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Solutions to Nutrition-related Health Problems of Preschool Children: Education and Nutritional Policies for Children

Darnton-Hill, Ian*; Kennedy, Eileen; Cogill, Bruce; Hossain, SM Moazzem*

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Journal of Pediatric Gastroenterology and Nutrition: December 2006 - Volume 43 - Issue - p S54-S65
doi: 10.1097/01.mpg.0000255851.30400.e7
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More than 10 million children younger than 5 y old die every year. If proven interventions were to be applied, then more than 60% of these deaths could be averted (1). A few countries account for a large proportion of all child deaths, with more than 50% of global deaths occurring in just 6 countries, and 90% of deaths occurring in 42 countries, most of them in sub-Saharan Africa and in south Asia (2). More than half of all deaths from infectious diseases have underlying malnutrition and undernutrition as a contributing factor (3,4).

Measures of poor access to food, undernutrition and poverty are also strongly correlated, so that countries with food insecurity also have high prevalences of stunted and underweight children. In these same countries, large numbers of people live in conditions of extreme poverty, struggling to survive on less than US$1/d. Although poverty is undoubtedly a cause of hunger, malnutrition and undernutrition, poor health and nutrition are also conversely causes of poverty. Numerous studies have confirmed that hunger seriously impairs the ability of the poor to develop their skills and reduces the productivity of their labour (5–9).

Poor nutrition and inadequate education have pervasive effects on health and well-being and addressing these will have both direct and indirect benefits for child survival, growth and development (5–9). Alleviating poverty and addressing geopolitical factors such as fair trade and debt relief must also be addressed if sustainable solutions are to be had (10). Although understandable, the decision of the Bellagio Child Survival Study Group (11), when they examined the reasons for sustained high levels of child mortality, not to address interventions with a more distal focus or ones that would normally be implemented by sectors other than health (eg, maternal education, reduction in crowding) meant that their suggested solutions were largely dependent on health facilities and systems (2). In many of the countries most affected these systems appear to be on the verge of collapse (12). Associated shortages of qualified staff are due to a severe “brain drain” to affluent countries (13), a high turnover and difficulty in training (14), as well as an infrastructure suffering from a lack of investment in countries where poor health care is the norm. Donors have not been investing in health systems, although this may be changing (15).

This article outlines the current burden of health and disease globally, especially as related to nutrition, with an emphasis on poorer countries. It then looks at the relationships between nutrition, ill-health and education, examines policies directed at all 3 and finally suggests some solutions to nutrition-related health problems of preschool children, with an emphasis on education and nutrition policies. The underlying contention of the article is that the impacts of nutrition are bidirectional in terms of education (ie, improved education leads to improved nutrition and improved nutrition leads to better educational attainments). In turn, both of these lead to improved health and economic development. The title of the article implies a biomedical model of identifying nutrition-related health problems of preschool children, and then addressing them one-by-one. However, we believe that a broader approach is required for a sustainable and equitable improvement in both nutrition and education. To understand what the determinants of preschool nutrition are and to address these factors, it is necessary to also examine the health and nutrition of older children and adults, especially women. The article therefore addresses programs that improve child, adolescent and adult health and nutrition, and those including education that intervene at key stages of the life cycle, at critical “windows of vulnerability,” and that must be applied and supported at several levels of policy development and application (16).


Nearly two thirds of deaths in the 42 countries occur in just 19 countries where the predominant causes are pneumonia, diarrhoea, and neonatal disorders (2). A World Health Organization (WHO) estimation in 2002 gave ≈15% as that part of the global burden of disease that can be attributed to the joint effects of childhood and maternal underweight and micronutrient malnutrition (17). A later estimation of the portion of global burden that would be removed by eliminating malnutrition is 32% (18). Because this was based on the effects of malnutrition on mortality and morbidity from infectious disease only, it is still a conservative figure, despite being higher than previous estimates, mainly through including micronutrient malnutrition, which was estimated to save 18% of the global burden of disease if it were to be eliminated.

