Agriculture’s role in the Indian enigma: help or hindrance to the crisis of undernutrition?

Mothers' dietary diversity and associated factors in megacity Dhaka, Bangladesh

Mothers in developing countries are nutritionally vulnerable due to an undiversified diet. Dietary diversity and healthy dietary patterns of mothers are necessary for the health and nutrition of both the mother and the child. Keeping these in mind, the study was designed to investigate the determinants of mothers' dietary diversity in the capital city (Dhaka) of Bangladesh. A total 613 mothers who had at least one child aged 6-59 months were surveyed in 2020. Dietary diversity (DD) was measured by 24 h recall period following the established guidelines. To explore the determinants of dietary diversity, a log linear regression model was employed. The findings revealed that the overall DD of mothers was low, with less than 15% of respondents consuming more than 5 of the 9 food groups. The study found that if a mother receives one more year of formal education, her DD, on average, would increase by 0.70%. Receiving antenatal care (ANC) for four or more times during pregnancy increases DD by 5.13% compared to mothers who receive ANC less than four times. The findings also showed that mothers with access to assets have 10.18% higher DD than mothers without access to assets. On the other hand, mothers' employment status was negatively associated with DD. Redistributing the household workload between mother and other household members can play a critical role in increasing mothers' DD. Providing care facilities and counseling to mothers about the nutritional value of consuming different food groups can substantially improve the situation.

Forty Years after Poverty Reduction in China: The Role of Women's Empowerment in Enhancing Food Security and Diet Diversity

This study analyzed the role of women's empowerment in diversifying the diet of households through their own production. Developed from empowerment and food security theories, this study constructed measures from the household dietary diversity score (HDDS) and Women's Empowerment Index (WEI). The study focused on poverty-stricken regions in China and conducted a thematic questionnaire-based household survey on gender and food consumption in 2021. Based on micro-level evidence from 1199 rural households, this research found a low score of women's empowerment and an average WEI of 0.689; the status of diet diversity, measured by the HDDS, varied by income and social class; and the average rate was low. Agricultural production diversity and women's empowerment are positively associated with diet diversity. There is strong evidence that women's employment mitigates the side effects of decreasing production diversity on households' diet security. As a result, women's empowerment can potentially mitigate the adverse consequences of low agricultural diversification in household diet quality in less developed areas. This study provides evidence for repurposing food and agricultural policies toward healthy diets and gender-responsive agrifood systems.

How are higher rice yields associated with dietary outcomes of smallholder farm households of Madagascar?

It is widely expected that agriculture would contribute to farmers’ food security and nutrition in developing countries. However, studies that directly explore the link between agricultural productivity and micronutrients intake by farmers are scarce. In this paper, we contribute to filling this gap by exploring two key channels by which agricultural production can influence dietary outcomes: a food consumption pathway and a cash revenue pathway. To achieve this, we used three-years panel data of rice farmers collected in the Vakinankaratra region of Madagascar. The results suggest that rice yield is positively and significantly associated with farmers’ calorie and micronutrients intake, though the observed elasticities are low. Secondly, raising rice yield has a positive significant impact not only on rice consumption but also on the share of the output sold and the cash revenue from rice sales. Lastly, the results suggest that households with higher cash revenue from rice sales purchase more nutritious foods. Therefore, we conclude that the market represents the channel through which increased rice yield translates into improved micronutrient intake. The findings of this study imply that in order to improve farm households’ nutrition through agricultural production, interventions that target yield enhancement should be accompanied by market access measures.

Household Dietary Diversity among the Ethnic Minority Groups in the Mekong Delta: Evidence for the Development of Public Health and Nutrition Policy in Vietnam

Poor household dietary diversity has been linked to malnutrition in individuals, households, and cumulatively in populations. High rates of malnutrition among Khmer ethnic children aged five years and younger have been reported in Tri Ton district, Vietnam. This paper aims to further investigate household dietary diversity and associated factors among Khmer ethnic minority populations in Vietnam. A cross sectional study was conducted from October 2018 to April 2019 in Tri Ton District, An Giang Province. By employing a multistage sampling technique, a total of 402 (99.8% response rate) participants were interviewed to measure household dietary diversity using a structured and validated questionnaire developed by FAO. Both bivariate and multivariate logistic regression analyses were carried out to identify factors associated with household dietary diversity. The results showed that the prevalence of low, medium and high dietary diversity scores were 21.4%, 70.4% and 8.2%, respectively. Male-headed households, literacy level, household income, exposure to mass media on nutrition and health information, and frequency of eating were positively associated with household dietary diversity (p < 0.05). However, owning a vegetable and rice farm was not statistically related to households’ dietary diversification. The paper concludes that the magnitude of household diversified dietary intakes was essentially low to medium in participants’ households. These findings have provided evidence to inform the development of the National Nutrition Strategy—2021−2030 in Vietnam, to be revised in 2045. This national strategy proposes appropriate interventions, programs and policies to improve socioeconomic status in ethnic groups and in mountainous areas to enhance populations’ health and well-being including controlling childhood malnutrition. In order to improve population health and wellbeing in Tri Ton District, further actions to address effective dietary practices including strengthening nutrition and health communication about the need to improve household dietary diversity to high levels are recommended.

