Malnutrition has many causes and consequences across all stages of life. It stunts growth, increases disease risk, and impacts cognitive development. Nearly half of under-5 deaths are due to undernutrition. The first 1000 days are critical for preventing stunting through breastfeeding, complementary foods, and maternal nutrition. A holistic, equitable, and multi-sectoral approach is needed to address the triple burden of undernutrition, micronutrient deficiencies, and overnutrition.

1. Nutrition
Dr. Mushtaq Khan
MBBS, MPH

2. The faces of malnutrition

3. Malnutrition: an invisible emergency
Malnutrition has a million faces:
• A child who never reaches full height due to poverty, poor sanitation, lack of
breastfeeding and limited access to nutritious foods
• A young woman who becomes anemic during her pregnancy and gives birth to an
underweight baby who later faces developmental delays
• A child rendered blind by vitamin A deficiency
• A child who becomes obese through overconsumption of low quality food
• A desperately thin and wasted child, at imminent risk of death

4. • Nearly half of all deaths in children under 5 can be attributed to undernutrition.
This translates into the unnecessary loss of about 3 million young lives a year.
• Only a fraction of these children die in catastrophic circumstances such as famine
or war. In the majority of cases, the lethal hand of malnutrition is far more subtle: it
stunts children’s growth, deprives them of essential vitamins and minerals, and
makes them more susceptible to disease.
• Malnutrition is a violation of a child’s right to survival and development – and its
consequences often remain invisible until it’s too late.
• Malnutrition is more than a lack of food - it is a combination of factors: insufficient
protein, energy and micronutrients, frequent infections or disease, poor care and
feeding practices, inadequate health services, and poor water and sanitation. The
lack of or inadequate breastfeeding practices alone result in almost 12 per cent of
all deaths among children under age 5

5. • Chronic malnutrition early in life leads to stunting, which prevents children’s
bodies and brains from growing to reach their full potential. The damage
caused by stunting is irreversible and has far reaching consequences, from
diminished learning and school performance, to lower future earnings.
Globally, 159 million children under 5 are stunted. These children often
come from the poorest households, making stunting a key marker of poverty
and inequality.
• Wasting – illustrated most starkly, as its name suggests, by the child that is
literally wasting away to skin and bones – is the crushing result of acute
malnutrition and poses an immediate threat to survival. In 2014, 50 million
children under 5 were wasted and 16 million were severely wasted.

6. Malnutrition’s emerging triple threat
• While stunting and wasting persist across the globe, the face of malnutrition is
rapidly changing. Over nutrition – including overweight and obesity – is now on the
rise in almost every country in the world.
• Globally, an estimated 41 million children are overweight. Many countries are now
facing an overlapping ‘triple burden’ of malnutrition: under-nutrition and
micronutrient deficiencies on the one hand, and overweight and obesity on the
other.
• The causes of under-nutrition and overweight and obesity are similar and
intertwined. Poverty, lack of access to adequate diets, poor infant and young child
feeding practices, and the marketing and sales of unhealthy foods and drinks can
lead to under-nutrition as well as to overweight and obesity.

7. The foundations of good nutrition
• Under-nutrition and overweight can be prevented with many of the same
approaches. A key set of tried and tested interventions– particularly during
the critical window of the first 1,000 days of life – can make all the
difference.
• The foundations of good nutrition include improving women’s nutrition
before, during, and after pregnancy; promoting and supporting exclusive
breastfeeding for the first 6 months of a child’s life, and continued
breastfeeding to age 2 or beyond; facilitating timely, safe, appropriate and
high-quality complementary foods; and providing appropriate micronutrient
interventions.

