Nature, Causes, and Burden of Undernutrition

The following section describes the magnitude, distribution, and etiology of growth faltering and specific micronutrient deficiencies in young children.

Growth Faltering

Because nutritional inputs are necessary for children's growth, undernutrition is generally characterized by comparing the weights or heights (or lengths) of children at a specific age and sex with the distribution of observed weights or heights in a reference population of presumed healthy children of the same age and sex and then calculating z-scores, that is, the difference between a child's weight or height and the median value at that age and sex in the reference population, divided by the standard deviation (SD) of the reference population. A child whose height-for-age is less than −2 SD is considered stunted, because the chances of the child's height being normal are less than 3 percent. A child whose weight-for-age is less than −2 SD is considered underweight, and one whose weight-for-height is less than −2 SD is deemed wasted. Stunting results from chronic undernutrition, which retards linear growth, whereas wasting results from inadequate nutrition over a shorter period, and underweight encompasses both stunting and wasting. Typically, growth faltering begins at about six months of age, as children transition to foods that are often inadequate in quantity and quality, and increased exposure to the environment increases their likelihood of illness.

Although knowledge about the prevalence of stunting and wasting is preferred, information about underweight is more available globally. The high correlation between stunting and underweight and the low prevalence of wasting mean that the prevalence of underweight directly describes the magnitude of the problem of growth faltering and stunting in young children. About 130 million children under the age of five are underweight, with the highest prevalences in South Asia and Sub-Saharan Africa (table 28.1). The prevalence of stunting, underweight, and wasting is decreasing in most areas of the world; however, in most of Africa, stunting is increasing.

Table 28.1

Estimated Prevalence of Selected Nutritional Deficiencies in Children Ages Birth through Four, by Region (percent).

Childhood malnutrition diminishes adult intellectual ability and work capacity, causing economic hardships for individuals and their families. Malnourished women tend to deliver premature or small babies who are more likely to die or suffer from suboptimal growth and development (Allen and Gillespie 2001). Poor early nutrition leads to poor school readiness and performance, resulting in fewer years of schooling, reduced productivity, and earlier childbearing. Thus, poverty, undernutrition, and ill-health are passed on from generation to generation. Undernutrition impedes economic progress in all developing countries.

Undernutrition raises the likelihood that a child will become sick and will then die from the disease. Morbidity and mortality are highest among those most severely malnourished; however, given the high prevalence of mild to moderate underweight, the mildly or moderately underweight individuals experience the greatest total burden of disease (Fishman and others 2004). Children whose weight-for-age is less than −1 SD are also at increased risk of death, and undernutrition is responsible for 44 to 60 percent of the mortality caused by measles, malaria, pneumonia, and diarrhea. Overall, eliminating malnutrition would prevent 53 percent of deaths in young children, with most of those deaths occurring in South Asia and Sub-Saharan Africa (table 28.2).

Table 28.2

Estimated Deaths of Children Ages Birth through Four Attributable to Selected Nutritional Deficiencies by Region (thousands).

Morbidity attributable to undernutrition depends on the nature of the illness. Susceptibility to a highly infectious disease such as measles is unlikely to be affected by nutritional status: all individuals are equally likely to become infected if they are unvaccinated and naive. However, 5 to 16 percent of pneumonia, diarrhea, and malaria morbidity is attributable to moderate to severe underweight (Fishman and others 2004). As table 28.3 shows, the number of disability-adjusted life years (DALYs) attributable to undernutrition is high and, as with mortality, is concentrated in South Asia and Sub-Saharan Africa. The tremendous costs associated with the care and treatment of childhood diseases that could be partially prevented through improvements in child nutrition have not been quantified.

Table 28.3

Estimated DALYs Lost by Children Ages Birth through Four Attributable to Selected Nutritional Deficiencies by Region (thousands).

