6 indirect approaches to improving nutrition – part one

Malnutrition, in its various forms, is thought to affect over 2 billion people in the world and, as such, has far reaching consequences for societies, economies and livelihoods. Tackling poor nutrition is both complex and opportunistic in that there are links between nutrition and a whole other range of factors. In other words by tackling nutrition directly we may positively contribute to other developmental problems but there are also multiple ways to address undernutrition indirectly. While there is broad consensus on the need to take direct nutrition interventions such as promoting exclusive breastfeeding or biofortification of crops with micronutrients such as vitamin A or zinc, there is also an urgent need to tackle the underlying and inter-related determinants of malnutrition. The Lancet, for example, suggests that direct nutrition interventions, even if implemented at 90% coverage in high-burden countries would only reduce global stunting by 20%.

So-called nutrition-sensitive approaches are gaining popularity and the importance of including nutrition in a wide variety of sectors and policies is becoming better understood. Here we discuss some of the alternative routes through which malnutrition is impacted and thus could be reduced.

1. Agriculture

The contribution of agriculture to meeting the nutritional needs of the population cannot be overstated, and the nutrition component of agricultural policies and investment plans needs to be strengthened. In Africa, agricultural development has been primarily focused on boosting production and developing markets with little attention given to nutrition. But agriculture is at the heart of addressing malnutrition. Its products provide us with the energy, protein, vitamins and minerals our bodies need. And in many developing countries the majority of people who are malnourished live in rural areas and depend on smallholder farming for their livelihoods. In fact, demographic and health survey (DHS) data shows that individuals living in rural areas are between 1.3 and 3.3 times more likely to be stunted than people in urban areas, which indicates that agriculture still has a long way to go in providing the global population with the right nutrition and adequate calories. It also indicates that by improving agricultural diversity and productivity in rural farming areas, malnutrition could be significantly reduced, although evidence on the impact agriculture can have on nutrition is currently limited in formal literature.

So how does agriculture need to change in order to better serve the world’s nutritional needs? The food system needs to provide access to enough nutritious foods, promote social norms that foster good nutrition practices and provide adequate income to purchase nutritious foods. Ensuring nutritious foods are affordable, accessible and available is essential and has typically been overlooked in the agricultural sector, rather being the domain of development and health. Home and school gardens, small livestock production, aquaculture and marketing policies which keep the prices of such foods at affordable levels are examples of food-based nutrition improvement initiatives. Some argue that the entire food chain needs to be put under a “nutrition lens” in order to identify areas for intervention such as “expanding and diversifying food production, improving food processing, preservation and preparation of foods, reducing losses and waste and assessing intervention impact on dietary consumption”.

The Soils, Food and Health and Communities (SFHC) project, used participatory research methods and awareness raising activities in Ekwendeni village in Northern Malawi to help smallholder famers select and test mixtures of diverse legume species for growing in combination with maize. Project results show that the intercropping of maize with legume mixes has led to improved nutrition for children in communities where the project is being implemented (over 9000 farmers have adopted this technology so far).

One regional initiative aiming to answer the question of what agricultural programmes can do to achieve positive nutrition outcomes is the Agriculture to Nutrition Initiative (ATONU) led by the South Africa-based Food, Agriculture and Natural Resources Policy Analysis Network (FANRPAN). A global consortium of African and international organisations will design, pilot, evaluate and promote a range of interventions that will improve nutritional outcomes of agricultural programmes and policies, combining research and technical assistance. Project objectives include:

• “Generating tools and frameworks for diagnosing the opportunities to incorporate tailored nutrition interventions into agriculture investments;
• Offering technical assistance for designing, testing, and rigorously monitoring and evaluating results of the tailored nutrition interventions (proof of concept)
• Documenting best practices and evidence and adding to the agriculture for nutrition knowledge base
• Advocating for evidence-based decision making at all levels
• Strengthening African capacity and building a community of practice in agriculture for improved nutrition.”

Currently in the inception and feasibility phase, the project is being implemented over a six-year period, commencing September 2014 and ending August 2020, and will be implemented in three phases.

2. Livestock

Long has it been known that animal source foods are important for providing a variety of micronutrients, nutrients that are tricky to consume in sufficient amounts in a diet based purely on plant source foods. In the 1980s, for example, the Nutrition Collaborative Research Support Program found that 6 micronutrients were particularly low in primarily vegetarian diets seen in schoolchildren in rural Egypt, Kenya and Mexico: vitamin A, vitamin B-12, riboflavin, calcium, iron and zinc. The lack of these nutrients led to health problems such as anaemia, poor growth, rickets, impaired cognitive performance, blindness, neuromuscular deficits and eventually, death. Animal source foods are particularly rich sources of all six of these nutrients, and their addition, in relatively small amounts, to a diet can significantly improve an individual’s nutrition.

A recent study has found that livestock ownership may contribute in some East African countries to reducing childhood stunting. Published in the PLOS One in September 2015, researchers analysed DHS datasets on thousands of children under five years old in Ethiopia, Kenya and Uganda. The study found that while households that owned more livestock had a lower prevalence of child stunting in Uganda and certain areas in Ethiopia, the same was not true in Kenya. Children were also more likely to be stunted if they had a low wealth status, which in many cases can go hand in hand with not owning livestock. When looking within wealth classes, however, livestock ownership, at least in Uganda, was correlated with lower levels of stunting. Despite our knowledge that animals provide income and nutritious foods such as milk, eggs and meat, this lack of strong association between livestock ownership and child stunting found in the study in certain places may suggest that families might not be making use of these foods. Promoting not only livestock ownership through programmes aimed to benefit rural and poor households but also how to make full use of livestock through the consumption and sale of its products is needed to improve nutrition.

3. Resilience

Hunger and malnutrition can be chronic or acute or both. In Burkina Faso, for example, the effects of the food and nutrition crisis brought about by drought in 2012 are ongoing. Poverty prevented full recovery while negative coping mechanisms, unsustainable in the long-term, such as increasing borrowing or purchasing on credit or illegally obtaining food, lower future resilience to acute shocks and contribute to chronic malnutrition. Over time, protracted crises undo years of previously accumulated development gains, and undermine livelihoods, making the global development goals such as eradicating hunger and poverty by 2030 much harder to achieve. Building resilience to environmental and other crises is critical then to protect progress made on reducing malnutrition.

Recently, the Committee on World Food Security (CFS) approved the world’s first global agreement on coordinated action to combat hunger and undernutrition among people living in protracted crises, where the prevalence of undernutrition is typically three times higher than in the rest of the developing world. The Framework for Action on Food Security and Nutrition in Protracted Crises is a voluntary agreement, which provides guidance, based on 11 principles, in addressing food security and nutrition needs in times of crisis but also longer term adaptation in areas with persistent crises such as natural disasters and civil conflict. The Framework puts resilience at the heart of efforts to help the most vulnerable and at-risk communities to improve their food security and nutrition. Long-term thinking is needed to enable communities to build a greater capacity to absorb, prepare for and prevent crises and long-term stresses, including the underlying causes of food insecurity and undernutrition, build resilient food systems. Key focuses of the Framework include women’s empowerment and improving the agricultural productivity of smallholders, showing that resilience as with nutrition is a multi-dimensional concept.

So far we’ve talked about how agriculture, livestock and resilience play a role in human nutrition. Read next week’s post to find out how social protection, gender equality and climate change mitigation are also critical for tackling global malnutrition.