Publications

PUBLICATIONS

by IFPRI | June 14, 2019

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Conflict of interest in nutrition: Where’s the power? Comment on “Towards preventing and managing conflict of interest in nutrition policy? An analysis of submissions to a consultation on a draft WHO tool”
Harris, Jody; Nisbett, Nicholas; Gillespie, Stuart. Article in press

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Actual or perceived conflict of interests (COIs) among public and private actors in the field of nutrition must be managed. Ralston et al expose sharply contrasting views on the new World Health Organization (WHO) COI management tool, highlighting the contested nature of global debates. Both the WHO COI tool and the Ralston et al paper are largely quiet on aspects of power among different actors, however, which we argue is integral to these conflicts. We suggest that power needs to be acknowledged as a factor in COI; that it needs to be systematically assessed in COI tools using approaches we outline here; and that it needs to be explicitly addressed through COI mechanisms. We would recommend that all actors in the nutrition space (not only private companies) are held to the same COI standards, and we would welcome further studies such as Ralston et al to further build accountability.

Food for thought? Experimental evidence on the learning impacts of a large-scale school feeding program
Aurino, Elisabetta; Gelli, Aulo; Adamba, Clement; Osei-Akoto, Isaac; Alderman, Harold. Madison, WI Article in press

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There is limited experimental evidence on the effects of large-scale, government-led interventions on human capital in resource-constrained settings. We report results from a randomized trial of the government of Ghana’s school feeding. After two years, the program led to moderate average increases in math and literacy standardized scores among pupils in treatment communities, and to larger achievement gains for girls and disadvantaged children and regions. Improvements in child schooling, cognition, and nutrition constituted suggestive impact mechanisms, especially for educationally-disadvantaged groups. The program combined equitable human capital accumulation with social protection, contributing to the “learning for all” sustainable development agenda.

Food consumption–production response to agricultural policy and macroeconomic change in Nigeria
Ecker, Olivier; Hatzenbuehler, Patrick L.. Article in press

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Achieving agricultural transformation and farmer resilience in resource‐dependent developing countries like Nigeria is complicated by volatile macroeconomic conditions, which disrupt agricultural supply chains through income, foreign exchange, and risk‐mitigation effects. This study examines the food consumption–production linkage in Nigeria at a time when the national Agricultural Transformation Agenda was implemented and an economic crisis was unfolding. Many farm households responded to expected shocks by planting more staple foods for own consumption at the expense of agricultural commercialization, income growth, and dietary diversification. A policy initiative to improve access to modern farm inputs appeared to mitigate these adverse effects.

Paying for digital information: Assessing farmers’ willingness to pay for a digital agriculture and nutrition service in Ghana
Hidrobo, Melissa; Palloni, Giordano; Aker, Jenny; Gilligan, Daniel O.; Ledlie, Natasha. Article in press

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Agriculture-nutrition linkages, cooking-time, intrahousehold equality among women and children: Evidence from Tajikistan
Takeshima, Hiroyuki; Akramov, Kamiljon T.; Park, Allen; Ilyasov, Jarilkasin; Ergasheva, Tanzila. Article in press

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Women’s empowerment and gender equality in South Asian agriculture: Measuring progress using the project-level Women’s Empowerment in Agriculture Index (pro-WEAI) in Bangladesh and India
Quisumbing, Agnes R.; Meinzen-Dick, Ruth Suseela; Malapit, Hazel J.. Article in press

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Economic evaluation of an early childhood development center–based agriculture and nutrition intervention in Malawi
Gelli, Aulo; Kemp, C. G.; Margolies, Amy; Twalibu, Aisha; Katundu, Mangani; Levin, Carol E.. Article in press

