tion-for-income plays in this scenario is secondarytothe principal purpose of producing food to meetthe household’s own food requirements.Income-oriented production for sale in markets. Asagricultural households become more market ori-ented, production-for-own-consumption becomesless significant relative to income from the sale ofwhat is produced. Technology becomes more im-portant relative to the household’s resource endow-ment, and the selection of crops to be grown isbased principally on their tradability and the pricethey are expected to command in local markets.Extra income may be used to buy more food,higher-quality (more nutrient-dense) foods, or both;the balance between the two affects the final impactof this additional income on the household’s con-sumption of energy and micronutrients. The trans-lation of increased income into better childnutrition, in turn, depends on a series of intrahouse-hold factors and processes. These include women’sstatus, education, knowledge, health-related prac-tices, decision-making power, income, and access toand use of health and sanitation services.The empowerment of women is a pathway that car-ries special significance for household nutritionoutcomes and in particular for children’s healthand nutrition outcomes. Women have consistentlybeen found to be morelikely than men to invest intheir children’s health and well-being, and the in-come and resources that women control wield dis-

proportionately strong effects on health andnutrition outcomes generally.Women who arereached by agricultural programs that relay infor-mation on nutrition issues appear to be particularlyeffective at delivering improved nutrition out-comes, and the effects appear to be most pro-nounced among the lowest income groups. Takentogether,these characteristics make women naturalpriorities for agricultural programs that aim at im-proving nutrition. These programs, however, musttake women’s time and resource constraints firmlyinto account and, whereand when possible, seekmeans of relieving them.Lowering food retail prices by increasing food pro-duction is another pathway linking agriculture tonutrition and is especially important in areas inwhich markets are less integrated. For net con-sumers, reduced food prices enable greater accessto food and essential nutrients, resulting in betterhealth and productivity for the general workforcewhile also freeing additional household resourcesfrom food to other expenditures, including produc-tive investments.Finally, a

gricultural growth itself represents an in-direct pathway to better nutrition through its con-tribution to macroeconomic growth and higherlevels of national income, which can support nutri-tional improvements by reducing poverty.Increases in agricultural productivity have beenvital factors in building sustained economicgrowth in both developed and developing coun-tries and have major impacts on poverty. Onecross-country analysis found that a 1 percent in-crease in agricultural yields lowers the percentageof a national population living on less than a dollaraday by between 0.64 and 0.91 percent—a povertyeffect that appears particularly great in Africancountries (Thirtle et al. 2002). Overall, however, theeconomic growth-to-malnutrition relationship ismodest. A doubling of gross national product(GNP) per capita in developing countries has beenassociated with a much more modest reduction inchildhood undernutrition—on the order of 23 to 32percent (Haddad et al. 2003).THE IMPACT OF AGRICULTURALINTERVENTIONS ON NUTRITIONOUTCOMESThe literaturereviewed in this report documentsthe nutrition outcomes of agricultural programsand can be usefully classified by the type of com-modity the program involved: staples, fruits andvegetables, or animal source foods. Studies on the

nutritional impacts of programs involving staplecrops such as maize and rice focused overwhelm-ingly on aggregate production and food availabil-ity rather than on individual- or household-levelindicators and therefore yielded little evidence thatis germane to this report. Moreover, the only agri-cultural interventions involving staple foods thathave been evaluated from a nutritional perspectiveconcern agricultural commercialization—the con-version from staple subsistence food production tocommercial food production. This type of interven-tion aims to improve nutritional outcomes throughboth the own-consumption and the income path-ways, with potential indirect impacts through theagricultural growth and price pathways. Evidencefrom the review of studies on agricultural commer-cialization shows increases in household income,Executive SummaryxiiixivFrom Agriculture to Nutrition: Pathways, Synergies, and Outcomes including greater income controlled by women insome cases and greater household food expendi-ture. These changes did not, however, translate intosubstantial improvements in child nutrition. Inorder to improve childhood nutrition, agriculturalcommercialization interventions would most likelyneed to be complemented by components or paral-lel interventions that specifically target other deter-minants of child nutrition. These would includeimproved health, care giving practices, and accessto water and sanitation facilities to address the highrates of infections affecting young children in poor

environments.Agricultural interventions promoting increasedproduction of fruit and vegetables—such as thoseinvolving homestead gardens—carry considerablepotential to effectively address micronutrient defi-ciencies. The review identified a significant body ofevidence documenting the success of homesteadgardens in raising production, income, householdconsumption, and the intake of targeted fruit andvegetables by vulnerable population groups.Several programs also showed significant impactson dietary and biochemical indicators of micronu-trient deficiencies, and especially so when they in-cluded components designed to change behaviorthrough education and to empower women.Programs and interventions involving animalsource foods have even greater potential to tacklemicronutrient deficiencies, especially vitamin A,iron, and zinc deficiencies. These micronutrientsare more readily bioavailable in animal sourcefoods than in plant foods. Several interventionsshowed gains in production, income, and house-hold food security, and significantly greater nutri-tion impacts when combined with interventionsinvolving women’s empowerment, education, andbehavior change.Four case studies of agricultural interventionswere reviewed because of their unique contribu-tion to the body of knowledge on the linkages be-tween agriculture and nutrition. They include an