So, what are the nutrition-related problems of preschool children mentioned in the title? As noted above, undernutrition is a contributing factor to mortality from infectious disease in more than half of all under-age 5 deaths. Other nutrition-related problems that have been shown to have an impact on growth, development and learning may be divided into 4 categories, further demonstrating the need for a life cycle approach. As seen in Table 1 factors act across the maternal and antenatal period, the infant and young child, at school, and the home environment.

Life cycle factors affecting nutritional and educational outcomes

For children under 5, undernutrition is caused directly by the interaction between a lack of nutritious food, the prevalence of common childhood illnesses such as diarrhoea and respiratory infections, and the impaired ability of caregivers to nurture their children because of resource or knowledge constraints. Eight of the 15 major risk factors of disease identified globally are nutrition-related: underweight, iron deficiency, vitamin A deficiency, zinc deficiency, high blood pressure, high cholesterol, high body mass index (overweight and obesity), and low fruit and vegetable intake (17). Child malnutrition is increasingly recognized to be largely determined during the period of foetal and infant growth, when maternal nutrition has its strongest influence. In policy terms, it is therefore necessary to recognize that women make up the majority of the world's poor (19) and, in many situations, are particularly disadvantaged in terms of nutrition and health (20).

The UNICEF schematic provides a framework showing direct causes of undernutrition: food security, care, health systems and environment (Fig. 1) (9). It then depicts that distal forces such as the political environment are every bit as important. This is particularly true of the chronic nature of the nutrition problem. When siblings in poor families are close in age, they compete for these constrained resources as well as for maternal care, further increasing the likelihood of malnutrition in this high-risk group (21). In 2005, despite apparently abundant global food supplies, at least 120 million children under 5 suffered various forms of malnutrition. The devastating results included underweight children, stunted growth, more severe infections, physical and cognitive disabilities, and the premature death of nearly 6 million children each year from the underlying causes of undernutrition (2). Alarmingly, the main killers of children in 1980 were the same as they are today (22).

FIG. 1
FIG. 1:
Causes of malnutrition (undernutrition and overnutrition) and death (9). *Resulting in malabsorption, bacterial overgrowth and nutrient loss in the gut.

Undernutrition remains a formidable global development challenge because it is both a cause and a manifestation of poverty. Malnutrition is used here to address both the prevailing chronic epidemic of undernutrition reflected in underweight and stunting in children and the emergence of overweight and obesity; both affect the more disadvantaged people in most populations. Worldwide, more than 180 million children under age 5—nearly 1 in 3—are stunted or low height for age. Stunting, along with underweight, is implicated in more than half of all child deaths and is a major contributor to ill health and cognitive underdevelopment in children (23). About 1 billion adults in developing countries are underweight, and an estimated 1.6 billion are anaemic, contributing to lower resistance to infection, impaired work capacity, and reduced economic productivity (24). In addition, foetal malnutrition threatens survival, growth, and development in childhood (6) and increases the risk of chronic diseases later in life (31,41).


The first years of life, including foetal life, are the most important periods in terms of mental, physical, and emotional development. It is during these critical windows of time that most of the basic human capital is formed. It is also the time, between 6 and 24 mo of age, that most growth failure occurs (25). Periods of increased risk are found particularly at 3 to 6 mo and 9 to 18 mo (26,27). Problems in the 3- to 6-mo period are related to nonexclusive breast-feeding or not breast-feeding at all, and a too-early introduction of complementary foods and solids. Much of the risk at 9 to 18 mo is related to inadequacy of nutrients in complementary feeding, cessation of breast-feeding, and increases in diarrhoeal disease associated with exposure to pathogens in foods.

Stunting is associated with many negative outcomes, including increases in morbidity and mortality, lower achievements in school, reduced labour capacity and smaller adult stature (28), and in later life increased risk of chronic diseases such as diabetes, hypertension and heart disease (31,41). The ability of the older child who was formerly malnourished to learn, communicate, analyze and socialize effectively and adapt to new environments is profoundly affected by early nutritional status. Poor prenatal, infant, and child nutrition impedes behavioural and cognitive development, potential work productivity and reproductive health (29). Early intellectual damage due to anaemia, iodine deficiency, and chronic undernutrition in the infant and young child can only partially be reversed in later life (30). The damage to cognitive development and attained schooling among these children is likely to be long lasting. Early undernutrition also contributes to increased risk for chronic disease in adulthood (31,41). Women who were stunted as young girls can be subject to increased obstetric risk later in life and are more likely to have low birth weight babies.

