From policy to action in the fight against malnutrition

Malnutrition is often viewed as purely a health issue, but it has far wider implications. By affecting the growth and cognitive function of individuals, it has social, developmental and broader economic impacts.

Dr Taddese Zerfu encountered cases of malnutrition regularly during his time as a clinician, public health official and nutrition specialist in East Africa. He also has a policy interest, as he was an adviser to a federal minister in Ethiopia.

He is especially interested in nutrition during the ‘first 1000 days’, from conception to two years – a “critical window of opportunity” to ensure children do not suffer malnutrition and all its subsequent negative impacts, and a chance to break the intergenerational malnutrition cycle .

Dr Zerfu wanted to research the impact of children’s intake of animal source foods such as meat, milk, eggs and cheese. The consumption of diverse diets, particularly including nutrient-rich animal source foods, is essential to meet childrens nutritional requirements and protect against stunting and wasting.

One particular issue puzzled him; many families kept cattle, but often chose not to feed children regularly with meat, milk and cheese.

To find out why, Dr Zerfu is combining a range of disciplines in his research, notably agriculture, health and nutrition. Large secondary data sets from the three countries of his study – Ethiopia, Kenya and Uganda – will be crucial to underpinning his research as a Marie Curie Fellow. His work is supported by the European Union Horizon 2020 fund, the Data-Driven Innovation initiative in Edinburgh and industry partner, the International Livestock Research Institute.

The large, national data sets from the three countries will be supported by primary data gathered in the field to find out, very directly, why people might be making decisions not to feed animal source foods to their children – using innovative data-gathering methods like PhotoVoice.

“During my earlier research, I found an interesting link between eating chicken and a lower incidence of anaemia,” says Dr Zerfu. “My interest in linking agriculture, nutrition and health has mounted over the years and led me to this latest work. There are very few professionals in our region working in this multidisciplinary way. It is important to do this because the three areas are so inter-linked.

“In eastern Africa, we have a lot of cattle, but the intake of animal source foods is very low, which is one main reason why we have very high rates of malnutrition. Iron and zinc deficiency is very common in sub-Saharan Africa and is linked to a lack of animal source foods.

“What I wanted to know is why the cattle are not being used to give milk, cheese and meat to children – the link between the availability of these foods and the actual intake.”

Dr Zerfu is looking at large national (and regional) data sets from all three countries to understand more about that link between availability and intake, especially in vulnerable population groups. His focus is on low income areas of the three countries.

“In some communities, you see that the intake of animal source foods is better – but in others, it is very low, and there is very little evidence of what links availability and intake,” he says.

The impacts can be very severe. In northern Ethiopia, for example, Zerfu says almost half of all children (46%) suffer from stunting. “They are shorter than they should be for their age, and this is associated with poor cognitive and social development as they grow older,” he explains.

“I am looking at the large data sets to try to understand what are the social and demographic variables to the ownership of cattle, and both the availability and intake of animal source foods. What policies can we devise to help children?

“Making this link and identifying policy actions could be a magic bullet to tackle intergenerational malnutrition – but we lack knowledge and evidence. That’s why I am using data to examine this.”

Dr Zerfu’s research is very relevant to the UN Sustainable Development Goals, and especially Goal 2, which aims to achieve “zero hunger”. The official wording is: “End hunger, achieve food security and improved nutrition and promote sustainable agriculture”.

Half of child deaths in sub-Saharan Africa are related to poor nutrition and Dr Zerfu says the first 1000 days is crucial. “Once nutritional problems are formed during early ages, it is very difficult to curb its effect later in life. The first 1000 days is the time to intervene – the critical window of opportunity. Children who have been malnourished during pregnancy are more likely to suffer from chronic diseases like cancer and diabetes later in life, which creates a huge burden.”

Dr Zerfu also stresses that the cognitive development impacts of malnutrition do not just affect individuals, but have far wider implications. The economic contribution of those individuals is limited and leads to lower productivity across the wider population.

He says there are even graver social implications of malnutrition, as the lack of cognitive development has been linked to individuals being drawn into civil wars, leading to constant instability in the region.

Despite the lack of research in large populations, Dr Zerfu is hopeful that his work can make a real difference: “Demographic and health survey data is collected regularly by experienced experts in all three countries and is of high quality.  What is lacking is advanced analysis of the data. That’s what I’m doing in this research – and supplementing it with primary data from the field.”

This primary data involves the use of an innovative technique called PhotoVoice. This involves supplying participants with a digital camera to capture images (in this case of children’s foods) which are used to discuss decisions about diet and nutrition. This will be supplemented by questionnaires to get additional qualitative information.

“Rather than using interviews or group discussions, PhotoVoice should shed more light on what is happening and give us richer information and more trustworthy, mature data,” says Dr Zerfu. “Pictures speak louder than words. It is about avoiding theoretical assumptions and allowing families to create real-life photo-stories. I have experience of using it in Kenya and believe it will offer strong results.

“We want the families to talk about pictures and explain how many cattle they have, but why they might still be feeding the baby thin maize porridge and not using the milk or meat. We might find, for example, that there are cultural reasons – meat is being saved for a special celebration, or for the adults of the family.”

After collecting the primary and secondary data, Phase 3 of the three-year research project is to engage a range of experts in workshops in Ethiopia, Kenya and Uganda. “We will segment the findings and use experts from a range of disciplines to analyse specific aspects and offer their insights,” says Dr Zerfu. “What does it mean to health experts, nutritionists, agriculture experts?

“These workshops will enrich the data and I hope my research will be published in high-impact journals and used to help influence policy in the sub-Saharan region. My personal ambition is to become a research scientist in this important area, where agriculture, health and nutrition meet.”

Dr Isabelle Baltenweck, Principal Scientist and Programme Leader at the International Livestock Research Institute, says: “The nutrition and health benefits of keeping livestock are complex, with many pathways that also vary by livestock system. The work led by Taddese Zerfu is key to better understanding that relationship with a focus on children under five, and it is rewarding working on this topic with him.”

This project has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 801215.