POLICY AND PROGRAM BRIEFS

Six policy and program briefs follow. The first describes the impressive efforts that Nepal has undertaken to
address micronutrient deficiencies, despite being a very poor country. The second discusses an effort in
Kenya to launch a flour fortification effort in an exceptionally short period of time, despite many years of not
having done so previously. The third brief illustrates the long-term impact of nutrition supplementation. It
reviews the findings of a study on Guatemala that examined the long-term impact of improved nutrition on
the stature, intellectual abilities, and wages of adults. The fourth discusses South Korea’s efforts to encourage
the maintenance of traditional diets. The fifth reviews a program in Brazil for encouraging physical activity.
The last examines efforts by Finland to reduce salt consumption.
Nepal Addresses Micronutrient Deficiencies
Many Nepali families lack the income needed to consistently buy nutrient-rich foods. Many families also lack
the knowledge of a healthy diet needed to ensure their children are well nourished. These issues have resulted
in high rates of undernutrition and micronutrient deficiencies, particularly in women and children.111
In the 1990s, for example, more than half of the under-5 children in Nepal were stunted.111,112 In addition,
nearly 75 percent of pregnant women and over half of all children were anemic. The coverage of nutritional
programs was low. Many pregnant women did not receive iron and folic acid supplements,111 and there was
little fortification of food.
Policy and Program Briefs 211
 More recently, however, Nepal has become a leader in addressing micronutrient deficiencies. To address
anemia, the government initiated the National Anemia Control Strategy and Iron Intensification Program in
2003, with support from WHO, UNICEF, and the Micronutrient Initiative. This program provides iron
supplements for pregnant women distributed by female community health volunteers, in addition to
deworming services, maternal care, and fortified foods. A monitoring system was established to identify
pregnant women as soon as possible and to ensure that women fully participate in the recommended services.
In addition, the United States Agency for International Development (USAID) and the Ministry of Health
collaborated to integrate zinc into the national diarrhea management plan. In 2006, only 0.4 percent of
caregivers provided zinc during any bout of diarrhea in the previous 2 weeks. To increase the use of both oral
rehydration therapy (ORT) and zinc when treating diarrheal disease, USAID has supported training for
private sector healthcare providers. In addition, efforts were undertaken to increase the availability of zinc in
the private sector. Linked with these efforts, public and private sector programs to increase the use of zinc
reached 65 percent of the population by 2009.112 The Micronutrient Initiative has also helped the
government to improve popular knowledge and awareness about zinc through local radio advertising, the
delivery of zinc in the public and private sectors, and has helped to strengthen the monitoring and reporting
system for zinc usage and the zinc supply chain.113
Vitamin A tablets are being distributed to children twice a year to help enhance children’s immunity,
prevent night blindness, and reduce morbidity and mortality from measles, pneumonia, and diarrhea. The
Micronutrient Initiative has also helped the government to pilot a vitamin A supplementation program for
newborns.113
Community health worker volunteers (CHWV), usually women who live in the community, play an
important role in implementing these programs. They administer the needed supplements in their
communities, recording the children or women who receive the supplements. Additionally, the CHWVs
spend time educating parents, particularly women, on nutrition topics such as the importance of eating
nutrient-rich foods and micronutrient supplements, good hygiene habits, and breastfeeding.114
Nongovernmental organizations (NGOs) have played an important role in addressing issues related to
micronutrient deficiencies by helping to train CHWVs to perform the tasks mentioned previously.114
The collaborative efforts of the government, NGOs, community volunteers, and Nepal’s development
partners have led to a number of successes. By 2009, over 80 percent of pregnant women were receiving iron
and folic acid supplements, and anemia had dropped 35 percent among these women. The usage of zinc had
increased from less than 1 percent in 2005 to nearly 16 percent in 2008, with 85 percent of users correctly
taking zinc and oral rehydration salts together, and 67 percent correctly taking zinc for the recommended 10
full days.114 By 2009, there was also 95 percent coverage of vitamin A supplementation among children.111
Linked to these efforts on micronutrient supplementation, among other programs, Nepal saw a decrease in
mortality of children under the age of 5 from 142 per 1,000 in 1990 to 51 per 1,000 in 2009.113
Nepal has demonstrated that it is possible for a country with limited finances to carry out cost-effective
programs to address micronutrient deficiencies with substantial results. This has been achieved in Nepal
largely through strong political support, the use of community health worker volunteers, effective spread of
knowledge about the importance of micronutrients, and careful program supervision and monitoring. It has
also been assisted by close collaboration with a number of Nepal’s development partners.
