The strength and stability of a country hinges on the health of its people. With one in three humans affected by malnutrition, global nutrition investments should be a higher political priority. Nutrition is essential to ensure that children reach their full potential and is one of the most cost-effective public health approaches, with a $16 return on every $1 invested.1 Worldwide, malnutrition costs $3.5 trillion annually, with overweight- and obesity-related noncommunicable diseases (NCDs), such as cardiovascular disease and type 2 diabetes, adding $2 trillion.2,3 Malnutrition robs countries of human capital, the foundation of economic development and resilience.
Malnutrition: Poor nutrition; experienced by 3 billion people worldwide. Three forms of malnutrition may contribute to reduced early child cognitive development, stunting and/or wasting, and/or greater risk for infectious and noncommunicable diseases (NCDs):
Stunting: low height for age; 150.8 million children under age 5 are stunted (1 in 4). More than 71 percent of all stunted children under 5 live in either Africa or Southeast Asia and 8.23 million children are both affected by stunting and overweight
Wasting: low weight for height; 50.5 million children under age 5 are wasted (7.5 percent)
Key Nutrition Stats
- One in three people globally experience a minimum of one form of malnutrition
- 9.7 percent of women (aged 20–49) and 5.7 percent of adolescent girls (aged 15–19) are underweight; 15.1 percent are obese
- Malnutrition contributes to 45 percent of all child deaths
- Twenty million newborns are low birth weight
- Anemia among pregnant girls and women is 40.1 percent
Like poverty, the negative outcomes of poor diets are constant and cyclical, affecting generation after generation. One in three countries experiences a minimum of one form of malnutrition; 88 percent of countries have two forms of malnutrition; and 29 percent have all three forms.4
Poor nutrition affects health at every stage of the life cycle, yet the first 1,000 days of a child’s life (conception to age 2) and adolescence (10–19 years) are especially significant because of the nutrients necessary for rapid growth. Undernutrition and micronutrient deficiencies during pregnancy result in low gestational weight gain, heightened risk for pregnancy complications and mortality, growth restriction, and increased risk of NCDs later in life. Optimal nutrition during the first 1,000 days is imperative to prevent stunting.
Being overweight or obese is now the primary risk factor for NCDs and undernutrition and micronutrient deficiencies throughout life contribute to both the risk and severity of infectious diseases and hinder treatment responses. Nutrition is foundational to the success of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), as adequate nutrition promotes adherence to HIV medication where side effects can be exacerbated by low food intake.5 Nutrition is also fundamental to the success of the President’s Malaria Initiative in that adequate nutrition lowers the morbidity and mortality of malaria.6
As the global workforce transitions to less physical labor and more science and technology employment, the future prosperity of a country is increasingly dependent on the education and health of its workforce. Stunting has a severe lifelong impact on brain development and contributes to cyclical poverty, reducing “gray matter infrastructure.” Stunted children experience reduced productivity because of fewer years of schooling and less learning per year in school.7 A 1 percent loss in adult height because of childhood stunting is associated with a 1.4 percent loss in economic productivity.8
“When malnutrition strikes children in the first five years of their lives, it permanently stunts their bodies, their minds, and their potential to fully contribute to their country’s economy.”
- Jim Yong Kim, Former President, World Bank Group, August 2014
Nutrition also affects human security. Undernourishment and acute food insecurity are both a cause and consequence of conflict. Sixty percent of undernourished and 79 percent of stunted children under 5 live in countries affected by conflict.9 Conflicts destroy agricultural infrastructure and healthcare resources, increasing infectious diseases, food insecurity, inadequate sanitation, violence, and refugees and migration.10
Food insecure countries with armed conflict have the highest outward migration of refugees.11 For example, the Venezuelan economic crisis has resulted in tremendous food insecurity: a 2017 survey showed that 64 percent of Venezuelans reported losing an average of 24 pounds and 90 percent of migrants to Colombia named lack of food as a reason for migrating.12,13
Nutrition did not gain global momentum as a health priority until 2008, when spiking food prices caused the UN Secretary-General to establish the High-Level Task Force on Food and Nutrition Security. During the same year, the first Lancet series on “Maternal and Child Undernutrition” provided the world with the evidence and consensus necessary to implement nutrition interventions. Then in 2012, the World Health Assembly (WHA) endorsed a set of six global nutrition targets for 2025. These events sparked a movement across governments, multilateral organizations, nongovernmental organizations, donors, advocacy organizations, and academia.