Evidence is accumulating that early malnutrition increases the risk of numerous chronic diseases later (Caballero 2001; Gluckman and Hanson 2004). Associations of early undernutrition with diabetes, hypertension, renal disease, and cardiovascular disease mean that child undernutrition also leads to high adult health care costs.

Interventions

Clearly, growth faltering and micronutrient deficiency disorders are prevalent, have deleterious consequences for children's health and development, and are primary contributors to the global burden of disease. Economic development is not the only path to solving childhood undernutrition. Improvements in family income may not translate into increased food intakes because the income elasticity for caloric intake is relatively low. The effects on micronutrient deficiencies might be greater if the food sources of those nutrients (meat, seafood, eggs, fortified food products) were more sensitive to income increases and if children had access to those foods. Price subsidies may reduce undernutrition in young children if targeted to foods consumed by them; the potential contribution of price subsidies to family nutrition is discussed elsewhere (see chapter 11). This chapter focuses on specific public health measures that are intended to address the problems directly. Progress has been made in some areas, but the current magnitude of the problems and of the associated disease burden underscore the need for more investment in nutritional interventions.

Growth Faltering and Childhood Stunting

Infants and young children falter in their growth because of inadequate dietary intakes and recurrent infectious diseases, which reduce appetite, increase metabolic requirements, and increase nutrient loss. Even though this problem is understood, progress to reduce malnutrition has been slow. Over time, thinking on how to reduce growth faltering and childhood stunting has shifted. Whereas previous efforts focused almost exclusively on identifying and rehabilitating severely malnourished children, current efforts emphasize prevention through combined nutritional and disease prevention and treatment interventions.

Initially, these efforts to prevent undernutrition focused on diseases rather than on improved child feeding practices as such. However, according to Becker, Black, and Brown (1991), despite the devastating effects of illness on nutritional status, improving dietary intakes is more effective than disease prevention efforts in reducing undernutrition. Because of dramatic reductions in appetite during illness, efforts to improve dietary intakes initially focused on maintaining energy intakes despite anorexia and on increasing intakes during recuperation, when appetite may be normal or high. More recent interventions aim at feeding healthy children optimal diets, which includes paying attention to dietary quality. Finally, some have argued that, for nutritional advice to be effective, it needs to be provided alongside growth monitoring and promotion; however, it is increasingly recognized that messages for prevention are largely universal and that integrated growth monitoring and promotion are not the only model for service delivery.

Promotion of Optimal Feeding of Infants and Young Children

Much of the early focus on optimal feeding was on breastfeeding, which should be immediate and exclusive until six months of age. At that time nutritious and safe foods should be added to a diet that is still based on breast milk until early in the second year of life. A consensus has been reached that six months is the recommended duration of exclusive breastfeeding (WHO 2002) and that the total duration is a decision left to the mother.

Multiple approaches exist to promote the initiation of breastfeeding and to prolong exclusive breastfeeding—health education; professional support; lay support; health sector changes (for example, infant friendly hospitals); and media campaigns—through health facilities and community programs. A recent Cochrane review estimates the potential effectiveness of these approaches (Sikorski and others 2002). Women who received any form of support for breastfeeding were 22 percent less likely to stop exclusive breastfeeding, and women who received lay support, in particular, were 34 percent less likely to stop exclusive breastfeeding. Substantial evidence indicates that interventions can be effective in prolonging breastfeeding and exclusive breastfeeding and that operational research is needed for program implementation and sustainability. If such programs were fully successful, they would reduce deaths in children under five by 13 percent (Jones and others 2003).

Complementary feeding is the process of introducing other foods and liquids into the child's diet when breast milk alone is no longer sufficient to meet nutritional requirements. According to Brown, Dewey, and Allen (1998), complementary feeding practices are suboptimal from several perspectives:

• Complementary foods are introduced too early or too late.
• Foods are served too infrequently or in insufficient amounts, or their consistency or energy density is inappropriate.
• The micronutrient content of foods is inadequate to meet the child's needs, or other factors in the diet impair the absorption of foods.
• Microbial contamination may occur.

