Context-Specific Food-Based Strategies for Improving Nutrition in Developing Countries

Abstract

Viable food approaches for achieving nutrient needs in underdeveloped countries are not well documented. The existing evidence indicates that one out of three people is facing single or multiple forms of malnutrition globally, in which the highly affected sections of the population are children and women from less developed countries. Economic losses, which result from undernutrition are between 3% and 16% of the GDP in the majority of poor countries. This problem is far bigger than what the government and donors can tackle alone. Thus, a new strategy, which is donor-independent, is required to address the problem of undernutrition in developing countries. In this chapter, we report on a food approach that is context-specific for grappling with malnutrition problems in low-income countries. The approach employs the model which encompasses public and private sectors to allow cost-sharing and productivity gains in tackling malnutrition in under-resourced countries. The model urges all stakeholders to consider consumers’ views, which are often overlooked, and properly engross them as key players.

1. Introduction

Suitable food approaches for attaining nutrient requirements in resource-poor communities are not well documented [1, 2]. Existing evidence indicates that not less than two billion individuals worldwide lack vital nutrients needed by the human body for its growth and proper functioning. Also, more than 0.84 billion people have no sufficient food to eat, whereas 1.4 billion people are morbidly obese or overweight. Overall, half of the world’s population suffers from malnutrition [3]. The world’s population is estimated to reach nine billion people by 2050, and these will require nutritious diets for healthy lives [4]. Therefore, it is essential to ensure that sustainable food approaches are initiated to achieve the global demands for nutrient-rich foods since the state of malnutrition is anticipated to be worse, if not addressed [1].

Although Sub-Saharan Africa has widely been regarded as the basket of foods rich in essential nutrients, malnourishment is still a great challenge, particularly, among children and women of reproductive age. More than 0.056 billion children, for example, are reported to be stunted due to chronic malnutrition, 0.03 billion are underweight, greater than 0.015 billion are wasted, nearly 50% of children are susceptible to blindness as a result of vitamin A deficiency, and four million low-birth-weight babies are born annually in the region [3]. In that regard, maternal undernutrition in Africa is considerably larger than in other parts of the world [1]. Nearly 5–20% of African women, for instance, have a low body mass index (BMI) attached to chronic hunger. Prevalence of anaemia varies from 21 to 80% of females across the African region. Moreover, vitamin A, zinc, and iron deficiencies are more prevalent in the continent [5]. To a great degree, maternal malnutrition accounts for millions of infancy morbidity, and death every year in less developed countries [6].

In Tanzania, for instance, more than 35.5% of all children below 2 years are reported to be chronically undernourished [7]. Also, nutritional deficiencies are widespread. For example, the prevalence of vitamin A deficiency, iron deficiency, and anaemia among children aged below 2 years are reported to be 33%, 42%, and 73%, respectively [8]. Equally, according to the Tanzania Demographic and Health Survey (TDHS) report of 2010, more than 30% of women of reproductive age had iron deficiency, 36% had iodine deficiency, 37% had vitamin A deficiency, and 40% had anaemia [8]. As a consequence, undernutrition affects the nutritional status of potential mothers, thereby leading to long-term negative health and economic consequences for their offspring [1].

2. Consequences of undernutrition

The adverse effects of undernutrition are pervasive, long-lasting, and irreversible, particularly when it happens during the critical first 1000 days of an individual’s life commencing at the onset of pregnancy and stretching through his/her second year after birth [1]. Undernutrition intensifies not only the risks of morbidity and death but also weakens the initial physical and intellectual development of survivors [6]. The short and long-term adverse effects of malnutrition are expounded below:

2.1 Increased risks of mortality

More than 45% of avertable child mortalities are attributed to undernutrition [6]. A report by Global Panel on agriculture and food systems for nutrition, for instance, showed that severely malnourished children are nine times more likely to die than well-nourished children [9]. Nevertheless, the underlying undernourishment is usually disguised by an immediate cause of mortality that frequently exhibits itself as an infection [1]. Maternal death has a substantial causal association with undernutrition, of which the most common maternal death linked to the perinatal period manifests itself either through pregnancy snags or death at childbirth [1]. Generally, undernutrition insidiously minimises the natural life span of women [10, 11]. Thus, evertable death signifies a loss of human resources which distress households by subjecting children to more helplessness [12, 13], and the community at large by debasing social interactions which were built by mothers [1].