Identifying the constraints to achieving gender parity in education, it is notable that mother's education is a key determinant (ie, children whose mothers had no education are more than twice as likely to be out of school). Other factors include poverty and geographic location. The impact of inadequate nutrition and hunger on the ability to learn and concentrate has been conclusively shown (32–34). School enrollment, attendance, progression and learning capacity both improve with improved nutrition of the preschool- and school-age child (32,35).

Smith and Haddad (36) have convincingly demonstrated that in the 63 developing countries they studied, improvements in women's education were associated with the reduction of malnourished children by 50% between 1970 and 1995. Many studies on women's status and childhood nutritional status have demonstrated that a woman's status has an impact on the nutritional status of her child (37). Because women with higher status (relative to men) have better nutritional status themselves, they are better cared for and provide higher-quality care to their children (38). Across countries, relative resources controlled by women tend to increase the share spent on education (39). Educated girls and women have fewer children, seek medical attention sooner for themselves and their children and provide better care and nutrition for their children (40). Education of poor girls and young women also helps reduce child and maternal mortality, enhances economic productivity, improves health and nutrition and protects girls from abuse, exploitation and exposure to HIV (35).


Programs addressing both nutrition/health and cognitive and physical development (and hence readiness for schooling) that have been evaluated and shown to have had some impact are briefly considered for both developed and developing countries in the following.

Early Childhood Programs in Developed Countries

Until recently it would have been considered somewhat unusual for programmes aimed at infants and preschoolers from developing and industrialized countries to be discussed in 1 paper. As noted from a WHO/FAO (Food and Agriculture Organization) report (41), increasingly problems of undernutrition, chronic diseases and food insecurity exist in all countries worldwide; in some of the poorer countries of the world, food insecurity and obesity are observed in the same households (42). Countries in Europe, particularly in eastern and northern Europe have long perceived a government's obligation to ensure adequate nutrition for all children through the education system (eg, the “Oslo lunch”). In Australia and the United Kingdom, primary schoolchildren in the 1950s received one third of a pint of milk every school day. The United States had a more targeted approach based on socioeconomic need. Other countries such as Chile started with programmes for all children, which were highly successful in a country that was poor at that time (43). Although it is recognized that obesity is now more of a problem than undernutrition, it is politically unacceptable to halt the programme (Uauy, personal communication), and which probably should not happen because it is more important to alter the kinds of foods being supplied to disadvantaged children. Here we briefly describe 2 major, US-based programs as illustrative of 1 possible approach taken by an affluent country.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is the largest supplemental nutrition program in the industrialized world serving ≈7.5 million participants annually. WIC participants are from low-income families, and the program targets pregnant, breast-feeding and nonbreast-feeding postpartum women, and infants and children up to their fifth birthday. It provides supplemental foods, nutrition education and serves as an adjunct to health care. Pregnant women and preschool-age children receive ≈900 supplemental kilocalories per day from a food package including milk and/or cheese, eggs, cereal, juice and peanut butter. Breast-feeding mothers are given a somewhat larger package of supplemental food. Nonbreast-fed infants receive iron-fortified formula and iron-fortified cereal. WIC is operated by the US Department of Agriculture (USDA) at the national level through local health centres and local health authorities at the community level.

The WIC program began in 1972 as a 2-year pilot project serving 100,000 people with a total budget of US$20 million. In 2004, WIC served 7.5 million people with an annual budget of US$5.235 billion in fiscal year 2005. Despite the exponential growth in the funding and participation in WIC, the program initially had a stormy history. In 1972 the USDA attempted to block the release of funds designated for WIC. A major argument against the creation of WIC was that evaluations of supplemental food programs in poor countries around the world had failed to demonstrate significant improvements in neonatal outcome or preschool nutritional status (44). Indeed, a later seminal report by Beaton and Ghassemi (45) of more than 200 supplementation schemes worldwide concluded that the programs were expensive for the benefit produced. Some policy makers therefore argued that the WIC program was unlikely to be effective in a country as wealthy as the United States. Ultimately the USDA was sued, lost the case and the WIC program was implemented.