Participating in a Nutrition-Sensitive Agriculture Intervention Is Not Associated with Less Maternal Time for Care in a Rural Ghanaian District

Background

Nutrition-sensitive agriculture (NSA) interventions may increase farm-related work for mothers, with consequences for child nutrition. The Nutrition Links (NL) intervention provided mothers with poultry, gardening inputs, technical support, and education to improve livelihoods and child nutrition outcomes in rural Ghana.

Objectives

Our objective was to compare time allocated to child care by a cross-section of mothers in the intervention group of the NL intervention with the control group (NCT01985243).

Methods

A cross-section of NL mother-child pairs was included in a time allocation substudy [intervention (NL-I) n = 74 and control (NL-C) n = 69]. In-home observations of the mother-child pair were conducted for 1 min, every 5 min, for 6 h. Observations were categorized into 4 nonoverlapping binary variables as follows: 1) maternal direct care, 2) maternal supervisory care, 3) allocare, and 4) no direct supervision. Allocare was defined as care by another person in the presence or absence of the mother. Any care was defined as the observation of maternal direct care, maternal supervisory care, or allocare. Generalized linear mixed models with binomial data distribution were used to compare the child care categories by group, adjusting for known covariates.

Results

Maternal direct care (OR = 1.07; 95% CI: 0.89, 1.28) and any care (OR = 1.56; 95% CI: 0.91, 2.67) did not differ by intervention group. However, there was a higher odds of allocare (OR = 1.36; 95% CI: 1.04, 1.79) in NL-I than in NL-C women.

Conclusions

Maternal participation in an NSA intervention was not associated with a decrease in time spent directly on child care but was associated with an increase in care from other household and community members.The clinicaltrials.gov number provided is for the main NL intervention and not this current substudy.

The Indirect Impact of Smallholder Vegetable Production on Children's Nutrition Outcomes in Rural Vietnam

Childhood undernutrition, particularly stunting, wasting, and micronutrient deficiencies, remains a major health concern in rural Vietnam. While literature suggests leveraging agriculture to improve child nutrition via agricultural diversification, market engagement, and women's empowerment, very few studies have empirically explored how smallholder vegetable production can influence household nutrition. This paper examines the association of household-level vegetable diversity, market access, and market participation with nutrition outcome measures of children in smallholder households. We use a cross-sectional household dataset, collected in 2016 in northwest Vietnam, covering 234 children aged 6–60 months. We estimate and compare the results of regression models using three-stage least squares (3SLS), ordinary least squares (OLS), logistic regression, and seemingly unrelated regression (SUR), to explore variations in six nutrition outcome measures: height-for-age z-score (HAZ), weight-for-height z-score (WHZ), weight-for-age z-score (WAZ), stunting, wasting, and underweight. Our results suggest smallholder vegetable production has a significant indirect association with children's nutrition status via market participation. Market participation is an important factor in improving girls' HAZ and WHZ, and in reducing the probability of boys being stunted and underweight. The additional income from selling vegetables allows households to purchase nutritious food, which is likely to have a positive impact on children's nutrition outcomes.

Low Birth Weight, the Differentiating Risk Factor for Stunting among Preschool Children in India

Background: The prevalence of low birth weight (LBW) is a major public health issue in India; however, the optimal growth pattern for such infants is not clear. The purpose of this study is to understand the causal association between LBW and stunting of preschool children in India. Methods: The National Family Health Survey-4 is a large cross-sectional survey based on a nationally representative sample of 699,686 women in the age group of 15−49 years and was conducted during 2015−2016 in India. The study used the children’s file with a sample of 259,002 of 0−59 months for investigation. Results: The data revealed that 38.7% of the children in India were stunted. The bivariate analysis revealed that, of the women who did not attend any antenatal care (ANC) meetings, 46.8% had stunted children compared to the women who attended more than three ANC meetings, which 30.7% had stunted children. The low birth weight children experienced a much higher chance of stunting compared to children with a normal birth weight (44.3% vs. 33.8%). The multivariable odds ratios of logistic regression, after adjusting for the confounding characteristics, showed that pregnant women attending more than three ANC meetings compared to not attending any ANC meetings experienced a 19% lower adjusted odds ratio (AOR) of having stunted children (AOR = 0.81; CI 0.78, 0.85; p < 0.001). Another important variable, such as women with underweight body mass index (BMI) compared with normal BMI, had 6% higher odds of having stunted children (AOR = 1.06; CI 1.03, 1.10; p < 0.001). Similarly, women who belong to the Scheduled Caste compared to the General Caste had 36% higher odds of having stunted children (AOR = 1.36; CI 1.30, 1.42; p < 0.001); and children aged 13−23 months compared to children up to one-year-old or younger had 141% higher odds of being stunted (AOR = 2.41; CI 2.32, 2.51; p < 0.001). The conspicuous finding is that LBW babies, after adjusting for other important confounding factors, such as BMI and ANC, experienced 19% higher odds of stunted children (AOR = 1.19; CI 1.14, 1.24; p < 0.001) compared to normal birth weight babies. Conclusions: The results revealed LBW is associated with stunting of preschool children in India.

Economic costs of childhood stunting to the private sector in low- and middle-income countries

Background

Stunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries.