In addition, because children often do not eat all the food offered to them, interaction between the caregiver and the child, along with other psychosocial aspects of care during feeding, requires attention. The amount of complementary food a child needs depends on breast milk intake. Guidelines are available for determining energy and nutrient intakes from complementary foods, given breast milk intakes (Dewey and Brown 2003).

Several reviews of the multiple approaches to improving infant and young child feeding practices are available (Allen and Gillespie 2001; Caulfield, Huffman, and Piwoz 1999; Dewey 2002; Hill, Kirkwood, and Edmond 2004; Swindale and others 2004). Caulfield, Huffman, and Piwoz (1999) review 16 programs in 14 countries to improve dietary intakes of infants 6 to 12 months of age. The programs were designed to promote exclusive breastfeeding and appropriate feeding during illness up to age three, and the content and approaches reflected current thinking regarding nutrition and behavior change. The approaches employed included using the mass media to reach both caregivers and the population as a whole to change cultural norms about complementary feeding and using one-on-one or small group interactions with community health workers to provide individualized information and support.

Most of the projects achieved good coverage (50 to 70 percent), with rates varying depending on the communication strategy. They resulted in large shifts in maternal knowledge and attitudes and changes in infant feeding practices. In the few programs assessing dietary intakes, intakes improved by 70 to 165 kilocalories per day. Differences in nutritional status at 12 months indicated weight-for-age and height-for-age gains of 0.24 to 0.87 SD. Even with a 50 percent overestimation of the effects, the effect of such programs could translate into tangible reductions in malnutrition and attributable mortality. In addition, these calculations do not consider the cumulative reduction in malnutrition from programs that benefit children's growth into the second and third years of life. Jones and others (2003) use the results of the analysis, along with knowledge of the relationship between underweight and child mortality, to estimate that programs to promote complementary feeding could reduce by 6 percent the deaths of children under five in developing countries.

Many programs provide supplemental food to participants either to provide them an incentive for participating in other activities (to offset time costs and increase consumer demand for preventive services) or to rehabilitate severely malnourished children. Although the latter approach is traditionally considered for supplemental food programs, the former approach is more common. Indeed, India's Integrated Child Development Services Program, the world's largest supplemental food program, plans to shift from rehabilitation to the use of supplemental food as a "magnet" for providing other integrated child development services (Kapil 2002). No consensus exists on when or how to include supplemental food to reduce undernutrition, and inefficient targeting is frequently a key constraint to effectiveness. Swindale and others' (2004) review of the effectiveness of food-assisted child survival programs concludes that such programs are reducing malnutrition by 2.0 to 2.5 percent per year.

Despite evidence of the effectiveness of nutritional interventions in improving feeding practices and preventing undernutrition, few programs take a comprehensive approach toward optimizing infant feeding, perhaps because of a lack of consensus on the key components of a comprehensive strategy. In 2002, participants at a WHO consultation developed 10 guiding principles for optimal feeding of the breastfed child (PAHO and WHO 2003). These principles, outlined in box 28.1, build on lessons from previous programmatic efforts such as those reviewed here and provide a basis for designing comprehensive programs to reduce malnutrition. The international public health community faces the challenge of implementing and evaluating these approaches.

Box 28.1

Guiding Principles for Complementary Feeding of the Breastfed Child. Practice exclusive breastfeeding from birth to six months of age and introduce complementary foods at six months of age (180 days) while continuing to breastfeed. Continue frequent, (more...)

Disease Control and Prevention

Interventions to prevent or decrease malnutrition or infectious disease are expected to decrease child mortality, and interventions that accomplish both will have the greatest effect (Pelletier, Frongillo, and Habicht 1993). This subsection considers the potential for disease control and prevention efforts to reduce undernutrition in young children.