orange-fleshed sweet potato intervention to im-prove vitamin A intake in Mozambique, a legumesystems and child nutrition program in Malawi, ahomestead gardening project integrated with pri-mary health care activities in South Africa, and anintegrated homestead gardening and livestock pro-gram in Asia. All four programs achieved their ul-timate objective of improving the intake of focusnutrient-rich foods by target population groups,and the two studies that measured biochemical in-dicators showed reductions in vitamin A defi-ciency. Common elements that appear to havecontributed to the success of these four programsinclude a strong behavior change component, care-ful consideration of local contexts, partnershipbuilding with different community members topromote ownership, and a specific focus onwomen’s empowerment. The studies also reaffirmthat careful evaluation design is critical but re-mains a challenge, as does the scaling up of suc-cessful pilot programs.Overall the review documents a wide range ofsuccessful agricultural interventions that have con-tributed to improved nutrition outcomes. In mostcases, however, the exact pathways by which im-pacts on nutrition have been achieved are difficultto track. Most studies document impacts on severalintermediary outcomes such as food security,in-come, or women’s empowerment, but without di-rectly modeling these pathways of impact tonutrition outcomes. Because these outcomes are so

closely intertwined, it is impossible to determinefrom this literaturethe relative importance of thedifferent pathways that connect agriculture andnutrition.The key lessons learned from this body of evi-dence arethat agricultural interventions aremostlikely to affect nutrition outcomes when they in-volve diverse and complementary processes andstrategies that redirect the focus beyond agriculturefor food production and toward broader considera-tion of livelihoods, women’s empowerment, and op-timal intrahousehold uses of resources. Successfulprojects are those that invest broadly in improvinghuman capital, sustain and increase the livelihoodassets of the poor, and focus on gender equality.THE CHANGING CONTEXT OFAGRICULTURE AND NUTRITIONLINKAGESOver time, changes in the global environmenthave been modifying how agriculture affects nu-trition and have made the need for integratingagriculture

and nutrition interventions even moreimperative. Four types of global changes areem-phasized in the report: changes in agricultural pol-icy, agricultural technology, food marketing sys-tems, and food consumption patterns. Thesechanges affect the broader context within whichnutrition-oriented agricultural interventions areimplemented. They also affect each of the path-ways through which agriculture affects nutrition,notably consumption of own-production, pro-ducer incomes, and food prices.Agricultural PolicyAgricultural policy in most developing countrieshas recently undergone a major paradigm shift aspart of what is often termed “globalization.”Although the role of the government in food mar-kets remains extensive, governments have disman-tled state marketing mechanisms and liberalizedtrade and investment. The level of taxation or “dis-protection” of agriculture has declined over timethrough trade liberalization in the nonagriculturalsectors and changes in exchange rate regimes.Private markets have generally assumed greater im-portance relative to state intervention, and agricul-ture’s increased market orientation has changedproducers’ incentives, with important effects onfood availability and prices.At the national level, the impact of liberalizationon commodity prices will vary across commoditiesdepending on whether the country is a net-importer

or a net-exporter of that commodity. The observedpattern of trade in which developing countries arenet exporters of high-value, micronutrient-richcrops implies that consumer prices are higher forthose products than the prices that would prevail inaclosed economy. The reverse would hold for thesupply of macronutrients since many developingcountries are net importers of grains. Agriculturalpolicy changes can also affect nutrition through theproducer income pathway. Again, the overall im-pact of trade liberalization on income is likely to dif-fer depending on the initial status of the country (asanet importer or exporter), and across farmerswithin the country depending on whether they arenet producers or net consumers.Agricultural TechnologyThe growth of agricultural technology has beendramatic over the past 25 years. Developments thatcarry particularly important implications for foodavailability, prices, demand, and consumption areplant breeding and technologies related to food pro-cessing and marketing, such as those that maintainacold-chain from farm to plate. Technologies thatincrease productivity, such as Green Revolutioncrop breeding technologies, have significantly re-duced food prices of the targeted crops. This in turnhas led to significant reductions in childhood mal-nutrition. Simulation models estimate that withoutthe Green Revolution, the proportion of malnour-ished children in South Asia would now be 12 to 15points higher than it is. Improvements in posthar-vest technology and marketing for fruit and vegeta-

