Energy and nutrient production in Ethiopia, 2011-2015: Implications to supporting healthy diets and food systems

Nutrition profiles of farm households across different farming systems in Ethiopia: Unpacking the determinants and implications for nutrition-sensitive interventions

Tackling nutrition insecurity remains a critical challenge in developing countries. In the predominantly rain-fed and smallholder-based farming systems of Ethiopia, production diversity and livelihood strategies of the farm households vary across geographic areas. However, the effects of household socioeconomic characteristics, production diversity, and household incomes on nutrition profiles in distinct settings have been inadequately understood. Therefore, this study was undertaken to examine the association of farming system type, sources of income, and household wealth status with household nutrition profiles in three remote locations such as Mennisa, Welmel Tiqa, and Agam Wuha that represent root crops-based farming, maize-based semi-pastoral farming, and teff-based cereal farming systems, respectively. A combination of qualitative and quantitative data collection techniques was employed. A multistage sampling procedure was used to select a total of 265 smallholder households for the structured survey interviews. Standard statistical tests and Tobit regression analyses were performed after determining the wealth category of each household. Results revealed a diversity of income sources used by each of the farm households with average values of 9 in Mennisa, 10 in Agam Wuha, and 11 in Welmel Tiqa, with the contributions of each income source varying by household wealth category and location. As expected, expenditures on food significantly exceeded those on non-food categories for poor households and vice versa for rich wealth households. The average total food variety score (FVS) for Welmel Tiqa was twice that for Agam Wuha, confirming the need for site-specific nutrition profile assessments. Despite the observed differences in household nutrition profiles among wealth categories and locations, the apparent intakes of vitamin A, vitamin B12, vitamin D, and calcium were consistently below the population-level estimated average requirements across all locations. The number of adequately consumed nutrients by farm households was negatively associated with family size, age of household heads, livestock holdings, wealth categories, and irrigation use, and positively associated with crop production diversity, income diversity, and FVS. The negative association between irrigation use and nutrition security was likely due to the focus on producing crops with a high market value on land under irrigation, coupled with ineffective allocation of generated income for enhancing household nutritional outcomes. Therefore, programs that include irrigated agriculture investments should consider adopting a more integrated nutrition-sensitive interventions, including consideration of locally adapted nutritious crops, such as orange-flesh sweet potato, to address critical deficiency of Vitamin A, nutrition training coupled with development of recipes and cooking demonstrations, and marketing and promotion for nutritious crops.

Complementary feeding and food-group level inequality among Ethiopian children 6-23 months of age (2011-2019)

Ensuring diet quality in the first 2 years of life is critical to preventing malnutrition and instilling healthy food preferences. Children's diet quality has changed little over time and inequalities by socioeconomic status, rural-urban residence, but also by food group may exist. Using data from the 2011, 2016 and 2019 demographic and health surveys (DHS), we estimated the prevalence and inequalities in the minimum diet diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD). We further assessed food group-level inequities. In 2019, only 13.5% of children 6-23 months of age met the MDD, 55% met the MMF and only 11% met the MAD indicator. Absolute and relative measures of inequality were calculated. Modest increases in MDD, MMF and MAD were observed over the past decade (2011-2019). These modest improvements were concentrated in limited geographical areas, among children in wealthier households, and urban residents. Unhealthy practices such as bottle-feeding and zero fruit and vegetables have been increasing; whereas, inequities in the consumption of nutrient-dense foods have widened. Nevertheless, children from the wealthiest quintile also failed to meet the MDD. Multisectoral efforts that span from diversifying the food supply, regulating the marketing of unhealthy foods, and promoting minimal processing of perishables (i.e., to extend shelf-life) are needed. Context-adapted behavioural change communication along with nutrition-sensitive social protection schemes are also needed to equitably improve the diet quality of children in Ethiopia.