8. Nutrition for sustainable
development
• Good nutrition lays the foundation for healthy, thriving and productive
communities and nations.
• Well-nourished children are healthier, more resistant to disease and crises, and
perform better in school. As they grow, they are better able to participate in and
contribute to their communities. The benefits of good nutrition thus carry across
generations and act as the “glue” binding together and supporting various facets of
a nation’s development.
• Now more than ever, there is global recognition that good nutrition is the key to
sustainable development. Specifically, Goal 2 of the 2015 Sustainable Development
Goals (SDGs) aims to “end hunger, achieve food security and improved
nutrition, and promote sustainable agriculture”.

9. • But good nutrition is more than just ending hunger: it is also vital to
achieving many SDG targets, including ending poverty, achieving gender
equality, ensuring healthy lives, promoting lifelong learning, improving
economic growth, building inclusive societies, and ensuring sustainable
consumption.
• To give just one example: breastfeeding prevents death, childhood illness and
non-communicable diseases, while supporting brain development and
protecting maternal health. It is also environmentally sustainable and reduces
inequalities by reaching even those with limited access to health services.

10. Transforming the nutrition
landscape
• The global nutrition landscape has changed immensely in recent years.
Countries are recognizing the power of nutrition to strengthen societies and
transform the lives of children and their families – even in the poorest and
most fragile places.

11. Nutrition’s lifelong impact

12. Our focus is on children, but
nutrition is a lifelong issue
The effects of poor nutrition begin in the womb, continue well into adulthood,
and cycle across generations. While malnutrition can trap generations of
children in a cycle of poverty, good nutrition, particularly in infancy, is the
building block for future health and development.

13. Nutrition across the lifecycle

14. Pregnancy through infancy
Also known as the first 1,000 days is the most critical period of growth and
development in a child’s life. Nutritional gains during this period continue to
benefit the child throughout life, while the damage from nutritional losses lasts
a lifetime.
No amount of food can cure a stunted child: good nutrition must start early
to prevent stunting before it starts.
Our interventions should target this key period, improving maternal nutrition,
supporting early and exclusive breastfeeding for the first 6 months of a child’s
life, and continued breastfeeding with appropriate complementary foods until
age 2 and beyond to ensure adequate intake of vitamins and minerals.

15. Throughout childhood
Good nutrition continues to play an important role in keeping children strong, healthy
and free of disease. Working with other stakeholders to improve water and sanitation
is critical because diarrheal disease in childhood, linked to unsafe drinking water, makes
it impossible for a child to absorb sufficient nutrients even when appropriate foods are
being consumed.
Where children are suffering from acute malnutrition, we should provides life-saving
therapeutic foods and medical care.
As children grow, an increasing number of them are becoming overweight and obese.
These conditions put children at risk for non-communicable diseases and disability,
which can persist into adulthood. We should works to identify evidence-based policies,
guidelines and regulatory frameworks that can address these emerging issues.

16. From adolescence through pregnancy
• We should works to improve the nutrition of adolescent girls and women.
Phenomenal growth occurs in adolescence – second only to that in the first year of
life – creating increased demands for energy and nutrients. Given that many
adolescent girls and women have nutrient deficits, our programs should support to
provide micronutrients such as iron and folate during this critical time.
• Micronutrients help support healthy pregnancy, prevent anaemia, promote foetal
growth, and ensure that babies are born at a healthy birth weight. They are crucial
to the health and survival of the growing baby – but also to the health and well-
being of girls and women themselves. Micronutrient supplementation can be
particularly important in countries where gender inequality denies women access to
nutritious foods and appropriate care during pregnancy.

17. Humanitarian crises can strike at any stage of the
lifecycle, and children and women are most affected. In these
contexts, all stakeholders should mobilizes a coordinated and
timely emergency response to safeguard the health and nutritional
status of those who need it most.