2.2 Intensified reoccurrance of illnesses

Over many years, it has been acknowledged that malnutrition causes nutrient deficiency-related diseases. For example, protein deficiency causes kwashiorkor and overall poor physical and mental development; vitamin A deficiency results in impaired vision; mineral deficiency, for example, iron causes iron-deficiency anaemia [14]. The devious effects of malnourishment are a general increase in vulnerability to infection, the severity of resultant ailments and dwindled outcomes of recovery periods and the high cost of handling the illness. In less developed countries, families bear a significant portion of the treatment costs, and to a certain extent, the national health care or health insurance companies. This causes a drain on the family budget, nation’s resources, and the diversion of limited resources to other endeavours [1]. As described in the Global Panel Report, for instance, a full course of remedies for saving the life of a sternly wasted child costs between US$ 100 and US$ 200 per child [9], which is more or less two times the average family earnings per month in affected communities. It is possible to save about USD18 on every dollar invested in thwarting chronic undernourishment. In the USA, where there is a crisis of obesity, the per capita healthcare expenses are 80% higher for perversely overweight people than those with healthy normal weight [9]. While the healthcare system in the USA noticeably differs from those in underdeveloped nations, it is obvious that as some sections of the population turn overweight (particularly among the escalating urban poor), the fiscal burden will be exacerbated by a triple helix of undernutrition, infection, and obesity [1].

2.3 Delayed physical development

Sub-optimal physical development, often accompanied by life-long exposure to diseases, weakens economic output through reduced labour efficiency or absence from work. While the losses to individuals from malnutrition in poor countries have been projected at 10% or more of lifetime incomes [9, 15], the cost of productivity foregone in resources-poor countries because of undernourishment has been estimated at 3–16% of country’s GDP [9, 16]. This lost income is equivalent to or surpasses the amount of GDP spent on agriculture or education, and this is likely to be more than what African states have devoted themselves to spending on scientific research and development [1]. It is useful to point out that the most developed countries like the United States, employment malingering associated with obesity causes lost output equal to US$ 4.3 billion per annum, and costs firms US$ 506 yearly per corpulent employee [9].

2.4 Poor cognitive development

Undernutrition from conception to 2 years of age and extending through school age and adolescence leads to a series of damages beginning with reduced cognitive development, delayed school starting, and poor educational achievements. As a result, the affected individuals miss opportunities related to lost employment and social relations during the course of life [1, 6, 9]. A longitudinal study conducted in Guatemala which involved 2392 children below 8 years, for example, revealed that malnourished children aged 6 years had a relatively high risk of losing the equivalent of four grades of schooling because of poor cognitive abilities [17]. Furthermore, a comparable long-term study piloted in Western Tanzania indicated that undernourished children are more likely to delay entry into school and perform poorer than well-nourished children of similar age [18].

Overall, malnutrition carries a substantial economic burden for the affected individuals, families, and communities as well as national and global economies [1]. The global analysis on nutrition economics indicates that a combined burden of malnutrition, micronutrient deficiencies, and obesity cost the world economy up to US$ 3.5 trillion [3, 9]. This level of economic burden is the main obstacle to efforts that are done by many governments to alleviate poverty and attain key development goals stipulated in the Sustainable Development Goals (SDGs) [9, 19]. These consequences emphasise the necessity of establishing suitable nutritional interventions for mitigating the problem of undernutrition in resource-poor communities [1].

