Unlocking the potential for achievement of the UN Sustainable Development Goal 2 – “Zero Hunger” - in Africa: Targets, strategies, synergies and challenges

Background: The UN Sustainable Development Goal (SDG) 2 (‘Zero Hunger’) aims to end all forms of hunger and malnutrition by 2030. Thus, a range of different strategies are needed to facilitate the achievement of SDG 2 to overcome challenges and enable synergies between various SDG targets. Objective: The aim of this review is to highlight Africa’s progress toward SDG 2, including targets, strategies, synergies and challenges. Methods: We scrutinized published research articles in peer-reviewed journals, UN reports and in-country Africa reports (between 2015 and 2020) that were relevant to the current topic. Results: Several hunger indicators are showing slow progress or even deterioration in Africa. The prevalence of undernourishment in the general population was 19.1% in 2019 and is expected to increase to 25.7% by 2030. Improvements in child stunting in several regions in Africa are slow, especially in sub-Saharan Africa where about 34% of under-fives were stunted in 2012 and 31% in 2019. In Eastern Africa, stunting prevalence decreased from 38% in 2012 to 34% in 2019. Major drivers of hunger are poor governance and state fragility, war and conflicts, increasing inequality, weak economic development, climate change, biodegradation – and now lately the Covid 19 pandemic – factors that all increase food insecurity. Conclusion: Africa is off track to reach SDG – ‘Zero Hunger’ – by 2030. Current efforts and progress are insufficient. Africa must champion the SDG agenda on a national, regional and global level to facilitate synergies to unlock the potential for reaching ‘Zero Hunger’ throughout the continent.publishedVersio

Cognitive development among children in a low-income setting: Cost-effectiveness analysis of a maternal nutrition education intervention in rural Uganda

Inadequate nutrition and insufficient stimulation in early childhood can lead to long-term deficits in cognitive and social development. Evidence for policy and decision-making regarding the cost of delivering nutrition education is lacking in low and middle-income countries (LMIC). In rural Uganda, we conducted a cluster-randomized controlled trial (RCT) examining the effect of a maternal nutrition education intervention on developmental outcomes among children aged 6–8 months. This intervention led to significantly improved cognitive scores when the children reached the age of 20–24 months. When considering the potential for this intervention’s future implementation, the desired effects should be weighed against the increased costs. This study therefore aimed to assess the cost-effectiveness of this education intervention compared with current practice. Health outcome data were based on the RCT. Cost data were initially identified by reviewing publications from the RCT, while more detailed information was obtained by interviewing researchers involved in processing the intervention. This study considered a healthcare provider perspective for an 18-months’ time horizon. The control group was considered as the current practice for the future large-scale implementation of this intervention. A cost-effectiveness analysis was performed, including calculations of incremental cost-effectiveness ratios (ICERs). In addition, uncertainty in the results was characterized using one-way and probabilistic sensitivity analyses. The ICER for the education intervention compared with current practice was USD 16.50 per cognitive composite score gained, with an incremental cost of USD 265.79 and an incremental cognitive composite score of 16.11. The sensitivity analyses indicated the robustness of these results. The ICER was sensitive to changes in cognitive composite score and the cost of personnel. The education intervention can be considered cost-effective compared with the current practice. The outcome of this study, including the cost analysis, health outcome, cost-effectiveness, and sensitivity analysis, can be useful to inform policymakers and stakeholders about effective resource allocation processes in Uganda and possibly other LMIC.publishedVersio

The association of urine markers of iodine intake with development and growth among children in rural Uganda: A secondary analysis of a randomised education trial

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Model selection reveals the butyrate-producing gut bacterium Coprococcus eutactus as predictor for language development in three-year-old rural Ugandan children

Introduction: The metabolic activity of the gut microbiota plays a pivotal role in the gut-brain axis through the effects of bacterial metabolites on brain function and development. In this study we investigated the association of gut microbiota composition with language development of 3-year-old rural Ugandan children. Methods: We studied the language ability in 139 children of 36 months in our controlled maternal education intervention trial to stimulate children’s growth and development. The dataset includes 1170 potential predictors, including anthropometric and cognitive parameters at 24 months, 542 composition parameters of the children’s gut microbiota at 24 months and 621 of these parameters at 36 months. We applied a novel computationally efficient version of the all-subsets regression methodology and identified predictors of language ability of 36-months-old children scored according to the Bayley Scales of Infant and Toddler Development (BSID-III). Results: The best three-term model, selected from more than 266 million models, includes the predictors Coprococcus eutactus at 24 months of age, Bifidobacterium at 36 months of age, and language development at 24 months. The top 20 four-term models, selected from more than 77 billion models, consistently include C. eutactus abundance at 24 months, while 14 of these models include the other two predictors as well. Mann–Whitney U tests suggest that the abundance of gut bacteria in language non-impaired children (n = 78) differs from that in language impaired children (n = 61). While anaerobic butyrate-producers, including C. eutactus, Faecalibacterium prausnitzii, Holdemanella biformis, Roseburia hominis are less abundant, facultative anaerobic bacteria, including Granulicatella elegans, Escherichia/Shigella and Campylobacter coli, are more abundant in language impaired children. The overall predominance of oxygen tolerant species in the gut microbiota was slightly higher in the language impaired group than in the non-impaired group (P = 0.09). Conclusion: Application of the all-subsets regression methodology to microbiota data established a correlation between the relative abundance of the anaerobic butyrate-producing gut bacterium C. eutactus and language development in Ugandan children. We propose that the gut redox potential and the overall bacterial butyrate-producing capacity in the gut are important factors for language development.publishedVersio