Interventions are divided into two categories: nutrition-specific and -sensitive. Nutrition-specific investments address the immediate causes of malnutrition and support interventions such as vitamin supplementation and exclusive breastfeeding. Nutrition-sensitive investments, such as fortification and biofortification, address the underlying causes of malnutrition. To achieve just four of the WHA nutrition targets (stunting, anemia, exclusive breastfeeding, and wasting), will require an additional estimated $70 billion over 10 years.14 This increased investment would prevent 3.7 million child deaths, 265 million cases of anemia in women, and 65 million cases of stunting, and 91 million children (under 5) affected by acute wasting would receive treatment.15 Achieving these goals will require scaling up diverse interventions.
Nutrition support occurs mainly through three U.S. Agency for International Development (USAID) arms: the nutrition-specific subaccount (which began in 2009) and related health priorities funded through the Bureau for Global Health; democracy, conflict, and humanitarian assistance through the Office of Food for Peace; and most recently, food security through the Feed the Future initiative.16 Since 2016, appropriations for the subaccount remained stagnant at $125 million until the slight bump to $145 million in 2019, which is approximately 0.003 percent of the total U.S. federal budget.
Additional nutrition funding within the global health programs (GHP) account is determined at the agency level and also may be provided from the Economic Support Fund, Development Assistance, and Food for Peace. Seven additional federal agencies engage in and/or implement global nutrition activities, but nutrition spending is subsumed in budgets and public financial reporting is limited. In addition, the U.S. government contributes annually to multilateral institutions, such as the World Food Programme and UNICEF, which provide nutrition support.
Nutrition spending is inherently difficult to track because of the cross-disciplinary nature of nutrition. Although there is a nutrition-specific GHP subaccount, many subaccounts that fund nutrition programming may not be categorized as nutrition spending. For example, the 2016 PEPFAR budget was $6.8 billion, with $8.2 million allocated to food and nutrition.17,18 From 2014 to 2018, the Maternal and Child Survival Program reported nutrition allocations of 5 percent of its $560 million budget.19
Additional nutrition-related programming within the GHP account includes capacity building of healthcare services and the promotion of zinc and oral rehydration salts for the treatment of childhood diarrhea. U.S. nutrition-specific funding consistently remained at approximately 1 percent of the annual GHP appropriation, which increased to 1.6 percent in 2019.
The United States does not systematically capture or publicly report detailed nutrition-sensitive investments, which adds to the nutrition budget complexities. Therefore, funding that affects the underlying causes of nutritional status is difficult to approximate.
Currently, USAID funds nutrition programs in 27 countries across its bureaus. The Global Nutrition Report collects investment data on both nutrition-specific and -sensitive funding provided by donors yearly; however, this reporting may include school feeding assistance from the McGovern-Dole International Food for Education and Child Nutrition Program. When disaggregated by sector, the U.S. 2015–16 disbursements targeting the WHA 2025 goals averaged $184 million.20
Measuring the impact of U.S. government nutrition investments is challenging because of the multitude of variables in play and the lack of coordination and integration across nutrition-related programs. USAID primarily tracks nutrition-related program outputs; long-term outcomes are limited and the public data currently available is not systematic. Most notably, indicators are not the same for each country and are not reported consistently through time.
While the metrics captured across USAID are not mid-to-long-term outcomes, the data do provide evidence of the reach of the program. USAID communicates aggregated outcome summaries in yearly reporting. The 2018 Feed the Future Snapshot reported that in areas where Feed the Future operated, a projected 3.4 million children are living without stunting and 5.2 million more families are not hungry. The USAID nutrition webpage reported that USAID integrated programs reached 22.6 million children with nutrition interventions in 2017.
The U.S. government can expand its leadership role by addressing significant gaps and challenges. This includes funding to expand multisectoral implementation, research, and operations. Increasing funding within the GHP nutrition subaccount from $145 million to $290 million would help fill these gaps, allowing programs to utilize a systems-based approach.