18. Approach to nutrition should be:
• Holistic – it looks at the child as an individual and as part of a wider family, community
and nation.
• Equity focused–it understands poverty, vulnerability, and marginalization as causes
and consequences of malnutrition, and recognizes that good nutrition puts all children on
the same starting line.
• Rights-based – it acknowledges that good nutrition is a fundamental right in itself,
and the basis for achieving all rights of the child.
• Gender sensitive – it ensures that girls and women have equitable access to good
nutrition, and recognizes that under nutrition is most rampant in settings where girls and
women face violence and discrimination.
• Evidence-based – it draws on evidence to identify both the problems and the
solutions.
• Multi-sectoral – it forges links with other sectors – including health, education, child
protection, and water and sanitation – to achieve maximum impact.

19. What we can do?
Malnutrition results in the loss of millions of young lives every year:
but together, we can prevent this through actions like:

20. 1. Improve breastfeeding and complementary feeding
2. Tackle micronutrient deficiencies
3. Treat and prevent severe acute malnutrition
4. Link nutrition support with the treatment of HIV/AIDS
5. Respond rapidly and effectively to nutrition emergencies

21. 1. Improve breastfeeding and
complementary feeding
• Babies need the right foods at the right time to grow and develop to their full
potential. The most critical time for good nutrition is in the brief 1,000 day
period from the start of a woman’s pregnancy until a child’s second birthday.
• Breast milk is the best food for children’s health and development during this
critical window. It provides all of the vitamins, minerals, enzymes and
antibodies that children need to grow and thrive.
• Breastfeeding is a miracle investment. It is a universally available, low-tech,
high impact, cost-effective solution for saving babies’ lives – but globally, it
hasn’t received the attention it should.

22. • In developing countries, optimal breastfeeding – starting within one hour of
birth, exclusive breastfeeding (no additional foods or liquids, including water)
for 6 months, and continued breastfeeding until age 2 or longer – has the
potential to prevent 12 per cent of all deaths in children under age 5.
Exclusively breastfed children are less susceptible to diarrhea and pneumonia
and are 14 times more likely to survive than non-breastfed children.
• Breast milk is safe: it is always the right temperature, requires no preparation,
and is available even in environments with poor sanitation and unsafe
drinking water. In this way, breastfeeding guarantees babies access to a
reliable, sufficient quantity of affordable, nutritious food. Breastfeeding also
supports healthy brain development, higher educational achievement, and
lowers the risk of obesity and other chronic diseases.

23. • Mothers also benefit from breastfeeding: it helps prevent post-partum hemorrhage,
reduce the risk of breast and ovarian cancers, and allows women to better space their
pregnancies.
• The role of the caregiver is as important as the food itself: caregivers need to interact
with the child, respond to his or her hunger signals, select appropriate foods, and
prepare those foods safely.
What are the challenges?
• Globally, breastfeeding and complementary feeding practices are poor. Only 38 per cent
of the world’s (0-6 month old) infants are exclusively breastfed and most young children
are not eating a minimally acceptable diet.
• One of the biggest challenges is a lack of awareness on the part of national
governments.
• Many countries have a shortage of health workers trained to counsel and support
mothers with both breastfeeding and complementary feeding. This needs to change.

24. • Strong national policies and legislation – reflecting the International Code of Marketing of
Breast Milk Substitutes – are needed to combat the aggressive and often unethical marketing
tactics of formula producing companies that undermine breastfeeding norms and practices.
• Governments also need to better support working mothers to breastfeed. Adopting supportive
national policies and legislation – such as paid maternity leave, breastfeeding breaks, and
designated spaces – will help guarantee that breastfeeding and working are not mutually
exclusive.
• The lack of access to affordable, nutrient-rich foods is an ongoing problem for many families
around the world.
• Inadequate food and hygiene practices are related to a number of factors: lack of education of
caregivers, beliefs and cultural taboos, the workload of the caregiver, poor access to resources,
poverty, and food insecurity.
• The marketing of unhealthy food and drinks to children is also a barrier to good nutrition.
• Feeding babies becomes even more challenging during emergencies. Caregivers often struggle
to find safe spaces to feed their children, and emergency-related food shortages hit vulnerable
populations the hardest.

