Let food be thy medicine:linking local food and health systems to address the full spectrum of malnutrition in low-income and middle-income countries

Hippocrates (fifth century BCE), the father of medicine and namesake of the Oath many medical students swear by to this day, was among the first to recognise the centrality of diet in disease prevention and treatment. In that Oath, the statement, ‘I will apply dietetic measures for the benefit of the sick according to my ability and judgement’, comes before statements about drugs and surgery. Unfortunately, the importance of diet and nutrition in medicine is lost in most discussions of health system reform today, especially in low-income and middle-income countries (LMICs).Moreover, few food system researchers and policymakers consider the myriad opportunities for improving health through forging partnerships between local food, agriculture and health systems.<br/

Diagnosing the performance of food systems to increase accountability toward healthy diets and environmental sustainability

To reorient food systems to ensure they deliver healthy diets that protect against multiple forms of malnutrition and diet-related disease and safeguard the environment, ecosystems, and natural resources, there is a need for better governance and accountability. However, decision-makers are often in the dark on how to navigate their food systems to achieve these multiple outcomes. Even where there is sufficient data to describe various elements, drivers, and outcomes of food systems, there is a lack of tools to assess how food systems are performing. This paper presents a diagnostic methodology for 39 indicators representing food supply, food environments, nutrition outcomes, and environmental outcomes that offer cutoffs to assess performance of national food systems. For each indicator, thresholds are presented for unlikely, potential, or likely challenge areas. This information can be used to generate actions and decisions on where and how to intervene in food systems to improve human and planetary health. A global assessment and two country case studies—Greece and Tanzania—illustrate how the diagnostics could spur decision options available to countries

The importance of food systems and the environment for nutrition

Global and local food system transformation is necessary in order to ensure the delivery of healthy, safe, and nutritious foods in both sustainable and equitable ways. Food systems are complex entities that affect diets, human health, and a range of other outcomes including economic growth, natural resource and environmental resiliency, and sociocultural factors. However, food systems contribute to and are vulnerable to ongoing climate and environmental changes that threaten their sustainability. Although there has been increased focus on this topic in recent years, many gaps in our knowledge persist on the relation between environmental factors, food systems, and nutritional outcomes. In this article, we summarize this emerging field and describe what innovative nutrition research is needed in order to bring about food policy changes in the era of climate disruption and environmental degradation. Am J Clin Nutr 2020;00:1–10

You Say You Want a Data Revolution? Taking on Food Systems Accountability

Dramatic improvements in data availability and quality are needed to meet the challenge of monitoring and analyzing food systems, so that appropriate policies and actions to improve human and planetary health can be identified and data-informed accountability mechanisms put in place to strengthen food systems governance. Studying food systems is complex due to diverse actors and interlinking processes that operate on multiple spatial and temporal scales, and their multiple outcomes, which may be subject to hidden feedback mechanisms and tradeoffs. However, descriptive research to characterize food system components and make comparisons across geography, income groups, and population groups is an important foundation. The first part of this article details a series of critical data gaps and limitations that are currently hindering food systems learning and accountability, also comparing these gaps across regions and income groups. The second part of the article introduces the Food Systems Dashboard, a new data visualization tool that aims to improve access to and usage of food systems-related data, thus strengthening the data value chain and better informing policies and actions intended to improve diets, nutrition, livelihoods, and environmental sustainability

Micronutrient Deficiencies among Breastfeeding Infants in Tanzania

Infant mortality accounts for the majority of child deaths in Tanzania, and malnutrition is an important underlying cause. The objectives of this cross-sectional study were to describe the micronutrient status of infants in Tanzania and assess predictors of infant micronutrient deficiency. We analyzed serum vitamin D, vitamin B12, folate, and ferritin levels from 446 infants at two weeks of age, 408 infants at three months of age, and 427 mothers three months post-partum. We used log-Poisson regression to estimate relative risk of being deficient in vitamin D and vitamin B12 for infants in each age group. The prevalence of vitamin D and vitamin B12 deficiency decreased from 60% and 30% at two weeks to 9% and 13% at three months respectively. Yet, the prevalence of insufficiency at three months was 49% for vitamin D and 17% for vitamin B12. Predictors of infant vitamin D deficiency were low birthweight, urban residence, maternal education, and maternal vitamin D status. Maternal vitamin B12 status was the main predictor for infant vitamin B12 deficiency. The majority of infants had sufficient levels of folate or ferritin. Further research is necessary to examine the potential benefits of improving infants' nutritional status through vitamin D and B12 supplements.</p

Home gardening improves dietary diversity, a cluster-randomized controlled trial among Tanzanian women

Homestead food production (HFP) programmes improve the availability of vegetables by providing training in growing nutrient-dense crops. In rural Tanzania, most foods consumed are carbohydrate-rich staples with low micronutrient concentrations. This cluster-randomized controlled trial investigated whether women growing home gardens have higher dietary diversity, household food security or probability of consuming nutrient-rich food groups than women in a control group. We enrolled 1,006 women of reproductive age in 10 villages in Pwani Region in eastern Tanzania, split between intervention (INT) and control (CON) groups. INT received (a) agricultural training and inputs to promote HFP and dietary diversity and (b) nutrition and public health counselling from agricultural extension workers and community health workers. CON received standard services provided by agriculture and health workers. Results were analysed using linear regression models with propensity weighting adjusting for individual-level confounders and differential loss to follow up. Women in INT consumed 0.50 (95% CI [0.20, 0.80], p = 0.001) more food groups per day than women in CON. Women in INT were also 14 percentage points (95% CI [6, 22], p = 0.001) more likely to consume at least five food groups per day, and INT households were 6 percentage points (95% CI [-13, 0], p = 0.059) less likely to experience moderate-to-severe food insecurity compared with CON. This home gardening intervention had positive effects on diet quality and food security after 1 year. Future research should explore whether impact is sustained over time as well as the effects of home garden interventions on additional measures of nutritional status.</p