The first two years of additional funding would serve as a startup and pilot phase, which could target a purposeful sample of geographic locations that are priorities for U.S. Global Health, Feed the Future, and Food for Peace funding. An analysis of countries should be conducted to identify current nutrition-specific and -sensitive programming where coordinated efforts are possible across health priorities. The populations and interventions that would provide the most cost benefit are adolescent girls and young women, pregnant women, and children during their first 1,000 days of life, with interventions focusing on the global reduction targets of lowering stunting by 40 percent, wasting to less than 5 percent, and anemia among women of reproductive age by 50 percent.
An overarching evidence-based plan for the additional $145 million in funding should be developed that includes a detailed implementation strategy for each pilot location, measures and indicators that are suitable for the intervention, and a monitoring and evaluation strategy linked to other global health and development goals. Ideal pilot characteristics include the capacity to execute similar interventions and an evaluation protocol so comparisons can be made across locations and coordinated programs.
Illustrative Allocations and Possible Impact of $145 Million:
Implementation: At least 80 percent of the budget increase ($116 million) is suggested for the USAID pilot of new interventions targeting the 1,000 days period and adolescent girls, the populations that provide the most cost benefit. The funding could reach an estimated additional 25.8 million children, increase the likelihood of undernutrition-related child survival by more than 396,000 children, and potentially reduce anemia by 25 percent among 10- to 24-year-old adolescent girls and young women through iron and folic acid supplementation and increase nutrition education and counseling to at least 75 percent of this population.20,21
Research: A suggested 10 percent of additional funds ($14.5 million) would support monitoring and evaluation of the pilot and implementation science of the new interventions. Data is needed at the U.S. federal government and local community levels to improve coordination, cost-effectiveness, and health outcomes across nutrition-related programs. Because of the gaps in nutrition and implementation research, this data would be a public good and therefore should be shared in a systematic and timely fashion.
Operations: Approximately 10 percent of the additional funds ($14.5 million) should support USAID headquarters and country mission staff to fully execute the USAID Multi-Sectoral Nutrition Strategy 2014‒2025, the Strategy’s Monitoring and Learning Plan, and the U.S. Government Global Nutrition Coordination Plan 2016‒2021. Without leadership and funding, these plans will not successfully move forward with proposed goals or reporting. This funding also would support the planning, identification of new strategies, and start-up phase of the pilot and the public dissemination of outcomes and reporting.
By allocating an additional $145 million to the GHP nutrition subaccount, USAID would have the resources to pilot and evaluate a new multisectoral approach. The pilot has the potential to provide an evidence base to U.S. policymakers and bilateral institutions on the cost-effectiveness of multisectoral nutrition programs; provide data to assist in the identification of the best approach to scale up services that work and better understand interventions that are not successful; and identify new pathways to integrate nutrition across U.S. government initiatives while not diluting nutrition as a priority.
Research Fellow, Global Food Security Project and Global Health Policy Center
Amy R. Beaudreault, PhD, is a research fellow in the Global Food Security Project and the Global Health Policy Center at the Center for Strategic and International Studies (CSIS). She focuses on the role of nutrition and food systems in global public health. Her broad experiences range from program development and evaluation to research and its translation, multisectoral partnerships, and consensus building. Prior to joining CSIS, Dr. Beaudreault was the director of nutrition and health at the World Food Center at the University of California, Davis. In addition, she was associate director at The Sackler Institute for Nutrition Science, a program at the New York Academy of Sciences; managed the Ohio State University Extension Agricultural Safety and Health Program; and worked in various capacities in research, health communication, and program management. She holds a B.S. in journalism from the E. W. Scripps School of Journalism at Ohio University and an M.S. in agricultural communication, a Ph.D. in agricultural education and extension, and a graduate certificate in survey research from The Ohio State University.Full Bio Here
View more of CSIS's work on Global Nutrition Policy at www.csis.org/nutrition.
Special thanks to those who participated in stakeholder meetings, external and internal reviews of the primer and fact sheet, and CSIS project support.
This project was made possible by the generous support of
the Bill & Melinda Gates Foundation.
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