bles can also lead to significantly reduced consumerfood prices. Changes in technology affect the de-mand for agricultural labor and thus the income offarm and nonfarm households in rural areas. Newtechnologies can be labor saving or labor enhanc-ing; some may have no effect at all on labor de-mand. Studies published during the 1990sdocumented a variety of positive impacts of tech-nology change on labor demand, incomes, foodconsumption, and diet quality—but failed to ex-hibit an impact on childhood nutrition. (This was infact attributed to the failureof increased income andfood consumption to translate into better childcare,feeding, and health-seeking behaviors—key ele-ments of improved nutrition.) Biofortification, anagricultural technology that can increase the mi-cronutrient content of staples, may confer large ben-efits to poor rural populations who have little accessto expensive high-quality foods. These improvedcrops can benefit nutrition through the own-con-sumption pathway when they are consumed byproducers, through the income pathway when theyare sold, or through the food price pathway whenthey increase the availability of micronutrient-richfoods in the marketplace.Food Marketing SystemsThe past two decades have seen a major transfor-mation and consolidation of food retail and an ex-

pansion of the food processing and food serviceindustries, especially in middle-income countriesand in urban areas of low-income countries. Thesetrends are driven by rising household incomes, ur-banization, improvements in transportation,lifestyle changes, and liberalized foreign invest-ment regulations. The rapid growth of supermar-Executive SummaryxvxviFrom Agriculture to Nutrition: Pathways, Synergies, and Outcomes kets in developing countries in the past 10 to 20years is increasingly important in shaping foodconsumption patterns and will most likely affectnutrition through changes in food availability andprices. With the rising availability and generallylower prices of processed foods in marketplacesand food service establishments throughout muchof the developing world, a growing proportion offood expenditures go to processed foods relative tofresh food sources. Changes in the composition ofagricultural exports also affect the types and priceof foods available and current trends show rapidgrowth in the share of agricultural products thatare processed compared with fresh products. Thischanging pattern of exports has implications fornutrition through the price pathway because it in-creases the availability of certain foods over othersin exporting and importing countries. Whereasconsumers in developing countries now consumemoreprocessed foods and vegetable oils exportedfrom developed and other developing countries,consumers in industrialized countries now con-

sume more fruits, vegetables, and fish exportedfrom developing countries.Changing Consumption PatternsThe demand for higher-value, micronutrient-richfoods increases as incomes rise and livelihoods di-versify around expanding markets, many of themurban. Increasing incomes and urbanization drivechanges in demand that provide food supplierswith market signals that tend to reorient agricul-tural production away from the cultivation of sta-ples and towardhigher-value products. Forsmallholders in particular, this reorientation isoften in effect compulsory, because the viability offarming lower-value staple crops relies on muchlarger scales of production than are possible onsmall farms. For food consumers, and especiallynet food consumers, the shift in consumption awayfrom staples and toward higher-value food sourcesbrings a phenomenon that is generically referred toas the “nutrition transition.” The phenomenon ismost pronounced in rapidly growing economiesand in urban areas, in which the proportion of foodprepar

ed at home declines in relation to the pro-portion of processed foods consumed in and out-side the home. Diets tend to become increasinglyenergy-dense, and very often excessively so, at thesame time that automation, transportation, andsedentary lifestyles are dramatically reducing thelevel of physical activity and thus energy require-ments. Negative outcomes like obesity, heart dis-ease, and diabetes quickly become endemic, whichin turn prompt additional changes in the demandfor food. Functional foods that carry health benefitsbecome the focus of advertising and the communi-cation of health-related information, with dramaticeffects on the types of foods that are demanded.The trend offers a variety of important opportuni-ties for producers who are able to respond to thechanging demand. As consumers manifest greaterwillingness to pay more for healthier foods, re-sponsive producers find a very real prospect thatthe downwardpressure on prices exerted by in-creased production may be reversed. Howeverpromising this prospect may be, the ability of poorproducers to capitalize on the emerging opportuni-ties is contingent on a number of factors, not theleast of which is the risk of converting to the culti-vation of unfamiliar crops. In the final analysis,much will depend on the success of arrangementslike contract farming, which enables poor farmersto link their production with large, often supermar-ket-led supply chains.ConclusionChanges in agricultural policy, technology, mar-

kets, and associated changes in food consumptionpatterns arechanging the pathways through whichagricultureand nutrition are linked. Today, themoremarket-oriented natureof agricultural poli-cies means that agricultural technology and mar-kets play a moreimportant role in determiningfood prices and rural incomes, as more food is con-sumed from the marketplace and less from house-holds’ own-production. The greater marketorientation of food production and consumptionhas increased the bidirectional links between agri-culture and nutrition. Agricultural production re-mains an important factor contributing tonutritional outcomes, but changing food and nutri-tional demands areexerting new effects on agricul-tural production. Agricultural programs withnutritional objectives need to take this changingcontext into account to ensurethat the synergies