Production Choices and Food Security: A Review of Studies Based on a Micro-Diversity Perspective

Given the 'subsistence' character of smallholder production, agricultural production diversification is often seen as an effective strategy for smallholders to improve their diets' diversity and nutritional status, yet the existing evidence remains inadequate. The study applies bibliometric data from the "Web of Science" database to synthesize 46 papers from developing countries to explore the relationship between production diversity, dietary diversity, and nutrition in smallholder households. The study identifies the most influential journals, authors, organizations, and countries and reveals research themes related to agricultural production and food security. This data analysis can help researchers target potential collaborators and access influential literature in agricultural production diversity and dietary diversity research. In addition, the results showed that agricultural production diversity potentially influences households' dietary diversity, with mixed results: Agricultural production diversification is the primary way to improve food and nutritional security among smallholder families with low socio-economic status, inaccessible transportation, and poverty; market access and trade have more potential to improve dietary diversity among smallholder households with well-developed markets and higher income levels; the significant measures of agricultural production diversity include Crop Counts, FGPD, SI, and SWDI; the significant measures of dietary diversity include HDDS and IDDS. This paper provides a roadmap for agricultural production and food security researchers by conducting a systematic review of the literature, summarizing some research methods and perspectives applicable to local socio-economic development.

Examining energy and nutrient production across the different agroecological zones in rural Ethiopia using statistical methods

Poor-quality diets are of huge concern in areas where consumption is dominated by locally sourced foods that provide inadequate nutrients. In agroecologically diverse countries like Ethiopia, food production is also likely to vary spatially. Yet, little is known about how nutrient production varies by agroecology. Our study looked at the adequacy of essential nutrients from local production in the midland, highland, and upper highland agroecological zones (AEZs). Data were collected at the village level from the kebele agriculture office and at the farm and household levels through surveys in rural districts of the South Wollo zone, Ethiopia. Household data were acquired from 478 households, and crop samples were collected from 120 plots during the 2020 production year. Annual crop and livestock production across the three AEZs was converted into energy and nutrient supply using locally developed crops' energy and nutrient composition data. The total produced energy (kcal) met significant proportions of per capita energy demand in the highland and upper highland, while the supply had a 50% energy deficit in the midland. Shortfalls in per capita vitamin A supply decreased across the agroecological gradient from midland (46%) to upper highland (31%). The estimated shortfall in folate supply was significantly higher in the upper highlands (63%) and negligible in the highlands (2%). The risk of deficient iron and zinc supply was relatively low across all AEZs (<10%), but the deficiency risk of calcium was unacceptably high. Agroecology determines the choice of crop produced and, in this way, affects the available supply of energy and nutrients. Therefore, agroecological variations should be a key consideration when designing food system interventions dedicated to improving diets.

The feasibility of implementing food-based dietary guidelines and food graphics in Ethiopia

This study aimed to test the acceptability, cultural appropriateness, consumers' understanding, and practicality of the Ethiopian food-based dietary guideline's messages, tips, and food graphics. A qualitative study design was applied with focus group discussions and key informant interviews. Four different participant groups were included: 40 consumers, 15 high-level nutrition experts, 30 frontline community health extension workers (HEWs), and 15 agriculture extension workers (AEWs) to incorporate different stakeholder perspectives. Data collection was conducted using 7 focus group discussions (FGDs) and 30 key informant interviews (KIIs). Collected data were coded and analyzed using QSR International NVivo V.11 software. Most of the study participants were highly interested in implementing the dietary guidelines once these guidelines are officially released. Based on the participants' views, most of the messages align with the current nutrition education materials implemented in the country except the messages about physical activity and alcohol intake. However, participants suggested defining technical terms such as ultra-processing, whole grain, safe and balanced diet in simpler terms for a better understanding. Practicality, affordability, availability, and access to the market were the major barriers reported for adherence to the guidelines. To be more inclusive of cultural and religious beliefs, findings show that the guideline should address fasting and traditional cooking methods. In conclusion, the dietary guidelines were well received by most stakeholders. They are thought to be feasible once feedback on wording, affordability, availability, and access is considered in the messages, tips, and graphic designs.

