National nutrition strategies that focus on maternal, infant, and young child nutrition in Southeast Asia do not consistently align with regional and international recommendations

Abstract We examined the consistency of national nutrition strategies and action plans (NNS) focusing on maternal, infant, and young child nutrition in Southeast Asia with regional and international recommendations. Between July and December 2017, we identified and extracted information on context, objectives, interventions, indicators, strategies, and coordination mechanisms from the most recent NNS in nine Southeast Asian countries. All NNS described context, objectives, and the following interventions: antenatal care, micronutrient supplementation during pregnancy, breastfeeding promotion, improved complementary feeding, nutrition in emergencies, and food fortification or dietary diversity. Micronutrient supplementation for young children was included in eight NNS; breastfeeding promotion during pregnancy and support at birth in seven; and school feeding, deworming, and treatment of severe acute malnutrition in six. All NNS contained programme monitoring and evaluation plans with measurable indicators and targets. Not all NNS covered wasting, exclusive breastfeeding, low birthweight, and childhood overweight. Strategies for achieving NNS goals and objectives were health system strengthening (nine), social and behaviour change communication (nine), targeting vulnerable groups (eight), and social or community mobilization (four). All addressed involvement, roles and responsibilities, and collaboration mechanisms among sectors and stakeholders. There was a delay in releasing NNS in Indonesia, Myanmar, and the Philippines. In conclusion, although Southeast Asian NNS have similarities in structure and contents, some interventions and indicators vary by country and do not consistently align with regional and international recommendations. A database with regularly updated information on NNS components would facilitate cross‐checking completeness within a country, comparison across countries, and knowledge sharing and learning.


| INTRODUCTION
Most countries in the world are facing multiple and overlapping burdens of malnutrition (Development Initiatives, 2018). More than 30% of children are stunted, wasted, or overweight, and 50% suffer from hidden hunger due to deficiencies in vitamins and other essential nutrients (UNICEF, 2019). The triple burden of malnutrition harms children, adolescents, and women in the short and long term as well as negatively affects a country's economic and social devel- For example, in the region's 11 countries, nine have a high or very high prevalence of stunting (≥20%), nine have medium, high, or very high prevalence of wasting (≥5%), and five countries have medium, high, or very high prevalence of overweight (≥5%) among children under 5 years of age (UNICEF, 2019). The prevalence of children under 5 suffering from micronutrient deficiencies in Southeast Asia is almost 50% (ASEAN et al., 2016;UNICEF, 2019). Rates of malnutrition among school-aged children and women are also high in this region (UNICEF, 2019). Seven of the 11 Southeast Asian countries belong to the lowest 20th percentile of height for men and women among 129 countries (N. C. D. Risk Factor Collaboration, 2016). This study also showed that men and women in Southeast Asia experienced a low increment in height between 1896and 1996(N. C. D. Risk Factor Collaboration, 2016. In addition, countries in this region are facing emerging issues related to health disparity, poor water and sanitation, food insecurity, climate change, globalization and urbanization, and sustainable agriculture production (ASEAN et al., 2016;UNICEF, 2019). To provide an overview of national nutrition policies, plans of action, and programmes, WHO conducted a Global Nutrition Policy Reviews 2009-2010(WHO, 2013, 2018a. The reviews found that most countries reported having national nutrition policies and plans of action and programmes to address undernutrition, obesity, diet-related chronic diseases, infant and young child feeding, and vitamin and mineral malnutrition, yet there were also identified gaps in their design, content, and implementation (WHO, 2013(WHO, , 2018a. The findings, however, were aggregated by WHO region (Southeast Asian countries were grouped in the South-East Asia Region and Western Pacific Region), resulting in the unavailability of detailed information by country (WHO, 2013(WHO, , 2018a. The Report on Nutrition Security in ASEAN (ASEAN et al., 2016) presents nutritionrelated issues covered by national policies in each of its 10 member countries. Other aspects of the policies, however, such as coverage of implementation, governance and partners, resources and capacity, and monitoring and evaluation, were not reported by country (ASEAN et al., 2016). In addition, because the information was updated by

Key messages
• National nutrition strategies or action plans (NNS) were available in nine of the 11 countries in Southeast Asia.
• The structure and some contents of the NNS were typically aligned with the First International Conference on Nutrition in 1992.
• NNS interventions and indicators vary by country and do not consistently align with regional and international recommendations for all countries.
• Reviewed NNS were not flexible for changes that limited their adaptability to new recommendations and might cause delay of releasing updated NNS.
• Establishing a database of nutrition strategy components would help to facilitate cross-checking completeness within a country, comparison across countries, and knowledge sharing and learning. member countries based on all national policies, we do not know how well the NNS covered the context, goals, targets, commitment, and monitoring and evaluation (ASEAN et al., 2016).
It is well established that if evidence-based interventions for women and children and evidence-based nutrition interventions for the whole population are implemented with supportive policies and legislation and functioning health, education, and social protection systems, we can improve nutrition and health status of women and children, which contributes to economic development and increased equity (Bhutta et al., 2008;Bhutta et al., 2013;Ruel, Alderman, Maternal, & Child Nutrition Study, 2013;UNICEF, 2019). An NNS can serve as a guide for such multisectoral actions and act as a reference point for nutrition actions across other policies in health and other sectors.
Although it is expected that an effective NNS would be aligned with international recommendations, few studies have been conducted to evaluate this aspect of NNS in Southeast Asia. To address this gap, we examined the alignment of NNS focusing on maternal, infant, and young child nutrition in Southeast Asia with regional and international recommendations.