between agriculture and nutrition are successfullyexploited and lead overall to better developmentoutcomes.INSTITUTIONSImproving nutritional outcomes is a decidedlymultisectoral goal and requires the involvement ofseveral players, including households and publicand private sector agents. It also requires the in-volvement of government institutions that formu-late public policy and that in so doing influence thesettings in which agriculture-nutrition pathwaysare or are not operationalized. Jurisdiction overfood production and food supply is generally as-signed to a country’s ministry of agriculture.Nutrition, however, is not ordinarily considered asector but rather a policy issue or area that does notfall cleanly within the jurisdiction of any particularministry or agency. Health ministries generally as-sume the most direct responsibility for nutrition,but they have no administrative jurisdiction or in-fluence over agriculture or trade—the most impor-tant sector ministries addressing food supply andavailability.Common sense may suggest the estab-lishment of a governmental multisector agency tocoordinate joint action among these ministries, acourse which has been pursued by a number ofcountries. These coordinating bodies have how-ever seen little if any success in achieving effectivecooperation between sector ministries, leaving lit-

tle empirical basis for assuming that such institu-tional adaptations actually work. Concertedprogrammatic coordination between different min-isterial-level institutions tends to run headlong intothe bureaucratic barriers that divide spheres of re-sponsibility between different line ministries.Bureaucracies in general areorganized to ration-ally divide responsibilities within institutions, notto orchestrate joint collaboration between them.Coordination between different government insti-tutions is therefore problematical, but cannot bedismissed altogether. Possibilities for such collabo-ration are by no means limited to systematic high-level institutional frameworks. More limited,lower-level opportunities for collaboration to ad-dress specific and local issues contributing to mal-nutrition appear to offer greater promise foreffective action. This local collaboration offers theprospect of incrementally improving higher-levelcoordination of multisectoral action to addressfood insecurity and malnutrition effectively on anational basis.LESSONS LEARNED AND NEXT STEPSPolicy makers and practitioners have long aimed to

influence nutritional outcomes through agriculturalprograms. Many of these programs supported com-mercialization and cash crop production or the pro-duction of fruit and vegetables or animal sourcefoods with overall objectives of raising agriculturalproductivity and household income. The assump-tion was that agriculture would tackle poverty andmalnutrition by increasing food production, lower-ing food prices, and increasing household income.While food production and household food avail-ability, income, and in many cases food consump-tion and diet quality increased, childhoodmalnutrition persisted. This led to the conclusionthat increasing agricultural production and incomewereprobably necessary but clearly not sufficientconditions to reducing malnutrition. Far more sub-stantial impacts were achieved when agriculturalinterventions incorporated nonagricultural compo-nents or combined with complementary nonagri-cultural interventions that addressed otherdeterminants of child nutrition. These other deter-minants included maternal health-seeking andcaregiving practices. Arming women with knowl-edge about appropriate child feeding practices, theimportance of different micronutrients, and thefood sources in which those micronutrients areavailable was a particularly effective way of im-proving child health and nutrition outcomes.Incorporating nonagricultural criteria like

health and nutrition into the design and conduct ofagricultural programs to improve nutrition sug-gests developing an effective interface betweenagricultural and other institutions. Yet systematichigh-level coordination between different sectorministries is challenging given the bureaucraticbarriers that typically divide them. The reporttherefore examined alternative approaches to for-mulating a morecomprehensive approach for agri-culture programs to embrace improved nutrition asadevelopment objective.The empirical evidence presented in this reportfocuses on agricultural programs and interventionscarried out at the level of local communities.Overall, the review found that the most successfulprojects were those that invested broadly in im-proving human capital and sustained and in-creased the livelihood assets of the poor.The fourExecutive SummaryxviixviiiFrom Agriculture to Nutrition: Pathways, Synergies, and Outcomes key lessons learned about how these programsshould be developed and implemented in order tohelp achieve improved nutrition outcomes aresummarized below.•Develop and implement agricultural programs

that take into account local contexts. The impor-tance of designing programs that accommo-date prevailing agricultural and nutritionalconditions has long been recognized and en-tails developing a sound understanding ofproducers’ priorities, incentives, assets, vul-nerabilities, and livelihood strategies. Forthese programs to benefit nutrition, however,thereis also a need to understand and targetthe major nutritional problems experiencedby the target communities an aspect that isusually ignored in agricultural program de-sign and development. Understanding themotives and constraints that affect householdconsumption decisions is no less importantthan understanding those that affect produc-tion decisions. Cultural norms, for instance,areoften key factors determining whichhousehold members maintain control overwhich household resources, and influencesuch nutritionally vital decisions as the allo-cation of types and quantities of food amonghousehold members. Thus, successful agri-cultureprograms aimed at improving nutri-tion must first develop an understanding ofthe economic, social, and cultural factors thatdetermine household decisions concerninglivelihood, agriculture production, household

