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Background: Global food insecurity persists despite continued international attention, necessitating evidence-based food assistance interventions that adequately address nutritional concerns. In June 2018, the US Agency for International Development's Office of Food for Peace through the Food Aid Quality Review (FAQR) project sponsored a "Food Assistance for Nutrition Evidence Summit" to share evidence relevant to policy and programmatic decision-making and to identify critical evidence gaps., Objective: This article presents 4 priority areas to advance nutrition in the international food assistance agenda generated through presentations and discussions with the food assistance community at the Evidence Summit., Methods: Priority areas were identified after the Evidence Summit using a combination of FAQR team discussions, review of presentations and official notes, and supporting literature., Results: Key priority areas to advance nutrition in the international food assistance agenda are as follows: (1) increase research funding for food assistance in all contexts, paying particular attention to emergency settings; (2) research and adopt innovative ingredients, technology, and delivery strategies in food assistance products and programs that encourage long-term well-being; (3) redefine and expand indicators of nutritional status to capture contextual information about the outcomes of food assistance interventions; and (4) augment communication and collaboration across the food assistance ecosystem., Conclusions: These priorities are critical in a time of increased humanitarian need and will be key to fostering long-term resilience among vulnerable groups.

Background: Food aid is a valuable tool for meeting global nutrition goals, particularly for vulnerable populations of children and reproductive-aged women. On October 21, 2017, the Food Aid Quality Review Project hosted a scientific symposium at the 21st International Congress on Nutrition in Buenos Aires, Argentina, to take stock of what the global community has learned about selected topics in the research literature on food aid used to address malnutrition., Objective: This article presents the discussion that took place during the symposium, which was guided by presentations by 6 experts from the field of nutrition, food aid, and humanitarian response., Conclusion: The recent upsurge in research on food aid has advanced the collective knowledge of what food aid products and programs work for addressing nutrition, but there is much more to learn. Presentations in this symposium called for further inquiry on (1) different and novel food aid formulations, (2) the cost-effectiveness of products and programs, and (3) market-based approaches to food assistance. Continuing to expand the evidence base on these topics is critical to improving global nutrition programs.

Ready-to-use foods are one of the available strategies for the treatment of moderate acute malnutrition (MAM), but challenges remain in the use of these products in programs at scale. This paper focuses on two challenges: the need for cheaper formulations using locally available ingredients that are processed in a safe, reliable, and financially sustainable local production facility; and the effective use of these products in large-scale community-based programs. Linear programming tools can be used successfully to design local compositions that are in line with international guidelines, low in cost, and acceptable, and the efficacy of these local formulations in the treatment of MAM was recently demonstrated in Malawi. The production of local formulations for programs at scale relies on the existence of a reliable and efficient local production facility. Technical assistance may be required in the development of sustainable business models at an early stage in the process, taking into account the stringent product quality and safety criteria and the required investments. The use of ready-to-use products, as of any food supplement, in programs at scale will be affected by the practice of household sharing and diversion of these products for other uses. Additional measures can be considered to account for sharing. These products designed for the treatment and prevention of MAM are to be used in community-based programs and should therefore be used in conjunction with other interventions and designed so that they do not replace the intake of other foods and breastmilk. Remaining challenges and implications for the (operations) research agenda are discussed.

Background: More than 50% of children in Nepal are malnourished. Economic growth and poverty reduction are not always sufficient to improve the health and nutritional status of children. Heifer Nepal uses livestock training as a tool for community development and poverty alleviation but does not directly address child health and nutrition., Objective: To systematically assess the effects of Heifer activities on child health and nutrition., Methods: The study was a 2-year, longitudinal, randomized, controlled trial in six communities in Nepal (both Terai and hills), pair-matched for specific characteristics, randomly assigned to receive Heifer community development activities at baseline (intervention) or 1 year (control). At 6-month intervals over a period of 2 years, child anthropometric and comprehensive household surveys were performed., Results: Four hundred fifteen households were enrolled containing 607 children 6 months to 5 years of age. The intervention and control communities were equivalent for baseline socioeconomic status, household size, ownership of land and animals, and child nutrition and health. At 12 months (prior to animal donations), the Terai intervention group had improved child weight (p = .04), improved child height (p = .05), and reduced sick days (p = .03), as well as increased household income (p = .004), increased ownership of animals (p = .04) and land (p = .04), and improved sanitation practices (p < .01). In all districts, longer participation in Heifer activities corresponded to more improvement in child height-for-age z-scores., Conclusions: Heifer interventions resulted in improved socioeconomic status and household income per family member. Children under 60 months of age in the intervention group had greater incremental improvement in height-for-age and weight-for-age z-scores than children in the control group, and longer participation in Heifer activities was associated with better growth. Poverty alleviation programs, such as Heifer, may indirectly benefit child growth.

Background: Dietary assessment data are essential for designing, monitoring, and evaluating food fortification and other food-based nutrition programs. Planners and managers must understand the validity, usefulness, and cost tradeoffs of employing alternative dietary assessment methods, but little guidance exists., Objective: To identify and apply criteria to assess the tradeoffs of using alternative dietary methods for meeting fortification programming needs., Methods: Twenty-five semistructured expert interviews were conducted and literature was reviewed for information on the validity, usefulness, and cost of using 24-hour recalls, Food Frequency Questionnaires/Fortification Rapid Assessment Tool (FFQ/FRAT), Food Balance Sheets (FBS), and Household Consumption and Expenditures Surveys (HCES) for program stage-specific information needs. Criteria were developed and applied to construct relative rankings of the four methods., Results: Needs assessment: HCES offers the greatest suitability at the lowest cost for estimating the risk of inadequate intakes, but relative to 24-hour recall compromises validity., Design: HCES should be used to identify vehicles and to estimate coverage and likely impact due to its low cost and moderate-to-high validity. Baseline assessment: 24-hour recall should be applied using a representative sample. Monitoring: A simple, low-cost FFQ can be used to monitor coverage. Impact evaluation: 24-hour recall should be used to assess changes in nutrient intakes. FBS have low validity relative to other methods for all programmatic purposes., Conclusions: Each dietary assessment method has strengths and weaknesses that vary by context and purpose. Method selection must be driven by the program's data needs, the suitability of the methods for the purpose, and a clear understanding of the tradeoffs involved.

