The prevalence of vitamin A (VA) deficiency, which affects about one-third of children in developing countries, is falling only slowly. This is despite extensive distribution and administration of periodic (4- to 6-monthly) high-dose VA capsules over the past 20 years, now covering a reported 80% of children in developing countries. This massive programme was motivated largely by an expectation of reducing child mortality, stemming from findings in the 1980s and early 90s. Efficacy trials since 1994 have in most cases not confirmed a mortality impact of VA capsules. Only one large scale programme evaluation has ever been published, which showed no impact on 1-6-year-old mortality (the DEVTA trial, ending in 2003, in Uttar Pradesh, India). Periodic high-dose VA capsules may have less relevance now with changing disease patterns (notably, reductions in measles and diarrhoea). High-dose VA 6-monthly does not reduce prevalence of the deficiency itself, estimated by low serum retinol. It is proposed that: (i) there is no longer any evidence that intermittent high-dose VA programmes are having any substantial mortality effect, perhaps due to changing disease patterns; (ii) frequent intakes of vitamin A in physiological doses -e.g. through food-based approaches, including fortification, and through regular low-dose supplementation-are highly effective in increasing serum retinol (SR) and reducing vitamin A deficiency; (iii) therefore a policy shift is needed, based on consideration of current evidence. A prudent phase-over is needed towards increasing frequent regular intakes of VA at physiological levels, daily or weekly, replacing the high-dose periodic capsule distribution programmes. Moving resources in this direction must happen sooner or later: it should be sooner.

Objective: To outline a framework and a process for assessing the needs for capacity development to achieve nutrition objectives, particularly those targeting maternal and child undernutrition. Design: Commentary and conceptual framework. Setting: Low-and middle-income countries. Result: A global movement to invest in a package of essential nutrition interventions to reduce maternal and child undernutrition in low-and middle-income countries is building momentum. Capacity to act in nutrition is known to be minimal in most low-and middle-income countries, and there is a need for conceptual clarity about capacity development as a strategic construct and the processes required to realise the ability to achieve population nutrition and health objectives. The framework for nutrition capacity development proposed recognises capacity to be determined by a range of factors across at least four levels, including system, organisational, workforce and community levels. This framework provides a scaffolding to guide systematic assessment of capacity development needs which serves to inform strategic planning for capacity development. Conclusions: Capacity development is a critical prerequisite for achieving nutrition and health objectives, but is currently constrained by ambiguous and superficial conceptualisations of what capacity development involves and how it can be realised. The current paper provides a framework to assist this conceptualisation, encourage debate and ongoing refinement, and progress capacity development efforts.

Background: From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months Á about 500 days Á is the most important and vulnerable in a child's life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here. Objective and design: This paper aims to summarize research on policies and programs to protect women's nutrition in order to improve birth outcomes in low-and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers. Results: The priority problems addressed are: intrauterine growth restriction (IUGR), women's anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with ironÁfolic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries. Conclusions: This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.