Equity implications of rice fortification: a modelling study from Nepal.

OBJECTIVE: To model the potential impact and equity impact of fortifying rice on nutritional adequacy of different subpopulations in Nepal. DESIGN: Using 24-h dietary recall data and a household consumption survey, we estimated: rice intakes; probability of adequacy (PA) of eight micronutrients commonly fortified in rice (vitamin A, niacin (B3), pyridoxine (B6), cobalamin (B12), thiamin (B1), folate (B9), Fe and Zn) plus riboflavin (B2), vitamin C and Ca and mean probability of adequacy (MPA) of these micronutrients. We modelled: no fortification; fortification of purchased rice, averaged across all households and in rice-buying households only. We compared adequacy increases between population subgroups. SETTING: (i) Dhanusha and Mahottari districts of Nepal (24-h recall) and (ii) all agro-ecological zones of Nepal (consumption data). PARTICIPANTS: (i) Pregnant women (n 128), mothers-in-law and male household heads; (ii) households (n 4360). RESULTS: Unfortified diets were especially inadequate in vitamins B12, A, B9, Zn and Fe. Fortification of purchased rice in rice-purchasing households increased PA > 0·9 for thiamin, niacin, B6, folate and Zn, but B12 and Fe remained inadequate even after fortification (PA range 0·3-0·9). Pregnant women's increases exceeded men's for thiamin, niacin, B6, folate and MPA; men had larger gains in vitamin A, B12 and Zn. Adequacy improved more in the hills (coefficient 0·08 (95 % CI 0·05, 0·10)) and mountains (coefficient 0·07 (95 % CI 0·01, 0·14)) but less in rural areas (coefficient -0·05 (95 % CI -0·09, -0·01)). CONCLUSIONS: Consumption of purchased fortified rice improves adequacy and gender equity of nutrient intake, especially in non-rice-growing areas

Maternal Dietary Diversity and Infant Outcome of Pregnant Women in Northern Ghana

Objective: Little is known regarding the role of maternal dietary diversity score (DDS) in predicting poor outcomes of pregnancy including preterm delivery, and low birth weight (LBW). The main aim of this study was to explore the relationship between dietary diversity scores of urban Ghanaian women and infant weight at birth. Methods: This analytical cross-sectional study comprised 524 pregnant women who delivered singleton babies. A Structured questionnaire was used to collect data on socio-demographic variables (e.g. educational status, age, maternal occupation, household wealth index), obstetric history (for example, gravidity, gestational weight gain), dietary intake, malarial infection and Sulphadoxine pyrimethamine (SP) uptake, blood pressure (BP), haemoglobin concentration (Hb), anthropometric measurements (e.g. weight of mother and new born baby). Results: This study showed that maternal dietary diversity as measured by individual dietary diversity score scores (IDDS) was a significant independent predictor for mean birth weight and LBW. Analysis of covariance (ANCOVA) showed there was a significant difference in adjusted mean birth weight between women on low and high diversified diets , F (1, 415) = 8.935, p = 0.003. The results further showed that maternal IDDS was negatively associated with the incidence of LBW (Adjusted OR = 0.43, 95% CI = 0.22–0.85, p = 0.014). Conclusion: In nutritional deprived populations, maternal diet in the third trimester appears to be an important determinant of LBW and that DDS can serve as useful predictive indicator of maternal nutrition during pregnancy and the likelihood of delivering LBW babies

Maternal psychosocial stressors, depression and its implications on maternal and infant nutrition : a longitudinal birth cohort study in South West Ethiopia

