Feed handling practices, aflatoxin awareness and children's milk consumption in the Sidama region of southern Ethiopia.

Consumption of milk is linked to improved nutrient intake and reduced risk of child malnutrition in low and middle-income countries. However, these benefits are contingent on the safety and quality of the milk. Milk consumption may alleviate the widespread risk of malnutrition in rural Ethiopia, but milk-borne contaminants may also compromise child health. We aimed to: i) identify the types of dairy feeds used, their storage conditions, and potential risk of aflatoxin contamination; ii) assess stakeholders' knowledge about aflatoxin contamination along the value chain; and iii) assess parental practices on feeding milk to infants and young children. This qualitative study was conducted in the Sidama region, southern Ethiopia. In-depth interviews (n = 12) and key-informant interviews (n = 18) were conducted with actors along the dairy value chain. Focus-group discussions were conducted with farmers (9FGD/n = 129) and child caregivers (9FGD/n = 122). Study participants were selected to represent a rural-urban gradient, as well as low- and high- dairy cow holdings. We found that while animal-feed processors and their distribution agents had relatively good knowledge about aflatoxin, farmers and retailers did not. Feed storage conditions were poor. Many respondents linked moldy feeds to animal health but not to human health. Farmers' feed choice was influenced by cost, seasonality, and herd size. Small-holding farmers had limited access to commercial feed. Children's consumption of milk was limited to skim milk, as butter was extracted and sold for income. The high cost of dairy products also led some parents to dilute skim milk with water before feeding children, compromising the nutritional value and safety of the milk. Our findings underscore the need to address the gaps in aflatoxin and food safety knowledge, improve storage conditions, and ensure the availability of quality feed to increase the sector's productivity, but most importantly to protect consumers' health and well-being, especially infants and young children.

Food prices and the wages of the poor: A cost-effective addition to high-frequency food security monitoring.

The affordability of nutritious food for "all people, at all times" is a critically important dimension of food security. Yet surprisingly, timely high-frequency indicators of food affordability are rarely collected in any systematic fashion despite price volatility emerging as major source of food insecurity in the 21st Century. The 2008 global food crisis prompted international agencies to invest heavily in monitoring domestic food prices in low and middle income countries (LMICs). However, food price monitoring is not sufficient for measuring changes in diet affordability; for that, one must also measure changes either in income or in an income proxy. We propose using the wages of unskilled workers as a cheap and sufficiently accurate income proxy, especially for the urban and rural non-farm poor. We first outline alternative measures of "food wage" indices, defined as wages deflated either by consumer food price indices or novel healthy diet cost indices. We then discuss the conceptual strengths and limitations of food wages. Finally, we examine patterns and trends in different types of real food wage series during well-known food price crises in Ethiopia (2008, 2011 and 2022), Sri Lanka (2022) and Myanmar (2022). In all these instances, food wages declined by 20-30%, often in the space of a few months. In Myanmar, the decline in real wages during 2022 closely matches declines in household disposable income. We strongly advocate tracking the wages of the poor as a timely, accurate and cost-effective means of monitoring food affordability for important segments of the world's poor.

Study protocol to assess aflatoxin M1 health risks versus benefits of dairy consumption in Ethiopian children: an epidemiological trial and risk-benefit analysis.

INTRODUCTION: In Sidama, Ethiopia, animal-source foods can be difficult to access. Milk has important nutrients for child growth, but carries the risk of aflatoxin M1 (AFM1) contamination. AFM1 is a metabolite of the mycotoxin aflatoxin B1 (AFB1) in dairy feed; cows secrete AFM1 in milk when their feed contains AFB1 produced by Aspergillus fungi in maize, nuts and oilseeds. It is unknown whether AFM1 compromises child growth and health. METHODS AND ANALYSIS: This protocol paper describes our study in Sidama to determine the impact of milk consumption and AFM1 on child growth in the first 18 months of life. We will collect baseline and end-line data on dairy production, socioeconomic and nutritional factors of 1000 dairy-owning households with children ages 6-18 months at baseline; and gather samples of milk and dairy feed and child anthropometrics. We will conduct phone interviews every 6 months to ascertain changes in practices or child health. Dairy feed will be tested for AFB1; milk for AFM1, pathogens and nutrients. Controlling for herd size, socioeconomic, nutritional and behavioural factors, we will determine the association between child anthropometrics and milk consumption, as well as AFM1 exposure. We will examine whether AFM1 exposure affects child growth in the first 18 months of life, and weigh the benefits and risks of milk consumption. ETHICS AND DISSEMINATION: The protocol is approved by the Institutional Review Boards of the Ethiopian Public Health Institute (EPHI-IRB-481-2022), Michigan State University (STUDY00007996) and International Food Policy Research Institute (DSGD-23-0102). Written informed consent will be obtained from all participants, who may withdraw from the study at any time. Confidentiality of collected data will be given high priority during each stage of data handling. The study's findings will be disseminated through stakeholder workshops, local and international conferences, journal articles and technical reports.