Malaria is responsible for a large portion of childhood mortality in Sub-Saharan Africa. The effect of undernutrition on susceptibility to malaria has been discussed at length elsewhere (Caulfield, Richard, and Black 2004), but the nutritional deficiencies resulting from malaria have been insufficiently explored. Insecticide-treated bednets have been shown to prevent clinical episodes of malaria and decrease the prevalence of anemia in children (Lengeler 2003). Improvements in growth have also been documented.

Water, sanitation, and hygiene interventions decrease childhood malnutrition primarily by preventing diarrheal disease (Checkley and others 2004). Hand-washing interventions can reduce the risk of diarrheal diseases by about 45 percent. Hand-washing interventions can be included in water and sanitation programs or can exist as a single intervention, and they are both effective and cost-effective (Borghi and others 2002).

Intervention Costs and Cost-Effectiveness

Multiple strategies exist for preventing malnutrition in young children in the short and long term. This section considers the costs and cost-effectiveness of these interventions for preventing malnutrition or deaths attributable to each nutritional problem. Table 28.4 presents a compendium of cost information, including, where possible, the costs of preventing a child death or saving a DALY.

Table 28.4

Costs and Cost-Effectiveness of Nutrition Interventions.

Horton and others (1996) use data from Brazil, Honduras, and Mexico to estimate the costs and cost-effectiveness of hospital-based programs to promote breastfeeding. Using standard costing methods, they examine the costs of breast-feeding promotion activities in each program and the additional inputs, as well as the savings. Savings accrued from the removal of infant formula where it was currently used. Using data on infant feeding practices and morbidity and mortality from Brazil, they estimated the costs of the programs per birth, per diarrhea case averted, and per death averted. As table 28.4 shows, the costs of such programs range from US$0.30 to US$0.40 per child, and from US$100 to US$200 per death averted, making them comparable in cost-effectiveness to measles and rotavirus vaccination. Assuming that deaths would otherwise have occurred around age one, and using average Latin American life expectancy at that age, yields a cost per DALY gained of only US$3 to US$7.

In many community-based strategies, multiple organizations work through a variety of communication channels to promote exclusive breastfeeding. Two studies in Ghana and Madagascar provide costs estimates for such programs (Chee, Makinen, and Sakagawa 2002; Chee and others 2003). The programs cost US$4 to US$16 per child, and given the effect on mothers' practices, the cost ranged from US$5 to US$58 per adopter of exclusive breastfeeding. In Ghana, an estimated 883 deaths were averted, yielding a program cost of US$7.80 per DALY gained or US$203 per death prevented. The range of costs within each program depended on the baseline prevalence of the behavior, the population density, and the characteristics of the implementing organizations themselves. Programs will be more cost-effective when the baseline prevalence is lower; the population density is higher; and the organizations involved are focused, highly motivated, and well organized.

Less information is available on the costs of community-based nutrition programs to prevent growth faltering, to control morbidity, and to improve survival. The costs of a program in Mali (Ross, Loening, and Mbele 1987), which included promotion of breastfeeding, counseling, and education on optimal child feeding; prevention of diarrheal disease; and growth monitoring, were estimated to be US$282 per death averted and US$11 per DALY gained. This estimate is consistent with others that nutrition programs cost US$2 to US$10 per child, depending on the intensity of nutrition counseling, including Fiedler's (2003) study of the Integrated Community Child Care Program in Honduras, which had an estimated cost of US$4 per child. (For a fuller analysis of such programs, including contextual and programmatic characteristics that affect outcomes, see chapter 56.)