Methods

This multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting.

Findings

Across 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied.

Interpretation

Childhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.

Reshaping Food Policy and Governance to Incentivize and Empower Disadvantaged Groups for Improving Nutrition

The coronavirus disease 2019 (COVID-19) pandemic has exacerbated global malnutrition challenges, disrupted food supply chains, and left poor and vulnerable people unable to produce and access safe and affordable food, especially in developing countries. Food policy and governance are currently malfunctioning, despite their recognized roles in improving food security and public nutrition in many local and national contexts. This article reviews existing food policies and governance with implications for disadvantaged groups in the food systems, particularly smallholder farmers, women, and small- and medium-sized enterprises (SMEs), highlighting the importance of reshaping food policies and governance. To end malnutrition in the post-COVID era, multiple sectors, including health, agriculture, social protection, education, and infrastructure, must make greater collaborative efforts to develop and implement food and nutrition policies. Several recommendations for reshaping food policy interventions and governance are summarized.

Elucidating the sustained decline in under-three child linear growth faltering in Nepal, 1996-2016

Childhood linear growth faltering remains a major public health concern in Nepal. Nevertheless, over the past 20 years, Nepal sustained one of the most rapid reductions in the prevalence of stunting worldwide. First, our study analysed the trends in height-for-age z-score (HAZ), stunting prevalence, and available nutrition-sensitive and nutrition-specific determinants of linear growth faltering in under-three children across Nepal's Family Health Survey 1996 and Nepal's Demographic and Health Surveys 2001, 2006, 2011, and 2016. Second, we constructed pooled multivariable linear regression models and decomposed the contributions of our time-variant determinants on the predicted changes in HAZ and stunting over the past two decades. Our findings indicate substantial improvements in HAZ (38.5%) and reductions in stunting (-42.6%) and severe stunting prevalence (-63.9%) in Nepalese children aged 0-35 months. We also report that the increment in HAZ, across the 1996-2016 period, was significantly associated (confounder-adjusted p < .05) with household asset index, maternal and paternal years of education, maternal body mass index and height, basic child vaccinations, preceding birth interval, childbirth in a medical facility, and prenatal doctor visits. Furthermore, our quantitative decomposition of HAZ identified advances in utilisation of health care and related services (31.7% of predicted change), household wealth accumulation (25%), parental education (21.7%), and maternal nutrition (8.3%) as key drivers of the long-term and sustained progress against child linear growth deficits. Our research reiterates the multifactorial nature of chronic child undernutrition and the need for coherent multisectoral nutrition-sensitive and nutrition-specific strategies at national scale to further improve linear growth in Nepal. [Correction added on 6 November 2020, after first online publication: in abstract, the citation year in the fourth sentence has been changed from '2001' to '2011'.].

Pathways to Diverse Diets-a Retrospective Analysis of a Participatory Nutrition-Sensitive Project in Kenya

BACKGROUND

There is a current need for better understanding the impact of nutrition-sensitive agriculture interventions. This study is based on a community-based participatory project that diversified diets of women and children by making use of local food biodiversity. This retrospective impact pathway analysis aims at explaining why and how impact was reached.

OBJECTIVES

This study aimed to understand how a nutrition-sensitive agriculture project improved people's diets by analyzing the pathways from agriculture to nutrition. It also aimed to test theoretical pathways by comparing the documented pathways with those from a widely used framework from the literature.

METHODS

A qualitative study was conducted in 2019 through 10 semistructured focus group discussions with community members engaging in the project and 5 key informant interviews with local authorities that worked with these communities during the project. Summative content analysis was used to identify pathways through which the project affected diets of beneficiaries. The defined pathways were compared with the pathways of the widely used Tackling the Agriculture-Nutrition Disconnect in India (TANDI) framework from the literature.

RESULTS

Out of the agriculture-nutrition pathways that are presented in the literature, 3 were found in the responses: 1) food from own production; 2) income from sale of foods produced; and 3) women's empowerment through access to and control over resources. In addition, 5 other pathways were identified and indicated spillover effects from the intervention to the control participants, increased nutrition knowledge, improved health, savings, and empowerment and harmony in the household.

CONCLUSIONS

Pathway analysis in nutrition-sensitive agriculture can provide valuable understanding on how and why dietary improvements have been achieved in an intervention. The approach can hence be instrumental in addressing the current demand within the field on understanding the progress and impact of interventions. Pathway analysis also helps to address knowledge gaps regarding theoretical frameworks, as in the present study, concerning women empowerment pathways.

The forgotten agriculture-nutrition link: farm technologies and human energy requirements

In the quest to reduce global under- and malnutrition, which are particularly high among smallholder farmers, agriculture-nutrition linkages are receiving increasing attention. Researchers have analyzed the link between the quantity and diversity of food that farmers produce and nutritional outcomes but paid limited attention to a third agriculture-nutrition link: the link between how food is produced and nutritional outcomes. This neglect persists despite the majority of smallholder farmers relying on hand tools for farming, which implies heavy physical work and, thus, high energy requirements. To address this research gap, this study compares the energy requirements of farm households in rural Zambia that are characterized by three different levels of mechanization: hand tools, animal drought power, and tractors. 1638 days of detailed time-use and nutrition data were collected from 186 male and female adults and boys and girls during different seasons (land preparation, weeding, and harvesting/processing) using an innovative picture-based smartphone app called “Timetracker”. This data served to calculate different proxies for physical activity and energy requirements using “Ainsworth’s Compendium of Physical Activities”. The results suggest that detailed time-use data offers great potentials to study physical activity and energy requirements. The findings show strong linkages between farm technologies, physical activity levels, and energy requirements, suggesting that this agriculture-nutrition link deserves more scientific and political attention to reduce under- and malnutrition among smallholder farmers.