| Subjects and methods
In a desk review of NNS focusing on MIYCN in Southeast Asian countries, we (a) identified NNS, (b) developed a quantitative data extraction form, (c) extracted information and managed the data, and (d) performed data analysis. Our study was based on a conceptual framework ( Figure 1) that was developed on the basis of previous literature (Bhutta et al., 2008;FAO & WHO, 1992, 2014Hausmann, Tyson, & Zahidi, 2006;Ruel et al., 2013;UNICEF, 2014UNICEF, , 2019United Nations, 2017b).

| Data extraction form
We developed a form that covered general characteristics of NNS (policy name, year published, publisher, year of adoption, adoptee, and start and end year); categories: material (to result in actual changes) and symbolic (to articulate aspirations for social betterment); governing resources: information or knowledge (to educate or change behaviour of policy targets); authority (to regulate); treasury (to specify the availability and use of financial resources); and organization structure (to stipulate tasks to be done by relevant sec-

| Data extraction and management
We extracted NNS data using the hardcopy data extraction form.
Number-coded information was then inputted into a Microsoft Excel data entry form. The NNS were reviewed by one researcher and cross-checked by another. We used PowerQuery in Microsoft Excel for data management and PowerPivot for data analysis and presentation.

| Data analysis
We provided descriptive findings of each NNS and compared its structure, interventions, and indicators with those from other NNS and previous studies or guidelines (Bhutta et al., 2008;Bhutta et al., 2013;FAO & WHO, 1992, 2014Ruel et al., 2013). We applied the effectiveness ranking for select interventions (e.g., strong evidence, mixed evidence, and weak evidence) produced by previous studies (Bhutta et al., 2008;Bhutta et al., 2013;Ruel et al., 2013;Webb & Kennedy, 2014). Indicators were cross-referenced with the Global Nutrition Targets, the Millennium Development Goals, and the Sustainable Development Goals (United Nations, 2008, 2017aWHO, 2017).