This thesis draws on theoretical background and a conceptual model of how selected psychosocial stressors (household food insecurity and intimate partner violence) and coping strategies (maternal social support) are linked to psychological distress (maternal depression) which can influence the nutritional status of mothers and infants. The scientific contribution of this work is threefold. First, it adds to the existing literature on the links between psychosocial stressors, social support and depression, by showing the degree to which household food insecurity and intimate partner violence during pregnancy are associated with the risk of antenatal depressive symptoms, and whether maternal social support plays a buffering role in this process. Second, it describes the longitudinal relationship of prenatal and postnatal depressive symptoms with infant feeding practices. Finally, this work contributes to the literature on depression by validating one of the most commonly applied depression measurement tools, the patient health questionnaire (PHQ-9), in a new culture and language. This thesis includes three research articles; two were published in peer-reviewed journals and the third manuscript is currently under peer review. The first article is a validation study of the depressive symptoms measurement tool in a new culture and language in a rural setting. The other two papers are based on ENGINE birth cohort data, a prospective community-based birth cohort study conducted by Tufts University in collaboration with Jimma and Hawassa Universities and the Ethiopian Public Health Institute in the southwest part of Ethiopia. The first article validated an Afaan Oromo language version of the Patient Health Questionnaire (PHQ-9). PHQ-9 is one of the most commonly used depressive symptoms measurement scales. Few validation studies have been conducted in sub-Saharan Africa for scales seeking to detect depression in pregnant women and to the authors knowledge this is the first validation of the PHQ-9 in this language. The main finding of the first paper was that the PHQ-9 scale has acceptable reliability and validity as a screening instrument for depressive symptoms among Afaan Oromo speaking Ethiopian pregnant women. The PHQ-9 score of eight or above was found to be an optimal cut-off point to diagnose prenatal depressive symptoms with a sensitivity and specificity of 80.8% and 79.5% respectively. The second article tested hypotheses derived from Lazarus and Folkmans stress and coping theory. This theory provides a basis for understanding the impacts of psychosocial stressors on the development and prognosis of depression and the buffering effect of coping mechanisms. The hypotheses are as follows: increased psychosocial stressors, specifically intimate partner violence and household food insecurity during pregnancy, lead to higher prenatal depressive symptoms, and strong social support from friends,families and partners have a buffering effect. The present results supported these hypotheses by demonstrating that both household food insecurity and intimate partner violence were positively associated with prenatal depressive symptoms. Simultaneously, strong social support from friends, families and partners was negatively associated with prenatal depressive symptoms. The second article tested another hypothesis that the risk of prenatal depression is higher in anemic pregnant women. The current study supported this hypothesis by demonstrating that anemic pregnant women experienced a higher risk of prenatal depressive symptoms than their non-anemic counterparts. The second paper also investigated the degree to which socio-demographic factors such as age, marital status, educational status, and family size predicted the risk for prenatal depression among pregnant women. The results suggested that unmarried pregnant women and women living in households with large family size were at higher risk of prenatal depressive symptoms. The third paper tested one hypothesis that infants born to mothers with maternal depressive symptoms (prenatal and postnatal) are more likely to have poor infant feeding practices than their counterparts. The present study findings supported this hypothesis by showing that immediate postnatal depressive symptoms are negatively associated with infant feeding practices. However, there was no association between prenatal depressive symptoms and infant feeding practices. The results also showed that intimate partner violence was negatively associated with infant feeding practices. In this study, strong maternal social support and active social participation were positive predictors of infant feeding practices. Contrary to expectations, the present study also found that household food insecurity and infant morbidity episodes were positively associated with infant feeding practices. Finally, the third articles findings suggested that maternal educational status was positively associated with infant feeding practices and preterm babies were at higher risk of poor infant feeding practices. Infant gender did not affect infant feeding practices in this study. Overall, this PhD thesis provided support for Lazarus and Folkmans stress and coping theory by demonstrating that psychosocial stressors were positively associated with prenatal depressive symptoms and perceived maternal social support was negatively associated with prenatal depressive symptoms. The thesis also found that anemia during pregnancy is a predictor of prenatal depressive symptoms. Additionally, early postnatal depression and intimate partner violence negatively affect infant feeding practices, whereas perceived maternal social support and active social participation predict appropriate infant feeding practices. The study has a number of implications for practice and future research including prioritization of early screening for maternal depressive symptoms and intimate partnerviolence, and promotion of social support and active social participation as a means of preventing maternal depression and improving maternal and infant nutritional status.Diese Dissertation stützt sich auf theoretische Grundlagen und konzeptionelle Modelle, wie ausgewählte psychosoziale Stressfaktoren (Ernährungsunsicherheit im Haushalt und Gewalt in der Intimpartnerschaft) und Bewältigungsstrategien (soziale Unterstützung von Müttern), die mit psychischen Belastungen (Depression von Müttern) in Verbindung stehen und sich ungünstig auf den Ernährungszustand von Mutter und Kind auswirken können. Der wissenschaftliche Beitrag dieser Arbeit wirkt auf drei Ebenen. Anfangs wurde die vorhandene Literatur zu den Zusammenhängen zwischen