Background: Food aid provided by the United States has saved lives for almost two centuries. Delivering the right products is important, but of equal concern are the ways in which products are delivered and to whom., Objective: The study addresses how food products are currently used, whether interventions are appropriate to achieve nutrition objectives, and whether nutrition targets could be met more cost-effectively with a different mix of products or programs., Methods: The team conducted consultations with a broad range of stakeholders. A survey of Title II implementing partners was conducted, focusing on procurement and logistics, and uses of FBFs and other foods. Input of implementing partners, civil society, and donor organizations was obtained through individual consultations, international and small group meetings. More than 400 individuals accessed the project's website. The project convened a panel of experts in food technology and science, food policy, law, industry, medicine, development and humanitarian work, and the maritime industry, and held regular joint meetings with USDA and USAID. The draft report was widely disseminated and posted on the website., Results and Conclusions: There is wide variation in the quantities of fortified blended foods provided to target populations. Most of these foods are used in health/nutrition programs, but they are also used in general family rations or as an incentive or pay. Clearer programming guidance and improved decision tools are needed to match products to nutrition goals, and programs should consider delivering nutrients across a basket of commodities, not single products. The evidence base for the effectiveness and cost-effectiveness of specific foods and programs needs to be strengthened and should be supported by FFP Research is needed to provide guidance on nutrition support for HIV/AIDS. Additional investments are needed in effective behavior change communication.

Background: Food aid provided by the United States has saved the lives of the vulnerable for many years. Recognizing the need for a thorough review of product formulations and specifications, the US Agency for International Development (USAID) commissioned a 2-year assessment of quality issues relating to Title II food aid products. This article presents findings and recommendations of that review relating to product enhancements., Objective: The core question addressed was: Are current commodity specifications for enriched FBFs appropriate in light of evolving nutritional science and food fortification technology, or do they need to be updated?, Methods: Empirical data were derived from a number of sources, including a survey of Title II implementing partners focusing on procurement and logistics, and uses of FBFs and other foods. Input of implementing partners, civil society, and donor organizations was obtained through individual consultations, international and small group meetings. More than 400 individuals accessed the project's website. The project convened a panel of experts in food technology and science, food policy, law, industry, medicine, development and humanitarian work, and the maritime industry, and held regular joint meetings with USDA and USAID. The draft report was widely disseminated and posted on the website., Results and Conclusions: The findings of this research led to the following broad areas of improvement in US Title II food aid products: 1) Improve the formulation of existing FBF products used in Title II programming. This includes the addition of a dairy source of protein to products targeted to children 6 to 24 months of age, pregnant and lactating women, wasted children, and wasted individuals undergoing HIV/AIDS treatment. 2) Upgrade the vitamin and mineral mixes used and diversify approaches to addressing micronutrient needs. Enhance the composition of premixes used to fortify blended foods as well as milled grains and vegetable oil; facilitate shipping offortificant premix with bulk cereals for in-country fortification; and develop micronutrient powders (sachets) and other point-of-use fortification options. 3) Develop or adopt non-cereal-based (e.g., lipid-based) products for the management of nutritional deficiencies. This is an argument for more choice among appropriate tools, not for discarding products that have already shown their value over many years. It also does not reduce the need to maintain a focus on supplying high volumes of quality grains as the main staple in food aid baskets.

Background: Enacted in 1950, Public Law 480 (PL480) dramatically increased the volume of U.S.food aid and the scope of interventions it supports. Billions of dollars have been invested, both to enhance the diets of chronically undernourished people in development settings, and to support nutritional needs during conflicts and natural disasters., Objective: Review the institutional processes-from procurement to delivery-that support this programming., Methods: We examined the systems that govern and oversee the many components of food aid programming and the extent to which they support a whole-of-government, multi-agency food aid agenda. We conducted consultations with US government employees and contractors, academics, industry representatives, donor agency staff United Nations personnel, and field-level food aid programming technical staff from many countries. A survey of USAID implementing partners conducted among 64 responding offices in 40 countries provided data on the use and effectiveness of enriched, fortified, or blended Title II commodities, the use of new commodities, and related procurement or logistics aspects. Expert panels provided input and feedback throughout the process., Results: We identified potential improvements to overall delivery and cost-effectiveness of USAID programming to better meet the nutrition needs of beneficiaries. Options include changes in product formulation, the range of products provided, and/or the modes of product approval, processing, procurement, and distribution. This research points to several improvements in processes related to food aid: 1) Establish an interagency committee to oversee all government interests in the food aid agenda through an ongoing review process. 2) Enhance processes and quality assurance along the product value chain including the importance of effective interaction with the private sector to incorporate industry best practices and create public-private partnerships to promote product innovations. 3) Strengthen the evidence base for innovations in products, programming approaches, and institutional processes., Conclusion: Successful programming requires knowledge and understanding of the unit cost of impact, not simply tonnage and "numbers of hungry people fed". Empirical rigor is essential; any significant program changes, including those recommended here, should be tested and monitored.