consumption, and intrahousehold allocationof resources, as well as the context-specifichealth and nutrition problems that prevail.•Develop and implement agricultural programsthat enable and empower women. The essentialrole of women in delivering health and nutri-tion outcomes makes gender an inevitablepriority area for agricultural programs andpolicies that seek to contribute to nutrition.Targeting women in their roles as economicagents and stewards of household food secu-rity and health generally entails increasingtheir access to productive resources and serv-ices—an ostensibly straightforwardproposi-tion that in reality must take into account andpurposefully navigate around a variety ofwomen’s constraints, including cultural con-straints. The significance of women’s educa-tion to the health and nutrition of their children is an established axiom of develop-ment planning. This education by no meanshas to be limited to formal education.Communication of information about healthissues such as appropriate child-feeding andchildcare practices, water sanitation, and foodsafety issues carries great importance for nu-trition by addressing caregiving and health asnecessary conditions of good nutrition. Otherpublic information services, including those

agricultural extension services that convey in-formation about issues like integrated pestmanagement, likewise have important posi-tive health impacts and many can also be tai-lored to reach women.•Develop and implement agricultural programsthat incorporate nutrition outreach and behaviorchange. Whether regarded as a resource or aservice, the value of information that is di-rected at behavior change among farmers andconsumers presents itself as a salient conclu-sion of this report. Agricultural interventionsthat include a nutrition education componentwill increase the likelihood of positive nutri-tional outcomes. Those who are armed withinformation and knowledge about the nutri-tional significance of the foods they produceand eat are able to make better productionand consumption decisions. Nutrition-relatededucation and communication strategies mayoffer instruction on food preparation andsafety and on child-careand feeding prac-tices, as well as on how to recognize and actupon signs of nutritional deficiencies. Here,too, targeting women with health and nutri-tion information is likely to have a still greatercatalytic ef

fect, given their typically closer af-filiation with the household and their crucialrole as child caretaker.*Provide small producers with help and support torespond to changes in the global environment andespecially to the changing food demand. Anti-cipating and responding to changing demandis a vital imperative for farmers in general, butamong poor farmers in developing countriesthe stakes are particularly high. A significantpart of their production is intended for theirhouseholds’ own consumption, and thereforemuch of the demand they aresatisfying is theirown. With respect to the proportion of foodthey produce for market, the changing agricul-tural context has important implications forthe prices they are paid for their products,while increasing demand for high-value foodsources represents an important opportunityto earn more income. Yet switching to new andunfamiliar crops and producing for foreignmarkets with stringent food quality and safetyrequirements is also fraught with risk, andboth opportunities and risks need to be ad-dressed by agricultural programs.This report consists mainly of a review of empir-ical evidence about past and ongoing cases of agri-cultural interventions with nutrition-relatedobjectives and more broadly about connections be-tween agricultural production and nutrition. Its

analysis of the practical implications of the lessonslearned sheds light on the dynamics and causal re-lations that agricultural practitioners should takeinto account when planning programs or providingpolicy advice that focuses the crosshairs of produc-tion goals onto a nutrition-related target or targets.There is by now good reason to anticipate that nutri-tional aims will come to play more prominently inthe calculus by which the value of agricultural pro-grams is rated. Future agricultural programs imple-mented with nutritional objectives will need toaddress the real challenge of going to scale andshould be carefully monitored and rigorously eval-uated to ensure that performance can be continuallytracked and improved. The expository account of-fered in this report, it is hoped, lays the groundworkfor morepractical work in which the details of ap-plying these lessons operationally can be prescribed.Executive Summaryxix1In a world abundant with food, millions of people suffer from poornutrition. In some parts of the world, the poor have inadequate ac-cess to energy (measured in calories) from food. In these locations,food shortages are often seasonal phenomena, and the quantitativedeficit of food energy is generally matched by deficits in food qualityreflected in insufficient essential micronutrients including vitamin A,iron, zinc, folate, and many others. Elsewhere consumption amongthe poor is characterized by monotonous diets in which these mi-cronutrient deficiencies are found despite stable and sufficient in-

takes of food energy. Still other places see a “nutrition transition”under way in which diets are characterized by excessive intakes ofenergy, largely from fat, added sugars, and energy-dense processedfoods, and in which lifestyles are characterized by generally lowlev-els of physical activity. This combination of excessive energy intakeand low activity patterns is associated with overweight and obesityand a variety of chronic diseases including diabetes and heart dis-ease. Together these adverse nutrition outcomes affect some 2 billionpeople worldwide.The factors that contribute to malnutrition and poor nutrition out-comes are complex and vary across production and consumption set-tings. Sector-specificstrategies tend to approach nutrition issuesalong narrowly disciplinary lines and generally disregard contribut-ing factors that fall outside the purview of that particular field.Agriculture’s role as the source of food production makes its signifi-cance to nutrition unquestionable. Yet the persistence of malnutritionas a global public health concern despite increasing agriculturalpro-duction belies any notion that the malnutrition and undernutritionproblem can be solved entirely from the supply side by increasingproduction. Nutrition is intrinsically multisectoral, and strategies to

improve nutrition outcomes should seek to purposefully integratethe contributions of relevant disciplines. How agriculture’s necessaryinput into nutrition issues is to be operationally coordinated with thelikewise necessary input of nonagricultural sectors is a more difficultmatter. Historically, multisector efforts intended to simultaneouslyaddress agriculture and nutrition have often been hindered by insti-tutional barriers and insufficient resources.Agricultural investments and interventions supported by theWorld Bank and other international development and donor agencieshave seldom explicitly incorporated nutrition-related objectives.The