| RESULTS
Of the 11 Southeast Asian countries, nine had approved NNS as a national guiding document to provide information knowledge, organization structure, and type of instrument (Table 1). Five NNS have a treasury governing resource cited, seven have mixed, and two have voluntary legal binding (Table 1). Although the nine Southeast Asian NNS were aligned with the structure proposed by the ICN in 1992, there was considerable variation in the level of detail included. Each NNS clearly outlined the country context in which the policy was developed (Table S1).
NNS outlined interventions for women at reproductive age, including teenagers, during pregnancy such as dietary counselling (seven), deworming (five), and protein and energy and micronutrient supplementation (nine; Table 2). Breastfeeding promotion during pregnancy (using individual or group counselling) was not included in the NNS of Cambodia or Laos, and breastfeeding support at birth was not included in that of the Philippines or Vietnam (Table 2). Nutrition during the preconception period and for teenagers (other than during pregnancy) was not included in the majority of NNS.
Promotion of optimal breastfeeding and complementary feeding after the post-natal period was included in nine NNS. Regarding nutrition interventions for children and the general population, micronutrient supplementation (e.g., zinc, iron, and vitamin A) was included in all but the NNS of Brunei. NNS from Brunei, Malaysia, and Indonesia did not include child deworming and treatment of severe acute malnutrition interventions among children. NNS from Brunei, the Philippines, and Timor-Leste did not mention school feeding programmes (Table 2).
Interventions relating to food, food safety, and food security were commonly listed in the NNS: food diversity strategies (nine), food fortification interventions (eight), nutrition in emergencies (nine), food safety (nine), and provision of social safety nets (six; Table 2). Some NNS indicated relevant policies such as food fortification regulations (eight fortification policies under development), food safety (seven, and two under development), regulations on the marketing of breastmilk substitutes (eight), and maternity protection, including maternity leave and workplace lactation support (five; Table 2). Only a subset of NNS included nutrition and HIV (six), chronic diseases (seven), and healthy lifestyle (five).
Cross-cutting strategies for achieving the goals and objectives of NNS were interpersonal communication (nine NNS), national health campaigns (eight), mass communication (six), health system strengthening (nine), agriculture or food system strengthening (eight), and interventions for vulnerable groups (eight; Table 2). NNS from Laos, Myanmar, Timor-Leste, and Vietnam had social or community mobilization strategies. All NNS contained strategies for monitoring, evaluation, surveillance, and implementation of surveys to measure progress and impact (Table 2).
All nine NNS had indicators and targets relating to MIYCN. Indicators of infant and young child nutrition status included low birthweight (seven NNS), stunting (nine), wasting (eight), underweight (seven), overweight (six), iron deficiency anaemia (six), vitamin A deficiency (six), and iodine deficiency disorders (six). Indicators for breastfeeding practices included early initiation of breastfeeding (four), exclusive breastfeeding (eight), and continued breastfeeding at 1 or 2 years (four; Table 3). The NNS in Laos, Malaysia, Myanmar, and Timor-Leste had at least three out of four recommended indicators relating to complementary feeding or dietary quality. Those from Cambodia and Vietnam had one indicator, whereas the remaining three countries had none. Indicators for nutrition status of women at reproductive age included iron deficiency anaemia (nine NNS), underweight (a body mass index <18.5 kg m −2 ; six), and overweight or obesity (five; Table 3).
Each NNS outlined sector and stakeholder roles, responsibilities, collaborative mechanisms, and whether the strategy is executed through a focal sector, among sectors, or among stakeholders (Table 4). The roles of governmental stakeholders (at national and subnational levels) were measured by the contribution of financial resources, provision of technical support, and implementation (Table S2). Technical support was typically the role of international organizations, donors, the private sector, and academic or research institutions (Table S2) Note. A newer policy for Indonesia, Myanmar, and the Philippines has not been released as of December 31, 2017. Categories of policy instrument: material (to result in changes in actual) and symbolic (to articulate aspirations for social betterment); governing resources: information or knowledge (to educate or change behaviour of policy targets); authority (to regulate); treasury (to specify the availability and its use of financial resources); and organization structure (to stipulate tasks to be done by relevant sectors or stakeholders).
T A B L E 2 Interventions included in national nutrition strategies, by country monitoring, and evaluation, which help to improve nutrition and health status in the world (FAO & WHO, 1992, 2014. Limitations include the long process of developing and obtaining high-level government approval of an NNS, which may have delayed release in Indonesia, Myanmar, and the Philippines. Similarly, developing or revising an NNS requires progress and impact data from the previous 5-10 years, and such evidence requires a robust, streamlined, reliable electronic monitoring system for inputs, outputs, outcomes, and impacts, which may be lacking in some countries. Due to these factors, modifying approved NNS to adopt new interventions or indicators during implementation is typically not feasible. Although determining reasons for these delays was beyond the scope of this study, often policy development is affected by a lack of evidence, consensus, or champion (Baker et al., 2018;Pelletier et al., 2013).
Successful implementation of NNS required involvement of different stakeholders and sectors (FAO & WHO, 1992, 2014). Yet, similar to findings from the Global Nutrition Policy Report (WHO, 2018a), we found that not all NNS specified sector and stakeholder engage-  Findings of this study could also help to facilitate ongoing efforts by ASEAN to develop a regional surveillance system for nutrition indicators among member states. The data extraction form, data entry form, data management and analysis tools, and data are publicly available to facilitate study replication and used by researchers who wish to examine existing nutrition policies in other regions or the longitudinal policy progress in a given country.
Our study has several limitations. First, we did not examine how the NNS were implemented and interacted with other policies, the costs and benefits of the interventions within, or stakeholders' perception of the policies. These topics were beyond the scope of this study. Evidence from South and Southeast Asian countries show that stakeholders' engagement in infant and young child feeding policy may vary substantially by country (Michaud-Letourneau, Gayard, & Pelletier, 2019;Uddin et al., 2017). Second, although various platforms have been used for regional and global coordination for improving MIYCN such as the SUN movement, Zero Hunger, Nutrition for Growth, REACH, United Nations Global Nutrition Agenda, and the regional frameworks of UNICEF and WHO, we did not consider the contribution of these platforms. These, however, have been discussed previously (ASEAN et al., 2016;Nutrition for Growth, 2018;REACH, 2018;Scaling Up Nutrition, 2018;UNICEF, 2014;United Nations, 2015;WHO South-East Asia, 2011;Zero Hunger, 2018). Third, there were limitations of analysing only a single NNS policy for each country, including the lack of NNS in two key ASEAN countries, Singapore and Thailand, creating a missed opportunity for a full regional comparative analysis. Additionally, the NNS is specific to MIYCN and therefore may not fully cover other aspects of nutrition and health.
Nonetheless, the list of interventions from all relevant policies could be found in other policy reviews (ASEAN et al., 2016). Fourth, although all NNS were officially translated into English and released by the countries, there was a potential for information bias if there were any discrepancy between the English and the local language versions. To minimize this risk, NNS were reviewed and verified by at least two researchers or experts, and the findings were verified by our multidisciplinary team and in-country experts.
In conclusion, although Southeast Asian NNS have similarities in structure and some contents, some interventions and indicators vary by country and do not consistently align with regional and international recommendations. Updating information on nutrition strategy components in a new or existing database would help to facilitate cross-checking completeness within a country, comparison across countries, and knowledge sharing and learning. This effort would facilitate coordination of an evidence-based, well-measured policy framework with clearly defined roles and responsibilities for ending all forms of malnutrition in the region in the world.