Rapid Results Initiative for Food Fortification in Kenya
For many years, African countries have fortified salt with iodine and have even made salt fortification a
requirement. However, progress on food fortification in the Africa region has been relatively slow and in
2011 there were no requirements in the region for the fortification of other foods. This is despite the
substantial nutritional gaps in Africa that could be addressed at least partly through fortification.115
Until recently, Kenya was among the countries that had successfully fortified salt but had not fortified other
staple foods. The failure to move on fortification stemmed at least partly from difficulty in getting the public
and private sectors to work together on fortification. In order for fortification to succeed, these parties must
collaborate, because both play an important role in food fortification. The public sector is responsible for food
safety. The private sector is responsible for producing and selling the fortified foods.116
The Kenyan National Food Fortification Alliance (KNFFA) was established to mobilize food companies and
government organizations to fortify foods.116 Initially, the process proved to be slow and little progress was
made. Food companies felt that the government would not create and monitor food standards and the
government felt that food companies would not willingly fortify foods.
To help overcome these barriers, the KNFFA leadership decided to collaborate with the Micronutrient
Initiative (MI) and the Rapid Results Institute (RRI) to produce a fortified
CHAPTER 8 Nutrition and Global Health 212
 food in 100 days or less. The MI is a nonprofit organization based in Canada that is the leading global
agency focusing exclusively on addressing micronutrient deficiencies, particularly in poor women and
children in low-income countries. The RRI is a nonprofit organization that focuses on helping countries
achieve rapid and sustainable results in key areas of health, education, water supply, and related social
investments.
In order to move ahead on a fortification program, the stakeholders were brought together to address
concerns surrounding food fortification, such as quality standards and standard enforcement, and to invite
participation in the project. Second, a training meeting was held for stakeholders, such as food companies and
government organizations. During this time, goals were set: in 130 days, a fortified food certification process
would be developed and three brands of edible oils would be fortified with vitamin A.115,116
Through this effort, Kenya was able to meet its goal and achieve in a very short amount of time what it
had not been able to do at all previously. By the end of the 130 days, three brands of oil, or 15 percent of the
edible oil market, met international standards for vitamin A fortification in edible oils. Additionally,
fortification standards, a fortification certification process, and a fortification logo, which can be put on a
product to show that it meets standards, were developed.116 The Kenya Bureau of Standards monitors food
fortification standards and the Ministry of Health now regulates the certification process.116 As a result of the
initiative, there has been increased collaboration and trust between the public and private sectors, laying the
foundation for future fortification of additional staple foods.
Childhood Nutrition Supplementation and Adult Productivity in Guatemala
A number of countries have undertaken efforts to provide supplementary food to undernourished children.
Some of those programs, such as the Tamil Nadu Nutrition Project, have been evaluated carefully. However,
very rarely has anyone followed for more than 2 decades the children who participated in a supplementary
feeding program in order to gauge long-term program impact in adulthood. One such study was done for a
program in Guatemala, as described in this section.
In four Guatemalan villages between March 1, 1969, and February 28, 1977, the Institute of Nutrition of
Central America and Panama (INCAP) initiated the first phase of a study on nutrition supplementation and
child development among 2,392 children who were under the age of 7. Researchers randomly assigned one of
two treatments to each of the children. In two villages, children were offered a dietary supplement called
“atole” that provided protein and energy. This supplement consisted of dry skim milk, Incaparina (a protein
mixture), and sugar. In the other two villages, children were offered a supplement called “fresco.” Unlike
atole, fresco did not provide fat or protein and offered only minimal energy. Both supplements were equally
fortified with micronutrients before being distributed twice daily from a central location in each village.117
The study followed the cohort of children over time and compared the effects of the nutritional supplement on
schooling, adult intellectual functioning, child birthweight, and individual productivity. As part of this effort,
between 2002 and 2004—25 years after the nutrition supplementation ended—researchers, in collaboration
with Emory University, surveyed 1,448 of those who participated in the original study as children.117 In
order to measure literacy and reading comprehension, the InterAmerican Series Test was used. The Raven
Progressive Matrices Test was used to determine cognitive development.
Children who had received the supplement of protein and energy, atole, scored higher on both tests as adults
than those who received fresco. Among men, there was no significant relationship between the type of
supplement taken and the amount of school completed. However, women who received atole completed 1.2
more years of school than the other women.53 Overall, after controlling for the number of years of school
completed, it was found that receiving the atole supplement was positively related for both men and women
to higher adult intellectual functioning.117
Researchers also examined the relationship between economic productivity of individuals, measured through
their wages, and which of the supplements was given in the INCAP nutrition intervention. Boys who were
under the age of 3 when they first received atole had 46 percent higher wages as adults, compared to the boys
who received fresco in the original study. There was no significant increase in economic productivity in
women who received one supplement, compared to the other group.118
However, a girl’s involvement in the INCAP intervention positively affected her offspring. Compared to
those who received fresco, women who had received atole as children were found to have babies, especially
sons, with a higher birthweight, a larger head circumference, and a greater height at birth. Additionally, their
offspring had greater height-for-age and weight-for-age.119
Overall, this study has helped to shed light on the value of nutritional supplementation among children. The
protein- and energy-based atole nutritional supplement resulted in
Policy and Program Briefs 213
 higher literacy rates and cognitive development among men and women, higher employment wages for
men, and offspring with a higher birthweight. This study further supports the premise that some forms of food
supplementation in the early years of life can affect the remaining years of life in substantial and positive
ways.