The glass of milk half-empty? Dairy development and nutrition in low and middle income countries.

Dairy products have an exceptionally rich nutrient profile and have long been promoted in high income countries to redress child malnutrition. But given all this potential, and the high burden of undernutrition in low- and middle-income countries (LMICs), why isn't dairy consumption more actively promoted in the developing world? In this review we focus on a broadly defined concept of "dairy development" to include production, trade, marketing, regulation, and demand stimulation. We address three key questions. First, how strong is the evidence on the importance of dairy production and consumption for improving nutrition among young children in LMICs? Second, which regions have the lowest consumption of dairy products? Third, what are the supply- and demand-side challenges that prevent LMICs from expanding dairy consumption? We argue that although more nutrition- and consumer-oriented dairy development interventions have tremendous potential to redress undernutrition in LMICs, the pathways for achieving this development are highly context-specific: LMICs with significant agroecological potential for dairy production primarily require institutional solutions for the complex marketing challenges in perishable milk value chains; lower potential LMICs require consumer-oriented trade and industrial approaches to the sector's development. And all dairy strategies require a stronger focus on cross-cutting issues of nutrition education and demand creation, food safety and quality, gender and inclusiveness, and environmental sustainability and resilience. We conclude our review by emphasizing important areas for research and policy expansion.

Can phone surveys be representative in low- and middle-income countries? An application to Myanmar.

For decades, in-person data collection has been the standard modality for nationally and sub-nationally representative socio-economic survey data in low- and middle-income countries. As the COVID-19 pandemic rendered in-person surveys impossible and unethical, the urgent need for rapid monitoring necessitated researchers and statistical agencies to turn to phone surveys. However, apart from pandemic-related factors, a variety of other reasons can render large segments of a population inaccessible for in-person surveys, including political instability, climatic shocks, and remoteness. Such circumstances currently prevail in Myanmar, a country facing civil conflict and political instability since the February 2021 military takeover. Moreover, Myanmar routinely experiences extreme weather events and is characterized by numerous inaccessible and remote regions due to its mountainous geography. We describe a novel approach to sample design and statistical weighting that has been successfully applied in Myanmar to obtain nationally and sub-nationally representative phone survey data. We use quota sampling and entropy weighting to obtain a better geographical distribution compared to recent in-person survey efforts, including reaching respondents in areas of active conflict. Moreover, we minimize biases towards certain household and respondent characteristics that are usually present in phone surveys, for example towards well-educated or wealthy households, or towards men or household heads as respondents. Finally, due to the rapidly changing political and economic situation in Myanmar in 2022, the need for frequent and swift monitoring was critical. We carried out our phone survey over four quarters in 2022, interviewing more than 12,000 respondents in less than three months each survey. A survey of this scale and pace, though generally of much shorter duration than in-person interviews, could only be possible on the phone. Our study proves the feasibility of collecting nationally and sub nationally representative phone survey data using a non-representative sample frame, which is critical for rapid monitoring in any volatile economy.

Food inflation and child undernutrition in low and middle income countries.

The 21st Century has been marked by increased volatility in food prices, with global price spikes in 2007-08, 2010-11, and again in 2021-22. The impact of food inflation on the risk of child undernutrition is not well understood, however. This study explores the potential impacts of food inflation on wasting and stunting among 1.27 million pre-school children from 44 developing countries. On average, a 5 percent increase in the real price of food increases the risk of wasting by 9 percent and severe wasting by 14 percent. These risks apply to young infants, suggesting a prenatal pathway, as well as to older children who typically experience a deterioration in diet quality in the wake of food inflation. Male children and children from poor and rural landless households are more severely impacted. Food inflation during pregnancy and the first year after birth also increases the risk of stunting for children 2-5 years of age. This evidence provides a strong rationale for interventions to prevent food inflation and mitigate its impacts on vulnerable children and their mothers.

Higher food prices can reduce poverty and stimulate growth in food production.