25. How to respond?
• Protective policies and legislation
• Program guidance
• Training and capacity strengthening
• Baby friendly hospital initiative to support early breastfeeding
• Community-based approaches (to target behaviors)
• Improving access to nutritionally adequate complementary foods
• Support in emergencies
• Support on the feeding of HIV-exposed infants

26. 2. Tackle micronutrient deficiencies
• Micronutrients – also known as vitamins and minerals – are essential components
of a high-quality diet and have a profound impact on health. While they are only
required in tiny quantities, micronutrients are the essential building blocks of healthy
brains, bones and bodies.
• Micronutrient deficiencies are often referred to as ‘hidden hunger’ because they
develop gradually over time, their devastating impact not seen until irreversible
damage has been done.
• Millions of children suffer from stunted growth, cognitive delays, weakened
immunity and disease as a result of micronutrient deficiencies. For pregnant women,
the lack of essential vitamins and minerals can be catastrophic, increasing the risk
of low birth weight, birth defects, stillbirth, and even death.

27. What are the main deficiencies?
• Iodine deficiency is the primary cause of preventable brain damage in children.
• Vitamin A deficiency weakens the immune system and increases a child’s risk of
contracting and dying from infections like measles, and diarrheal illnesses.
• Iron deficiency can lead to anemia, which increases the risk of hemorrhage and
bacterial infection during childbirth and is implicated in maternal deaths.
• Zinc deficiency impairs immune function and is associated with an increased risk of
gastrointestinal infections.
• Calcium, vitamin D, and folate deficiencies are a particular concern during
pregnancy, and can lead to a number of health complications for both the mother
and growing baby.

28. How are micronutrient deficiencies prevented
and treated?
• Dietary diversification strategies help families access a range of nutrient-rich
foods.
• Supplementation programs provide specific micronutrients that are not available
as part of the regular diet e.g. iron and folic acid supplements for pregnant women,
which can reduce the risk of low birth weight, maternal anemia and iron deficiency.
• Mass fortification is the process of adding micronutrients to foods or condiments
that are consumed regularly by the population, such as flour, sugar, salt and cooking
oils.
• Home fortification programs provide caregivers with micronutrient powders to
sprinkle on the foods they prepare for children at home.

29. What are the challenges?
• Micronutrient deficiencies are caused by immediate factors – such as inadequate intake of
nutritious foods and infectious disease – and underlying factors – like poverty and unhealthy
environments.
• Increasing dietary intake of nutritious foods can be challenging because micronutrient-dense
foods are often expensive and not readily accessible.
• Infectious disease and micronutrient deficiencies exacerbate one another in a vicious cycle.
Infections deplete micronutrients at a time when the body needs them the most. With
limited stores to draw upon, the immune system weakens further and becomes less capable
of fighting the infection.
• Underlying factors, such as inadequate care practices and an unhealthy household
environment, including unsafe drinking water and poor sanitation, also threaten food intake
and increase infections.
• Reaching the most vulnerable populations of women and children is also a challenge,
particularly during the critical 1,000 day developmental period from pregnancy to a child’s
second birthday.

30. How to respond?
• Improving dietary diversity using community-based approaches to promote
breastfeeding, improve complementary feeding, and encourage consumption
of a diverse range of locally available foods.
• Providing supplementation
• Supporting universal salt iodization
• Promoting other forms of mass fortification
• Supporting home fortification programs

31. 3. Treat and prevent severe acute
malnutrition
• Severe acute malnutrition is the most extreme and visible form of under-nutrition.
Its face is a child – frail and skeletal – who requires urgent treatment to survive.
• Children with severe acute malnutrition have very low weight for their height and
severe muscle wasting. They may also have nutritional edema – characterized by
swollen feet, face and limbs. About two thirds of these children live in Asia and
almost one third live in Africa.
• Severe acute malnutrition is a major cause of death in children under 5, and its
prevention and treatment are critical to child survival and development.
• Across the globe, an estimated 16 million children under the age of 5 are affected
by severe acute malnutrition.
• Severe acute malnutrition can increase dramatically in emergencies. But despite what
we see in the headlines, the majority of cases occur in developing countries not
affected by emergencies.