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Malnutrition is a leading cause of death and disability among children in low-income countries. Nutrition-sensitive interventions show promise in increasing food access and improving diets. There are possible synergies of integrating these programs with other sectors, improving effectiveness by leveraging resources. However, economic evaluations of these multi-sectoral programs are limited. We aimed to estimate the cost efficiency, cost-effectiveness, benefit-cost ratio, and net benefit of using community-based early childhood development (ECD) centers as platforms for an intervention promoting agricultural production and nutrition among households with young children in Malawi. The intervention was costed using bottom-up micro-costing and top-down expenditure analysis with a societal perspective and a 12-month horizon. Effectiveness estimates were derived from a cluster-randomized control trial. Premature deaths and stunting cases averted were estimated using the Lived Saved Tool. We calculated DALYs averted, and the value of three benefits streams resulting from reductions in premature mortality, increases in lifetime productivity and household agricultural productivity. We transferred the US value of a statistical life (VSL) to Malawi using an income elasticity of 1.5, and a 10% discount rate. Probabilistic sensitivity analysis was conducted using a Monte Carlo model. The intervention cost $197,377, reaching 4,806 beneficiaries at $41 per beneficiary, $595 per case of stunting, $18,310 per death, and $516 per DALY averted. Net benefit estimates ranged from $507,589 to $4,678,258, and benefit-cost ratios from 3.57 to 24.70. Sensitivity analyses confirmed a positive return on investment. Implementing agriculture-nutrition interventions through ECD platforms may be an efficient use of resources in Malawi and similar contexts.

The impact of an integrated value chain intervention on household poultry production in Burkina Faso: Evidence from a randomized controlled trial
Leight, Jessica; Awonon, Josué; Pedehombga, Abdoulaye; Ganaba, Rasmané; Martinez, Elena M.; Heckert, Jessica; Gelli, Aulo. Article in press

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Trends and factors associated with the nutritional status of adolescent girls in Ghana: A secondary analysis of the 2003-2014 Ghana Demographic and Health Survey (GDHS) data
Azupogo, Fusta; Abizari, Abdul-Razak; Aurino, Elisabetta; Gelli, Aulo; Osendarp, Saskia J. M.; Bras, Hilde; Feskens, Edith J.; Brouwer, Inge D.. Article in press

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Heat shocks, maize yields, and child height in Tanzania
Block, S.; Haile, Beliyou; You, Liangzhi; Headey, Derek D.. Article in press

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The growing threat that climate shocks pose to food, water and nutrition security makes understanding the linkages between climate and nutrition increasingly urgent. The article demonstrates an empirical connection between rising temperatures, cereal yields, and poorer growth outcomes for children—the first time such a link has been established between climate shocks, agricultural productivity, and health.
The authors find that extreme temperature shocks can severely reduce maize yields, and that lower yields in the season prior to birth are a strong predictor of reduced height in later years, especially among boys. They also show that lower maize yields are predictive of lower body mass among women but not predictive of diarrhea or fever incidence in children. Taken together, these results suggest that maternal malnutrition during pregnancy is a key pathway linking heat shocks and agricultural production to subsequent child health.
The findings have important implications for policymakers responding to climate impacts, who must weigh whether to focus more on agricultural interventions and social protection or on public health interventions. Our research suggests the first approach could be particularly important in rural Africa.

Specificity matters: Unpacking impact pathways of individual interventions within bundled packages helps interpret the limited impacts of a maternal nutrition intervention in India
Kachwaha, Shivani; Nguyen, Phuong Hong; Mai Tran, Lan; Avula, Rasmi; Young, Melissa; Menon, Purnima. Article in press

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Background: To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive (I-ANC) to standard (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight gain monitoring.
Objectives: This study examined intervention-specific program impact pathways (PIP) and identified reasons for limited impacts of the A&T maternal nutrition intervention package.
Methods: We used mixed methods: frontline workers surveys (FLWs, n∼500); counseling observations (n = 407); and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed seven PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling.
Results: Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC versus S-ANC (90 vs.70%), but gaps remained for training content and refresher trainings. FLW's knowledge improvement was higher in I-ANC than S-ANC (22–36 percentage points), but knowledge on micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30–50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52 vs. 36%), but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight gain monitoring were low (30–40%).
Conclusions: Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.