psychosozialen Stressfaktoren, sozialer Unterstützung und Depressionen ergänzt, indem aufgezeigt wird, inwieweit Ernährungsunsicherheit im Haushalt und Gewalt in der Partnerschaft während der Schwangerschaft mit dem Risiko vorgeburtlicher depressiver Symptome verbunden sind und ob mütterliche soziale Unterstützung diesen Prozess verringern kann. Zusätzlich wirddie längerfristige Beziehung von pränatalen und postnatalen depressiven Symptomen zu Ernährungspraktiken bei Säuglingen aufgezeigt. Darüber hinaus hat diese Arbeit einen konstruktiven Beitrag zur Erfassung von Depressionen geleistet, indem sie den häufig verwendeten Patientengesundheitsfragebogen (PHQ-9) in einer neuen Kultur und Sprache (Afaan Oromo) validierte. Die vorliegende Arbeit enthält drei Forschungsartikel; die ersten beiden wurden bereits in begutachteten Fachzeitschriften veröffentlicht und das dritte Manuskript befindet sich noch im Peer-Review-Verfahrens. Der erste Artikel präsentiert eine Validierungsstudie zur Messung depressiver Symptome in einer neuen Kultur und Sprache in ländlicher Umgebung in Äthiopien. Die beiden anderen Studien basieren auf ENGINE-Geburtskohortendaten, einer prospektiven, gemeindenahen Erhebung, die von der Tufts University in Zusammenarbeit mit den Universitäten Jimma und Hawassa sowie dem Ethiopian Public Health Institute im Südwesten Äthiopiens durchgeführt wurden. Der erste Artikel validierte die Afaan Oromo-Sprachversion des Patientengesundheitsfragebogens (PHQ-9). PHQ-9 ist eine der am häufigsten verwendeten Messskalen für depressive Symptome. In Afrika südlich der Sahara wurden nur wenige Validierungsstudien für Skalen durchgeführt, mit denen Depressionen bei schwangeren Frauen festgestellt werden sollen. Meines Wissens nach ist dies die erste Validierung von PHQ-9 in der SpracheAfaan Oromo. Das wichtigste Ergebnis der ersten Arbeit war,dass die PHQ-9-Skala als Screening-Instrument für depressive Symptome bei Afaan Oromo-sprechenden schwangeren äthiopischen Frauen eine akzeptable Zuverlässigkeit und Validität aufweist. Der PHQ-9-Score von acht oder mehr wurde als optimaler Grenzwert für die Diagnose pränataler depressiver Symptome mit einer Sensitivität und Spezifität von 80,8% bzw. 79,5% ermittelt. Der zweite Artikel testete Hypothesen, die aus der Stress- und Bewältigungstheorie von Lazarus und Folkman abgeleitet wurden. Diese Theorie liefert eine Grundlage für das Verständnis der Auswirkungen psychosozialer Stressfaktoren auf die Entwicklung und Prognose von Depressionen und die Pufferwirkung von Bewältigungsmechanismen. Die Hypothesen sind wie folgt: erhöhte psychosoziale Stressfaktoren, insbesondere Gewalt in der Partnerschaft und Ernährungsunsicherheit im Haushalt während der Schwangerschaft führen zu höheren pränatalen depressiven Symptomen. Dagegen wirkt eine starke soziale Unterstützung durch Freunde, Familien und Partner lindernd. Die vorliegenden Ergebnisse untermauern diese Hypothese, indem sie zeigen, dass sowohl Ernährungsunsicherheit im Haushalt als auch Gewalt in der Intimpartnerschaft mit erhöhten pränatalen depressiven Symptomen assoziiert sind. Andererseits stellte eine starke soziale Unterstützung durch Freunde, Familien und Partner einen gewissen Schutz gegen vorgeburtliche depressive Symptome dar. Im zweiten Artikel wurde auch die Hypothese getestet, ob das Risiko einer pränatalen Depression bei anämischen Schwangeren erhöht ist. Die aktuelle Studie untermauerte diese Hypothese, indem sie zeigte, dass anämische Schwangere im Vergleich zu nicht anämisch schwangeren Frauen ein höheres Risiko für pränatale depressive Symptome aufwiesen. Zusätzlich wurde untersucht, inwieweit der soziodemografische Status schwangerer Frauen wie Alter, Familienstand, Bildungsstand, und Familiengröße das Risiko für eine pränatale Depression prognostiziert. Die Ergebnisse zeigten, dass unverheiratete Schwangere und Frauen, die in Haushalten einer Großfamilie leben, einem höheren Risiko für pränatale depressive Symptome ausgesetzt waren. Im dritten Manuskript wurde die Hypothese geprüft, ob Säuglinge, die von Müttern mit depressiven Symptomen (vor und nach der Geburt) geboren wurden, mit höherer Wahrscheinlichkeit unzureichenden Ernährungspraktiken ausgesetzt sind im Vergleich zu Säuglingen deren Mütter nicht unter Depressionen litten. Die Ergebnisse der vorliegenden Studie unterstützen diese Hypothese, indem sie zeigen, dass unmittelbare postnatale depressive Symptome verstärkt zu inadäquatenErnährungspraktiken bei Säuglingen führen. Es gab jedoch keinen Zusammenhang zwischen pränatalen depressiven Symptomen und Säuglingsernährungspraktiken. Die Ergebnisse zeigten auch, dass sich Gewalt in der Partnerschaft negativ auf die Ernährung von Säuglingen auswirkt. Eine starke soziale Unterstützung der Mütter und eine aktive soziale Beteiligung stellen positive Prädiktoren für Säuglingsernährungspraktiken dar. Auch wurde festgestellt, dass Haushaltsnahrungsunsicherheit und Säuglingskrankheiten positiv mit günstigen Ernährungspraktiken von Säuglingen assoziiert sind, sehr wahrscheinlich bedingt durch Kompensationsmechanismen. Die Ergebnisse des dritten Artikels zeigten auch, dass sich ein hoher mütterlicher Bildungsstatus positiv aufdie Ernährung von Säuglingen auswirkt. Frühgeborene hingegenscheinen einem höheren Risiko für inadäquate Ernährungsweisenausgeliefert zu sein. Das Geschlecht des Kindes hatte in dieser Studie keinen Einfluss auf die Säuglingsernährungspraktiken. Insgesamt lieferte diese Dissertation eine Unterstützung für die Stress- und Bewältigungstheorie von Lazarus und Folkman, indem gezeigt wurde, dass psychosoziale Stressfaktoren pränatale depressive Symptome verstärken, während wahrgenommene mütterliche soziale Unterstützung sich lindernd auf pränatale depressive Symptomeauswirkt. Die Arbeit zeigte auch, dass Anämie während der Schwangerschaft zusätzlich einen Prädiktor für pränatale depressive Symptome darstellt. Darüber hinaus wirken sich frühe postnatale Depressionen und Gewalt gegen den Intimpartner negativ auf die Ernährungspraktiken für Säuglinge aus, wohingegen die wahrgenommene soziale Unterstützung der Mütter und ihre aktive soziale Beteiligung eine positive Prognose für angemessene Säuglingsernährungspraktiken darstellen. Die vorliegende Studie hat viele Implikationen für die Praxis und zukünftige Forschungen, einschließlich der Priorisierung des frühen Screenings von depressiven Symptomen bei Müttern und die Vermeidung von Gewalt in der Intimpartnerschaft sowie die Förderung der sozialen Unterstützung und aktiven sozialen Beteiligung als Mittel zur Vorbeugung von Depressionen bei Müttern und zur Verbesserung des Ernährungszustandes von Müttern und Säuglingen