Introduction

1World Bank itself last examined this issue in 1981 inastudy by Per Pinstrup-Andersen, which made anumber of recommendations for incorporating nu-tritional effects into the design and planning of agri-cultural policies and programs. A recent review ofits agriculture and rural development portfolio re-vealed little or no lending for nutrition issues to beincluded in agricultural education or extension ser-vices. The only nutrition-focused agricultural inter-ventions to receive significant support frominternational development and donor agencies inrecent years involved the still-developing technol-ogy of biofortification.

The contexts in which agriculture and nutritionare linked have, moreover, changed since the 1980s(Hawkes and Ruel 2006b). The focus of nutrition asadevelopment issue, and a human developmentissue in particular, has expanded from an early em-phasis on energy-protein deficiency to include mi-cronutrient deficiencies, and more recently extendsto the relationship between excess energy intake,poor-quality diets, obesity, and chronic diseases.The agricultural context itself is also changing.Although 75 percent of the world’s poor still live inrural areas with poor access to markets and ser-vices, fewer people are now dependent on agricul-ture for their livelihoods and more are connected tomarkets. The percentage of poor people who live inurban areas in developing countries is growing.Urbanization reflects a migration away from rural,agriculture-based employment and into urbanlivelihoods. People in cities are less likely to experi-ence undernutrition and more likely to experiencethe “nutrition transition” toward energy-densediets high in fats, sweeteners, and highly refinedcarbohydrates (Popkin 1999). Overall, the processesof global market integration, or “globalization,”have increased the market-orientation of the agri-food system worldwide, unleashing dynamicsthroughout the food supply chain that affect foodproducers and consumers.Malnutrition remains an urgent global publichealth concern. The question of how agriculturecan most effectively contribute to improved nutri-tion outcomes remains unanswered. It is thereforetime to revisit what is known and what can be done

to improve the synergies between agriculture andnutrition. The potential contribution of agricultureneeds to be reexamined, especially in light of thechanges the sector has undergone, by reviewinglessons from past experience and by analyzing cur-rent developments and what they mean for futurechange. This is the purpose of this report.More specifically, the report seeks to analyzewhat has been learned about how agricultural inter-ventions influence nutrition outcomes in low- andmiddle-income countries, focusing on the targetpopulations of the Millennium DevelopmentGoals—people living on less than a dollar a day. Italso sets out to synthesize lessons from past institu-tional and organizational efforts to improve the syn-ergies between agriculture and nutrition outcomes.The report identifies a number of developments inagriculture and nutrition that have transformed thecontext in which nutrition is affected by agriculture.These developments have considerable practicalsignificance for nutrition-related agricultural pro-grams—including the design of those programs thataim to improve nutritional outcomes. Finally, the re-port sets out a number of practical conclusions thatshed light on how agricultural interventions and in-vestments may improve nutrition outcomes in low-and middle-income countries.WORLD FOOD SECURITY ANDNUTRITION SITUATIONThe Food and Agricultural Organization (FAO) es-timates that in 2000–03, 854 million people world-wide were undernourished, as defined by foodintakes that are continuously inadequate to meet

dietary energy requirements (FAO 2006). The num-ber included 820 million people in developingcountries, 25 million in transition countries, and 9million in industrialized countries. In developingcountries, this represents a decline of only 3 millionpeople since 1990–92. And although significantprogress has been achieved in Asia, the number ofundernourished people in Africa has been increas-ing, as shown in table 1.Food security, a broader concept than under-nourishment, necessarily goes beyond the satisfac-tion of people’s energy requirements throughsufficient intakes to encompass access to “suffi-cient, safe and nutritious food to meet dietaryneeds and food preferences for an active andhealthy life” (FAO 1996). A summary of the nutri-tional situation in the world is presented here inthree categories: childhood undernutrition, mi-cronutrient deficiencies, and overweight and obe-2From Agriculture to Nutrition: Pathways, Synergies, and Outcomes sity and related chronic diseases. More completeanalyses of these trends are available in the 2006World Bank report Repositioning Nutrition forDevelopment and in the fourth and fifth reports onthe world nutrition situation issued by the UnitedNations Standing Committee on Nutrition in 2000and 2004.Child UndernutritionIt is well recognized that the most nutritionally vul-nerable population groups are pregnant and lac-tating women, whose bodies must cope with theadditional nutritional stresses and demands of