From the mid-1970s to the mid-1980s a series of evaluations of the WIC program were conducted. Although each of the studies had different strengths and weaknesses, taken together they collectively indicated that WIC participation is associated with significant improvements in neonatal outcomes, haematological status, dietary intake and nutritional status. This body of evidence also concluded that the positive effects were most dramatic in the higher-risk individuals; thus the effects of WIC on birth weight and increased gestational age were most pronounced in teenage, underweight, and unmarried females, particularly those who smoked tobacco products.

Head Start (3–5 y olds) and Early Head Start (<3 y old) serve the same target low-income population as WIC and together are a comprehensive child development program that aims to prepare children for success in school by providing education, health, nutrition and social services components for children and their families. In addition to educational activities, Head Start provides meals and snacks, which provide at least one third of nutrition requirements. Children who arrive at Head Start without breakfast are given a morning meal. Infants and toddlers are given foods that are appropriate to their developmental needs. In 2000 Head Start served 857,664 children through 2060 agencies throughout the United States. The Head Start program has an ongoing monitoring system. The latest findings from 2004–2005 (47) indicate:

  • Head Start preschoolers were twice as likely as non–Head Start preschoolers to use center-based care in 2003.
  • The largest impact on cognitive development of children is in prereading skills. In a comparison of 3 and 4 y olds in Head Start to the lower risk cohort of all 3 and 4 y olds in the United States, researchers found that Head Start participation of 1 y cut the gap in cognitive skill levels to half of what would be expected without the program.
  • Among the 3-y-old age group, the frequency and severity of behaviour problems reported by parents were lower for children in the Head Start group compared with children in the non–Head Start group.
  • For both 3 and 4 year olds in Head Start, dental health was better than for non–Head Start children of a similar age.

The nutritional profile of the at-risk WIC population has changed from 1972 to the present day. Similar to the experience in Chile, problems of overweight and obesity are more common in the preschool population than underweight, low energy intake and nutritional deficiencies. Research is under way to identify new approaches combining WIC services to prevent overweight and obesity (46,48). The challenge will be that healthier, lower energy (calorie) foods tend to be more expensive per unit of dietary energy and if fresh, logistics and availability are often constrained in poor populations (46). Nevertheless, the evaluations have demonstrated the synergistic effects of such food-based interventions in improving cognitive skill levels while having a positive impact on health, nutritional and behaviour problems.

Early Childhood Development Programs in Developing Countries

Much of the work in developing and transitional economy countries has been relatively small-scale research or pilot studies. Chile and several centrally planned economies have been among exceptions to this but have been, again except for Chile, relatively underevaluated and rarely bought to scale (43,48). A review by WHO demonstrated the potential of combining interventions that enhance early childhood development and those that improve child health and nutrition into an integrated model of care. WHO was able to conclude this by reviewing a series of efficacy studies as well as scaled-up effectiveness interventions (34). The effectiveness studies included Integrated Child Development Services from India, Head Start from the United States, Homes of Well-being from Colombia and others from Brazil, Indonesia, Peru and Thailand (34).

One of the few longer-term studies of effect of protein and/or energy supplementation occurred in 4 rural villages in Guatemala. A longitudinal study (1969–1977) of children ages birth to 7 y old was followed by a cross-sectional study when the same children were 11 to 24 y (1988–1989) (49). In the follow-up cross-sectional study there was a particular interest in children whose mother had received the protein/energy supplement prenatally and then during the first 2 y of life. Supplementation of children was found to have long-term nutritional and cognitive effects. In the initial study, supplementation was associated with significantly increased birth weights, lower infant mortality and improved growth rates for children up to 3 y of age in children receiving the protein/energy supplement (49); the follow-up study found long-term effects persisted, including greater height, particularly in females, and improved work capacity in males. In addition, long-term effects on cognition persisted. Adolescents who had been given the protein/energy supplement in early life scored significantly higher on tests of knowledge, numeracy, reading and vocabulary than teenagers receiving the lower-energy supplement. The authors, from a rigorous analysis of the data, concluded, “nutritional differences provide the strongest explanation for the test performance differences observed in the follow-up” (50).