Prevalence and possible factors associated with anaemia, and vitamin B \u3csub\u3e\u3csub\u3e12\u3c/sub\u3e\u3c/sub\u3e and folate deficiencies in women of reproductive age in Pakistan: Analysis of national-level secondary survey data

Objective: To determine the prevalence and possible factors associated with anaemia, and vitamin B12 and folate deficiencies in women of reproductive age (WRA) in Pakistan.Methods: A secondary analysis was conducted on data collected through the large-scale National Nutrition Survey in Pakistan in 2011. Anaemia was defined as haemoglobin levels \u3c12 g/dL, vitamin B12 deficiency as serum vitamin B12 levels of \u3c203 pg/mL (150 pmol/L) and folate deficiency as serum folate levels \u3c4 ng/mL (10 nmol/L).Results: A total of 11751 blood samples were collected and analysed. The prevalence of anaemia, vitamin B12 deficiency and folate deficiency was 50.4%, 52.4% and 50.8%, respectively. After adjustment, the following factors were positively associated with anaemia: living in Sindh province (RR 1.07; 95%CI 1.04 to 1.09)P\u3c0.00, food insecure with moderate hunger (RR 1.03; 95%CI 1.00 to 1.06)P=0.02, four or more pregnancies (RR 1.03; 95%CI 1.01 to 1.05)P\u3c0.00, being underweight (RR 1.03; 95%CI 1.00 to 1.05)P=0.02, being overweight or obese (RR 0.95; 95%CI 0.93 to 0.97)P\u3c0.00 and weekly intake of leafy green vegetables (RR 0.98; 95%CI 0.95 to 1.00)P=0.04. For vitamin B12 deficiency, a positive association was observed with rural population (RR 0.81; 95%CI 0.66 to 1.00)P=0.04, living in Khyber Pakhtunkhwa province (RR 1.25; 95%CI 1.11 to 1.43)P\u3c0.00 and living in Azad Jammu and Kashmir (RR 1.50; 95%CI 1.08 to 2.08)P=0.01. Folate deficiency was negatively associated with daily and weekly intake of eggs (RR 0.89; 95%CI 0.81 to 0.98)P=0.02 and (RR 0.88; 95%CI 0.78 to 0.99)P=0.03.Conclusions: In Pakistan, anaemia, and vitamin B12 and folate deficiencies are a severe public health concern among WRA. Our findings suggest that further research is needed on culturally appropriate short-term and long-term interventions within communities and health facilities to decrease anaemia, and vitamin B12 and folate deficiencies among Pakistani women