In the past five years, investigators have undertaken several cost analyses of national programs to distribute vitamin A capsules. Two reports from Ghana and Zambia are particularly informative (Rassas, Hottor, and others 2004; Rassas, Nakamba, and others 2004). As table 28.4 shows, such programs cost US$0.90 to US$1.23 per child, with the costs per death averted ranging from US$162 to US$277. (Deaths from micronutrient deficiencies are assumed to occur between ages one and five, and estimates of cost per DALY ranging from US$6 to US$11 reflect this range, as well as region-specific life expectancies at those ages.) These costs are comparable with estimates of a vitamin A program in Nepal that cost US$1.25 per child and US$327 per death averted (Fiedler 2000). Ching and others (2000) examine the costs of incorporating vitamin A capsule distribution into immunization campaigns in 50 countries in 1998 and 1999. Their analysis finds that the total costs per death averted ranged from about US$150 to US$600, with the incremental costs for vitamin A distribution amounting to only about US$30 to US$150 per death averted. The costs per death averted depended on the country setting, the program's coverage, the delivery of vitamin A (one or two doses), and the underlying level of mortality. The incremental cost per DALY gained could be as low as US$1 or as high as US$6.

Fewer examples of vitamin A fortification programs are available, with the only clear example being sugar fortification in Central America. In 1994, estimates indicated that a program in Guatemala cost US$0.17 per child, and US$1,000 per death averted. Counting only the losses from mortality, the cost of saving a DALY was US$33 to US$35. However, for each death prevented, there were probably several cases of eye damage prevented and of improved general health; thus, taking full account of nonfatal effects would reduce the cost per DALY somewhat.

Iron supplementation is more costly than distribution of vitamin A capsules, as it involves a daily supplement over an extended period. Estimates indicate that such programs cost US$3.17 to US$5.30 per child. Numerous cost estimates are available for iron fortification programs, because these programs have been the principal strategy to prevent and control iron deficiency anemia. Such programs have traditionally cost US$0.09 to US$1.00 per child, depending on the country and the vehicle for fortification. These estimates are based on elemental iron as the fortifier. Even though this is the cheapest form available, critics have questioned the bioavailability of elemental iron, and many researchers now advocate using other forms of iron.

Iodine fortification programs cost little, about US$0.02 to US$0.05 per child. Iodized oil injections are more costly at US$0.80 to US$2.75 per beneficiary, but these programs may be recommended for settings where people consume little commercialized and easily fortified food.

Currently, no examples of zinc intervention programs are available from which to estimate cost-effectiveness. However, Robberstad and others' (2004) simulation analysis examines the potential costs and cost-effectiveness of providing zinc as an adjunct to oral hydration salts in treating diarrhea in young children. Providing zinc as part of case management carries an estimated incremental cost of US$0.47 per treatment, ranging from US$0.33 to US$0.62. Given the relationship between zinc provision and mortality risk, this addition to current management programs would cost, on average, US$2,100 per death adverted and US$73 per DALY gained.

Despite the enormity of the nutritional problems, the associated loss of DALYS, and the existence of programs to combat malnutrition, surprisingly little data on the costs or cost-effectiveness of nutritional programs are available. This problem represents a serious gap in information for health planning, implementation, and advocacy. Nonetheless, considerable evidence indicates that when programs to promote breastfeeding or child growth or to correct micronutrient deficiencies are delivered to populations with a relatively high prevalence of malnutrition, the cost per participating child is usually so low that deaths can be averted at a cost per DALY that is less than US$100, and often less than US$10, even in regions with low life expectancy. Few health interventions are comparably cost-effective.

Economic Benefits of Intervention

The previous sections outlined the costs to society in terms of deaths and disabilities resulting from growth faltering and micronutrient malnutrition, as well as the costs and cost-effectiveness of options for their alleviation and prevention; however, DALYs do not capture the full range of potential benefits to society from effective nutrition programs. For example, even though the effect of iron deficiency on mental retardation in children contributes to the attributable DALYs (Stoltzfus, Mullany, and Black 2004), the negative effects of iron deficiency on cognition that do not constitute retardation are not considered. Other effects of malnutrition on cognitive and physical functioning that ultimately affect labor productivity are also not considered, nor are other long-term health consequences of child undernutrition. Finally, because undernutrition increases the frequency and severity of disease, undernutrition is associated with considerable health care costs, which are also not captured in burden estimates.