Child saliva microbiota and caries: a randomized controlled maternal education trial in rural Uganda

Throne Holst Foundation and the Centre for Global Health at the University of Oslo’s Research ExceLlence and Innovation in Global HealTh (RELIGHT) programmepublishedVersio

Improved child development outcomes in rural Uganda: long-term follow-up of a randomized maternal education trial

Background: Uganda, being a low-and-middle income country, struggles with high stunting (low height-for-age) rates which may result in impaired child development. Although there are several causative factors of child stunting and inadequate development, low nutrient supply, poor hygiene and lack of stimulation, are main promoters. In addition, a dysregulated gut microbiota, inadequate iodine status and maternal depression may play a role. Up until 2013, few if any maternal education intervention studies had been conducted within the framework of a community-based randomized controlled trial (RCT), and long-term follow up studies were not performed. We therefore conducted a cluster-RCT in 2013-14 comprising a six months’ maternal education intervention primarily to reduce child stunting. The study included 511 mother-child pairs and started when the children were 6-8 months. Whereas we found no effects on growth when the children were 20-24 months, several developmental outcomes were markedly improved in the intervention group compared to the controls. Aims: Given these promising data on developmental outcomes we performed a follow-up study when the children were 20-24 and 36 months (current thesis). In addition to assessments of developmental outcomes and growth, we investigated child gut microbiota, iodine status and maternal depression symptoms. Methods: The maternal education in the original trial focused on nutrition, hygiene and stimulation. Anthropometry was measured using WHO-standards whereas development outcomes were assessed with three independent neuropsychological tools. We used 16S rRNA gene sequencing to study gut bacteria whereas a colorimetric method was used to determine urine iodide concentration (a marker of iodine intake). Maternal depression symptoms were self-reported. Results: The intervention significantly improved child development outcomes at 20-24 and at 36 months. Linear growth faltering was significantly less at 36 months in the intervention compared with the control group. The intervention did not lead to any significant changes in gut microbiota or iodine intake, but iodine intake was associated with child cognitive scores. The intervention reduced maternal depression symptoms and this reduction was associated with improved child cognitive- and language development. Conclusion: Our maternal education intervention had long-lasting positive effects on child development and perhaps linear growth. Possible explanations for these findings include adequate iodine intake and reduced maternal depression while gut microbiota was not affected by the intervention. To identify the mechanism(s) underlying the detrimental effects of child undernutrition on growth and development requires multiple approaches including mechanistic studies and well-conducted community-based RCTs

Nutrition, hygiene and stimulation education for impoverished mothers in rural Uganda: Effect on maternal depression symptoms and their associations to child development outcomes

Optimal nutrition improves child development, and impaired development is associated with maternal depression symptoms, in particular in low resource settings. In this follow-up of an open cluster-randomized education trial, we examined its effects among mothers in rural Uganda on their depression symptoms and the association of these symptoms to child development. The education comprised complementary feeding, stimulation, and hygiene. We assessed 77 intervention mothers and 78 controls using Beck Depression Inventory-II (BDI-II) and Center for Epidemiologic Studies Depression Scale (CES-D) scores. Child development was assessed with Bayley Scales of Infant and Toddler Development-III (BSID-III) composite scores for cognitive, language and motor development. Compared to controls, the intervention reduced depression symptoms’ scores with mean (95% CI) differences: −8.26 (−11.49 to −1.13, p = 0.0001) and −6.54; (−8.69 to −2.99, p = 0.004) for BDI II at 20–24 and 36 months, respectively. Similar results were obtained with CES-D. There was a negative association of BDI-II scores and BSID-III cognitive and language scores at 20–24 (p = 0.01 and 0.008, respectively) and 36 months (p = 0.017 and 0.001, respectively). CES-D associations with BSID-III cognitive and language scores showed similar trends. BSID-III motor scores were associated with depression scores at 36 months for both BDI-II and CES-D (p = 0.043 and 0.028, respectively). In conclusion, the group education was associated with reduced maternal depression scores. Moreover, the depression scores were inversely associated with child cognitive and language development outcomes