Gaps in the implementation and uptake of maternal nutrition interventions in antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India
Sanghvi, Tina; Nguyen, Phuong Hong; Tharaney, Manisha; Ghosh, Sebanti; Escobar-Alegria, Jessica; Kim, Sunny S.. Article in press

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Antenatal care (ANC) is the largest health platform globally for delivering maternal nutrition interventions (MNIs) to pregnant women. Yet, large missed opportunities remain in nutrition service delivery. This paper examines how well evidence-based MNIs were incorporated in national policies and programs in Bangladesh, Burkina Faso, Ethiopia and India. We compared the nutrition content of ANC protocols against global recommendations. We used survey data to elucidate the coverage of micronutrient supplementation, weight gain monitoring, dietary and breastfeeding counselling. We reviewed literature, formative research and program assessments to identify barriers and enabling factors of service provision and maternal nutrition practices. Nutrition information in national policies and protocols was often fragmented, incomplete and did not consistently follow global recommendations. Nationally representative data on MNIs in ANC was inadequate, except for iron and folic acid supplementation. Coverage data from subnational surveys showed similar patterns of strengths and weaknesses. MNI coverage was consistently lower than ANC coverage with the lowest coverage of weight gain monitoring and variable coverage of dietary and breastfeeding counselling. Key common factors associated with coverage were micronutrient supply disruptions; suboptimal counselling on maternal diet, weight gain, and breastfeeding; and limited or no record keeping. Adherence of women to micronutrient supplementation and dietary recommendations was low and associated with late and too few ANC contacts, poor maternal knowledge and self-efficacy, and insufficient family and community support. Models of comprehensive nutrition protocols and health systems that deliver maternal nutrition services in ANC are urgently needed along with national data systems to track progress.

Can information drive demand for safer food? Impact of brand-specific recommendations and test results on product choice
Wairimu Kariuki, Sarah; Hoffmann, Vivian. Article in press

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As an unobservable attribute, food safety is likely to be under-provided by markets where regulatory enforcement is weak. In such settings, stimulating consumer demand for safer food can potentially encourage market actors to invest in food safety. Through a randomized trial in Kenya, we test the impact of informing consumers about which maize flour brands are most likely to comply with the regulatory standard for aflatoxin, a carcinogenic fungal byproduct. Providing information on safer brands alone does not significantly affect consumption behavior. However, when the same information is combined with a test performed on the maize flour stocked by the household, the likelihood that a safer brand is consumed 2 months later is 76% higher than in the comparison group. Our findings suggest that providing information on the relative riskiness of substitute foods could encourage consumers to make safer choices.

World Health Organization and knowledge translation in maternal, newborn, child and adolescent health and nutrition
STAGE (Strategic Technical Advisory Group of Experts); Duke, Trevor; AlBuhairan, Fadia S.; Agarwal, Koki; Arora, Narendra K.; Arulkumaran, Sabaratnam; Bhutta, Zulfiqar A.; Ruel, Marie T.. Article in press

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Calcium supplementation for the prevention of hypertensive disorders of pregnancy: Current evidence and programmatic considerations
Gomes, Filomena; Ashorn, Per; Askari, Sufia; Belizan, Jose M.; Boy, Erick. Article in press

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Most low- and middle-income countries present suboptimal intakes of calcium during pregnancy and high rates of mortality due to maternal hypertensive disorders. Calcium supplementation during pregnancy is known to reduce the risk of these disorders and associated complications, including preeclampsia, maternal morbidity, and preterm birth, and is, therefore, a recommended intervention for pregnant women in populations with low dietary calcium intake (e.g., where ≥25% of individuals in the population have intakes less than 800 mg calcium/day). However, this intervention is not widely implemented in part due to cost and logistical issues related to the large dose and burdensome dosing schedule (three to four 500-mg doses/day). WHO recommends 1.5–2 g/day but limited evidence suggests that less than 1 g/day may be sufficient and ongoing trials with low-dose calcium supplementation (500 mg/day) may point a path toward simplifying supplementation regimens. Calcium carbonate is likely to be the most cost-effective choice, and it is not necessary to counsel women to take calcium supplements separately from iron-containing supplements. In populations at highest risk for preeclampsia, a combination of calcium supplementation and food-based approaches, such as food fortification with calcium, may be required to improve calcium intakes before pregnancy and in early gestation.