32. How is severe acute malnutrition prevented
and treated?
• Ending acute malnutrition is a complex social and political challenge.
Prevention and long term solutions involve dismantling unequal power
structures, improving equitable access to health services and nutritious foods,
promoting breastfeeding and optimal infant and young child feeding
practices, improving water and sanitation, and planning for cyclic food
shortages and emergencies.
• Provision of ready-to-use therapeutic food (RUTF). The use of RUTF has
transformed the treatment of severe acute malnutrition, in part, because it
allows those children without medical complications to be cured right in their
own homes and communities. This approach is referred to as the
community-based management of severe acute malnutrition.

33. What are the challenges?
• In 2014, just over 3 million children under age 5 were treated for severe acute
malnutrition. This figure had almost doubled in only a few years.
• Governments face immense challenges in building capacity and allotting sufficient
resources to prevent and treat acute malnutrition. Progress has been particularly
slow in non-emergency contexts.
• Introducing treatment for severe acute malnutrition in health facilities and
communities can be extremely challenging in some contexts. Countries need to have
supportive national policies, well-trained health workers, adequate supplies and
financing, and a central operational plan to scale-up treatment at all levels.
• Addressing the underlying social determinants of severe acute malnutrition is
perhaps the greatest challenge of all.

34. How to respond?
• Supply and delivery of RUFT
• Capacity building
• Leadership and technical guidance – work with governments to develop
national policies, strategies, protocols, and training packages for health
workers, and provides technical support to national actors in their
implementation.
• Norms and standards setting
• Advocacy – At global and national level

35. 4. Link nutrition support with the
treatment of HIV/AIDS
• Globally, 2.6 million children under age 15 are living with HIV.
• Children living with HIV/AIDS are at great risk of
malnutrition. HIV/AIDS stunts child growth and can reduce appetite, food
intake, and nutrient absorption at a time when the body needs good nutrition
the most to fight the infection. The result is a further weakened immune
system that is ill equipped to fight the virus and infections like tuberculosis.
• Many HIV-positive children suffer from severe acute malnutrition, a life-
threatening condition. To increase their chances of survival, these children
need therapeutic foods to urgently treat malnutrition, combined with
antiretroviral treatment to stop the disease from progressing.

36. How can we prevent children from getting
HIV in the first place?
• HIV can be transmitted to babies from an infected mother during breastfeeding or
pregnancy and birth – but the good news is that in most cases, it can be prevented.
• In the form of just one pill a day, antiretroviral treatment can protect the health of a
mother living with HIV and prevent transmission to her child – in the womb, during
delivery, and throughout the breastfeeding period. Treatment adherence and
continued medical care are critical to suppress the virus in the mother and ensure
safe breastfeeding.
• Experience has shown that when mothers living with HIV take antiretroviral
treatment and practice exclusive breastfeeding during the first six months of life, the
risk of transmitting HIV to their babies is significantly reduced. In fact, exclusive
breastfeeding is associated with a three or four-fold lower risk of HIV transmission
than mixed feeding. The key is that breast milk be given exclusively – i.e. without
any other foods or fluids, including water – for the first six months.

37. But why breastfeed at all when there is still a
small risk of transmission?
• The answer is: breastfeeding ensures the greatest chance of child survival.
This is particularly true in low and middle income countries where HIV
prevalence is the highest.
• Breastfeeding reduces the chances that a child will fall ill and die from
common illnesses such as diarrhea and pneumonia. In settings where
children live in poverty and are exposed to disease, poor sanitation and
contaminated drinking water, the benefits of breastfeeding greatly outweigh
the risk of HIV infection. With its unique combination of nutrients and
antibodies, breast milk is the healthiest food for babies, and provides
unmatched protection from disease and death.