pregnancy and lactation, and infants and youngchildren up to age two. The present report ad-dresses these vulnerable groups, but with a greateremphasis on children’s nutrition because most ofthe work linking agriculture and nutrition to datehas focused on this age group. Childhood under-nutrition is typically reflected in anthropometricindicators such as stunting (low height-for-age),wasting (low weight-for-height), and underweight(low weight-for-age). Stunting reflects the cumula-tive effects of inadequate nutrition, whereas wast-ing reflects more recent or acute weight loss. Thesesymptoms are nonspecificand reflect a combina-tion of nutritional deficiencies including protein,energy, and/or micronutrients. They may be sea-sonal or chronic. Dietary shortages of vitamin A,iodine, iron, and zinc are the most widespread mi-cronutrient deficiencies and disproportionately af-fect women and young children.Childhood undernutrition dropped globally be-tween 1980 and 2005. Stunting now affects approx-imately one-third of all children in the developingworld, compared to one-half in 1980. The propor-tion of underweight children fell from 38 percent to25 percent during the same period. Yet there werean estimated 164.79 million stunted and 137.95 mil-lion underweight children in developing countriesin 2005. Figures 1 and 2 show that most of the re-ductions in undernutrition since the 1980s havebeen achieved in Asia and Latin America. In Africa,the number of stunted children decreased, whilethe proportion and number of those who are un-derweight increased slightly

Micronutrient DeficienciesVitamin A, iron, zinc, and iodine are the mostwidespread nutritional deficiencies globally, andthey affect women and young children dispropor-tionately. They may or may not overlap with pro-tein and energy deficits. Vitamin A deficiency iswidespread throughout the developing world, af-fecting between 78 and 254 million people, includ-ing an estimated 127 million children (UN SCN2004; West 2002). Shortage of the nutrient in thediet can limit growth, weaken immunity, cause xe-rophthalmia (an irreversible eye disorder leadingto blindness), and increase mortality. Seventy per-Introduction3Table 1 Prevalence and Number of Undernourished People in Developing Countries 1990–2003Prevalence of Undernourished Number of Undernourished (%)a

(million)FAO Region 1990–92 2001–03 1990–92 2001–03Developing countries 20 17 823.1 820.2Sub-Saharan Africa 35 32 169.0 206.2Near East and North Africa 8 9 25.0 37.6Asia 20 6 569.7 524.0Latin America and Caribbean 13 10 59.6 52.4 Source: FAO 2006.a. Undernourishment is defined as food intake that is continuously inadequate to meet dietary energy requirements.cent of preschool children in Benin and Kenya aresubclinically vitamin A deficient, compared to just5percent in Venezuela, revealing the wide vari-ability in the condition’s prevalence among devel-oping countries (Sommer and West 1996).

Iron deficiency is estimated to be the mostprevalent nutritional deficiency, affecting 4 billionto5billion people. The estimated prevalence ofiron deficiency among children under five years ofage in 80 developing countries in 2004 was 54 per-cent, as compared to an estimated 34 percent whoare vitamin A deficient. Again, the range in preva-lence between countries is wide. An estimated 20percent to 35 percent of children under five years ofage are iron deficiency anemic in Latin Americaand Southeast Asia, compared to an estimated 75percent to 85 percent in many African countries(Adamson 2004). In young children, iron deficiencymay impair growth, cognitive development, andimmune function. In school-age children, it can af-fect school performance, and in adults it may lowerwork capacity. Iron deficiency anemia is responsi-ble for tens of thousands of maternal deaths eachyear (UN SCN 2004).Iodine and zinc deficiency are also widespreadand account for a large share of the poor develop-ment, health, and survival outcomes of children indeveloping countries (UN SCN 2004). Deficienciesof key vitamins and minerals continue to be perva-sive, and they overlap considerably with problemsof general undernutrition (underweight, wasting,and stunting).Overweight, Obesity, and Diet-RelatedChronic DiseasesAset of very different nutrition-related outcomesaffect people whose nutrient intakes exceed their4

From Agriculture to Nutrition: Pathways, Synergies, and Outcomes Figure 1 Estimated Prevalence of Stunted Preschool Children 1980–2005Source: UN SCN 2004.Note: Preschool children defined as children less than five years of age.01020304050601980 1985 1990 1995 2000 2005Year%ofpopulationAfricaAsiaLati A eric a d t e Carib eanAll Develo in Co ntriesAfricaAsiaLatin America and the CaribbeanAllDeve

loping Countries60504030201001980 1985 1990 1995 2000 2005%ofpopulationYearenergy expenditures, resulting in obesity and a va-riety of chronic diseases associated with excessweight, including heart disease and diabetes.Among poorer populations in particular, energy-dense, low-quality diets are likely to remain defi-cient in essential micronutrients. Overweight andobesity are now highly prevalent in every region ofthe world.1