Understanding the pathways to women’s empowerment in Northern Ghana and the relationship with small-scale irrigation
Bryan, Elizabeth; Garner, Elisabeth. Article in press

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Women’s empowerment is often an important goal of development interventions. This paper explores local perceptions of empowerment in the Upper East Region of Ghana and the pathways through which small-scale irrigation intervention targeted to men and women farmers contributes to women’s empowerment. Using qualitative data collected with 144 farmers and traders through 28 individual interviews and 16 focus group discussions, this paper innovates a framework to integrate the linkages between small-scale irrigation and three dimensions of women’s empowerment: resources, agency, and achievements. The relationship between the components of empowerment and small-scale irrigation are placed within a larger context of social change underlying these relationships. This shows that many women face serious constraints to participating in and benefitting from small-scale irrigation, including difficulties accessing land and water and gender norms that limit women’s ability to control farm assets. Despite these constraints, many women do benefit from participating in irrigated farming activities leading to an increase in their agency and well-being achievements. For some women, these benefits are indirect—these women allocate their time to more preferred activities when the household gains access to modern irrigation technology. The result is a new approach to understanding women’s empowerment in relation to irrigation technology.

The ambivalent links between internal migration and food security in Uganda
Mekonnen, Daniel A.; Soma, Katrine; Ruben, Ruerd. Article in press

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This study examines the drivers for and consequences of internal migration to household food security in Uganda. Based on the Ugandan National Panel Surveys conducted between 2010/11 and 2015/16, we estimate differences in food energy adequacy of households receiving internal migrants from elsewhere. Besides food energy consumption, this study applies household food consumption score (FCS) and looks at vulnerability in terms of household’s expenditures on food. This enables to explore (a) the extent to which food insecurity is driving internal migration, and (b) whether remittances can reduce food security of the remitter. We find that households are usually worse-off when migrants join the receiving family. This seems a departure from previous studies that tend to find welfare gains to internal migration, mostly due to changes in expenditures or dietary consumption without considering any thresholds for achieving food security. Based on these findings and responding to rising youth employment challenges associated with rapidly growing urban slums in Uganda, policies that simultaneously support employment creation in both urban and rural areas are urgently needed to enable better steering of the flow of voluntary migration and to help ensuring food security.

Can it be all more simple? Manufacturing aflatoxin biocontrol products using dry spores of atoxigenic isolates of Aspergillus flavus as active ingredients
Ortega‐Beltran, Alejandro; Kaptoge, Lawrence; Senghor, Amadou L.; Aikore, Morounranti O. S.; Jarju, Patrick; Momanyi, Henry; Konlambigue, Matieyedou; Falade, Titilayo D. O.; Bandyopadhyay, Ranajit. Article in press

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Aflatoxin contamination of staple crops, commonly occurring in warm areas, negatively impacts human and animal health, and hampers trade and economic development. The fungus Aspergillus flavus is the major aflatoxin producer. However, not all A. flavus genotypes produce aflatoxins. Effective aflatoxin control is achieved using biocontrol products containing spores of atoxigenic A. flavus. In Africa, various biocontrol products under the tradename Aflasafe are available. Private and public sector licensees manufacture Aflasafe using spores freshly produced in laboratories adjacent to their factories. BAMTAARE, the licensee in Senegal, had difficulties to obtain laboratory equipment during its first year of production. To overcome this, a process was developed in Ibadan, Nigeria, for producing high‐quality dry spores. Viability and stability of the dry spores were tested and conformed to set standards. In 2019, BAMTAARE manufactured Aflasafe SN01 using dry spores produced in Ibadan and sent via courier and 19 000 ha of groundnut and maize in Senegal and The Gambia were treated. Biocontrol manufactured with dry spores was as effective as biocontrol manufactured with freshly produced spores. Treated crops contained safe and significantly (P < 0.05) less aflatoxin than untreated crops. The dry spore innovation will make biocontrol manufacturing cost‐efficient in several African countries.