3. Potential causes of undernutrition in resource-poor countries

It is clearly understood that undernutrition among individuals in poverty-stricken families and societies is caused by insufficient intake of nutritious foods. Nonetheless, this hypothesis is a generalisation because the insufficiency of food intake is itself caused by underlying factors, including poverty as chief among them [1]. Another aspect of the underlying causes of undernourishment is linked to eating habits that are monotonous, mainly cereal-based intakes, which tend to have low dietary diversity, low nutrient density, and meagre micronutrient bioavailability [20]. Also, for a long time, it has been widely acknowledged that most poor families concentrate on tackling the challenge of hunger and normally forget to take into account the quality and quantity of essential nutrients in foods [21]. A study on the formulation of evidence-based dietary references for women and children, for instance, revealed that foods rich in carbohydrates are more frequently consumed than locally available micronutrient-rich foods in Guatemala [22]. Likewise, an analysis of data from the TDHS indicated that highly sugared foods are more frequently consumed than foods with high content of essential micronutrients, suggesting that eating habits among toddlers in Tanzania are certainly poor [23]. Most Tanzanian families trade nutrition for food, meaning that they would rather sell their high-value nutrient-dense foods in exchange for bulky low-nutrient dense cereal, sugar, and other foodstuffs [1]. Undoubtedly, this is mainly because most of people in Tanzania have no enough nutritional education about the health benefits of nutrient-rich foods. This evidence indicates that it is necessary to have a robust nutrition intervention that would help households in disadvantaged communities to make informed choices on what, when, and how to eat.

4. Existing approaches for addressing malnutrition in developing countries

For the past 50 years, initiatives to addressing malnourishment in underprivileged communities have focused mainly on three areas of intervention. The interventions include (1) nutritional education to the public, (2) provision of micronutrients via salt iodisation, vitamin A supplements etc., and (3) the treatment of severe acute undernutrition through clinical intensive care fortification [1, 2].

Public nutrition education intervention aims to improve the consumption of available nutrient-dense foods for the nutritional benefits of disadvantaged groups. This intervention intends to change the purchasing, preparations, and eating behaviours to counter some deleterious food-related practices that tend to exist in diverse communities [1]. Precisely, nutrition education aims at creating changes in feeding habits based on the supposition that such changes will improve the nutritional status of the target community. For that matter, knowledge and attitude changes are expected to contribute to behavioural changes among individuals. In case the changes in behaviour do not positively impact the nutritional status of the target population, it might imply that the messages promoted in nutritional education were incorrect or that other causes were the major constraints to impaired growth [1, 24].

Fortification is normally done by adding micronutrient powder, ready-to-use therapeutic foods (RUTFs) and lipid-based nutrient supplements (LNS) in diets consumed in household. On the other hand, supplementation is usually done by providing a single nutrient (say vitamin A or D, iron) to infants and toddlers in the form of drops or syrups [1]. Regrettably, LNS and RUTFs cannot be afforded by many families in low-income countries and they are intended for use under clinical prescriptions only [25, 26]. Fortification and supplementation interventions have been based on the aids from donors who are always more reactive than proactive as their strategy has for a long time been on the treatment of severe acute malnutrition (SAM) rather than prevention of malnutrition [5, 27, 28]. Although these approaches are indispensable for mitigating life or death circumstances on an emergency basis, these efforts are generally considered to have been inadequate, leaving more than one-third of the global population to suffer from malnutrition [27].

5. Innovative approaches for meeting nutrient need in poor countries

At present, the WHO recommends the food-based strategy as a favoured long-term solution to addressing the problem of malnutrition in developing countries. The approach intends to enhance the nutritional quality through improved intake of local foods rich in essential nutrients [29]. Yet, for the intervention to work better, it must be specific to the culture and local context. The approach needs to be executed based on the acceptance, local availability, and affordability of the nutrient-rich foods in the community [30]. Studies from countries such as Cambodia, Guatemala, Indonesia, and Myanmar have shown that different vicinities may have diverse local foods with variable nutrient densities [7, 31, 32]. The fact that local foods can vary from one location to another highlights the need for examining how local diets in a specific locality can attain the nutritional goals of disadvantaged groups towards food-based interventions [1]. The local analysis helps nutrition stakeholders and practitioners resolve the obstacles that may be caused by factors like access and high prices of nutrient-rich foods, particularly in under-resourced settings [1].