Benchmarking policy goals and actions for healthy food environments in Ethiopia to prevent malnutrition in all its forms using document analysis

OBJECTIVE

Unhealthy diets resulting in overweight and obesity and diet-related non-communicable diseases are of increasing concern in Ethiopia, alongside persistent undernutrition, and have been linked to unhealthy food environments. Little is known about the policy response to unhealthy food environments in Ethiopia. The objective of this study was to assess how different food environment domains have been addressed in Ethiopian policy goals and action over time and how this compares with global good practice benchmarks.

SETTING

Ethiopia.

PRIMARY AND SECONDARY OUTCOME MEASURES

We analysed intentions and plans of the government to act, using policy documents (outputs of decision-making in the form of published strategies, plans or policies) related to improving diets and nutritional status through healthy food environments in Ethiopia between 2008 and 2020. Our coding framework was guided by the policy component (n=7 domains) of the Healthy Food-Environment Policy Index, which was modified to include food quality and safety as an eighth domain.

RESULTS

From the 127 policy outputs identified, 38 were retained, published by 9 different government ministries and institutions. Our results show that eight food environment domains have been addressed to some extent, but gaps remain compared with global best practice, especially in food promotion, processing, retail, price and trade. From 2018, policy began to embrace the wider food system, with more explicit food environment interventions becoming apparent.

CONCLUSIONS

Policy efforts achieved in food safety, food processing, marketing and labelling are important stepping stones to building future policy actions addressing the food environment domains of food retail, food provision and food trade. Benchmarking of food environment policy actions should also consider actions on food fortification, agro-processing and informal markets in the context of multiple forms of malnutrition.

Dietary diversity and associated factors among preschool children in selected kindergarten school of Horo Guduru Wollega Zone, Oromia Region, Ethiopia

BACKGROUND

Preschool children are the most vulnerable group because of their high nutritional needs for growth and development. The study assessed dietary diversity scores and associated factors among preschool children in selected kindergarten schools of Horo Guduru Wollega Zone, Western Ethiopia.

METHODS

The institutional-based cross-sectional study design was conducted on a total 440 of preschool children. A semi-structured questionnaire was used to collect information on the dietary diversity score of preschool children using a 24 h dietary recall method. Binary logistic regression was used to identify variables associated with dietary diversity scores of preschool children.

RESULTS

The result showed that the majority (87.3%) of preschool children in the selected kindergarten school practiced a low dietary diversity score (less than four food groups). The result obtained from multivariate logistic regression analysis indicated that the age of preschool children [AOR 9.58(2.26-40.60)], sex of child [AOR 3.21(1.71-5.99)], and work of mother [AOR 7.49(2.33-24.07)] were significantly (p < 0.05 associated) with dietary diversity of children.

CONCLUSIONS

The findings indicated that many preschool children in the study area did not get a minimum dietary diversity score. Therefore, health extension workers must organize community-based behavior change nutritional education for mothers or caregivers to create awareness of preschool child dietary diversity practices.

Food biodiversity: Quantifying the unquantifiable in human diets

Dietary diversity is an established public health principle, and its measurement is essential for studies of diet quality and food security. However, conventional between food group scores fail to capture the nutritional variability and ecosystem services delivered by dietary richness and dissimilarity within food groups, or the relative distribution (i.e., evenness or moderation) of e.g., species or varieties across whole diets. Summarizing food biodiversity in an all-encompassing index is problematic. Therefore, various diversity indices have been proposed in ecology, yet these require methodological adaption for integration in dietary assessments. In this narrative review, we summarize the key conceptual issues underlying the measurement of food biodiversity at an edible species level, assess the ecological diversity indices previously applied to food consumption and food supply data, discuss their relative suitability, and potential amendments for use in (quantitative) dietary intake studies. Ecological diversity indices are often used without justification through the lens of nutrition. To illustrate: (i) dietary species richness fails to account for the distribution of foods across the diet or their functional traits; (ii) evenness indices, such as the Gini-Simpson index, require widely accepted relative abundance units (e.g., kcal, g, cups) and evidence-based moderation weighting factors; and (iii) functional dissimilarity indices are constructed based on an arbitrary selection of distance measures, cutoff criteria, and number of phylogenetic, nutritional, and morphological traits. Disregard for these limitations can lead to counterintuitive results and ambiguous or incorrect conclusions about the food biodiversity within diets or food systems. To ensure comparability and robustness of future research, we advocate food biodiversity indices that: (i) satisfy key axioms; (ii) can be extended to account for disparity between edible species; and (iii) are used in combination, rather than in isolation.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2022.2051163 .