Tracing the Single and Combined Contributions of Home-Grown Supply and Health Literacy on Fruit and Vegetable Consumption: An Empirical Exploration in Rural India

Low fruit and vegetable consumption (FVC) remains a global health challenge. Fostering subsistence agriculture through the production and home-grown consumption (HGC) of fruits and vegetables are seen as potential strategies for improving overall FVC, in particular, for developing countries like India. In addition, educational strategies targeting FVC health literacy are also used. Little evidence has documented a connection between these two strategies. We examine the single and combined influence of HGC and health literacy with regard to benefits from fruits and vegetable consumption. Data were collected from 427 rural households in the state of Odisha, India. Three outcomes were examined: FVC, as well as fruit and vegetables separately. Linear and Poisson regression were used to examine the association among home-grown consumption (HGC), FVC health literacy, and the FVC outcomes. Findings show that HGC, but not FVC health literacy, was directly associated with FVC (β = 0.65, SE = 0.10, p = 0.008) and vegetable consumption (β = 0.57, SE = 0.11, p = 0.02). However, both HGC (β = 0.58, SE = 0.05, p < 0.01) and FVC health literacy (β = -0.07, SE = 0.02, p = 0.001) were associated with fruit consumption. In addition, HGC effect is concentrated among participants who reported low FVC health literacy, especially on overall FVC and vegetables alone. Results are discussed in relation to the beneficial role played by HGC in those particularly vulnerable households who perceived little FVC health literacy. Our results provide insights on novel improved FVC consumption across all population segments. Future research should explore the complex interplay between agricultural policies and educational programs in the design of interventions promoting fruit and vegetable production and consumption.

Effects of short birth spacing on birth-order differences in child stunting: Evidence from India

Do firstborn children have a height advantage? Empirical findings have found mostly that, yes, second or higher-order children often lag behind firstborns in height outcomes, especially in developing countries. However, empirical investigations of birth-order effects on child height overlook the potential impact that birth spacing can have. We provide an explanation for the negative birth-order effect on stunting outcomes for young Indian children and show it is driven by short preceding-birth spacing. We find that firstborn children are taller than children of higher birth order: The height-for-age gap for third (or higher)-order children is twice the gap for children second in birth order. However, this pattern is observed when spacing between later-born children and their immediate elder siblings is fewer than 3 y. Interestingly, the firstborn height advantage disappears when later-born children are born at least 3 y after their elder siblings. Thus, our findings indicate that spacing length between children explains differences in height, over birth order. Although India's family planning policy has resulted in a substantial reduction in total fertility, its achievement in spacing subsequent births has been less impressive. In showing that spacing can alleviate or aggravate birth-order effects on attained height, our study fills an evidence gap: Reducing fertility alone may not be sufficient in overcoming negative birth-order effects. To reduce the detrimental effects of birth order on child stunting, policy responses-and therefore research priorities-require a stronger focus on increasing the time period between births.

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.

Conceptual frameworks linking agriculture and food security

Many conceptual frameworks have been developed to facilitate understanding and analysis of the linkages between agriculture and food security. Despite having usefully guided analysis and investment, these frameworks exhibit wide diversity in perspectives, assumptions and application. This Review Article examines this diversity, providing an approach to assess frameworks and suggesting improvements in the way they are specified and applied. Using criteria-based systems modelling conventions, we evaluate 36 frameworks. We find that many frameworks are developed for the purpose of illustration rather than analysis and do not clearly indicate causal relationships, tending to ignore the dynamic (stability) dimensions of agriculture and food security and lacking clear intervention points for improving food security through agriculture. By applying system modelling conventions to a widely used framework, we illustrate how such conventions can enhance the usefulness of a framework for overall illustration purposes, delineate hypotheses on agriculture-food security links and examine potential impacts of interventions.

Disparity in childhood stunting in India: Relative importance of community-level nutrition and sanitary practices

Despite rapid macro-economic growth, one-third of the global burden of childhood stunting is contributed by India. This burden is characterized by wide-spread geographical variation within the country. This paper explores two research questions: (i) are the drivers of severe and moderate stunting similar? (ii) differential endowments or policy-effect, how do community-level nutrition and sanitary practices affect inter-state differences? Using data from Indian National Family and Health Survey 4, 2015-16, six states holding different ranks in the stunting continuum are compared to Tamil Nadu, taken as the benchmark state due to its laudable performance in the health care sector. Applying quantile regression approaches, the difference in state-level performance is decomposed into detailed covariate effects (differential endowments) and coefficient effects (differential strength of association between the drivers and outcome). The explanatory variables are not similarly associated with severe and moderate stunting. Decomposition results demonstrate a significant role of community-level sanitation practices compared to child nutrition behaviour in explaining the inter-state disparity. Coefficient effects play a dominant role in the lower tail of HAZ distribution for the poor performing states indicating that the worse outcomes of these states are due to weaker policy effects of the control variables on stunting. Multi-sectoral approach, identification and differentiation between severe and moderate stunting cases can be more instrumental in managing and reducing the scourge. This paper also advocates the potential benefits of customizing centrally-launched policies as per the state's performance and introducing the concept coproduction in the existing nutrition and health policy framework. This will instigate a feeling of ownership of the problem of childhood stunting among the policy consumers and strengthen the influence of policies on the outcomes.