Food prices spiked sharply in 2007-2008, in 2010-2011 and again in 2021-2022. However, the impacts of these spikes on poverty remain controversial; while food is a large expense for the poor, many poor people also earn income from producing or marketing food, and higher prices should incentivize greater food production. Short-run simulation models assume away production and wage adjustments, and probably underestimate food production by the poor. Here we analyse annual data on poverty rates, real food price changes and food production growth for 33 middle-income countries from 2000 to 2019 based on World Bank poverty measures. Panel regressions show that year-on-year increases in the real price of food predict reductions in the US$3.20-per-day poverty headcount, except in more urban or non-agrarian countries. A plausible explanation is that rising food prices stimulate short-run agricultural supply responses that induce increased demand for unskilled labour and increases in wages.

Growth in milk consumption and reductions in child stunting: Historical evidence from cross-country panel data.

Agricultural and food policies are increasingly being tasked with doing more to improve the nutritional status of low-income populations, especially reductions in child stunting. Which specific food sectors warrant additional policy attention is less clear, although a growing body of research argues that increased animal-sourced food consumption in general, and increased dairy consumption specifically, can significantly reduce the risks of stunting, as well as deficiencies in micronutrients and high quality protein. However, experimental research on dairy's impacts on child growth in developing countries is very limited, and non-experimental evidence is confined to cross-sectional surveys. In this study we adopt a more macro lens by using a cross-country panel to show that increases in milk consumption over time are associated with large reductions in child stunting even after controlling for important confounding factors. Countries with high rates of stunting should therefore consider nutrition-sensitive strategies to increase dairy consumption among young children through both supply- and demand-side interventions.

Effects of an integrated poultry value chain, nutrition, gender and WASH intervention (SELEVER) on hygiene and child morbidity and anthropometry in Burkina Faso: A secondary outcome analysis of a cluster randomised trial.

Nutrition-sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition- and gender-sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2-4 years in Burkina Faso. A 3-year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15-49 years with an index child aged 2-4 years. We assessed the effects 1.5-years (WASH substudy) and 3-years (endline) post-intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH-livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04-0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03-0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock-related risks and improve livestock-hygiene-related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.

Poverty, price and preference barriers to improving diets in sub-Saharan Africa.

Suboptimal diets are the most important preventable risk factor for the global burden of non-communicable diseases. The EAT-Lancet reference diet was therefore developed as a benchmark for gauging divergence from healthy eating standards. However, no previous research has comprehensively explored how and why this divergence exists in poorer countries undergoing nutrition transitions. This study therefore analyzes dietary patterns and drivers of the demand for nutritious foods using nationally representative household surveys from Ethiopia, Kenya, Tanzania, and Uganda. We show how barriers to dietary convergence stem from combinations of poverty, high relative food prices and weak preferences for some specific healthy foods. The article concludes by discussing interventions for strengthening consumer demand for healthy diets in Africa.

A Prepandemic Nutrition-Sensitive Social Protection Program Has Sustained Benefits for Food Security and Diet Diversity in Myanmar during a Severe Economic Crisis.

BACKGROUND: One-third of preschool children in Myanmar were stunted in 2015-2016, and three-quarters of children 6-23 mo had inadequate diet diversity. In response, a large-scale nutrition-sensitive social protection program was implemented over 2016-2019. In 2020, however, Myanmar's economy was hit hard by the COVID-19 pandemic and harder still by a military takeover in 2021. OBJECTIVE: The objective of this study was to examine whether former beneficiaries of this program experienced better food security, food consumption, and diet diversity outcomes in the wake of major economic shocks. METHODS: In a previous cluster-randomized controlled trial conducted over 2016-2019, pregnant women and their children aged <2 y were randomly assigned to either: 1) CASH; 2) CASH + social and behavioral change communication (SBCC); or 3) a control group. Subsamples of these former participants were then resurveyed 10 times from June 2020 to December 2021 during Myanmar's protracted economic crisis. Randomized treatment exposure was used in a regression analysis to test for postprogram impacts on Food Insecurity Experience Scale indicators, household food consumption, and maternal and child diet diversity. We also examined the impacts on household income as a secondary outcome and potential impact pathway. RESULTS: Both intervention arms reported lower food insecurity, more frequent consumption of nutritious foods, and more diverse maternal and child diets compared with households in the control group. However, the improved dietary outcomes were larger for mothers and children exposed to CASH+SBCC compared with CASH, as was their monthly household income. CONCLUSIONS: The findings suggest that a program combining cash transfers with nutrition-related education can yield sustained benefits 1-2 y after the program was completed. This strengthens the evidence to support the expansion and scale-up of nutrition-sensitive social welfare programs to redress chronic malnutrition and enhance nutritional resilience in the face of a severe economic crisis.