Iron-biofortified pearl millet consumption increases physical activity in Indian adolescent school children after a 6-month randomized feeding trial
Pompano, Laura M.; Luna, Sarah V.; Ghugre, Padmini S.; Przybyszewski, Eric M.; Haas, Jere D.. Article in press

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Background: Iron deficiency has negative effects on voluntary physical activity (PA); however, the impact of consuming iron-biofortified staple foods on voluntary PA remains unclear. This study compared the effects of consuming iron-biofortified pearl millet or a conventional pearl millet on measures of voluntary PA in Indian school children (ages 12-16 years) during a six-month randomized, controlled feeding trial. PA data were collected from 130 children using Actigraph GT3X accelerometers for six days at baseline and endline. Minutes spent in light and in moderate-to-vigorous PA were calculated from accelerometer counts using Crouter’s refined two-regression model for children. Mixed regression models adjusting for covariates were used to assess relationships between intervention treatment or change in iron status and physical activity. Results: Children who consumed iron-biofortified pearl millet performed 22.3 (95% CI: 1.8, 42.8, p = 0.034) more minutes of light PA each day compared to conventional pearl millet. There was no effect of treatment on moderate-to-vigorous PA. The amount of iron consumed from pearl millet was related to minutes spent in light PA (estimate and 95% CI: 3.4 min/mg iron (0.3 to 6.5, p = 0.031)) and inversely related to daily sedentary minutes (estimate and 95% CI: −5.4 min/mg iron (−9.9 to −0.9, p = 0.020)). Conclusion: Consuming iron-biofortified pearl millet increased light PA and decreased sedentary time in Indian school children in a dose-dependent manner.

The effect of zinc-biofortified rice on zinc status of Bangladeshi pre-school children: A randomized, double-masked, household-based controlled trial
Jongstra, Roelinda; Mokbul Hossain, Md; Galetti, Valeria; Hall, Andrew G.; Holt, Roberta R.. Article in press

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Background: Zinc biofortification of rice could sustainably improve zinc status in countries where zinc deficiency is common and rice is a staple, but its efficacy has not been tested. Fatty acid desaturases (FADS) are putative new zinc status biomarkers.
Objective: Our objective was to test the efficacy of zinc-biofortified rice in preschool-aged children with zinc-deficiency. Our hypothesis was that consumption of zinc-biofortified rice would increase plasma zinc concentration (PZC).
Design: We conducted a 9-month, double-masked, intervention trial in 12–36 month-old rural Bangladeshi children, most of whem were who were zinc-deficient (PZC < 70 µg/dL) and stunted (n = 520). The children were randomized to receive either control rice (CR) or zinc-biofortified rice (BFR) provided in cooked portions to their households daily, with compliance monitoring. The primary outcome was PZC. Secondary outcomes were zinc deficiency, linear growth, infection-related morbidity, FADS activity indices, intestinal fatty acid binding protein (I-FABP) and fecal calprotectin. We applied sparse serial sampling for midpoint measures and analyzed data by intention-to-treat using mixed-effects models. The trial was registered under NCT03079583. Results: At baseline, median (IQR) PZC was 60.4 (56.3–64.3) µg/dL, 78.1% of children were zinc deficient and 59.7% were stunted. Mean ± SD daily zinc intakes from the CR and BFR during the trial were 1.20 ± 0.34 and 2.22 ± 0.47 mg/day, respectively (P < 0.001). There were no significant time-by-treatment effects on PZC, zinc deficiency prevalence, FADS activity, I-FABP or fecal calprotectin (all P > 0.05). There was a time-treatment interaction for height-for-age z scores (P < 0.001) favoring the BFR group. The morbidity longitudinal prevalence ratio (LPR) (95% CI) was 1.08 (1.05,1.12) comparing the BFR and CR groups, due to more upper respiratory tract illness in the BFR group. Conclusions: Consumption of zinc-biofortified rice for 9 months providing ∼1 mg of additional zinc daily to Bangladeshi children did not significantly affect PZC, prevalence of zinc deficiency or FADS activity. Clinical Trial Registry: https://clinicaltrials.gov/ct2/show/NCT03079583