The best achievable results of an integrated health and nutrition programme probably come out of the Narangwal study in India (51). Health care plus nutrition supplementation of high-risk women and their children resulted in a significant decrease in neonatal and infant mortality and decreased infant morbidity. There was also an increased weight and height in participating children. Worth noting is that this was a well-controlled research study and thus may be the upper limit of effects that would be expected from an integrated health and nutrition program.

The Bangladesh Integrated Nutrition Project (BINP), implemented by the government of Bangladesh, Ministry of Health and Family Welfare, between 1996 and 2002 had the aim of reducing the prevalence of severe underweight by 40% and moderate underweight by 25% in young children in the project areas (52). It was largely funded by the Bangladesh government through a US$59.8 million loan from the International Development Association, the concessionary lending affiliate of the World Bank (52). The project covered a population of 15.6 million in 59 thanas (a locality with a population of ≈200,000–450,000). The project was designed on the assumption that poor caring practices are an important cause of malnutrition and that a change in caring practices will lead to a decrease in malnutrition. Key objectives were to be achieved through education: to improve the capacity of individuals, household, communities and national institutions to prevent and alleviate malnutrition. Supplementary food was given to children with severe malnutrition or with growth failure (53). The basic model of the project was borrowed from the Tamil Nadu Integrated Nutrition Project, a large-scale nutrition intervention project in India started in 1980 with a US$32 million credit from the International Development Association. The project aimed to reduce severe and moderate malnutrition among children under 4 y old by half, infant mortality and vitamin A deficiency, and anaemia in pregnant and nursing women. The project reduced severe malnutrition among children 6 mo to 5 y old by half, but with limited impact on moderate malnutrition and anaemia, and a large number of those who graduated from feeding centres relapsed. The second Tamil Nadu Nutrition Project began in 1991 to address these problems. A key change was the addition of preschool education to the program. The idea was to provide nutrition, health and preschool services to young children under 1 roof. A strategic change was the focus on expectant mothers, who would receive a full range of antenatal services, including iron and food supplements, instead of only those who showed faltering growth. The project design stressed beneficiary participation through groups for women and adolescent girls and special community organisations (54).

In Africa a large nutrition programme was initiated in 1982 in the Iringa region of Tanzania with the assistance of UNICEF and WHO and has since been partly replicated in many other African countries. The scheme addressed food production, infant physical growth monitoring and health-related activities. Communities and villages in the Iringa region set up their own day care centres, with the villagers paying from their own resources for up to 70% of the wages of the day care attendants. In 4 y the prevalence of moderate undernutrition dropped from 50% to 37% and that of severe undernutrition from 6% to 2%. Attendance at the weighing clinics rose from 25% to 80% (55,56).

The WHO review of interventions for physical growth and psychological development (34), since confirmed by other evaluations, was able to demonstrate from such large-scale programs the following:

  • Nutritional interventions significantly improve physical growth in poor and malnourished populations.
  • Combined interventions to improve both physical growth and psychological development have an even greater impact in disadvantaged populations at risk for malnutrition.
  • Full-scale programs that include both nutrition and psychological components have been implemented throughout the world.
  • The effects of such combined programs are often greatest for children <3 y old and those who are most malnourished (eg, in Jamaica) (32), and these findings have obvious conclusions for policy.

It is important to define what the large-scale interventions require to be achieved at a minimum to be seen as successful. Purely in terms of growth, several critical studies have questioned the total success of the Tamil Nadu project and Bangladesh Integrated Nutrition Project because evaluations (internal and external) were not able to demonstrate significant improvement in nutritional status due to the interventions' inputs. There were however, many other gains documented, particularly in terms of nutrition knowledge and practices of caregivers, antenatal care and immunisation coverage (53). Specific components such as child growth monitoring, strengthening the health infrastructure, health education, and women's activities have had variable success. As in other nutrition success stories, government and community commitment are essential. Longer sustainability has been more difficult to ensure. The high levels of inputs required of the donor community can lead to failure when these cease, and thus larger antipoverty efforts are also essential. Environmental factors such as a tradition of local participation, supported by national policies that can improve basic equity, literacy, local governance and engagement are crucial for the success of such programs.