Program Implementation: Lessons of Experience

For decades, countries have implemented programs to alleviate growth faltering and micronutrient deficiencies in children; therefore, it is timely to consider what has been accomplished and what can be learned from successes and failures. The task is difficult, because nutrition programs are diverse, ranging from the simple fortification of salt with iodine to multifaceted programs to improve dietary intakes and prevent growth faltering. Nonetheless, some general statements about the state of programming in this area are possible.

Success in conceptualizing and implementing programs to reduce growth faltering by combining disease control strategies with the promotion of breastfeeding and optimal complementary feeding has been demonstrable. The focus has shifted away from growth monitoring and promotion (counseling) strategies to population-based assessment with more generalized dissemination of key messages for behavior change. Available data suggest high cost-effectiveness for such programs. Key challenges involve scaling up and sustainability, as well as strengthening of monitoring and evaluation systems. A gap in this knowledge concerns optimal feeding in the presence of HIV infection, and testing options and designing programs in such settings are of the highest priority.

Iodine fortification has been a clear success over decades, which underscores the need for continued and consistent funding and advocacy for such programs. Even when universal access to iodine becomes a reality, policy and programmatic supports will be necessary to maintain it.

The success of iodine fortification contrasts with other examples of fortification that have made slow and uneven progress. Fortification of foodstuffs with vitamin A is limited geographically, and even though many countries have embarked on iron fortification, these programs lag because of controversies about the effectiveness of existing programs, the evaluation methods used, and the lack of infrastructure for fortification in some settings. Concerted efforts to address the controversies and to provide evidence of the effectiveness of fortification in controlling iron deficiency are under way. In addition, recognition that fortification should address multiple micronutrient deficiencies, chiefly the B vitamins and zinc, has grown.

Programs to distribute vitamin A capsules twice a year are a reality in many areas characterized by VAD. Jones and others (2003) estimate that current coverage of supplementation for children living in areas with VAD is 55 percent. In the past few years, studies have provided solid data on the costs and cost-effectiveness of such programs in diverse settings.

In contrast, despite concerns about the health and developmental consequences of iron deficiency and anemia, few examples are available of even small-scale iron supplementation programs for young children. Supply and adherence continue to constrain progress, with adherence depending on program workers' and families' perceptions of benefits and their reluctance to continue the long-term use in children of what are often considered to be medicines. Similar constraints apply to programs to provide iron supplements to pregnant women, but operational research has overcome many obstacles, and the hope is that the lessons learned can inform the design and implementation of iron supplementation programs for young children.

Food-based strategies, particularly dietary diversification and the promotion of specific food groups for preventing micronutrient malnutrition, are less advanced than other programs. In part, this lack of advancement reflects the diverse nature of the behaviors to be changed and of the available options. Given this diversity and the fact that such strategies are more setting specific than, for example, capsule distribution, the lack of summary estimates of effectiveness is not surprising. Consensus is growing that improving dietary intakes through agricultural innovations and dietary diversification represents long-term answers to micronutrient malnutrition, but progress is slow because of the urgency of alleviating deficiencies in the short term. More research is needed to define the policies that will promote these strategies.

Research over the past decade has articulated a strong case for interventions to prevent zinc deficiency, with supplementation and fortification identified as important approaches. Experiences with zinc supplementation or fortification programs are needed to provide estimates of costs and cost-effectiveness. If the costs of providing zinc supplements to young children are in line with those reported earlier, then such programs would be highly cost-effective, considering the prevalence and burden of disease associated with zinc deficiency.

Child malnutrition results from multiple factors, and even though each context has its own unique features, the etiology has many more commonalities. Thus, for program planners and policy makers intent on alleviating malnutrition to begin designing and implementing programs in their particular settings from scratch is strikingly inefficient. In the past decade, this point has been recognized, and documents that articulate processes for program implementation and evaluation have mushroomed. These "road maps" permit policy makers and program planners to capitalize rapidly on interest in addressing nutrition problems. The road maps also communicate a sense of feasibility by streamlining the complex processes of program design and evaluation. Thus, their use can reduce the likelihood that programs will be diffuse (too many inputs), will be culturally inappropriate, will have unrealistic expectations, and will have no possibility of sustainability and no plans for process or impact evaluation.