Stories of change in nutrition: lessons from a new generation of studies from Africa, Asia and Europe.

How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded experiential learning across contexts. This article provides an overview of findings from 14 studies undertaken in nine countries in South Asia, sub-Saharan Africa, and Europe between 2017 and 2021. The studies used a combination of methods, including regression-decomposition analyses of national datasets to assess determinants of nutritional change; policy process and food environment analyses; and community-level research assessing attitudes to change. This article takes a narrative synthesis approach to identify key themes across the studies, paying particular attention to multisectoral determinants, changes in the food environment, the role of structural factors (including longstanding social inequities), and changes in political commitment, cross-sectoral coherence and capacity. Given the inherent multisectoral nature of nutrition, many countries are experimenting with different models of ensuring coherence across sectors that are captured in this body of work. The relative immaturity of the policy sector in dealing with issues such as obesity and overweight, and associated influences in the wider food environment, adds a further challenge. To address these interrelated issues, policy must simultaneously tackle nutrition's upstream (social/economic/equity) and downstream (health and dietary) determinants. Studies synthesised here provide empirically-driven inspiration for action.

Understanding drivers of stunting reduction in Nigeria from 2003 to 2018: a regression analysis.

Nigeria is a high burden country for stunting. Stunting reduction has been slow and characterized by unequal progress across the 36 states and federal capital territory of the country. This study aimed to assess the changes in prevalence of stunting and growth determinants from 2003 to 2018, identify factors that predicted the change in stunting, and project future stunting prevalence if these predicted determinants improve. Trend and linear decomposition analyses of growth outcomes and determinants were conducted using 2003, 2008, 2013, and 2018 Nigeria Demographic and Health Survey data. Pooled data included 57,507 children 0 to 59 months old. Findings show that stunting and severe stunting significantly reduced from 43 to 37% and 23% to 17%, respectively (p < 0.001), between 2003 and 2018. Disturbingly, height-for-age z-scores at birth significantly decreased, indicating risks of potential future stunting increase. Improvements in nine stunting determinants (maternal body mass index, maternal height, ≥ 4 antenatal care visits, health facility delivery, reduced child illnesses, asset index, maternal education, paternal education, and preceding birth interval) predicted stunting reductions in children 0-59 months. Few of these nine determinants improved in subpopulations with limited stunting progress. Intra-sectoral and multisectoral coordination were potentially inadequate; 12% of children had received all of three selected health sector interventions along a continuum of care and 6% had received all of six selected multisector interventions. Forward looking projections suggest that increased efforts to improve the nine predictors of stunting change can reduce under-five stunting in Nigeria to ≤ 27% in the short term. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01279-8.

Economic shocks predict increases in child wasting prevalence.

In low and middle income countries macroeconomic volatility is common, and severe negative economic shocks can substantially increase poverty and food insecurity. Less well understood are the implications of these contractions for child acute malnutrition (wasting), a major risk factor for under-5 mortality. This study explores the nutritional impacts of economic growth shocks over 1990-2018 by linking wasting outcomes collected for 1.256 million children from 52 countries to lagged annual changes in economic growth. Estimates suggest that a 10% annual decline in national income increases moderate/severe wasting prevalence by 14.4-17.8%. An exploration of possible mechanisms suggests negative economic shocks may increase risks of inadequate dietary diversity among children. Applying these results to the latest economic growth estimates for 2020 suggests that COVID-19 could put an additional 9.4 million preschoolers at risk of wasting, net of the effects of preventative policy actions.

Poverty and food insecurity during COVID-19: Phone-survey evidence from rural and urban Myanmar in 2020.

Myanmar first experienced the COVID-19 crisis as a relatively brief economic shock in early 2020, before the economy was later engulfed by a prolonged surge in COVID-19 cases from September 2020 onwards. To analyze poverty and food security in Myanmar during 2020 we surveyed over 2000 households per month from June-December in urban Yangon and the rural dry zone. By June, households had suffered dramatic increases in poverty, but even steeper increases accompanied the rise in COVID-19 cases from September onwards. Increases in poverty were much larger in urban areas, although poverty was always more prevalent in the rural sample. However, urban households were twice as likely to report food insecurity experiences, suggesting rural populations felt less food insecure throughout the crisis.

Affordability of nutritious diets in rural India.