Gender effects of agricultural cropping work and nutrition status in Tanzania

Although agriculture is an important source of food and income for food expenditures, women's involvement in the agricultural cropping production process could increase their work load and reduce their BMI. Using three waves of the Tanzania National Panel Survey, we investigate the extent to which time spent in agricultural crop production affects women and men's nutritional status among non-overweight individuals (age 20-65). We also test whether the impact of agricultural cropping work on nutritional status is modified by access to agricultural equipment, and whether gender differences exist. The study finds that time spent in agricultural cropping work is negatively associated with BMI for non-overweight individuals, albeit of small magnitude, and this finding is consistent across different crop production processes. This suggests that agricultural interventions should not ignore the implications of increasing work intensities on nutrition. While increased agricultural production could improve nutritional status by increasing agricultural income and food, the gains in nutritional status could be offset by an increase in work effort of doing agricultural work. Our results suggest that it is possible that access to equipment reduced effort for one production activity, but increased work for other activities in the production process, such as in harvesting. Furthermore, we find that the BMI of women in households with a hand powered sprayer is positively related to time spent in weeding, fertilizing, and non-harvest activities, while it is negatively correlated for men. It is possible that access to a hand powered sprayer may have helped reduce women's work, for example, in weeding, while this was not the case for men's work such as in ridging and fertilizing. Further disaggregation of agricultural activities in the dataset would have been helpful to provide more insights on the gender roles.

Dietary Transition in India: Temporal and Regional Trends, 1993 to 2012

BACKGROUND

Rapid economic growth, urbanization, and globalization have resulted in dietary transformation in India. Triple burden of malnutrition remains a significant concern, with high prevalence of undernutrition, widespread micronutrient deficiencies, and rising obesity.

OBJECTIVE

This article reviews the dietary transition in India by analyzing trends in food consumption across time and space.

METHODS

Household consumption survey data from 1993 to 2012 are analyzed to examine both national- and state-level trends to investigate how diets have changed and vary across the country. Typical Indian diets are characterized using k-mean cluster analysis and associated with socioeconomic and geographical aspects.

RESULTS

The article finds that on average Indian household diets have diversified slowly but steadily since the 90s. Indians diets have shifted away from cereals to higher consumption of milk. However, progress on micronutrient-rich food groups such as fruits, vegetables, meat, and egg has been worryingly slow. Even by 2012, about a fifth of rural Indian households did not consume fruits or milk, while more than half of both urban and rural households did not consume any meat, fish, or eggs. Five predominant dietary types are identified. Sections of the Indian households do consume reasonably balanced diets, but large percentages consume cereal-focused, dairy-focused, or processed food heavy diets with high processed food content.

CONCLUSIONS

Diets in India have not transformed sufficiently to overcome major gaps in intakes of micronutrient-rich foods. Large regional heterogeneities in diets call for regionally differentiated strategies to improve diets.

The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) Indicator Is Related to Household Food Insecurity and Farm Production Diversity: Evidence from Rural Mali

BACKGROUND

The popularity of nutrition-sensitive interventions calls for high-quality monitoring and evaluation tools. In this context, the Minimum Dietary Diversity for Women of Reproductive Age (MDD-W), validated as a proxy of micronutrient adequacy, does fill a gap. However, because it is a newly endorsed indicator, information on its linkages with other dimensions of food and nutrition security is still scarce.

OBJECTIVE

The objective of this study was to investigate whether the MDD-W is related to household food insecurity and farm production diversity.

METHODS

A cross-sectional survey on a representative sample of 5046 women of reproductive age was conducted in the region of Kayes, Mali, in 2013. Dietary diversity was assessed through qualitative 24-h recall, and MDD-W was computed. MDD-W equaled 1 if the women consumed at least 5 different food groups and 0 otherwise. Food insecurity was measured using the Household Food Insecurity Access Scale and the Household Hunger Scale (HHS), and a farm production diversity score (FPDS) was calculated based on a count of food crops/livestock groups produced. Logistic regressions were used to assess the relation between MDD-W and the indicators of household food security.

RESULTS

Only 27% of women reached the MDD-W. These women consumed animal source foods and/or vitamin A-rich vegetables and fruits more frequently than did other women. Women from extremely food insecure households (moderate to severe hunger according to the HHS) were less likely to reach the MDD-W (OR: 0.70; 95% CI: 0.50, 0.97). One more group in the FPDS increased the odds of attaining the MDD-W (OR: 1.12; 95% CI: 1.06, 1.18).