Prevalence and possible factors associated with anaemia, and vitamin B 12 and folate deficiencies in women of reproductive age in Pakistan: analysis of national-level secondary survey data

Objective: To determine the prevalence and possible factors associated with anaemia, and vitamin B12 and folate deficiencies in women of reproductive age (WRA) in Pakistan. Methods: A secondary analysis was conducted on data collected through the large-scale National Nutrition Survey in Pakistan in 2011. Anaemia was defined as haemoglobin levels /dL, vitamin B12 deficiency as serum vitamin B12 levels of /mL (150 pmol/L) and folate deficiency as serum folate levels /mL (10 nmol/L). Results: A total of 11 751 blood samples were collected and analysed. The prevalence of anaemia, vitamin B12 deficiency and folate deficiency was 50.4%, 52.4% and 50.8%, respectively. After adjustment, the following factors were positively associated with anaemia: living in Sindh province (RR 1.07; 95% CI 1.04 to 1.09) PConclusions: In Pakistan, anaemia, and vitamin B12 and folate deficiencies are a severe public health concern among WRA. Our findings suggest that further research is needed on culturally appropriate short-term and long-term interventions within communities and health facilities to decrease anaemia, and vitamin B12 and folate deficiencies among Pakistani women

Depression among women of reproductive age in rural Bangladesh is linked to food security, diets and nutrition

Objective: To quantify the relationship between screening positive for depression and several indicators of the food and nutrition environment in Bangladesh. Design: We used cross-sectional data from the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) trial in Bangladesh to examine the association of depression in non-peripartum (NPW) and peripartum women (PW) with food and nutrition security using multivariable logistic regression and dominance analysis. Setting: Rural north-eastern Bangladesh. Participants: Women of reproductive age. Results: Of 2599 women, 40 % were pregnant or up to 1 year postpartum, while 60 % were not peripartum. Overall, 20 % of women screened positive for major depression. In the dominance analysis, indicators of food and nutrition security were among the strongest explanatory factors of depression. Food insecurity (HFIAS) and poor household food consumption (FCS) were associated with more than double the odds of depression (HFIAS: NPW OR = 2·74 and PW OR = 3·22; FCS: NPW OR = 2·38 and PW OR = 2·44). Low dietary diversity (<5 food groups) was associated with approximately double the odds of depression in NPW (OR = 1·80) and PW (OR = 1·99). Consumption of dairy, eggs, fish, vitamin A-rich and vitamin C-rich foods was associated with reduced odds of depression. Anaemia was not associated with depression. Low BMI (<18·5 kg/m2) was also associated with depression (NPW: OR = 1·40). Conclusions: Depression among women in Bangladesh was associated with many aspects of food and nutrition security, also after controlling for socio-economic factors. Further investigation into the direction of causality and interventions to improve diets and reduce depression among women in low- and middle-income countries are urgently needed

