1. Advocacy to Reduce Malnutrition: Using PROFILES and Nutrition Costing
Alice Nkoroi
Food and Nutrition Technical Assistance III (FANTA) Project
Using a collaborative approach, the Food and Nutrition Technical Assistance III Project (FANTA), funded by USAID and managed by FHI 360,  has facilitated nutrition advocacy in several countries using a nutrition advocacy tool, PROFILES, and has developed country-specific nutrition costing models. The estimates generated from this tool and models are the cornerstone of this nutrition advocacy process.

2. Presentation Outline Nutrition Advocacy Terms and Steps in the Process
Examples of Results from Various Countries
New PROFILES Models Related to Breastfeeding
Today, I’ll talk to you about:
What is included in the nutrition advocacy process
Examples of results from Uganda and Ghana where we’ve done PROFILES and from Bangladesh where we’ve done PROFILES and Nutrition Costing – and how those results were used to create change in the country
New PROFILES models related to breastfeeding

3. Nutrition Advocacy Terms and Steps in the Process

4. What is Nutrition Advocacy?
Planned, deliberate and systematic process to ignite social change for greater political and social commitment to improve the nutrition situation
Promotes accountability for nutrition and strengthens nutrition governance
Defined and shaped by a specific country context
Can support a country at any stage of commitment
We define Nutrition Advocacy as:
A systematically planned process to ignite social change for greater political and social commitment to improve the nutrition situation
It promotes accountability for nutrition and strengthens nutrition governance
Nutrition Advocacy is defined and shaped by specific country context
And can support a country at any stage of commitment

5. What is PROFILES? Evidence-based tool to support nutrition advocacy
Uses computer-based models using scientific literature and current country-specific data
Estimates the benefits of improved nutrition and the negative consequences if malnutrition does not improve
PROFILES estimates are used to engage government and other high level stakeholders for a collaborative nutrition advocacy process
First, let me briefly review what is PROFILES.
PROFILES is a computer-based model that serves as a tool to support nutrition advocacy.
It consists of a set of spreadsheet models reflecting current scientific nutrition knowledge and is designed to estimate the functional consequences of malnutrition to support advocacy and communication with policymakers, program implementers, and other stakeholders.

6. Nutrition Problems Addressed in PROFILES and the Benefits of Their Reduction
PROFILES calculates an estimate for a specific outcome.
As you can see, a reduction in maternal iron deficiency anaemia would result in a reduction in maternal and perinatal mortality – this is what we know from the scientific literature – that if iron status improves, there would be fewer maternal and perinatal deaths as a result.
Similarly for a reduction in low birth weight would reduce infant mortality
A reduction in vitamin A deficiency in children would reduce child mortality
A reduction in iodine deficiency during pregnancy would reduce permanent disabilities in children
A reduction is stunting, underweight, and wasting and sub-optimal breastfeeding practices would reduce child mortality
A reduction in sub-optimal breastfeeding practices would also decrease child overweight and obesity
Similarly a reduction in stunting would increase human capital through improved childhood learning.
And lastly a reduction in stunting, low birth weight, iron deficiency anaemia and iodine deficiency would increase economic productivity.
PROFILES also estimates economic productivity losses if there is no change in the nutrition situation.

7. Information Required in PROFILES
Prevalence of nutrition indicators
Demographic information such as mortality, population size and structure; employment and wage information
A time period for the estimates
Targets for improvement in nutrition by the end of the time period
In order to utilize the PROFILES process, the PROFILES spreadsheet requires information on the current prevalence of various nutrition indicators, mortality rates, and projected population growth, and assumptions are made about what the targets for improvement in nutrition should be.
The other steps in the nutrition advocacy process can address the need for various nutrition services, interventions, and programs.
The PROFILES model assumes a steady linear reduction in the prevalence of nutrition problems from the starting point until the end of the specified selected time period

8. What is Nutrition Costing?
Estimates costs of implementing a comprehensive set of nutrition programs in a country or prioritized geographic area over a specific time period
Complements PROFILES estimates (PROFILES does not calculate costs)
Nutrition Costing refers to estimating costs of implementing a comprehensive set of nutrition programs in a country or prioritized geographic area over a specific time period.
It involves a collaborative exercise to:
Identify an appropriate structure for the nutrition program
Select interventions and activities
Determine a management structure
Select an approach to service provision
Identify inputs and obtain unit costs