38. • The World Health Organization and UNICEF recommend that mothers
with HIV practice exclusive breastfeeding in combination with antiretroviral
treatment. Infant formula should only be used when safe water and
sanitation are assured, when access to formula is affordable and sustainable,
and when it can be safely prepared. It is rare for all of these conditions to be
met in much of the developing world.

39. What are the challenges?
• Antiretroviral drugs are most effective when children are well-nourished and have
safe and sufficient access to food. Unfortunately, this is not the case for many
mothers and children living with HIV. To complicate matters, diarrhea and nausea
can be side effects of antiretroviral drugs, making eating a challenge even in settings
where there is easy access to nutritious foods.
• There are also challenges in reaching vulnerable populations of children,
adolescents, pregnant women and nursing mothers with HIV. Many of them lack
access to antiretroviral treatment due to barriers such as poverty, social and gender
norms, stigma and discrimination, as well as weak and inefficient health care
systems.
• The knowledge that most HIV-infected mothers can breastfeed safely is relatively
new – but cultures, attitudes and public health practices can take time to change.

40. How to respond?
• Training and support –health and community workers to prevent mother-
to-child transmission of HIV, and to support safe breastfeeding.
• Integrated testing and treatment – confidential HIV testing to women
throughout pregnancy, at delivery, and during the breastfeeding period.
• Nutritional care and therapeutic feeding – for nutritional assessments
and counselling to manage HIV disease and the side effects of antiretroviral
drugs.
• Norms and standards setting –leadership in developing global guidelines
on infant and young child feeding in the context of HIV/AIDS.
• Policy development

41. 5. Nutrition in emergencies
• Around the world, the number and scale of emergencies continue to rise – and
children are most affected. Climate change, environmental degradation and natural
hazards such as earthquakes, floods and drought are wreaking havoc in vulnerable
communities. Violent conflicts threaten the lives of millions of children and their
families.
• At the same time, economic inequality is growing in every country in the world and
the poor are the most susceptible to food price inflation.
• Emergency situations or crises are often characterized by limited access to adequate
safe food and water, as well as disruptions in health and nutrition services and
constraints to protecting, promoting and supporting optimal infant and young child
feeding.
• Young children and pregnant and breastfeeding women are extremely vulnerable
in emergencies and their nutritional status must be protected to prevent under-
nutrition and guarantee survival.

42. Coordinated efforts to ensure equity, rights
and survival
Supports mothers to safely and adequately feed their babies during emergencies.
Where children are suffering from acute malnutrition, provides therapeutic feeding to
save lives and delivers essential micronutrients to prevent and treat deficiencies. These
are critical interventions to support infant and young child survival.
Over the long term, works with communities to address the underlying problems that
create these dire situations and to build resilience in households, communities and
systems to withstand crises and cumulative stresses.
Works with partners in emergency settings to design and deliver key nutrition
interventions as part of the emergency nutrition response. Equitable access to services
and timely provision of essential supplies are key to this work’s success. Therapeutic
foods to treat acute malnutrition, micronutrients to address deficiencies, or counselling
to ensure that appropriate nutrition practices continue are all crucial.
A coordinated response is critical in emergencies.

43. Nutrition encompass a number of key
actions:
• Providing life-saving treatment
• Delivering key micronutrients to vulnerable populations
• Supporting infant and young child feeding
• Conducting assessment and surveillance
• Strengthening monitoring
• Developing norms and standards
• Fostering resilience – by working with communities to plan for, withstand
and bounce back from crises and enable local communities to be less
dependent on outside interventions.

44. Proper nutrition is a powerful good: people
who are well nourished are more likely to be
healthy, productive and able to learn. Good
nutrition benefits families, their communities
and the world as a whole. Malnutrition is, by
the same logic, devastating.