If the reality were as simple as the title of this article, the solutions would not be still being discussed here. What we have done is to take an evidence-based approach on what may work. Some factors are clear: interventions need to be supported through all levels of policy and administration, integrated, properly financed and sustained. Successful examples, such as Chile (43) and other evaluations have shown various positive impacts (29,34,56–58). It is often the case that solutions are proposed that take a problem analysis and then make a link with a needs assessment. The loose relationship between the 2 analyses results in a long list of program and policy options. A more challenging task is to match the problem with the needs and then prioritise actions. It is important to be able to assist policymakers and programmers to respond to the problem analysis by developing models that show how the amount and allocation of funding is related to the achievement of goals, such as reduction of undernutrition prevalence and expansion of prevention of anaemia, and to outcomes such as improved growth and development.

Adequate and targeted human and financial resources are required (16,59), as well as improved ways to track such investments. As noted by the Commission on Macroeconomics and Health, a substantial proportion of the required funds for programs aimed at improving health and national development by addressing nutrition and education, amongst other inputs, could be largely mobilised from within the countries themselves; for a set of essential interventions costing $34/person/y and for all age groups, even the least-developed countries could raise $15/y by 2007, leaving $19 to come from international assistance (59). As also noted by the Bellagio Child Survival Study Group in 2003, human resources are at least as important as financial resources, especially at the country and community levels.

There are 4 levels of policy that will have positive effects on nutrition and education outcomes and the resultant additional and larger national impacts of such outcomes. As WHO has demonstrated, policies that promote integrated programs addressing nutrition and early childhood development have a synergistic outcome (34). These levels could be grouped as family/community (micro); district/health systems (meso); national policies (macro); and global (or mega) (Fig. 1, Table 2).

Matrix of possible nutrition intervention recommendations by the 3 levels of causation in Figure 1


Family/community would correspond in Figure 1 to inadequate dietary intake and disease, as well as part of the underlying causes such as insufficient household food security and inadequate mother and child care. It has been demonstrated that an estimated 66% of the >10 million deaths among children under 5 y could have been prevented by interventions that are available today and are feasible for implementation in low-income countries at high levels of population coverage (2). Breast-feeding and oral rehydration therapy alone are estimated to be able to prevent 13% to 15% of all under-age 5 deaths, respectively. Complementary feeding could reduce 6% of all under-age 5 deaths, zinc to reduce diarrhoea and pneumonia deaths by 5% and vitamin A could reduce 2% of all under-age 5 deaths (60). Hence, among children living in the 42 countries with 90% of child deaths, this group of effective nutrition interventions could save about 2.4 million children each year (25% of all deaths).

The key long-term nutrition improvement lies in family and community action to prevent and treat undernutrition. This requires harnessing the resources of governments, civil society, and the private sector to empower individuals, families, and communities with knowledge and to support them with services, including universal access to reproductive health services. It also requires much greater emphasis on enhancing nutrition knowledge at the household level. This means increasing people's access to both formal and informal sources of nutrition education and information. It also means standardising messages based on best practices, tailoring the communication method to local cultural norms, investing in the measurement of impacts, and systematising the use of information across all aspects of nutrition programming. Micronutrient deficiencies can be addressed through supplementation, home fortification and other food-based interventions. Public action should include strong community initiatives to support breast-feeding. The HIV/AIDS pandemic has illustrated that in resource-limited settings, exclusive breast-feeding by HIV-infected mothers may be lifesaving if done for the first 6 mo. Increasing women's income and control over family assets is critical. Focusing on disadvantaged groups and ensuring opportunities for girls' education will make a difference, as will efforts to address inequity in gender roles and women's entitlements.