Predictors of wasting among children under-five years in largely food insecure area of north Wollo, Ethiopia: a cross-sectional study

Child undernutrition is widespread in low- and middle-income countries and is linked with weakened immunity and increased risks of morbidity and mortality. Ethiopia has made a marked reduction in stunting, but there has, however, been little progress in wasting reduction and limited evidence in food insecure areas may hamper the design of effective interventions. Therefore, the aim of the present study was to determine the contributing factors to persistent high prevalence of wasting among 6-59-month-old children. A community-based cross-sectional study was employed in February to March 2020, and included 384 mother-child pairs. Data were collected using a structured interviewer-administered questionnaire. Bivariate and multivariable logistic regression analyses were conducted. The overall prevalence of wasting was 12⋅8 % (95 % CI 9⋅1, 16⋅1); with 5⋅8 % severely wasted. Factors significantly associated with wasting were child age 6-23 (v. 24-59 months), delayed initiation of breast-feeding, diarrhoeal illness in the last 2 weeks, poor dietary diversity and low socioeconomic status. The present findings support that aligning poverty reduction interventions and healthcare services is important to accelerate wasting reduction more equitably and achieve the World Health Assembly's target and SDG goal #2 in the coming years. Improving accessibility and affordability of nutritious foods and early diagnosis and treatment of childhood morbidity are critical to address childhood wasting in the context of food insecure areas.

Spatial farming systems diversity and micronutrient intakes of rural children in Ethiopia

Own production contributes much of the food supply in smallholder production systems in low- and middle-income countries like Ethiopia. Understanding the potential as well as constraints of these production systems in terms of nutrient supplies is thus a critical step to design interventions to improve nutrient intakes. The objectives of this study were (1) to assess the usual total intakes of vitamin A, iron and zinc among rural children and (2) to investigate whether the intakes these nutrients are associated with differences in the dominant farming systems between spatial clusters. Using nationally representative intake data of 4,902 children 6-35 months of age, usual intake and the proportion of inadequate intakes of vitamin A, iron and zinc were calculated. A multi-level model was used to examine the association between individual-level and cluster-level variables with the usual total dietary intakes of these nutrients. The diet was dominated by starchy foods. Consumption of animal source foods, vitamin A-rich fruits and vegetables was low. We found a high prevalence of inadequate intake of vitamin A and zinc (85.4% and 49.5%, respectively). Relatively, low prevalence of inadequate intake of iron (8.4%) was reported. The spatial farming systems diversity across the rural clusters explained 48.2%, 57.2% and 26.7% of the observed variation in the usual total dietary intakes of vitamin A, iron and zinc, respectively. Our findings indicated the importance of farming system diversity at the landscape level as one of the determinant factors for individual usual total dietary intakes of vitamin A, iron and zinc.

Optimization of nutritional and sensory qualities of complementary foods prepared from sorghum, soybean, karkade and premix in Benishangul - Gumuz region, Ethiopia