In 2015-16 some 38% of preschool children in India were stunted, 21% wasted, and more than half of Indian mothers and young children were anemic. Though widely studied, surprisingly little research on malnutrition in India explores the role of diets, particularly the affordability of nutritious diets given low wages and the significant structural problems facing India's agricultural sector. To explore this we used nationally representative rural price and wage data to estimate the least cost means of satisfying India's national dietary guidelines, referred to as the Cost of a Recommended Diet (CoRD), and assessed the affordability of this diet relative to male and female wages for unskilled laborers. Although we find that dietary costs have increased substantially for both men and women, rural wage rates increased more rapidly, implying that nutritious diets became substantially more affordable over time. However, in absolute terms nutritious diets in 2011 were still expensive relative to unskilled wages, constituting approximately 80-90% of female and 50-60% of male daily wages. Overall, we estimate that 63-76% of the rural poor could not afford a recommended diet in 2011. Achieving nutritional security in India requires a much more holistic focus on improving the affordability of the full range of nutritious food groups (not just cereals), a reappraisal of social protection schemes in light of the cost of more complete nutrition, ensuring that economic growth results in sustained income growth for the poor, and more timely and transparent monitoring of food prices, incomes and dietary costs.

Cost and affordability of nutritious diets at retail prices: Evidence from 177 countries.

Many policies and programs aim to bring nutritious diets within reach of the poor. This paper uses retail prices and nutrient composition for 671 foods and beverages to compute the daily cost of essential nutrients required for an active and healthy life in 177 countries around the world. We compare this minimum cost of nutrient adequacy with the subsistence cost of dietary energy and per-capita spending on all goods and services, to identify stylized facts about how diet cost and affordability relate to economic development and nutrition outcomes. On average, the most affordable nutrient adequate diet exceeds the cost of adequate energy by a factor of 2.66, costing US$1.35 per day to meet median requirements of healthy adult women in 2011. Affordability is lowest in Sub-Saharan Africa. The sensitivity of diet costs to each requirement reveals the high cost of staying within acceptable macronutrient ranges, particularly the upper limit for carbohydrates. Among micronutrients, total diet costs are most sensitive to requirements for calcium as well as vitamins A, C, E, B12, folate and riboflavin. On average, about 5% of dietary energy in the least-cost nutrient adequate diets is derived from animal source foods, with small quantities of meat and fish. Over 70% of all animal products in least-cost diets is eggs and dairy, but only in upper-middle and high-income countries. In lower income countries where egg and dairy prices are significantly higher, they are replaced by larger volumes of vegetal foods. When controlling for national income, diet costs are most significantly correlated with rural travel times and rural electrification. These data suggest opportunities for targeted policies and programs that reduce market prices and the cost of nutritious diets, while improving affordability through nutrition assistance, safety nets and higher earnings among low-income households.

The double burden of malnutrition in India: Trends and inequalities (2006-2016).

Rapid urban expansion has important health implications. This study examines trends and inequalities in undernutrition and overnutrition by gender, residence (rural, urban slum, urban non-slum), and wealth among children and adults in India. We used National Family Health Survey data from 2006 and 2016 (n = 311,182 children 0-5y and 972,192 adults 15-54y in total). We calculated differences, slope index of inequality (SII) and concentration index to examine changes over time and inequalities in outcomes by gender, residence, and wealth quintile. Between 2006 and 2016, child stunting prevalence dropped from 48% to 38%, with no gender differences in trends, whereas child overweight/obesity remained at ~7-8%. In both years, stunting prevalence was higher in rural and urban slum households compared to urban non-slum households. Within-residence, wealth inequalities were large for stunting (SII: -33 to -19 percentage points, pp) and declined over time only in urban non-slum households. Among adults, underweight prevalence decreased by ~13 pp but overweight/obesity doubled (10% to 21%) between 2006 and 2016. Rises in overweight/obesity among women were greater in rural and urban slum than urban non-slum households. Within-residence, wealth inequalities were large for both underweight (SII -35 to -12pp) and overweight/obesity (+16 to +29pp) for adults, with the former being more concentrated among poorer households and the latter among wealthier households. In conclusion, India experienced a rapid decline in child and adult undernutrition between 2006 and 2016 across genders and areas of residence. Of great concern, however, is the doubling of adult overweight/obesity in all areas during this period and the rise in wealth inequalities in both rural and urban slum households. With the second largest urban population globally, India needs to aggressively tackle the multiple burdens of malnutrition, especially among rural and urban slum households and develop actions to maintain trends in undernutrition reduction without exacerbating the rapidly rising problems of overweight/obesity.