District/Health Systems

Policies and programs are needed that address the scaling-up of known positive household behaviours, including feeding practices, especially exclusive breast-feeding and appropriate complementary feeding (27), but also adequate micronutrient intake and appropriate intrahousehold food distribution, and health-seeking behaviours and knowledge. Insufficient household food security and mother and child care are reflected at this level, because although they have the most impact at the household level, the causes are usually beyond the control of the household.

Starting life as a low birth weight baby leads to poor child nutritional status and is directly related to the mother's health before and during pregnancy. Expanding access to reproductive and antenatal health care and ensuring adequate nutrition has been conclusively demonstrated to greatly enhance the health of mothers and their children (61). Improvement of nutrition education delivered through health services has been shown to decrease the prevalence of stunted growth in childhood in areas where access to food is not a limiting factor (14). Conversely, food distribution serves as a strong incentive to use health care services (62).

Efforts to increase educating women and girls are essential. The provision of food to children at school is only the basic element of a school feeding program and will have only a relatively minor impact on nutritional status at that age. However, food for schoolchildren represents a contribution of food and nutrients as well as an income transfer for the family and often additional resources for the school and community. The primary objective of a snack or meal is to alleviate short-term hunger (63,64). Meals provided early in the day to alleviate hunger will result in children being more attentive and to children being enrolled for longer periods (32). Nevertheless, it is critical for a school to provide a minimum standard of educational quality for a snack or meal to be effective. Although school meals have been shown to improve enrollment and attendance (50,65,66), food alone is insufficient to bring about changes in educational outcomes. It is the combination of well-motivated and well-trained teachers, appropriate curricula, support and related materials, and infrastructure together with good nutrition and health care (eg, deworming, micronutrients) that translates into improved performance (63,64).

National Policies and Actions

Few of the above interventions will be effective in a nonsupportive environment. The supportive environment must be provided by functioning national governments or sometimes subnational or even district governance. The importance of supporting action at community and district levels can be demonstrated by the changes in iodine sufficiency when, for example, national legislation or regulations on the appropriate iodisation of salt are not enforced or are rescinded, as happened in India (which has wisely reimposed a national mandate that all salt should be iodized; Schultink, personal communication, 2005). Both formal (government) and informal (nongovernmental) institutions are essential, as is a functioning and responsible private sector.

In Thailand, where nutrition has improved remarkably, women enjoy high literacy, high participation in the labour force, and a strong place in social and household-level decision making. Within India, women have similarly better relative status in Kerala as compared to other states and the state has better health, social and nutrition indicators and, not coincidently, the highest levels of female education (67). There are other examples: Chile, Costa Rica, Cuba, Sri Lanka (and others), where even at relatively low per capita income, health indicators remain far better than in other countries with higher per capita incomes (15,68). Conversely, in settings that experience little nutrition improvement despite economic growth, social discrimination against women is common (67). In Pakistan, for example, widespread discrimination against girls and women is high and child malnutrition rates are among the highest in the world, as is the proportion of low birth weight infants, at 25% (67).

Poverty-oriented approaches are much more likely to be accepted in environments characterised by a strong commitment to equity among policymakers and programme managers. Developing and maintaining such a commitment to equity is more probable if policymakers, programme managers, and communities feel that they are being involved in policy formulation. Several types of monitoring and reporting can provide useful information for policymaking: the simple measurement of health status and programme use disaggregated by socioeconomic status, gender, or ethnic group; another is the establishment and monitoring of health objectives in terms of health status or service use among disadvantaged groups. Food distribution often does not have clearly stated objectives, lacking specificity and clear time frames (62). Nevertheless, a subsequent review of food supplementation programs by Ghassemi a decade after his earlier review (45) was much more optimistic. He considered food supplementation to be a further type of intervention, especially as an income distribution device, and for improving nutritional outcomes in the poorest people. The establishment of monitoring mechanisms to track progress among the targeted groups reinforces their effectiveness (69). Equity must be a priority in the design of interventions and delivery strategies, including accountability at national and international levels (69). The first goal of the Millennium Development Goals (MDGs), poverty and hunger reduction, should be brought together with the other goals, producing synergistic effects on under-age 5 y child survival and development through mechanisms already proven (16).