9. How are PROFILES and Nutrition Costing Results Used?
PROFILES and Nutrition Costing estimates are the cornerstone of this nutrition advocacy process
Using a consensus-building process coupled with systematic planning, multi-sectorial country teams develop nutrition advocacy plans and targeted materials to disseminate PROFILES and Nutrition Costing results to key audiences
Using a consensus-building approach coupled with systematic planning with government and nongovernment stakeholders, country teams develop nutrition advocacy plans and targeted materials to disseminate PROFILES and Nutrition Costing results to key audiences.

10. Steps in the Nutrition Advocacy Process
Step 1: Convene multi-stakeholder core working group to oversee the process
Step 2: Conduct a PROFILES workshop to develop estimates and share preliminary results
Step 3: Develop nutrition costing estimates and share preliminary results
Step 4: Conduct a Nutrition Advocacy Planning workshop to develop a National Advocacy Plan and corresponding nutrition advocacy materials
Step 5: Conduct sub-national nutrition advocacy planning and development of materials, as needed
1. The first step is to convene a multi-stakeholder core working group that will oversee the entire process.
The core working group contribute to the planning and implementation of PROFILES, Nutrition Costing estimates, nutrition advocacy plan and review materials. The team also plays a key role in discussing a time period for the estimates created in PROFILES, identify data sources for indicators used in the PROFILES spreadsheet to create the estimates, discuss possible targets for the indicators, and have initial discussions on nutrition costing. Participants also discuss and identify nutrition advocacy needs at the national level.
2. The second step in the process is conducting a consultative PROFILES workshop and developing estimates. Workshop participants build on the work done during the core working groups on sources of information, time period, and targets for PROFILES. During the 4-days workshop, participants work with PROFILES spreadsheet models to produce preliminary estimates of the negative consequences if there is no improvement in malnutrition in the country
3. Step 3 includes developing Nutrition Costing estimates. To begin developing Nutrition Costing estimates, individual and/or group consultations are held with key multisectoral stakeholders and health economists. During the consultations, stakeholders engage collaboratively in defining the assumptions upon which the costing estimates will be based—for instance, selecting necessary interventions and activities, and defining a management structure for service provision—which helps to identify the required inputs for each activity, and to estimate the program cost for a specified time period. 
4. Step 4 includes conducting a Nutrition advocacy planning workshop to develop a National Nutrition Advocacy Plan and nutrition advocacy materials. Building on current advocacy efforts to create an enabling environment for nutrition programs, a 4-day workshop at the national level identifies nutrition problems, establishes advocacy objectives, and identifies the steps needed to achieve those objectives. The process includes segmenting target audiences (e.g., media, policymakers, politicians, civil society, etc.) and determining materials and activities for each audience based on desired changes and perceived barriers and benefits among each audience. In addition, the national nutrition advocacy plan includes an implementation plan with a timeline. During the workshop, participants begin the process of developing advocacy materials for each target audience.
5. Finally Step 5 includes nutrition advocacy planning at the district level and assisting districts to develop and implement nutrition advocacy implementation plans.

11. Examples of Results
PROFILES has been used by FHI 360 in more than 20 countries; over time, the approach has evolved. Since 2010, FANTA used PROFILES with country stakeholders as a comprehensive platform for advocacy campaigns in Bangladesh, Uganda, Ghana, Ethiopia, Haiti, Malawi and Tanzania. Nutrition Costing was conducted in Guatemala, and in Bangladesh, PROFILES was complemented with Nutrition Costing to give estimates of both gains from improvements in nutrition and costs of addressing nutrition needs at scale.
I will share with you some results in the following slides.