Nutrition, hygiene and stimulation education for impoverished mothers in rural Uganda: Effect on maternal depression symptoms and their associations to child development outcomes

Optimal nutrition improves child development, and impaired development is associated with maternal depression symptoms, in particular in low resource settings. In this follow-up of an open cluster-randomized education trial, we examined its effects among mothers in rural Uganda on their depression symptoms and the association of these symptoms to child development. The education comprised complementary feeding, stimulation, and hygiene. We assessed 77 intervention mothers and 78 controls using Beck Depression Inventory-II (BDI-II) and Center for Epidemiologic Studies Depression Scale (CES-D) scores. Child development was assessed with Bayley Scales of Infant and Toddler Development-III (BSID-III) composite scores for cognitive, language and motor development. Compared to controls, the intervention reduced depression symptoms’ scores with mean (95% CI) differences: −8.26 (−11.49 to −1.13, p = 0.0001) and −6.54; (−8.69 to −2.99, p = 0.004) for BDI II at 20–24 and 36 months, respectively. Similar results were obtained with CES-D. There was a negative association of BDI-II scores and BSID-III cognitive and language scores at 20–24 (p = 0.01 and 0.008, respectively) and 36 months (p = 0.017 and 0.001, respectively). CES-D associations with BSID-III cognitive and language scores showed similar trends. BSID-III motor scores were associated with depression scores at 36 months for both BDI-II and CES-D (p = 0.043 and 0.028, respectively). In conclusion, the group education was associated with reduced maternal depression scores. Moreover, the depression scores were inversely associated with child cognitive and language development outcomes

Child stunting concurrent with wasting or overweight: A 6-year follow-up of a randomized maternal education trial in Uganda

Objectives There is paucity of longitudinal data on combined anthropometric deficiencies in children. Herein, we present data on child stunting concurrent with wasting or being overweight among children in a 6-y follow-up study of a maternal education trial in rural Uganda. Methods We previously performed a randomized controlled trial where half of 511 mothers of 6- to 8-mo children were given a 6-mo education concerning nutrition, hygiene, and child stimulation. Anthropometry and prevalence of stunting with wasting or being overweight were determined. We applied multilevel mixed-effect logistic regression models and χ2 statistic to assess the effects of the intervention and trend in prevalence over time, respectively. Results Complete data sets were obtained from 307 of 511 children (60%). The prevalence of stunting and wasting or being overweight was <7% both, and did not change significantly over time. Notably, the prevalence of concurrent stunting and being overweight was significantly reduced in the intervention group compared with the controls among children age 36 mo and 60 to 72 mo, with corresponding odds ratios at 0.24 (95% confidence interval, 0.06–0.90) and 0.10 (95% confidence interval, 0.01–0.82), respectively. Conclusions The prevalence of stunting concurrent with wasting or being overweight remained low during the observation period. The intervention may have reduced concurrent stunting and being overweight over time

Longitudinal assessments of child growth: A six-year follow-up of a cluster-randomized maternal education trial

Background & aims Child growth impairments are rampant in sub-Saharan Africa. To combat this important health problem, long-term follow-up studies are needed to examine possible benefits and sustainability of various interventions designed to correct inadequate child growth. Our aim was to perform a follow-up study of children aged 60–72 months whose mothers participated in a two-armed cluster-randomized education intervention trial lasting 6 months in rural Uganda when their children were 6–8 months old with data collection at 20–24 and at 36 months. The education focused on nutrition, hygiene, and child stimulation. Methods We measured growth using anthropometry converted to z-scores according to WHO guidelines. We also included assessments of body composition using bioimpedance. We used multilevel mixed effect linear regression models with maximum likelihood method, unstructured variance-covariance structure, and the cluster as a random effect component to compare data from the intervention (receiving the education and routine health care) with the control group (receiving only routine health care). Results Of the 511 children included in the original trial, data from 166/263 (63%) and 141/248 (57%) of the children in the intervention and control group, respectively, were available for the current follow-up study. We found no significant differences in any anthropometrical z-score between the two study groups at child age of 60–72 months, except that children in the intervention group had lower (P = 0.006) weight-for-height z-score than the controls. There were no significant differences in the trajectories of z-scores or height growth velocity (cm/year) from baseline (start of original trial) to child age of 60–72 months. Neither did we detect any significant difference between the intervention and control group regarding body composition (fat mass, fat free mass, and total body water) at child age 60–72 months. Separate gender analyses had no significant impact on any of the growth or body composition findings. Conclusion In this long-term study of children participating in a randomized maternal education trial, we found no significant impact of the intervention on anthropometrical z-scores, height growth velocity or body composition