Consumption of nutritionally deficient complementary foods in developing countries is among the main contributing factors to infants and young children's malnutrition. Therefore, this study was aimed to optimize the nutritional and sensory properties of complementary food made from malted sorghum, blanched soybean, boiled karkade seeds and premix. A D-optimal mixture experimental design with 18 runs was generated by design expert software within in the constrained: 40-60% malted sorghum, 20-30% blanched soybean, 10-20% boiled karkade seeds and 10% premix (5.0% figl leaf powder, 4.5% sugar and 0.5% iodized table salt). Statistical model evaluation and optimization were done using D-optimal mixture design expert software. Sensory evaluation was conducted using 53 untrained panelists on two selected formulations and the control (local formulation). The study shows that with an increasing ratio of blanched soybean and boiled karkade seeds flour in the blend, a significant (p < 0.05) increase in protein, fat, energy and mineral contents, and a decrease in tannin and phytic acid contents of high mineral bioavailability except for oxalate: calcium ratio in the formulations were observed. The optimal blending ratio was 45.0% malted sorghum, 26.0% blanched soybean, and 19.0% boiled karkade seeds flour plus 10.0% premix. The gruel made from the new formula was significantly (p < 0.05) liked in terms of aroma, flavor, mouthfeel and overall acceptability than the control sample. The findings suggested that the optimal mix of these traditionally processed ingredients can potentially alleviate protein-energy malnutrition and micronutrient deficiency to mitigate expensive commercial infant complementary foods sold in the market.

Effects of different drying methods and ascorbic acid pretreatment on carotenoids and polyphenols of papaya fruit in Ethiopia

Frequent consumption of fruits can prevent nutrient deficiencies and promote health. However, the perishability and unaffordability of fruits had led to very low levels of fruit consumption in low- and middle-income countries (LMICs). The objective of this study was to evaluate the retention of nutrients and bioactive compounds of papaya fruit (Carica papaya L) with/without ascorbic acid pretreatment and drying under different techniques, to then estimate the vitamin A intakes for vulnerable population. Yellow pulp ripped papaya fruits (i.e., >75% level of skin color/stage level 4) (n = 14), with and without ascorbic acid pretreatment were dried using (a) solar drying: open-air, tray driers, and glasshouse; (b) refractance window drying; (c) oven drying; and (d) freeze-drying (control). The fresh fruit had high moisture content (87%) and an acidic pH. The dried papaya had a water activity of 0.5-0.6. The highest TPC, TFC, total carotenoids, and ß-carotene were found in freeze-dried papaya samples, followed by refractance window, and solar glass house (p < .05). The highest retention in total carotenoids (81.5%) and ß-carotene (61.9%) relative to freeze-drying was for the refractance-window; 25 g of dried papaya could contribute to 38% of the retinol equivalents' requirement for young children. Ascorbic acid pretreatment increased the retention of total carotenoids, ß-carotene, TPC, and TFC (p < .05) by (6-11)%, (8-34)%, (7-58)%, and (6-30)%, respectively, for all the drying methods. Refractance window and solar glass house drying can improve diets and constitute a promising food systems' intervention that can increase year-round availability, accessibility, and affordability of vitamin A-rich fruits like papaya.

Behavioural insights to support increased consumption of quality protein maize by young children: a cluster randomised trial in Ethiopia

Introduction

Biofortified crops have tremendous potential to improve child nutrition. We tested whether complementing the distribution of quality protein maize (QPM) with a package of interventions informed by behavioural insights could support greater consumption of QPM by young children and translate into improved growth.

Methods

We conducted a cluster-randomised trial in Oromia, Ethiopia. Clusters of households with a child between 6 and 35 months were randomised into an arm receiving QPM seed only (320 households, 203 clusters) or an arm receiving QPM seed and a child consumption targeting intervention (290 households, 183 clusters). The intervention package included tools to help caregivers keep QPM separate from conventional maize and to earmark QPM specifically for child consumption, as well as encouragement regarding cooking QPM specifically for young children. We analysed the impact of the intervention on food storage, cooking and consumption behaviours and on anthropometric measures (weight-for-age, height-for-age z scores).

Results

The consumption targeting intervention increased the probability of child consumption of QPM in the past week by 17.3 percentage points (pp) (95% CI 9.4 pp to 25.1 pp; p<0.01), increased the probability that QPM flour was stored separately from conventional maize by 46.5 pp (95% CI 38.3 pp to 54.7 pp; p<0.01) and increased the probability that caregivers cooked QPM specifically for young children in the past week by 14.4 pp (95% CI 7.9 pp to 20.9 pp; p<0.01). These effects persisted, but were attenuated, 10 months postintervention. No significant effects on anthropometric outcomes were found.