South Korea’s Promotion of and Adherence to a Traditional Diet
South Korea’s economy grew rapidly after its recovery from the Korean War (1950–1953).120 This growth
was accompanied by changes in lifestyle, including the rapid introduction of a more Western diet; fast-food
restaurants in particular were popular among the younger generation, especially after the country hosted the
Olympics in 1988.121 A transition in the cause of death from communicable to noncommunicable diseases is
estimated to have occurred in South Korea around 1970, compared with 1940 for the United States and 1950
for Japan.122
Unlike other Asian countries, however, South Korea maintained many of the aspects of its low-fat, high-
vegetable traditional diet through its economic and nutrition transition. Based on its level of economic
development, a 1998 dietary evaluation found that South Korea had lower than expected levels of fat intake
(by 16.7 percentage points) and obesity prevalence, found to be largely due to government programs
encouraging the retention of the traditional South Korean diet.120
The Korea Dietetic Association (KDA), a private organization, provided nutrition education through
seminars and obesity camps, aided nutrition services at local health centers, and offered nutrition information
for citizens on its website.120 The KDA also monitored food and nutrition advertising disseminated through
mass media and organized national nutrition campaigns.120 The association also provided a variety of
traditional menus to elementary schools, along with letters about preserving traditional dietary culture to
students’ homes. It also held lectures for parents.123
The combination of these efforts led to a retention of the traditional Korean diet and subsequent positive
health outcomes. Vegetable consumption in South Korea was among the highest in Asia in 1998, comprising
around 20 percent of total food consumption (280 grams daily per capita).120 Kimchi remained the most
consumed food after rice, accounting for approximately 40 percent of the total vegetable intake.124 In
addition, the daily per capita intake of fruits in South Korea increased significantly during the economic
transition period; the increase was especially rapid in the 1990s. In 1998, 197.5 grams of fruits were
consumed daily per capita, more than a tenfold increase from the 18.9 grams consumed in 1970.120
Daily per capita fat intake in South Korea more than doubled from 16.9 grams in 1969 to 41.5 grams in 1998,
and animal fat increased from 30.6 percent of total fat consumed in 1970 to 48.2 percent in 1998.120
However, the proportion of fat-derived energy was still significantly lower than in other Asian countries, in
part due to a traditional cooking style involving small amounts of oil.121 Furthermore, the majority of meat
consumed was cooked in a Korean style, as opposed to a Western style, and was typically accompanied by
vegetables.120
Obesity rates in South Korea in 1998 remained quite low, at 1.7 percent for men and 3.0 percent for women.
These rates were much lower than Western and other Asian countries.120 Obesity rates in Korea today
remain among the lowest in the Organisation for Economic Co-operation and Development (OECD), at 4
percent of the adult population. However, 30 percent of the population is overweight, and OECD projections
indicate that rates of overweight will increase by a further 5 percent within 10 years.125
Through this initiative, South Korea has demonstrated the potential for effective public/private collaboration
in the pursuit of a healthy diet. Using a combination of information dissemination and provision of skills, the
country was able to adapt its message to contemporary society and successfully retain its traditional diet,
preventing the spread of obesity.