A rapid review of key policies and programs linked with nutrition and health in Ghana

As part of the process by the government of Ghana to develop food-based dietary guidelines, a review of policies and programs was commissioned. The review aimed to identify and describe the policy environment, with a focus on identifying the type of existing policies, priorities, and programs related to nutrition and health between 2010 and 2020. The review also tracked the evolution of changes in policies and programs over the same period. Using a systematic rapid scoping review approach, policy and program documents were identified and classified according to relevant nutritionspecific and nutrition-sensensitive sectors, including health, agriculture and food, human development, social protection, and trade. Data from included documents were extracted using an excel extraction tool. The extracted data including policies, programs, objectives, coverage of the policies/programs, intended outcomes, target groups, and agencies responsible for implementing these policies and programs. More than 70 government documents, plus other reports and literature sources describing government policy and programs with relevance for nutrition were identified. Most of these policies and programs were not designed to directly address malnutrition. This is because, the policies and programs neither referenced nutrition objectives, nor nutrition outcomes. However, the existing policies and programs had aspects that can be leveraged (either through redesign or implementation) to contribute to improved nutrition outcomes. A key challenge in the nutrition programming landscape is the nonexistence of a comprehensive and costed national nutrition strategic plan to accompany the national nutrition policy. The key nutrition priorities of the Government of Ghana and its partners, as expressed in the documents reviewed included infant and young child feeding, stunting reduction, anemia, and food security. There were key nutritionrelated issues which have not been prioritized, although current local and global evidence as well as stakeholder opinion suggests these have already become, or are rapidly becoming important priorities. These include overweight and obesity, dietrelated chronic diseases, nutrition of school-age children, and nutrition of the elderly. These nutrition issues, if not appropriately addressed, will continue to exact significant human health, economic, and social costs for Ghana. There is need for a comprehensive nutrition strategy that leverages opportunities across multiple sectors to improve nutrition for today and for the future.&nbsp

A rapid review of key policies and programs linked with nutrition and health in Ghana

As part of the process by the government of Ghana to develop food-based dietary guidelines, a review of policies and programs was commissioned. The review aimed to identify and describe the policy environment, with a focus on identifying the type of existing policies, priorities, and programs&nbsp; related to nutrition and health between 2010 and 2020. The review also tracked the evolution of changes in policies and programs over the same&nbsp; period. Using a systematic rapid scoping review approach, policy and program documents were identified and classified according to relevant&nbsp; nutritionspecific and nutrition-sensensitive sectors, including health, agriculture and food, human development, social protection, and trade. Data&nbsp; from included documents were extracted using an excel extraction tool. The extracted data including policies, programs, objectives, coverage of the&nbsp; policies/programs, intended outcomes, target groups, and agencies responsible for implementing these policies and programs. More than 70&nbsp; government documents, plus other reports and literature sources describing government policy and programs with relevance for nutrition were&nbsp; identified. Most of these policies and programs were not designed to directly address malnutrition. This is because, the policies and programs&nbsp; neither referenced nutrition objectives, nor nutrition outcomes. However, the existing policies and programs had aspects that can be leveraged&nbsp; (either through redesign or implementation) to contribute to improved nutrition outcomes. A key challenge in the nutrition programming landscape&nbsp; is the nonexistence of a comprehensive and costed national nutrition strategic plan to accompany the national nutrition policy. The key&nbsp; nutrition priorities of the Government of Ghana and its partners, as expressed in the documents reviewed included infant and young child feeding,&nbsp; stunting reduction, anemia, and food security. There were key nutritionrelated issues which have not been prioritized, although current local and&nbsp; global evidence as well as stakeholder opinion suggests these have already become, or are rapidly becoming important priorities. These include&nbsp; overweight and obesity, dietrelated chronic diseases, nutrition of school-age children, and nutrition of the elderly. These nutrition issues, if not&nbsp; appropriately addressed, will continue to exact significant human health, economic, and social costs for Ghana. There is need for a comprehensive&nbsp; nutrition strategy that leverages opportunities across multiple sectors to improve nutrition for today and for the future.&nbsp