, the intervention looked to change behaviours through “emo-demo” sessions in local communities. Rather than handing out instructions, the aim of these games is to engage mothers emotionally. For example, blue lights are used to highlight bacteria on mothers’ hands, giving them a feeling of disgust which compels them to wash it off with soap. So far, the programme has reached more than 250,000 women in East Java and is being expanded to more districts. An independent evaluation found that children aged 6–23 months were significantly more likely to achieve minimum dietary diversity and consume iron-rich foods, while rates of breastfeeding also increased.30 Anaemia during pregnancy hadn’t yet improved, but that intervention had been active for 12 months, whereas the other four focus areas were evaluated over a two-year period. Indonesia’s national efforts have helped the rate of stunting start to drop in recent years.31 Though much more work needs to be done, this has been made possible by high-level political support: every district has to report on progress to central government. Policy Brief: Malnutrition in the Early Years
2020
READ MORE
The Lancet The Double Burden of Malnutrition https://www.thelancet.com/series/double-burden-malnutrition
UNICEF The State of the World’s Children 2019 https://www.who.int/mental_health/publications/mhgap_hig/en/
For: an in-depth look at the “double burden” from leading academics
For: a comprehensive report on child malnutrition around the world
Scaling Up Nutrition SUN in Practice
Guy's & St Thomas' Charity Bite Size: Breaking down the challenge of inner-city childhood obesity
https://scalingupnutrition.org/news/category/sun-in-practice/
For: practical tips and case studies for scaling up nutrition interventions
https://www.gsttcharity.org.uk/what-we-do/bitesize
For: the role of behavioural science in tackling inner-city childhood obesity
REFERENCES 1
Scorza, P. and Monk, C. (2019) Anticipating the Stork: Stress and Trauma During Pregnancy and the Importance of Prenatal Parenting, Zero to Three Journal, May 2019: 5-19. 2 The American Academy of Pediatrics (2012) Breastfeeding and the Use of Human Milk. Paediatrics, 129(3):827-841. Available at: https://pediatrics. aappublications.org/content/129/3/e827. 3 World Health Organization: Stunting in a Nutshell. Available at: https:// www.who.int/nutrition/healthygrowthproj_stunted_videos/en/ (accessed November 2019). 4 UNICEF (2019) The State of the World’s Children 2019. Available at: https:// www.unicef.org/media/60806/file/SOWC-2019.pdf. 5 Nyaradi, A. et al. (2013) The role of nutrition in children's neurocognitive development, from pregnancy through childhood, Front Hum Neurosci., 7:97. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607807/ 6 UNICEF (2019) The State of the World’s Children 2019. Available at: https:// www.unicef.org/media/60806/file/SOWC-2019.pdf. 7 Haire-Joshu, D. and Tabak, R. (2016) Preventing Obesity Across Generations: Evidence for Early Life Intervention, Annu. Rev. Public Health, 37:253–71. Available at: https://www.annualreviews.org/doi/pdf/10.1146/annurevpublhealth-032315-021859 8 UNICEF (2019) The State of the World’s Children 2019. Available at: https:// www.unicef.org/media/60806/file/SOWC-2019.pdf. 9 Ward, Z. J. et al. (2017) Simulation of Growth Trajectories of Childhood Obesity into Adulthood, N Engl J Med., 377:2145-2153. Available at: https:// www.nejm.org/doi/full/10.1056/NEJMoa1703860. 10-11 UNICEF (2019) The State of the World’s Children 2019. Available at: https:// www.unicef.org/media/60806/file/SOWC-2019.pdf. 12 Hefferon, K. (2019) Biotechnological Approaches for Generating ZincEnriched Crops to Combat Malnutrition, Nutrients, 11(2):253. Available at: https://www.mdpi.com/2072-6643/11/2/253/htm. 13 Myatt, M. et al. (2018) Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries, Arch Public Health., 76(28). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6047117/. 14 UNICEF (2019) The State of the World’s Children 2019. Available at: https:// www.unicef.org/media/60806/file/SOWC-2019.pdf. 15 UNICEF Data: Malnutrition. Available at: https://data.unicef.org/topic/ nutrition/malnutrition/ (accessed October 2019). 16 The Lancet Series (2019) The Double Burden of Malnutrition, Lancet, 395. Available at: https://www.thelancet.com/series/double-burdenmalnutrition.. 17 World Health Organization (2016) Report of the Commission on Ending Childhood Obesity. Available at: https://www.who.int/end-childhoodobesity/publications/echo-report/en/.
18
UNICEF (2019) The State of the World’s Children 2019. Available at: https:// www.unicef.org/media/60806/file/SOWC-2019.pdf. 19 The Scaling Up Nutrition (SUN) Movement (2019) Annual Progress Report 2019. Available at: https://scalingupnutrition.org/progress-report-2019/. 20 Bhutta, Z. A. (2013) Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet, 382:452–77. Available at: https://www.thelancet.com/pdfs/journals/lancet/ PIIS0140-6736(13)60996-4.pdf. 21 GAIN, MUFPP and RUAF (2019) A menu of actions to shape urban food environments for improved nutrition. Available at: https://www.gainhealth. org/sites/default/files/publications/documents/gain-mufpp-ruaf-a-menu-ofactions-to-shape-urban-food-environments-for-improved-nutrition-2019.pdf. 22 World Health Organization (2017) Taxes on sugary drinks: Why do it? Available at: https://apps.who.int/iris/bitstream/ handle/10665/260253/WHO-NMH-PND-16.5Rev.1-eng. pdf;jsessionid=08CC1961F5D18857260AEE6058BE9429?sequence=1. 23 Fernandez, M. A. and Raine, K. D. (2019) Insights on the Influence of Sugar Taxes on Obesity Prevention Efforts, Curr Nutr Rep, 8(4):333-339. Available at: https://link.springer.com/article/10.1007/s13668-019-00282-4. 24 Alviola IV, P. A. et al. (2012) Food Deserts and Childhood Obesity, AEPP, 35(1):106-124. Available at: https://academic.oup.com/aepp/article-abstract /35/1/106/8302?redirectedFrom=fulltext. 25 Graham, J. (2018) Childhood obesity is dropping in Amsterdam — but not for toddlers. Apolitical, 5 June. Available at: https://apolitical.co/ solution_article/childhood-obesity-is-dropping-in-amsterdam-but-not-fortoddlers/. 26 Waters, E. (2011) Interventions for preventing obesity in children. Cochrane Database Syst Rev., 7(12). Available at: https://www.ncbi.nlm.nih.gov/ pubmed/22161367. 27 GAIN (2019) Indonesia: improving child nutrition through behaviour change communication. Press release, 7 November. Available at: https://www. gainhealth.org/media/news/indonesia-improving-child-nutrition-throughbehaviour-change-communication. 28 Keats, S. (2019) The Baduta Programme in East Java, Indonesia, GAIN Working Paper. Available at: https://www.gainhealth.org/sites/default/ files/publications/documents/gain-working-paper-series-1-the-badutaprogramme-in-indonesia.pdf. 29-30 GAIN (2019) Indonesia: improving child nutrition through behaviour change communication. Press release, 7 November. Available at: https://www. gainhealth.org/media/news/indonesia-improving-child-nutrition-throughbehaviour-change-communication. 31 Fardah (2019) Indonesia prioritizes fight for healthy golden generation, Antara, 4 November. Available at: https://en.antaranews.com/news/135936/ indonesia-prioritizes-fight-for-healthy-golden-generation.
Policy Brief: Malnutrition in the Early Years
2020