CONCLUSION

In the rural region of Kayes, Mali, women's dietary diversity, as measured by the MDD-W, was associated with household-level food security indicators. This study was registered at ISRCTN.org as ISRCTN08435964.

Understanding the geographical burden of stunting in India: A regression-decomposition analysis of district-level data from 2015-16

India accounts for approximately one third of the world's total population of stunted preschoolers. Addressing global undernutrition, therefore, requires an understanding of the determinants of stunting across India's diverse states and districts. We created a district-level aggregate data set from the recently released 2015-2016 National and Family Health Survey, which covered 601,509 households in 640 districts. We used mapping and descriptive analyses to understand spatial differences in distribution of stunting. We then used population-weighted regressions to identify stunting determinants and regression-based decompositions to explain differences between high- and low-stunting districts across India. Stunting prevalence is high (38.4%) and varies considerably across districts (range: 12.4% to 65.1%), with 239 of the 640 districts have stunting levels above 40% and 202 have prevalence of 30-40%. High-stunting districts are heavily clustered in the north and centre of the country. Differences in stunting prevalence between low and high burden districts were explained by differences in women's low body mass index (19% of the difference), education (12%), children's adequate diet (9%), assets (7%), open defecation (7%), age at marriage (7%), antenatal care (6%), and household size (5%). The decomposition models explained 71% of the observed difference in stunting prevalence. Our findings emphasize the variability in stunting across India, reinforce the multifactorial determinants of stunting, and highlight that interdistrict differences in stunting are strongly explained by a multitude of economic, health, hygiene, and demographic factors. A nationwide focus for stunting prevention is required, while addressing critical determinants district-by-district to reduce inequalities and prevalence of childhood stunting.

Composition of Household Income and Child Nutrition Outcomes Evidence from Uganda

This study targets the empirical space between cross-country analyses exploring links between income and nutrition without insights on micro-level determinants, and relevant microeconomic studies hindered by small sample size and/or incomplete data. We use the rural samples of the three waves of the Uganda National Panel Survey, and estimate panel regressions of child height-for-age z-scores (HAZ) controlling for time-invariant child-level heterogeneity. On the whole, we find no impact of short-term changes in total gross income on HAZ but document small positive correlations for younger children. Sector-differentiated analyses indicate that compared to wage earnings, only share of income from non-farm self-employment correlates positively with HAZ. Within agriculture, shares of income from consumption of own crop production and from low-protein crop production underlie the negative effect of share of income from crop production. While we cannot claim causal relationships, our findings suggest the possibility of "stickiness" of crop production to own consumption.

The role of agriculture in women's nutrition: Empirical evidence from India

In this paper, we establish a statistically important relationship between household agricultural income and women's BMI using a five-year panel dataset of rural households drawn from 18 villages across five Indian states. Using within household variation over time, we estimate both the extent to which short-term changes in agricultural income are associated with short-term changes in BMI, and the effect of agricultural income growth on BMI growth over a longer term. Over the longer term, and for the group of households that regularly farm, we find a 10 percentage point agricultural income growth to be associated with a 0.10 percentage point growth in BMI. Consistent with the literature, this effect is economically modest, but important considering that we do not find a corresponding effect for growth in non-agricultural income. We show that both the own-production and market purchase of food are associated with nutritional improvements. While women's BMI is associated with an increase in the consumption of own-produced cereals, the market plays an important role in facilitating access to more nutritious foods like pulses. Lastly, we also find that effects of agricultural income are driven by younger women, in the age-group 15-25 years, who face a particularly strong nutritional disadvantage in India.

Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child nutritional outcomes in rural Odisha, India: study protocol for a cluster randomised controlled trial

BACKGROUND

Maternal and child undernutrition have adverse consequences for pregnancy outcomes and child morbidity and mortality, and they are associated with low educational attainment, economic productivity as an adult, and human wellbeing. 'Nutrition-sensitive' agriculture programs could tackle the underlying causes of undernutrition.

METHODS/DESIGN

This study is a four-arm cluster randomised controlled trial in Odisha, India. Interventions are as follows: (1) an agricultural extension platform of women's groups viewing and discussing videos on nutrition-sensitive agriculture (NSA) practices, and follow-up visits to women at home to encourage the adoption of new practices shown in the videos; (2) women's groups viewing and discussing videos on NSA and nutrition-specific practices, with follow-up visits; and (3) women's groups viewing and discussing videos on NSA and nutrition-specific practices combined with a cycle of Participatory Learning and Action meetings, with follow-up visits. All arms, including the control, receive basic nutrition training from government community frontline workers. Primary outcomes, assessed at baseline and 32 months after the start of the interventions, are (1) percentage of children aged 6-23 months consuming ≥ 4 out of 7 food groups per day and (2) mean body mass index (BMI) (kg/m2) of non-pregnant, non-postpartum (gave birth > 42 days ago) mothers or female primary caregivers of children aged 0-23 months. Secondary outcomes are percentage of mothers consuming ≥ 5 out of 10 food groups per day and percentage of children's weight-for-height z-score < -2 standard deviations (SD). The unit of randomisation is a cluster, defined as one or more villages with a combined minimum population of 800 residents. There are 37 clusters per arm, and outcomes will be assessed in an average of 32 eligible households per cluster. For randomisation, clusters are stratified by distance to nearest town (< 10 km or ≥ 10 km), and low (< 30%), medium (30-70%), or high (> 70%) proportion of Scheduled Tribe or Scheduled Caste (disadvantaged) households. A process evaluation will assess the quality of implementation and mechanisms behind the intervention effects. A cost-consequence analysis will compare incremental costs and outcomes of the interventions.