12. Nutrition Situation Among Children Under 5
Uganda (2011)
Ghana (2008)
Bangladesh (2007)
Ethiopia (2011)
Haiti (2013)
Tanzania (2011)
Malawi (2014)
Percent -2 SD (z-score)
Stunting (chronic malnutrition) 33 28 43 44 22 42
Underweight 14 41 29 11 16 17
Wasting (acute malnutrition) 5
8.5 10 4
[see slide]
Source: Demographic and Health Surveys and the Multiple Indicator Cluster Survey

13. Saving Lives by Reducing Chronic and Acute Malnutrition
Stunting
Lives Saved
~160,000
~17,000
~150,700
~9,000
Wasting
~150,000
~28,000
~108,000
~3,800
Bangladesh 2011–2021
Ghana
2011–2020
Ethiopia
These slides give you an idea of the results from PROFILES in various countries [see slide]
Haiti

14. Saving Lives by Reducing
Chronic Malnutrition
Stunting
Lives Saved
~118,700
~120,600
~97,700
Uganda
Tanzania
[see slide] Note: wasting was not calculated for these countries since wasting prevalence was low.
Malawi

15. Saving Lives and Preventing Disabilities
Maternal Deaths Averted
Iron deficiency anemia
~6,000
~4,700
~6,400
~1,300
Perinatal Deaths Averted
~150,000
~32,000
34,000
~4,000
Infant Deaths Averted
Low birth weight
~230,000
~14,000
~57,700
~7,400
Child Deaths Averted
Vitamin A deficiency
~50,000
~25,000
~106,500
~5,100
Permanent Disabilities Averted*
Iodine deficiency
~2,000,000
~700,000
~7,000,000
~90,700
Bangladesh 2011–2021
Ghana 2011–2020
Ethiopia
[see slide]
Haiti
* Cretinism and mild to severe permanent brain damage prevented

16. Saving Lives and Preventing Disabilities
Maternal Deaths Averted
Iron deficiency anemia
~6,600
~15,500
~6,200
Perinatal Deaths Averted
~19,700
~72,700
~22,600
Infant Deaths Averted
Low birth weight
~25,800
~20,500
~22,800
Child Deaths Averted
Vitamin A deficiency
~61,000
~101,900
~27,700
Permanent Disabilities Averted*
Iodine deficiency
~236,500
~869,800
N/A
Uganda
Tanzania
Malawi
[see slide]
* Cretinism and mild to severe permanent brain damage prevented

17. Infant Lives Saved Related to Improved BF Practices
Uganda ( )
101,100
Tanzania ( )
85,500
Malawi ( )
81,400
[see slide]

18. Economic Productivity Gains That Would Result from Reduced Micronutrient and Chronic Malnutrition
Bangladesh
2011–2021
US$
Ghana
2011–2020
Ethiopia
Haiti
2013–2022
Iodine Deficiency
900 Million
300 Million
2.9 Billion
34 Million
Anemia
1 Billion
350 Million
.5 Billion
37 Million
Stunting
13 Billion
500 Million
5 Billion
218 Million
[see slide]

19. Economic Productivity Gains That Would Result from Reduced Micronutrient and Chronic Malnutrition
Uganda
US$
Tanzania
Malawi
Iodine Deficiency
75.9 Million
479.1 Million
N/A
Anemia
108.8 Million
381.7 Million
170.6 Million
Stunting
1.7 Billion
3.9 Billion
1.8 Billion
[see slide]

20. Equivalent School Years of Learning Gained
Human Capital Gains That Would Result from Reduced Chronic Malnutrition
Equivalent School Years of Learning Gained
Uganda ( )
19.8 Million
Tanzania ( )
24.7 Million
Malawi ( )
18.2 Million
[see slide]

21. Bangladesh Advocacy Work with Gov’t
Using the estimates for advocacy
Created a multisectoral advocacy strategy and implementation plan with key stakeholders Disseminated PROFILES and costing final results in June 2012 Developed targeted materials and conducted advocacy efforts with 20 members of parliament, including the chief whip; 20 high-level GOB policy makers; 30 CSOs; 15 development partners; and several representatives of political parties.
Worked with each audience to move the nutrition agenda forward through discussions and roundtables
Outcome Highlights
Within GOB, cost estimates guided national budget allocation for nutrition for the next 5 years
Raised the visibility, commitment, and accountability for nutrition in Bangladesh among GOB and development partners
Parliamentarians requested to join nutrition task force after discussions
These slides show how we’ve used the PROFILES and costing results in a few countries.
Both Nutrition Costing and PROFILES were conducted in Bangladesh to give estimates of both gains from improvements in nutrition and costs of addressing nutrition needs at scale.
These were completed and launched during a government planning year to ensure adequate resources for the implementation of national nutrition services during the following 5-year period.
A package of advocacy materials were developed for policymakers, parliamentarians, media, civil society and donors – A series of nutrition advocacy activities with these audiences led to increased commitment and coordinated action.
[See slide]