Conclusions

Enhancing the distribution of new, biofortified crop varieties with a consumption targeting campaign can change storage, cooking and consumption behaviours. However, these improved behaviours did not translate into increased growth in this setting.

Trial registration number

NCT02710760 and AEARCTR0000786.

The Social Stratification of Availability, Affordability, and Consumption of Food in Families with Preschoolers in Addis Ababa; The EAT Addis Study in Ethiopia

The aim of this study was to understand the quality of diet being consumed among families in Addis Ababa, and to what extent social stratification and perceptions of availability and affordability affect healthy food consumption. Data were collected from 5467 households in a face-to-face interview with mothers/caretakers and analyzed using mixed effect logistic regression models. All family food groups, except fish were perceived to be available by more than 90% of the participants. The food groups cereals/nuts/seeds, other vegetables, and legumes were considered highly affordable (80%) and were the most consumed (>75%). Households with the least educated mothers and those in the lowest wealth quintile had the lowest perception of affordability and also consumption. Consumption of foods rich in micronutrients and animal sources were significantly higher among households with higher perceived affordability, the highest wealth quintile, and with mothers who had better education. Households in Addis Ababa were generally seen to have a monotonous diet, despite the high perceived availability of different food groups within the food environment. There is a considerable difference in consumption of nutrient-rich foods across social strata, hence the cities food policies need to account for social differences in order to improve the nutritional status of the community.

Socio-Economic Inequalities in Child Stunting Reduction in Sub-Saharan Africa

Stunting in children less than five years of age is widespread in Sub-Saharan Africa. We aimed to: (i) evaluate how the prevalence of stunting has changed by socio-economic status and rural/urban residence, and (ii) assess inequalities in children's diet quality and access to maternal and child health care. We used data from nationally representative demographic and health- and multiple indicator cluster-surveys (DHS and MICS) to disaggregate the stunting prevalence by wealth quintile and rural/urban residence. The composite coverage index (CCI) reflecting weighed coverage of eight preventive and curative Reproductive, Maternal, Neonatal, and Child Health (RMNCH) interventions was used as a proxy for access to health care, and Minimum Dietary Diversity Score (MDDS) was used as a proxy for child diet quality. Stunting significantly decreased over the past decade, and reductions were faster for the most disadvantaged groups (rural and poorest wealth quintile), but in only 50% of the countries studied. Progress in reducing stunting has not been accompanied by improved equity as inequalities in MDDS (p < 0.01) and CCI (p < 0.001) persist by wealth quintile and rural-urban residence. Aligning food- and health-systems' interventions is needed to accelerate stunting reduction more equitably.

Prioritizing the Scale-Up of Evidence-Based Nutrition and Health Interventions to Accelerate Stunting Reduction in Ethiopia

Despite some progress, stunting prevalence in many African countries including Ethiopia remains unacceptably high. This study aimed to identify key interventions that, if implemented at scale through the health sector in Ethiopia, can avert the highest number of stunting cases. Using the Lives Saved Tool (LiST), the number of stunting cases that would have been averted, if proven interventions were scaled-up to the highest wealth quintile or to an aspirational 90% coverage was considered. Stunting prevalence was highest among rural residents and households in the poorest wealth quintile. Coverage of breastfeeding promotion and vitamin A supplementation were relatively high (>50%), whereas interventions targeting women were limited in number and had particularly low coverage. Universal coverage (90%) of optimal complementary feeding, preventive zinc supplementation, and water connection in homes could have each averted 380,000-500,000 cases of stunting. Increasing coverage of water connection to homes to the level of the wealthiest quintile could have averted an estimated 168,000 cases of stunting. Increasing coverage of optimal complementary feeding, preventive zinc supplementation, and Water, Sanitation and Hygiene (WASH) services is critical. Innovations in program delivery and health systems governance are required to effectively reach women, remote areas, rural communities, and the poorest proportion of the population to accelerate stunting reduction.