Life expectancy and agricultural environmental impacts in Addis Ababa can be improved through optimized plant and animal protein consumption

In Ethiopia, children and adults face a double burden of malnutrition, with undernutrition and stunting coexisting with non-communicable diseases. Here we use a framework of comparative risk assessment, local dietary surveys and relative risks from large observational studies to quantify the health and environmental impacts of meeting adult and child recommended daily protein intakes in urban Addis Ababa. We find that plant-based foods, especially legumes, would have the lowest environmental impact and substantially increase life expectancy in adults, while animal-source proteins could be beneficial for children. This context-specific approach—accounting for regional constraints and trade-offs—could aid policymakers in developing culturally appropriate, nutritionally adequate and sustainable dietary recommendations

Women's input and decision-making in agriculture are associated with diet quality in rural Tanzania

BackgroundWomen's empowerment is one critical pathway through which agriculture can impact women's nutrition; however, empirical evidence is still limited. We evaluated the associations of women's participation, input, and decision-making in key agricultural and household activities with women's diet quality.MethodsWe analyzed data from a cross-sectional study of 870 women engaged in homestead agriculture. We used food frequency questionnaires to assess women's diets and computed women's diet quality using the Prime Diet Quality Score (PDQS) (range 0–42), which captures healthy and unhealthy foods. We evaluated women's decision-making in 8 activities, food crop farming, cash crop farming, livestock raising, non-farm economic activities, wage/salary employment, fishing, major household expenditures, and minor household expenditures. Generalized estimating equations (GEE) linear models were used to evaluate associations between (a) women's participation, (b) decision-making, (c) adequate input, (d) adequate extent of independence in decision-making in agriculture, and (e) adequate input in use of agricultural income with their PDQS. Adequate input was defined as input into some, most or all decisions compared to input into few decisions or none. Adequate extent of independence was defined as input to a medium or high extent compared to input to a small extent or none.FindingsMedian PDQS was 19 (IQR: 16–21). Women's adequate input in decision-making on wage and salary employment (estimate: 4.19, 95% CI: 2.80, 5.57) and minor expenditures were associated with higher PDQS vs. inadequate input. Women with independence in decision-making on livestock production (estimate: 0.97, 95% CI: 0.05, 1.90) and minor household expenditures, and women with adequate decision-making in the use of income from wages/salaries (estimate: 3.16, 95% CI: 2.44, 3.87) had higher PDQS. Participation in agricultural activities was positively associated with PDQS.ConclusionsWomen's participation and input in decision-making in wage and salary employment, livestock production, and minor household expenditures were strongly associated with the consumption of better-quality diets. Women participating in multiple farm activities were also likely to have better diet quality. This study adds to the growing evidence on the pathways through which women's empowerment may influence women's nutrition in rural Tanzania

Characterizing the food environment and its relationship with dietary intake and nutritional status of women in rural Bangladesh

Background The double burden of malnutrition in many low- and middle- income countries (LMICs) is driven by the nutrition transition. The food environment has been identified as a common driver for the double burden of malnutrition and also a critical point of intervention. Few studies have assessed food environments in a rural context, where undernutrition is still a predominant concern. Objectives The goal of this dissertation is to describe how the food environment has changed over time, the relationship between food environment and diet quality, and risk factors for both under and overnutrition among women in rural Bangladesh. Methods This dissertation utilizes household, maternal, and geospatial data from four randomized controlled trials conducted from 2004–2020 at the JiVitA Research Site in the Gaibandha District of Bangladesh. We characterized the food environment using geospatial measures of food vendor availability and accessibility. Availability was defined as number of food vendors within a specified radius and accessibility was defined as distance to the nearest food vendor. We calculated three measures of diet quality: food variety scores, dietary diversity scores, and less healthy food consumption. Nutritional status was defined at 6 months postpartum using standard cut-offs of body mass index (BMI). We used linear and Poisson models to estimate the association between community-level urbanicity and accessibility and availability of food vendors. To assess the association between food environment indicators and diet quality, we fit linear regression models for food variety score outcomes, Poisson regression models for dietary diversity outcomes, and logistic regression models for individual food group outcomes. We ran multivariable multinomial logistic regression models to identify risk factors for underweight and overweight/obesity in this population. Results The number of markets increased by 21%, while variety stores and tea shops increased by 66% and 270%, respectively. Households in more urban areas had higher food vendor access and availability. Women who lived in households with the highest market availability had an average of 0.84-unit (95% CI: 0.53, 1.16) higher food variety score compared to women who lived in households with lowest market availability (p<0.001). The prevalence of underweight and overweight/obesity exhibited clustering among neighboring communities. Women in the highest SES quintile were 50% (95% CI: 0.35-0.71) less likely to be classified as underweight (p<0.001) while 2.3 (95% CI:1.66, 3.24) times more likely to be classified as overweight/obese compared to women in lowest SES quintile (p<0.001). Women who lived in households with highest market density had a 28% reduction in risk of being classified as underweight. For overweight/obesity, women in the top quartile for food variety scores were 1.39 (95% CI: 1.05, 1.84) times more likely to classified as overweight/obese compared to women in the lowest quartile. Conclusions In rural Bangladesh, food environments are rapidly transforming. Increased market availability was associated with increased diet quality and decreased risk of underweight. These findings highlight the importance of the food environment as a critical point of intervention to prevent all forms of malnutrition