DISCUSSION

This trial will contribute evidence on the impacts of NSA extension through participatory, low-cost, video-based approaches on maternal and child nutrition and on whether integration with nutrition-specific goals and enhanced participatory approaches can increase these impacts.

TRIAL REGISTRATION

ISRCTN , ISRCTN65922679 . Registered on 21 December 2016.

Drivers of nutritional change in four South Asian countries: a dynamic observational analysis

This paper quantifies the factors explaining long-term improvements in child height for age z-scores in Bangladesh (1996/1997-2011), India (1992/1993-2005/2006), Nepal (1997-2011) and Pakistan (1991-2013). We apply the same statistical techniques to data from a common data source from which we have extracted a set of common explanatory variables that capture 'nutrition-sensitive' factors. Three are particularly important in explaining height for age z-score changes over these timeframes: improvements in material well-being; increases in female education; and improvements in sanitation. These factors have comparable associations across all four countries.

Agriculture, Food Systems, and Nutrition: Meeting the Challenge

Malnutrition is a global challenge with huge social and economic costs; nearly every country faces a public health challenge, whether from undernutrition, overweight/obesity, and/or micronutrient deficiencies. Malnutrition is a multisectoral, multi-level problem that results from the complex interplay between household and individual decision-making, agri-food, health, and environmental systems that determine access to services and resources, and related policy processes. This paper reviews the theory and recent qualitative evidence (particularly from 2010 to 2016) in the public health and nutrition literature, on the role that agriculture plays in improving nutrition, how food systems are changing rapidly due to globalization, trade liberalization, and urbanization, and the implications this has for nutrition globally. The paper ends by summarizing recommendations that emerge from this research related to (i) knowledge, evidence, and communications, (ii) politics, governance, and policy, and (iii) capacity, leadership, and financing.

Impact of agricultural interventions on the nutritional status in South Asia: A review

Nearly half of the malnourished population of the world lives in South Asia, and agriculture is the main source of livelihood of the people in this region. Many review exercises have analysed the available evidences to understand the ways in which agriculture can be leveraged to enhance nutritional status; however, very few of them have employed a systematic approach ensuring internal and external validity. The present paper seeks to fill this gap for strengthening the policy recommendations. It demonstrates an association between agricultural interventions and nutritional outcomes; and it shows that the production of targeted nutrition-rich crops, homestead gardens, and diversification of the agricultural production system towards fruits and vegetables and aquaculture can potentially improve nutrient intake and nutritional outcomes. The empowerment of women and nutrition knowledge play a crucial role in establishing linkage between agriculture and nutritional outcomes.

Toward Food Policy for the Dual Burden of Malnutrition: An Exploratory Policy Space Analysis in India

BACKGROUND

There is global consensus that a strong policy response is essential for addressing the dual burden of malnutrition. However, policy makers in low- and middle-income countries may perceive a conflict between food supply policies to combat persistent undernutrition and more recent recommendations for policies addressing rising rates of diet-related noncommunicable diseases (NCDs).

OBJECTIVE

This article explores the potential to use policy space analysis to identify food supply policy opportunities for addressing both undernutrition and diet-related NCDs and to support improved policy coherence.

METHODS

We conducted an exploratory policy space analysis to identify opportunities and constraints for integrated nutrition policy with respect to the food supply in India, where a dual burden of malnutrition has been well documented. We conducted a review of food supply policies and 27 key informant interviews (16 with stakeholders active in India's national nutrition policy space, and 11 with policy makers and experts in food supply policy).

RESULTS

The analysis suggests several opportunities for an integrated food supply policy agenda, including targeting common foods of concern (such as highly processed foods) and foods that present common benefits (such as fruits and vegetables), and scaling up existing small-scale policy initiatives that support the availability of nutrient-rich foods. Challenges include policy inertia and competing priorities within the economic sector.

CONCLUSION

This scoping study indicates that the policy space analysis framework used here can help to identify specific, contextually appropriate policy options and strategies for strengthening public health nutrition policy within sectors responsible for food supply policy.

Understanding the Rapid Reduction of Undernutrition in Nepal, 2001-2011

South Asia has long been synonymous with unusually high rates of undernutrition. In the past decade, however, Nepal has arguably achieved the fastest recorded decline in child stunting in the world and has done so in the midst of civil war and post-conflict political instability. Given recent interest in reducing undernutrition–particularly the role of nutrition-sensitive policies–this paper aims to quantitatively understand this surprising success story by analyzing the 2001, 2006, and 2011 rounds of Nepal’s Demographic Health Surveys. To do so, we construct models of the intermediate determinants of child and maternal nutritional change and then decompose predicted changes in nutrition outcomes over time. We identify four broad drivers of change: asset accumulation, health and nutrition interventions, maternal educational gains, and improvements in sanitation. Many of these changes were clearly influenced by policy decisions, including increased public investments in health and education and community-led health and sanitation campaigns. Other factors, such as rapid growth in migration-based remittances, are more a reflection of household responses to changing political and economic circumstances.