Brazil: The Agita São Paulo Program Uses Physical Activity to Promote Health
Starting in the 1970s, Brazil began experiencing rapid economic growth and major socioeconomic shifts,
resulting in lifestyle changes promoting obesity and overweight. By 1990, 69.3 percent of the adult Brazilian
population led a sedentary lifestyle.126
After 2 years of preparatory consultation with the Pan-American Health Organization and other international
agencies, the Agita São Paulo Program was launched in 1996 to address São Paulo’s growing problem of
obesity and overweight. The objective was to increase the level of knowledge among the São Paulo
population about the importance of physical activity by 50 percent and the level of actual physical activity by
20 percent over a period of 10 years.127 School children, the workforce, and the elderly were the main
targets. The program concentrated on feasible, low- or no-cost ways to achieve at least 30 minutes of
moderate-intensity physical activity per day, most days of the week. The goal was to convince the population
that this physical activity could come from routine, daily activities such as walking to and from
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 work or household chores, as opposed to less convenient exercises more likely to cause injury, such as
structured fitness programs in gyms or organized sports.127
The program was structured as a partnership between government, industry, nongovernment
organizations, and academic communities. Coordinated by the Studies Center of the Physical Fitness
Research Laboratory of São Caetano do Sul (CELAFISCS), it was largely funded by the São Paulo State
Secretariat of Health.127 It was an extremely cost-effective program. Its annual budget ranged from $150,000
to $400,000, representing an investment of less than $0.01 per state inhabitant per year. In contrast, the
estimated costs of illness related to a sedentary lifestyle in the state were about $1.00 per person per year.128
The program was overseen by a scientific board and an executive board. The scientific board consisted of
Brazilian and international academics and doctors and provided the program’s scientific foundation, assessed
its implementation, and allowed it to better integrate with the medical community.127 The executive board
included more than 300 governmental, nongovernmental, and private organizations representing a wide range
of sectors. These organizations were directly responsible for planning, organizing, and carrying out the
program’s activities.129
The program used three main types of activities to reach its target groups of students, workers, and the
elderly: mega-events, actions carried out with partner institutions, and partnerships.127 Mega-events were
intended to reach the majority of cities in São Paolo state and involved at least a million people. Often
coinciding with major cultural or seasonal holidays, they raised awareness of the importance of an active
lifestyle through their activities and broad media coverage. Different mega-events were tailored to promoting
specific activities for students, workers, and the elderly, but the most popular was “Agita Galera” (“Move,
Crowd” or “Active Community Day”). It was celebrated across the 6,800 public schools in the state, reaching
6 million students and 250,000 teachers. Schools received a handbook and poster, as well as flyers for
students and their families communicating the program’s message. Students were also encouraged to prepare
their own materials on the subject of physical activity and spread the message of the program in their
communities while getting exercise. Partner institutions were also crucial to the program’s success. The
diversity in focus and type of partners encouraged innovation and a greater exchange of ideas for new
activities. Each partner used a variety of pamphlets, manuals, advertising tools, and scientific information to
promote physical activity among their employees and the communities they served. Finally, the program
partnered with more than 50 municipalities to establish 50 municipal communities throughout the state, that
each planned, implemented, and monitored physical activities in their area.127
Various evaluations of the program were conducted and found positive effects for both increasing physical
activity awareness and physical activity itself. Over a 3-year period, recall of the main program objective rose
from 9.5 percent to 24.0 percent across the states. Recall increased with socioeconomic status level, reaching
67 percent of the most educated.127 Furthermore, people who were aware of the program were more likely to
be physically active; 54.2 percent of those familiar with the program were physically active in 2002, versus a
rate of 31.9 percent for those who were not familiar with the program.13 An analysis supported by the World
Bank, the Centers for Disease Control and Prevention, and CELAFISCS concluded that the program was a
good public health investment, achieving a cost-effectiveness ratio of less than R$50,000/QALY (quality-
adjusted life year).128
Agita São Paulo has been a role model for similar local and national programs across Brazil and in other Latin
American countries.128 The World Health Organization has praised it as a model for other low- and middle-
income countries, and it has since spurred an international mega-event celebrated annually to promote
worldwide physical activity.127
Finland Uses Labels to Reduce Salt Consumption
Finland has traditionally had a diet high in salt, as it was used for conservation of food before other methods
were available.130 In the 1970s, Finnish salt intake was estimated to be approximately 12 grams per day
(4,800 mg/day sodium), more than twice the value recommended by the World Health Organization, putting
the population at risk for hypertension, stroke, and coronary heart disease.131 This high intake spurred
Finland’s National Nutrition Council to recommend in 1978 steps to reduce salt consumption
nationally.132,133 From 1979 to 1982, a community-based intervention to reduce population-wide sodium
intake called the North Karelia project was conducted to reduce mortality associated with cardiovascular
disease.
Multiple stakeholders were involved with the project, including health service organizations, schools,
nongovernmental organizations, media outlets, and the food industry.130 The project was expanded to span
the entire country after 3 years. Finnish media aided the effort by releasing numerous reports on the harmful
health effects of salt, which raised both public and government awareness of salt and lower-sodium alterna-
tives.134 Health education of consumers and training programs for healthcare professionals, teachers, and
caterers on how to reduce salt were also important components of the project.130
Policy and Program Briefs 215
 Building on the momentum from this movement, a number of labeling systems were
implemented to inform consumers and discourage them from consuming high amounts of
sodium. In 1993, the Ministry of Trade and Industry and the Ministry of Social Affairs and
Health implemented salt-labeling legislation for food categories that contribute high amounts of
sodium to the diet, such as breads, sausages and other meat products, fish products, butter, soups
and sauces, ready-made meals, and spice mixtures containing salt, requiring that such foods be
labeled with percentage of salt by weight.135 The legislation required a “high salt content” label
on foods with high levels of sodium, while allowing low sodium foods to carry a “low salt”
label.132,134 In 2000, the Finnish Heart Association began putting a “Better Choice” label on
low-sodium products, and the Pansalt logo was used on products with sodium-reduced,
potassium- and magnesium-enriched mineral salts.132,134 It is estimated that these labeling
initiatives caused the industry to reduce the salt content of targeted foods by about 20–25
percent.136
Salt intake was monitored using urinary sodium excretion every 5 years. By 2002, mean
sodium intake was 3,900 mg/day for men and 2,700 mg/day for women. Diastolic blood pressure
also decreased substantially, by more than 10 mm Hg.130 This was caused by a combination of
consumers choosing lower-sodium products and food companies discontinuing or reformulating
their products to avoid high-salt labels through the use of alternatives such as mineral
salts.132,136 There was an 80 percent reduction in death rates from stroke and heart disease
among the middle-aged population, contributing to a reduction in overall mortality in Finland
and an increase in life expectancy by several years for both men and women.136

CASE STUDIES
There are a number of investments in improving nutrition status on a large scale that have made
a significant difference to the communities in which they took place. One of the best known is
the Tamil Nadu Nutrition Project in India. China has also made considerable progress in the last
10 years in controlling iodine deficiency.