The prevalence of overweight childrenunder five is also increasing throughout the devel-oping world. The prevalence of childhood obesityin the developing world increased by 17 percentbetween 1995 and 2005, whereas in Africa it in-

creased by 58 percent. The reason that Africa is ex-periencing such an exaggerated trend is notentirely clear, owing to a lack of data, but the risein prevalence of overweight among mothers islikely to be part of the explanation (World Bank2006b). The prevalence of overweight is consider-ably higher in urban areas in the developing world,but in Latin America, the Middle East, and SouthAfrica, overweight is also higher than underweightin rural areas (Mendez and Popkin 2004). Overall,the World Health Organization predicts that by2015, approximately 2.3 billion adults will be over-weight and more than 700 million will be obese(WHO 2006).Overweight and obesity are strongly associatedwith the risk of several chronic diseases, includingdiabetes, cardiovascular diseases, and severaltypes of cancer. Figures 3 and 4 show trends inoverweight by region since the 1980s among adultwomen and among preschool children. Chronicdiseases are the largest cause of death in the world,Introduction5Figure 2 Estimated Prevalence of Underweight Preschool Children 1980–2005Source: UN SCN 2004.Note: Preschool children defined as children less than five years of age.AfricaAsiaLatin America and

the CaribbeanAllDeveloping Countries60504030201001980 1985 1990 1995 2000 2005%ofpopulationYear1Overweight is defined as a body mass index (BMI)(weight/height square) greater than 25; obesity is defined asBMI greater than 30.

led by cardiovascular disease (17 million deaths in

2002, mainly from ischemic heart disease andstroke) followed by cancer (7 million deaths),chronic lung diseases (4 million), and diabetes mel-litus (almost 1 million) (Yach et al. 2004). Althoughchronic diseases have been the leading cause of

death in developed countries for decades, 80 per-cent of deaths from chronic diseases now occur indeveloping countries, in which cardiovascular dis-ease is the leading cause of mortality (WHO 2005).The global prevalence of the leading chronic dis-eases is projected to increase substantially duringthe next two decades. The number of individualswith diabetes, for instance, is projected to rise from171 million or 2.8 percent of the global populationin 2000 to 366 million, or 6.5 percent in 2030—298million of whom will live in developing countries(Wild et al. 2004).6From Agriculture to Nutrition: Pathways, Synergies, and Outcomes Figure 3 Overweight and Obesity among Women 45–59 Years of Age, byWHO RegionSource: Source: James et al. 2004. Data collected between 1990 and 2000.*Africa D comprises northern and western parts of Sub-Saharan Africa, e.g., Nigeria, Ghana.Africa E comprises central, eastern, and southern parts of Sub-Saharan Africa, e.g., Kenya, Mozambique.America A comprises North America and Cuba.America B comprises the Caribbean and some Latin American countries, e.g., Mexico,Venezuela.America D comprises some Latin American countries, e.g., Guatemala, Peru.Eastern Med B comprises much of the Middle East and some of North Africa, e.g., Tunisia, Saudi Arabia.Eastern Med D comprises countries in the Middle East, North Africa, and Asia, e.g., Egypt, Morocco.Europe A comprises most of Western Europe.Europe B comprises some of Eastern Europe and Central Asia.Europe B comprises the rest of Eastern Europe and Central Asia.Southeast Asia B comprises Indonesia, Sri Lanka, and Thailand.Southeast Asia D comprises most of South Asia, e.g., Bangladesh, India.Western PacificAcomprises Australia, New Zealand, Singapore, Japan, and Brunei.Western Pacific B comprises China and some countries of East Asia, e.g., Vietnam, and the Pacific Islands.Af

ricaDAfricaEAmericasAAmericasBAmericasDEaster

nMedBEasternMedDEuropeAEuropeBEuropeCSEAsiaBS

EAsiaDW.PacificAW.PacificB1009080706050403020100ObesityOverweight

WHORegionPercentageofPopulationSTRUCTURE OF THE REPORTThe background and description of types of ad-verse nutrition outcomes given in this introductionare followed in chapter 2 by an analysis of the de-terminants of human nutrition, setting out a num-ber of pathways through which agriculture canpotentially affect nutrition. Chapter 3 presents a re-view of available evidence of how agricultural in-terventions influence nutrition outcomes. Chapter4presents a series of four more detailed case stud-ies of agricultural interventions that had explicitnutrition-related objectives. Chapter 5 examinesthe changes in agriculture and nutrition that are af-

fecting the operational contexts in which nutrition-focused agricultural interventions are carried out.Chapter 6 focuses on the institutional issues relatedto the operationalizing agricultural developmentstrategies that have nutritional objectives, primar-ily at the national level. It maps out the state-levelinstitutions involved with agriculture and nutri-tion and analyzes the barriers that have posedproblems for closer coordination in the past.Chapter 7 draws a set of conclusions as to how agri-cultural interventions and investments could ac-celerate improvements in nutrition in low- andmiddle-income countries.Introduction7Figure 4 Estimated Prevalence of Overweight Preschool Children (%)65432101995 2000 2005AfricaAsiaLatin America and the CaribbeanAllDeveloping Cou

ntriesSource: UN Standing Committee on Nutrition 2004.Note: Preschool children defined as children under the age of 5.