The importance of both nutrition and education to a nation's development has been acknowledged in the importance given to these 2 sectors by the Millennium Declaration and the MDGs: 8 goals accepted by virtually all nations, affluent and least developed (40). Political, ideological and economic structures are seen as the most basic causes, and the causality is likely to be stronger with increasing globalisation. It is contended that by extending the coverage of crucial health services, including specific interventions, to the world's poor, millions of lives each year would be saved, poverty reduced and economic development accelerated, and all of these results would help promote global security (59). International goals are 1 mechanism at this level; the MDG's are partly an expression of humanitarian concern, but they are also an investment in the well-being of the rich countries as well as the poor (59). Malnutrition and disease breeds instability in poor countries, with rebounds to the security of rich countries. A high infant mortality rate was found to be 1 of the main predictors of subsequent state collapse in a study of state failure during the period 1960 to 1994 (59). International agreements and trade and other global agreements and laws can have both positive and negative effects on education and nutrition at the community level. At present, the evidence suggests (at least in sub-Saharan Africa) that the impact of these international trade laws have been largely negative for the poor (10). Others have also argued that 1 of the negative impacts of globalisation has been a substantial reduction of public spending, particularly in the areas of education and health care (70).


In terms of possible solutions, 4 levels have been discussed: (1) microlevel changes at community and household levels, especially in terms of gender equity and nutrition education and scaling-up of proven child survival interventions; (2) known and proven interventions at a district level, such as strengthening health systems and making them more effective and accessible; (3) national, such as pro-poor development and economic policies, policies towards parity in education and improved accessible health systems; and (4) global policy and the reduction of inequities (Table 2). To implement these proven interventions, there is a need to prioritise choices for interventions, apply them based on negotiated actions with the affected communities and individuals; and support them by appropriate policies and programmes. There is at this point no need to reinvent wheels. Differential rates of improvement in stunting were recently reported to be due to improved immunisation rates, improved water and sanitation and improved female literacy rate, as well as economic and agricultural variables, none of which is a surprise (71). Achieving the MDGs would address the nutrition-related concerns and educational needs (eg, cognitive development, forming social skills and preparedness for schooling) of under-age 5 y old children (16). The challenge, which is now being heard, for example, at the G8 Summit and at the UN High Level Plenary in New York, is whether resources and commitment will be sufficient.

Of the measurable health goals, the world is further from achieving the one for child mortality—a two-thirds reduction by 2015—than any other (72). Universal education may seem a relatively straightforward goal, but it has proven as difficult as any to achieve. So many countries around the world that will fall far short of the MDGs in the remaining 9 y to 2015 points to an urgent need to change course (73).

In conclusion, the reasoning and evidence above suggests the following:

  • To accelerate economic development, it is necessary to improve health, nutrition, education and gender parity.
  • To improve each one of these will have a positive impact on the others, and conversely, not addressing one will impede progress in another: consequently programs need to be integrated.
  • Equity is both a right and an obligation, but it will also accelerate the development process. To ensure equity, governments must take an active role. Reliance on market forces alone is not appropriate when there are extremely poor populations and weak infrastructures for health, education and other systems. Consequently, both government and global commitment are essential.
  • For improved outcomes in the under–age 5 y age group, there is a need to address life stages outside of this period, particularly maternal and antenatal health, nutrition and education; thus antenatal programmes are essential, as is breast-feeding promotion and appropriate complementary feeding. Accelerating programmes aimed at adolescents seems logical based on the available evidence, but further assessment of their impact is needed.
  • Improvement of community involvement continues to be invoked, but is still infrequently done adequately; the same could be said of upfront planning for monitoring and evaluation.
  • Biomedical or vertical models to address nutrition-related health problems are insufficient, although effective nutrition education and other nutrition interventions can be delivered successfully through health services.
  • Structural and political changes are also needed to support interventions, as are adequate and consistent family, community and donor support.
  • Although apparently not cheap, interventions such as those outlined above are cost-effective, especially when contributions to national economic development are assessed properly.
  • The achievement of the MDGs remains an appropriate overarching policy goal to provide solutions to nutrition-related health problems of preschool children.


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Undernutrition; Overnutrition; Double burden of disease; Nutrition policies; Education and nutrition

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