Agriculture, health, and wealth convergence: bridging traditional food systems and modern agribusiness solutions

The causes of many vexing challenges facing 21st-century society are at the nexus of systems involved in agriculture, health and wealth production, consumption, and distribution. Using food as a test bed, and on the basis of emerging roadmaps that set achievable objectives over a 1- to 3-year horizon, we introduce this special feature with convergence thinking and practice at its core. Specifically, we discuss academic papers structured around four themes: (1) evidence for a need for convergence and underlying mechanisms at the individual and societal levels; (2) strategy for mainstreaming convergence as a driver of business engagement and innovation; (3) convergence in policy and governance; (4) convergence in metrics and methods. Academic papers under each theme are accompanied by a roadmap paper reporting on the current status of concrete transformative convergence-building projects associated with that theme. We believe that the insights provided by these papers have the potential to enable all actors throughout society to singly and collectively work to build supply and demand for nutritious food, in both traditional and modern food systems, while placing the burdens of malnutrition and ill health on their core strategic agendas.

Under-five mortality among mothers employed in agriculture: findings from a nationally representative sample

Background. India accounts for 24% to all under-five mortality in the world. Residence in rural area, poverty and low levels of mother’s education are known confounders of under-five mortality. Since two-thirds of India’s population lives in rural areas, mothers employed in agriculture present a particularly vulnerable population in the Indian context and it is imperative that concerns of this sizeable population are addressed in order to achieve MDG4 targets of reducing U5MR to fewer than 41 per 1,000 by 2015. This study was conducted to examine factors associated with under-five mortality among mothers employed in agriculture.

Methods. Data was retrieved from National Family Household Survey-3 in India (2008). The study population is comprised of a national representative sample of single children aged 0 to 59 months and born to mothers aged 15 to 49 years employed in agriculture from all 29 states of India. Univariate and Multivariate Cox PH regression analysis was used to analyse the Hazard Rates of mortality. The predictive power of child mortality among mothers employed in agriculture was assessed by calculating the area under the receiver operating characteristic (ROC) curve.

Results. An increase in mothers’ ages corresponds with a decrease in child mortality. Breastfeeding reduces child mortality by 70% (HR 0.30, 0.25–0.35, p = 0.001). Standard of Living reduces child mortality by 32% with high standard of living (HR 0.68, 0.52–0.89, 0.001) in comparison to low standard of living. Prenatal care (HR 0.40, 0.34–0.48, p = 0.001) and breastfeeding health nutrition education (HR 0.45, 0.31–0.66, p = 0.001) are associated significant factors for child mortality. Birth Order five is a risk factor for mortality (HR 1.49, 1.05–2.10, p = 0.04) in comparison to Birth Order one among women engaged in agriculture while the household size (6–10 members and ≥ 11 members) is significant in reducing child mortality in comparison to ≤5 members in the house. Under-five mortality among mothers employed in agriculture in India discriminated well between death and survival (Area Under ROC was 0.75, 95% CI [0.73–0.77]) indicating that the model is good for appropriate prediction of child mortality.

Conclusion. In a nationally representative sample of households in India, mother’s age, breastfeeding, standard of living, prenatal care and breastfeeding health nutrition education are associated with reduction in child mortality.

Maternal factors contributing to under-five mortality at birth order 1 to 5 in India: a comprehensive multivariate study

The objective of the study is to assess maternal factors contributing to under-five mortality at birth order 1 to 5 in India. Data for this study was derived from the children's record of the 2007 India National Family Health Survey, which is a nationally representative cross-sectional household survey. Data is segregated according to birth order 1 to 5 to assess mother's occupation, Mother's education, child's gender, Mother's age, place of residence, wealth index, mother's anaemia level, prenatal care, assistance at delivery , antenatal care, place of delivery and other maternal factors contributing to under-five mortality. Out of total 51555 births, analysis is restricted to 16567 children of first birth order, 14409 of second birth order, 8318 of third birth order, 5021 of fourth birth order and 3034 of fifth birth order covering 92% of the total births taken place 0-59 months prior to survey. Mother's average age in years for birth orders 1 to 5 are 23.7, 25.8, 27.4, 29 and 31 years, respectively. Most mothers whose children died are Hindu, with no formal education, severely anaemic and working in the agricultural sector. In multivariate logistic models, maternal education, wealth index and breastfeeding are protective factors across all birth orders. In birth order model 1 and 2, mother's occupation is a significant risk factor. In birth order models 2 to 5, previous birth interval of lesser than 24 months is a risk factor. Child's gender is a risk factor in birth order 1 and 5. Information regarding complications in pregnancy and prenatal care act as protective factors in birth order 1, place of delivery and immunization in birth order 2, and child size at birth in birth order 4. Prediction models demonstrate high discrimination that indicates that our models fit the data. The study has policy implications such as enhancing the Information, Education and Communication network for mothers, especially at higher birth orders, in order to reduce under-five mortality. The study emphasises the need of developing interventions to address the issues of anaemia, mothers working in the agricultural sector and improving relevant literacy among mothers.