137
Tamil Nadu State, India
Background
The Tamil Nadu Integrated Nutrition Project in India is one of the most important efforts ever
undertaken to improve nutritional status on a large scale. This project began in 1980 in the South
Indian state of Tamil Nadu. It aimed at improving the nutritional status of poor women and
children in the rural areas of the state through a set of well-focused interventions.
These specific goals were set for several reasons. First, the levels of malnutrition in poor women
and children in Tamil Nadu were very high at the time the project was conceived. Second,
malnutrition persisted despite considerable investments that had already been undertaken to
improve nutrition status. Third, studies that had been done on those investments showed that they
were not working as planned and were not cost-effective. Rather, the children who needed
assistance most were not getting it. In addition, food that was given to children at feeding centers
that was meant to be supplementary to their regular diet often replaced their regular food or was
taken home and consumed by family members other than the intended children. The form of the
food supplement was also difficult for children to eat. Moreover, little attention had been paid to
nutrition education for families or to health investments that could complement the investments
made in nutrition.
The project design was based on the idea that much of the malnutrition present in Tamil Nadu
was because of inappropriate childcare practices, rather than just a lack of money to buy food.
Thus, the project focused considerable attention on nutrition education and efforts to improve
care and feeding practices for young children. In addition, because deficits at an early age often
produce irreversible damage to children’s physical and mental development, project
interventions focused on pregnant and lactating women and on children younger than 3 years of
age.
The Intervention
In line with this approach, the project included a package of services that were delivered by
health and nutrition workers that consisted of nutrition education, primary health care,
supplementary on-site feeding for children who were not growing properly, vitamin A
supplementation, periodic deworming, education of mothers for managing childhood diarrhea,
and the supplementary feeding of a small number of women.
An important innovation of the project was that it used growth monitoring of the children as a
device for mobilizing community action. Groups of mothers met regularly to weigh their young
children. They then plotted their weight-for-age on a growth chart. Together with the community
nutrition worker, they identified which children were not growing properly. A related innovation
of great importance was that supplementary feeding was targeted only to the children identified
as faltering. In addition, children received food supplements only while they were not growing
well. This was done in conjunction with nutrition education for mothers. The intent of this
approach was that short-term feeding, combined with better childcare practices, could return the
CHAPTER 8 Nutrition and Global Health 216
 child to normal growth. This was a major change compared with previous practice in which
supplementary feeding was more universal and longer term.
Impact
The nutrition interventions of the project were largely implemented as planned, but the health
efforts were not fully implemented. Nonetheless, through careful evaluation the project was
shown to have significantly reduced the levels of malnutrition of the targeted children. These
improvements also continued over a substantial time, suggesting that the gains of the project
were sustainable. The project was also more cost-effective than other investments that had tried
to achieve similar aims in India.
Lessons Learned
This project was pioneering and revealed some very important lessons, including:
Growth monitoring, coupled with short-term supplementary feeding of children who are
faltering, can be a cost-effective way of improving nutritional status.
More universal and longer term feeding of children is not necessary to achieve improvements in
nutrition.
Women can be organized to participate actively in growth monitoring efforts.
Nutrition education can have a permanent and sustainable impact on child care and child feeding
practices, even in the absence of other interventions.

The Challenge of Iodine Deficiency Disease in China

Background
For many years China had the heaviest burden of iodine deficiency in the world. In 1995, 20
percent of children ages 8 to 10 showed signs of goiter. Overall, some 400 million people in
China were estimated to be at risk of iodine deficiency disorders, constituting 40 percent of the
global total. Fortunately, iodine deficiency can be simply remedied by adding iodine to salt, a
cheap and universally consumed food. Implementing this in a relatively poor and vast country
like China at that time, however, was far from simple.