22. Uganda Advocacy Work Using the estimates for advocacy
Convened multisectoral national task force
Launched PROFILES results and held advocacy activities with key audiences
Developed advocacy materials focused on nutrition and sectors and also targeted to media, CSOs, donors, policymakers, district level officials, faith leaders, and community-based services officers
Created nutrition advocacy training for district-level officials to help them develop advocacy implementation plans and talking points
Outcome Highlights
Culminated in the development and adoption of a multisectoral Uganda Nutrition Action Plan operationalized by the Office of the Prime Minister
Worked with policymakers to contribute to the Food and Nutrition Bill Developed a budgeting tool for districts to allocate funds for nutrition programming 10 districts are now implementing their advocacy plans to support integration of nutrition into sector work plans and budgets
In Uganda, working closely with the Uganda Civil Society Coalition on Scaling Up Nutrition (UCCO-SUN), government and other partners, dissemination of PROFILES results and nutrition advocacy materials and subsequent nutrition advocacy activities contributed to the adoption of the multisectoral Uganda Nutrition Action Plan and contributed to the Food and Nutrition Bill. It also led to work on development of a budgeting tool for districts and DNNC nutrition action plans for select districts.
With new country data available PROFILES estimates were updated in 2014.
Since then, FANTA has continued to partner with UCCO-SUN in country to conduct nutrition advocacy activities at national and district levels. We conducted a training of 10 districts this year in northern and southwestern Uganda on nutrition advocacy and helped district nutrition coordination committees develop nutrition advocacy implementation plans and talking points to advocate for the nutrition interventions they’ve prioritized in their district nutrition action plans.

23. New PROFILES Models Related to Breastfeeding
The newest PROFILES models related to breastfeeding that FANTA has developed that many of you may not be familiar with are:
One that examines the relationship between suboptimal breastfeeding (BF) and child mortality
One that examines the relationship between suboptimal breastfeeding (BF) and overweight/obesity in childhood
I want to focus on those during the time that we have left.

24. Examining the Relationship Between Suboptimal Breastfeeding (BF) and Child Mortality: A New Model Within PROFILES
Suboptimal BF practices result in more than 800,000 child deaths annually (Black et al. 2013).
New model shows benefits of optimal breastfeeding practices on reduced child mortality
Uses coefficients from peer-reviewed literature and country-specific BF information
Calculates proportion of child mortality related to suboptimal BF
New model used in Tanzania, Uganda and Malawi
In Tanzania, for example, improving BF practices would save ~86,000 children’s lives by 2025
We know that suboptimal breastfeeding practices result in more than 800,000 child deaths annually (Black et al. 2013).
FANTA developed a model to show the benefits of optimal breastfeeding practices on reduced child mortality
Using coefficients (on increased mortality risk due to suboptimal breastfeeding) from peer reviewed literature and country-specific breastfeeding information, the model calculates the proportion of child mortality (among children 0–5 months and 6–23 months) related to suboptimal breastfeeding
The results provide country-specific estimates of the number of lives lost among children under 2 years of age related to suboptimal breastfeeding practices over a certain period of time (assuming that there is no change in breastfeeding practices) and the number of lives that could be saved among children under 2 related to improved breastfeeding practices over the same period of time.
The new model has been used to date in Tanzania, Uganda and Malawi.
In Tanzania, for example, the PROFILES model showed that improving breastfeeding practices would save ~86,000 children’s lives by 2025.

25. Estimating the Effect of Suboptimal Breastfeeding Practices on Child Mortality: A Model in PROFILES for Country-Level Advocacy
I’ve brought some handouts of this brief explaining the model is more detail.