As such, diet optimisation using linear programming (LP) is instrumental in formulating nutritious diets and providing sensible use of scarce high value nutrient-rich foods in a target population. LP is a mathematical tool used to optimise a linear objective function subject to a set of constraints [33]. Several objective functions can be selected, for instance, through minimising or maximising particular nutrients and the selected local food ingredients. The LP approach considers numerous factors including food costs and cultural factors in ensuring the smooth development of a reasonably priced and culturally acceptable diet [34]. The evidence from Kenya and Mozambique reveals how low-cost diverse diets can be attained from local nutrient-rich foods using linear programming. In Kenya, for example, the LP approach was used to model available wild foods to achieve nutritional goals for mothers and children aged below 2 years at a minimal cost [35]. In Mozambique, the LP technique was used to model local nutrient-dense foods to meet micronutrients necessities for children aged between 1 and 3 years [36]. Their LP diets formulated from local foods were reasonably affordable when compared to the cost of commonly used lipid-based nutrient supplements (LNS) [26]. These case studies confirmed the usefulness of food-based approaches that are context-specific and their ability to successfully tackle the problem of malnourishment in developing countries [1].

6. Necessities for the success of food-based approaches

For a food-based intervention to succeed, programme executers need to focus on developing foodstuffs that can meet consumer preferences and experiences, especially where obstacles are too deeply rooted to be altered in the short-term by educational tactics [1]. Foods need to be nontoxic and rich in the most deficient micronutrients, and they should be consumed as per intake recommendations [37]. In some situations, one must ensure that the product is acquired by dispensing it directly to the target population. Nevertheless, in this case, investigators and programme executors cannot guarantee the actual consumption of the product by the intended customers since the target beneficiaries may not necessarily consume the presented food product as planned [1]. This may partly be attributed by the circumstance that consumers dislike the product or are not aware that the product is intended for particular persons, or consumers feel anxious to share the food with other members inside or outside their households [37]. In view of that, prior to introducing a food-based intervention, it is imperative to carry out the analysis of total nutrient intakes, including that of a specific product and the whole diet. Also, to ensure consumption, ingredients of interest need to achieve consumer preferences, preparations, and consumption experiences. Equally, one requires to know the purchasing power of consumers and their willingness to pay for the product [37, 38]. In the same vein, in order to arouse consumption as planned and limit the sharing of foods in communities, clear and well-tailored communications should be developed and delivered to the target population [37, 39].

After identifying the characteristics of target consumers such as consumers’ purchasing power and behaviours, eating manners, and food consumption patterns, products or formulations can be developed and tested at a small scale to establish consumer preferences and viable affordability. Data from such a study may act as a basis for moving into a larger micro-testing [3]. Once consumer preferences and purchasing power have been resolved, one needs to develop a well-tailored delivery system to ensure the sustainable distribution of nutritious food products to the target population [1].

7. Proposed delivery system for nutritious food products in developing countries

A sustainable delivery model for effective distribution of nutritious products to the target population is needed in resource-poor settings. Studies have shown that in real-life situations, target consumers can be reached through health care, market networks, and community-based channels. However, according to de Pee [37], the choice of a channel or combination of channels depends on the context, type of product, consumers’ purchasing power and their preferences, likelihood for behavioural change, available platforms and assurance among the target users [37].

Segre and the team, for instance, carried out research that assessed the ‘actual’ consumers’ willingness to pay for nutrient-dense foodstuffs among urban people in Ethiopia. The study’s objectives were to: (1) explore the size of the market and purchasing power of individuals, (2) determine the local manufacturer’s business case, and (3) establish the required attributes of the distribution channel. The study found that although the majority of consumers preferred to buy the food product and that 25% of participants were ready to pay an unsubsidised price, yet, most of them were not used to buying packaged foods, and hence, the total market size was small [40]. The study’s findings suggest that to reach 75% of urban consumers who were not willing to pay the unsubsidised price for the products in Ethiopia would need a departure from the business as usual approach. It would possibly need a delivery model which embraces a public-private mix, which allows cost-sharing and efficiency gains [28].