Demonstrating that nutrition programs are effective is key to translating scientific findings into policies and programs as well as to ensuring the continuity and expansion of funding. Despite decades of nutrition programs, with identifiable successes, uncertainty about their effectiveness persists. The value of publishing solid process and outcome evaluations in the scientific literature in addition to project reports has only recently been recognized and cannot be overstated. Whereas outcome evaluations provide data on program effects, process evaluations provide key information to maintain quality assurance and to support the plausibility of key outcomes. Consensus is growing on the need to evaluate a package of services rather than use complex strategies to tease apart the effects of specific program elements. Well-designed programs with process evaluation efficiently provide this information.

Although following standard scientific approaches to establish program effectiveness has enabled progress in many interventions, alternative designs can and should be used for this purpose. Scientists traditionally argue that randomized controlled trials are needed to establish causal evidence of effectiveness and that multiple trials are needed in diverse settings, perhaps followed by pooled or meta-analyses to provide summary estimates. Others argue that designs that provide plausible evidence of program effects or adequate information to support continued funding should be recognized as valid by funders and publishers in refereed journals and should be implemented more broadly (Victora, Habicht, and Bryce 2004).

Research and Development Agenda

Despite progress, much work remains unfinished. Other chapters focus on research and development needs in relation to packaging services, scaling up, and ensuring sustainability. Here the focus is on research for strengthening the database for policy making.

Gaps in knowledge remain with respect to recognized strategies for intervention programs. Often information on intervention efficacy exists, yet little scientific literature on program effectiveness is available. Key gaps include the following:

• evaluation of the effectiveness of national iron fortification programs to reduce iron deficiency anemia
• implementation and evaluation of the effectiveness of iron supplementation programs for young children
• evaluation of the effect on child mortality of multifaceted programs to reduce child undernutrition
• evaluation of the effectiveness of programs based on the new guiding principles for reducing undernutrition and micronutrient malnutrition in young children
• implementation and evaluation of the effectiveness of food-based strategies to reduce micronutrient malnutrition
• implementation and evaluation of the effectiveness of early postnatal vitamin A supplementation to reduce infant mortality.

Costing studies should accompany the evaluations to allow estimates of cost-effectiveness for decision making.

Because of the logistical difficulties in developing fortification approaches in settings with little industry infrastructure, alternative fortification approaches are needed, such as micronutrient sprinkles or foodlets. In addition, operational research is needed to develop, implement, and evaluate programs to improve zinc status. Never has so much evidence been amassed on the consequences of a deficiency disorder without programmatic application. The challenge now is to develop and implement programs for preventing and treating zinc deficiency and to evaluate their effectiveness for child growth, health, and survival. The International Zinc Nutrition Consultative Group (2004) has laid out a research agenda with these aims in mind.

Conclusions

Undernutrition is a major cause of death and disability in young children. When ranked among other causes, growth faltering and micronutrient deficiencies figure prominently, both because they are prevalent and because their consequences are devastating. Not included in the numbers, however, are the losses of lifetime productivity associated with early malnutrition and the resources that must be allocated to confront the developmental and morbidity consequences of child malnutrition, which last a lifetime.

Success has been achieved in preventing and controlling iodine deficiency, and palpable progress has been made in the past 20 years in correcting vitamin A deficiency and promoting breastfeeding; however, for iron, articulated goals have not been translated into programs, and the problem has remained the same or worsened. Zinc deficiency is now recognized as an important new challenge.

As shown here, solid evidence shows that nutrition programs can be effective at addressing nutritional problems in young children. Increasingly available cost data, when combined with outcome evaluations, demonstrate that nutritional interventions rank favorably in terms of cost-effectiveness when compared with competing interventions. The case that further investment in nutrition interventions is warranted is thus compelling.

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