26. Examining the Relationship Between Suboptimal Breastfeeding (BF) and Overweight/Obesity in Childhood: A New Model Within PROFILES
As of 2014, as many as 41 million children under 5 worldwide are overweight or obese
New model shows benefits of optimal BF practices on reduced overweight/obesity among children
Uses coefficients from peer-reviewed literature and country-specific BF information
Calculates country-specific estimates of children months who are likely to become overweight/obese related to suboptimal BF
New model was just added and will be used for the first time this year
As of 2014, as many as 41 million children under 5 worldwide are overweight or obese – More children are affected in Lower middle income countries than high-income countries
This new model shows the benefits of optimal BF practices on reduced overweight/obesity among children
It uses coefficients (on increased risk of overweight/obesity due to suboptimal BF) from peer-reviewed literature and country-specific BF information
And, calculates country-specific estimates of children months who are likely to become overweight/obese related to suboptimal BF
It was just added and will be used for the first time this year in Zambia and Kenya

27. [Comms to insert screen shot of brief]
The Effect of Suboptimal Breastfeeding on Preschool Overweight/Obesity: A Model in PROFILES for Country-Level Advocacy
I’ve brought some handouts of this brief explaining the model is more detail.

28. Why Did FANTA Create These Models?
Consistent and substantial evidence that early, exclusive and continued BF significantly reduces neonatal and child mortality and decreases risk of later overweight/obesity.
Despite this, little improvement in optimal BF practices globally.
Delayed initiation of BF, pre-lacteal feeding and short duration of EBF is a consistent pattern seen across many countries – Often due to lack of family and community support and lack of understanding of importance of BF.
Globally, there is consistent and substantial evidence that early, exclusive, and continued breastfeeding through 23 months significantly reduces neonatal and child mortality, and decreases the risk of later overweight/obesity. Despite this, there has been little improvement in optimal breastfeeding practices globally.
Delayed initiation of breastfeeding, provision of prelacteal feeds, and a short duration of exclusive breastfeeding is a consistent pattern seen across many countries and is often due to a lack of family and community support for mothers to breastfeed and a lack of understanding about the importance of quality (early, exclusive, and continued) breastfeeding.
Advocacy for optimal breastfeeding is needed at the national, community, and family level to create an enabling environment where women are supported to breastfeed. To support this, FANTA updated PROFILES to include two new models - one estimates child mortality related to suboptimal breastfeeding practices and the number of lives that could be saved by improving breastfeeding practices; and the other estimates the risk of overweight/obesity among children aged months related to suboptimal breastfeeding practices.

29. Why Did FANTA Create These Models?
Advocacy for BF is needed at the national, community and family level to create an enabling environment where women are supported to BF.
Globally, this is opportune time to focus on advocating for BF given the focus on first 1,000 days.
Advocacy is important to build momentum to reach WHA targets and SDGs - Reductions in child mortality, stunting and overweight/obesity depend on good BF practices.
Advocacy for optimal breastfeeding is needed at the national, community, and family level to create an enabling environment where women are supported to breastfeed. To support this, FANTA updated PROFILES to include two new models - one estimates child mortality related to suboptimal breastfeeding practices and the number of lives that could be saved by improving breastfeeding practices; and the other estimates the risk of overweight/obesity among children aged months related to suboptimal breastfeeding practices.
Globally, this is an opportune time to focus on advocating for optimal breastfeeding practices given the renewed and targeted focus on the first 1,000 days
Nutrition advocacy is also important now in order to build momentum to reach the World Health Assembly 2025 Global Nutrition Targets, which aim to increase the prevalence of exclusive breastfeeding to 50 percent globally, and reach the Sustainable Development Goals in which addressing poor nutritional status and practices (including suboptimal breastfeeding) will be critical to achieving the goals of reduced maternal, neonatal, infant, and child mortality.
Further reductions in child mortality and stunting depend on good breastfeeding practices.
The model on overweight/obesity among children related to suboptimal breastfeeding practices is particularly relevant now due to rising concern about the increase in the prevalence of childhood overweight and obesity across the globe. In fact, there are more children who are overweight and obese in LMIC countries now than in high-income countries.

30. Thank You
For more information, contact:
Alice Nkoroi
Food and Nutrition Technical Assistance III Project (FANTA)
FHI 360
For more information on the FANTA Project or PROFILES and Nutrition Costing, please visit
This presentation is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID) under terms of Cooperative Agreement No. AID-OAA-A , through FANTA, managed by FHI 360. The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID or the United States Government.