The hybrid public-private delivery model is being proposed as a more profound and beneficial channel of distribution for nutritious foods over other channels in developing countries. This delivery model crafts an environment that forces key nutrition players and other practitioners to seriously take into account consumers’ views that are often ignored, and truly engross them as key stakeholders [28, 41]. In this model, the public sector is responsible for providing conducive environments for investments, infrastructure, and legal frameworks needed to support the private sector (both inside and outside the country) to engage more extensively in executing the nutrition business [1]. The public sector can also provide a direct subsidisation, which plays a key role in lowering the retail price of nutritious products. Likewise, the public sector can assist in reducing production costs by eliminating unnecessary trade obstacles and tariffs for key production inputs. Buyers from the public sector also have an important role to play in minimising the uncertainty related to the demand for potential nutritional products. Public sector procurers and purchasers can also sign credible and long-term contracts to stimulate private sector investments in resource-poor countries [41]. Eventually, this would ensure that there is a sustainable supply of nutritional products and formulations to the target population [1].

Given that the problem of undernutrition is far bigger than what the donor-driven and government intervention programmes can tackle alone, a context-specific food-based approach that would allow cost-sharing and efficiency gains in low-income countries is needed [1]. This approach is grounded on the fact that a mixed hybrid public-private delivery model is not donor-dependent and hence, can assure and enhance a sustainable delivery of nutritious nutrient-dense foodstuffs to the target consumers. In that way, the hybrid public-private delivery model guarantees a sustainable supply of nutritious commodities to the target population, including those who cannot manage to pay for the unsubsidised price. This delivery model considers retail channels as a potential delivery platform for sharing the cost burden with consumers. The model provides an avenue for key nutritional actors to leverage a private demand by marketing nutritious foodstuffs in the famous retail channels or outlets at a subsidised price or by charging fees at the distribution health care centres [1]. Nevertheless, market demand will set a basis not only for designing, testing, and scaling up production and delivery options but also for tackling cost-sharing issues in less developed countries.

8. General conclusions

Food-based nutrition intervention options that are context-specific can be used to address malnutrition problems in developing countries. Based on the available analysis and our recent pilot study on the nutritional framework in Tanzania [1], we recommend three key food-based nutrition intervention options in resource-poor settings.

The first intervention option is by providing new avenues for increasing the production and wide consumption of rarely consumed micronutrient-dense foods in the target population. This will ensure the availability and accessibility of nutrient-rich foods in the target population. The approach may work better in areas with high ecosystem productivity. Apart from increased production of nutrient-dense foods, this model can provide economic incentives for caregivers to generate household income that can be spent on health care and the purchase of diverse micronutrient-rich foods at the household level.

The second intervention option is to establish the hybrid public-private delivery model that enables cost-sharing and efficiency gains among stakeholders. This model is more suitable in areas with relatively lower productivity ecosystems. In this model, the primary caregivers or consumers are truly engaged as key stakeholders. The role of the public sector in this hybrid model is to provide investments, infrastructure and legal frameworks for the private sectors to engage themselves in the production and distribution of nutrient-dense foods or formulations. The public sector in this hybrid model can also lower production costs through the reduction of trade barriers and tariffs for basic production inputs. Direct subsidies from the public sector can also lower the price of the formulation and hence increase the pool of purchasers from low-income households. However, one needs to persuade the governments in developing countries to understand the economic gain of investing in nutrition through direct subsidies. This can be compared with the costs governments are incurring in treating nutrition-related diseases.

The third intervention option is to empower mothers or primary caregivers by training them on skills for formulating nutritious products and diets at the household level using locally available foods and resources. The economic returns for this model are likely to be relatively high and stable because it minimises costs associated with labour, overhead costs, production, packaging, marketing, and distribution of the nutritional formulations. This approach can expand the pool of primary caregivers from low-income households to access nutritional solutions at a relatively lower cost.