The Intervention
Scientific evidence linking iodine deficiency to mental impairment was seen by the Chinese
government as a threat to its one-child-per-family policy, and so the government strengthened its
resolve to tackle this widespread health risk. In 1993, China launched the National Iodine
Deficiency Disorders Elimination Program, with technical and financial assistance from the
donor-funded Iodine Deficiency Disorders Control Project. The public needed to be made aware
of the risk of iodine deficiency, especially in regions where goiter was so common that it was
regarded as normal. A nationwide public education campaign was launched, using posters on
buses, newspaper editorials, and television documentaries to inform consumers and persuade
them to switch to iodized salt. Provincial governors ensured that government education efforts
reached even the most remote villages. The supply of iodized salt was increased by building 112
new salt iodination factories and enhancing capacity at 55 existing ones. Bulk packaging systems
were installed to complement 147 new retail packaging centers, with packaging designed to help
consumers easily recognize iodized salt. The sale of noniodized salt was banned, and
technological assistance was provided to salt producers to adopt iodination. Salt quality was
monitored, both at production, where the amount of iodine added needs to be just right, and in
distribution and sales, because iodine in salt dissipates easily, reducing the shelf life of iodized
salt. China’s nationally controlled network of production and distribution made licensing and
enforcement of legislation easier.
The Impact
By 1999, iodized salt was reaching 94 percent of the country, compared to 80 percent in 1995.
The quality of iodized salt also improved markedly. As a result, iodine deficiency was reduced
dramatically, and goiter rates for children ages 8 to 10 fell from 20.4 percent in 1995 to 8.8
percent in 1999.138
Costs and Benefits
At the time of these efforts, fortifying salt with iodine cost about 2 to 7 cents per kilogram, or
less than 5 percent of the retail price of salt in most countries. The Chinese government invested
approximately $152 million in the program, recovering some of this cost by raising the price of
iodized salt. The World Bank, one of several donors, deemed the project extremely cost-
effective.
Lessons Learned
China’s success in reducing iodine deficiency offers valuable lessons for future efforts to reduce
other micronutrient deficiencies such as iron and vitamin A through fortification. The
government made a firm and long-standing commitment to tackle the problem and brought about
administrative, legal, technical, and sociocultural changes that were needed to do so. Donor
coordination was strong and effective and was managed by the Chinese government and the
donors themselves, and the major players offered mutual support across all activities. The
financing strategy was clearly defined from the start. The salt industry seized the opportunity of
the
Case Studies 217
investment in eliminating iodine deficiency to restructure and modernize the industry, gaining a
firmer commercial footing and positioning itself to compete in the international market, given its
cost advantages.
China’s iodination program continues, with special targeting of resources on areas where the
consumption of iodized salt is particularly low, usually in poor and remote mountainous regions
where residents see iodized salt as too costly, especially when salt can be obtained cheaply from
local salt hills, dried lakes, or the sea. Research will be needed to determine the best way to
ensure iodine intake in these areas—through price subsidies, iodination of well or irrigation
water, or even iodine capsules or injections, in the case of nomadic peoples. Through a variety of
approaches, China is fast approaching the day when iodine deficiency will be unknown
throughout its population. A more detailed review of this case is available in Case Studies in
Global Health: Millions Saved.139

ADDRESSING FUTURE NUTRITION CHALLENGES

As noted earlier, the world has made progress in the last several decades in addressing key
nutrition problems. Nonetheless, the world’s nutritional status still faces critical issues in
undernutrition, overweight and obesity, and the dietary risks to good health. Problems of
undernutrition are especially severe in South Asia and sub-Saharan Africa. Problems of
overweight and obesity are growing in many low- and middle-income countries. The world will
not meet the MDGs that relate to nutrition. What steps will have to be taken to speed the world’s
progress on nutrition?
If the world is to do better in nutrition, it will have to take a number of steps in a variety of
domains. First, policymakers who work both globally and in individual countries need to
understand the exceptional importance of nutrition to good health and human productivity and
act accordingly. About 45 percent of the under-5 child deaths globally are associated with
nutritional causes. In addition, low-cost, highly effective solutions are available to deal with a
number of critical nutrition issues, but they are not being implemented sufficiently. Thus, much
greater attention needs to be paid by all concerned parties to nutrition as an underlying health
issue. Nutrition does not fit neatly into governmental bureaucracies because it touches many
government units, such as agriculture, health, and education. Thus, governments will also need to
think creatively about how to ensure that there are government units accountable and responsible
for promoting enhanced approaches to nutrition.
Improving government policy and action on nutrition will also require a good understanding
of the nature of the nutrition problem in different settings. Nutritional concerns vary considerably
by income group, gender, and ethnicity, and solutions to these problems will need to be carefully
tailored to local circumstances. Moreover, almost all low- and middle-income countries will have
to deal simultaneously with undernutrition and overweight and obesity.
In addition, governments need to work more effectively with the food industry to improve the
way in which foods are fortified and to be sure that processed foods are healthy. Legal and finan-
cial arrangements need to be made in many countries so that more fortification can take place
and the demand for fortified foods will be increased, as noted in the policy brief on Kenya.
Similar arrangements will need to be made to limit sugar, salt, and some fats in processed foods.
We have also seen the power in Tamil Nadu, for example, of focusing efforts on community-
based action, in which affected people are involved in the design, implementation, and oversight
of nutrition activities.
Although there is much knowledge of what works in nutrition, there are also other areas in which
additional knowledge could fill important gaps. The world needs to continue gathering scientific
knowledge about how key nutrition issues can be addressed. It would be very valuable to the
world’s nutrition status and health if more easy-to-make, nutritious, and inexpensive food
supplements were available; if better formulas were available for some of the vitamin and
mineral supplements that could be given less frequently, very cheaply, and without side effects;
and, if additional cost-effective ways were found for fortifying foods. It will also be essential that
today’s low- and middle-income countries get a better sense of what works and at what cost to
reduce the nutritional risks to good health.
Lastly, it is important for all societies to make the health and nutritional well-being of their
citizens a national priority. One way to do this would be to create partnerships of civil society,
government, and the private sector that can work together to identify nutrition issues, plan on
how they can best be addressed, and then collaborate with each other and with communities to
implement solutions to these problems.
As we consider the measures that can be taken to address key nutritional issues, as rapidly as
possible and in cost-effective ways, it is essential to consider interventions in three domains:
Nutrition-specific interventions—those interventions that can have a direct impact on nutrition,
such as promotion of exclusive breastfeeding, micronutrient supplementation, and food
fortification
Nutrition-sensitive interventions—those interventions that address the underlying determinants
of malnutrition, such as vaccination programs or

CHAPTER 8 Nutrition and Global Health 218

nutrition programs to enable farmers to increase the yield of crops that they consume
••The enabling environment for nutrition—this concerns laws, policies, resources, and
institutional issues that relate to the approach countries take to nutrition and how effective they
are at formulating, implementing, and monitoring nutrition interventions.5 This could include,
for example, taxing sweetened beverages or foods high in fat.

Additional comments on other measures for addressing undernutrition and overweight and
obesity follow.

Undernutrition
It has already been noted that knowledge and behaviors are important determinants of what foods
people eat, how they cook them, and how they consume them. Studies have shown that people
can improve what they eat, how they cook, and how they eat their food by improvements in
knowledge, even in the absence of improvements in income.140 Nutrition education needs to be
spread much more widely and in more appropriate ways to promote appropriate breastfeeding
and complementary feeding and to help people eat better and more nutritious foods.
Growth monitoring and promotion programs, like that in Tamil Nadu, as well as others that
were carried out in Honduras, Indonesia, and Madagascar, can also be important to improving
nutrition outcomes at low cost. It is especially important that these programs be community-
based. In addition, mothers who participate in these programs need to understand the importance
of child growth and how they can carry out improved feeding and caring practices, such as
exclusive breastfeeding, appropriate introduction of complementary foods, and the management
of diarrhea. To succeed, growth monitoring and promotion programs must be coupled with
programs for behavior change communication.141
The two-way relationship between infection, disease, and nutrition status has been noted.
Many infections and diseases reduce one’s ability to eat or ability to absorb food. At the same
time, poor nutritional status reduces immunity to disease. To set the foundation for
improvements in the nutritional status of poor people in low- and middle-income countries,
especially poor infants, children, and women, it is very important to improve the control of
parasitic infections such as hookworm and to control diarrheal diseases, malaria, and measles. Of
course, doing this will also demand renewed efforts at health education; more effective basic
health services, such as immunization; and improvements in water supply and sanitation.
Some people will simply not eat enough food or enough of the right foods, largely because of
income gaps. These problems are also the result of, or are compounded by, natural disaster and
conflict. Under these circumstances, it may be necessary that people receive food supplements
like a high-protein, high-calorie ready-to-use therapeutic food. Alternatively, some people may
receive vouchers for food, such as food stamps, which are cash transfers that can be used only to
buy certain health and nutrition services or the right to buy certain foods at reduced prices.
Conditional cash transfer programs are also being used to promote better nutrition, and smart
cards are increasingly taking the place of food stamps or transfers of cash.
Vitamin and mineral supplementation is widespread in the world, is not expensive, and is often
used as a way of improving the micronutrient status of large numbers of people, especially
infants, children, and pregnant and lactating mothers. These can be given in capsules or syrups.
Vitamin A should be given twice per year and should be integrated with child survival and other
health services to minimize the cost of distribution.57 In the last decade or so, vitamin A has
been given orally to infants and children during national polio immunization days in many
countries. These efforts can be expanded. At the same time, additional and carefully monitored
efforts can be made to provide iron and folate to pregnant women. Unfortunately, these efforts
have not worked as well as planned and need to be carefully reviewed and refined to enhance
both coverage of supplementation and the extent to which women take the pills they do get.
Food fortification is practiced in many countries for a number of micronutrients. In fact,
fortification in the industrialized countries has contributed greatly to the disappearance of several
deficiencies. The fortification of salt with iodine is a very widespread practice and is very
inexpensive, as we have seen in the China case noted earlier. About two-thirds of the world now
consumes iodized salt, and the impact of fortification of salt could be further expanded through
its double fortification with iron, as well as iodine. In addition, many different food products can
be fortified. The key to effective fortification is to find a food product that is very widely
consumed, for which there are no technical impediments to fortification, and for which
fortification is inexpensive.142 Thus, increasingly one could fortify flour, cooking oil,
margarine, soy sauce, and other products, as well as salt. Multiple vitamin and mineral
supplements are also being manufactured, which can be sprinkled on children’s food to fortify it.
Fortification can cost as little as 3 to 5 cents per person reached per year.57 Clearly, fortification
is a good way to harness the resources of commercial marketing
Addressing Future Nutrition Challenges 219
 networks to enhance the health of the population. Given the difficulties of iron
supplementation, it may be that the most effective way of reducing iron deficiency in women is
to operate an effective program of fortification for iron and folic acid.
Efforts are also under way for biofortification. The aim of this work is to use technologies to
improve the nutritional content of foods, such as rice, yams, or other vegetables.
The latest studies show that young child deaths could be reduced by about 15 percent if the
appropriate countries could take to scale a package of nutritional interventions, including:8
Folic acid supplementation or fortification for pregnant women
Balanced energy protein supplementation for pregnant women
Calcium supplementation for pregnant women
Multiple micronutrient fortification for pregnant women
Promotion of appropriate breastfeeding practices
Appropriate complementary feeding
Supplementation with vitamin A and zinc for children aged 6 to 59 months
Appropriate management of severe acute malnutrition
Appropriate management of moderate acute malnutrition

Moreover, the evidence suggests that this package would be highly cost-effective at a cost
per DALY averted of about $179.91 In fact, a range of these and related nutrition interventions
are cost-effective or have a high ratio of benefits to costs. Table 8-6 indicates the cost per DALY
averted of a number of measures to address undernutrition, as well as the benefit-cost ratio of
some nutrition interventions.
These interventions compare favorably in their cost-effectiveness with a range of other health
interventions that are cost-effective. The cost-effectiveness of several vaccines and bednets for
malaria control, for example, is around $10 per DALY averted. Condom promotion to prevent
transmission of HIV has a cost per DALY averted of about $40. Even the most expensive
nutrition interventions, such as food supplements for young children, have a cost-effectiveness
that is similar to that of antiretroviral therapy for HIV/AIDS or the use of aspirin to prevent heart
disease.91
Overweight and Obesity
The obesity epidemic poses a serious global problem, especially in low- and middle-income
countries. Given its scope, it is important to use policy measures across multiple levels to prevent
obesity and reverse its trend. Strategies should include efforts on the international, national,
local, and individual levels. The involvement of the food industry, healthcare providers, schools,
urban planners, the agricultural sector, and the media is also essential.
International organizations can have a large impact on obesity by setting global nutrition and
physical activity standards. They can also encourage surveillance, monitoring, and evaluation
systems, to insure nutrition standards are met and to identify countries where obesity policies are
most needed. In September 2011, the United Nations General Assembly convened a summit on
global noncommunicable diseases, identifying key targets for strengthening and shaping primary
prevention to reduce risk factors for NCDs, including obesity.143 The World Health
Organization has also done a large amount of work on the subject, including developing best buy
cost-effective interventions to address NCDs. For diet and physical activity, WHO recommends
reduced salt intake in food, replacement of trans fat with polyunsaturated fat, and public
awareness through mass media on diet and physical activity. To address cardiovascular disease
 and diabetes, WHO recommends counseling and multidrug therapy for people with a high risk of
developing heart attacks and
TABLE 8-6 Cost-Effectiveness and
Benefit: Cost Ratios of Selected Nutrition
Interventions
Cost per DALY Averted:
$5–$15 for vitamin A and zinc
supplements
$40 for community-based management of
severe acute malnutrition
$50–$150 for behavior change
interventions taken to scale
$66–$115 for iron fortification
$90 for folic acid fortification
Benefit: Cost Ratios
6:1 for deworming
8:1 for iron fortification of staples
30:1 for salt iodination
46:1 for folic acid fortification
Data from Horton S. Economics of
nutritional interventions. In: Semba RD,
Bloem M, eds. Nutrition and Health in a
Developing World, third edition. Totowa,
New Jersey: Humana Press; 2015.
Forthcoming.