Five-step plan to prevent an impending nutrition famine during COVID-19 in India

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India’s isolation measures in response to COVID-19 are having a far-reaching impact and is among one of the largest initiatives globally to impose strict limitations on its 1.3 billion citizens. People with pre-existing vulnerabilities, marginalized communities, pregnant and lactating women (PLW), daily wage earners, migrant workers, and the elderly have been the hardest hit as the protective measures disrupt the economy.

To ease the effects of the pandemic, the national and state governments have announced extensive stimulus packages and policy measures. The national government on 12th May announced a $265 billion relief package aimed at injecting liquidity into the economy. The first tranche of $ 22.6 billion included several social protection measures such as payment of ex gratia amount to marginalized populations, increased wages for workers under the National Rural Employment Guarantee Act, doubling rations for three months, collateral-free loans to women’s Self Help Groups (SHGs), the inclusion of support to COVID-19 under Corporate Social Responsibility (CSR), and financial assistance to villagers through farmer cooperatives. These aid benefits are aimed to help more than 810 million Indians and are a step in the right direction.

In addition, integrating nutrition in the current policies will be fundamental to improving nutritional status and building immunity of the population, especially high need groups like PLW and children under 5 years of age. The WHO guidance on diet during the COVID-19 pandemic states that “good nutrition is crucial for health, particularly in times when the immune system might need to fight back”. India is already battling a high prevalence of malnutrition (Table 1). As India, in unison with the rest of the world, battles an evolving pandemic of unprecedented proportions, policymakers must be vigilant, agile, and innovative to halt our population from sliding into hunger and acute malnutrition due to the COVID-19 outbreak.

Table 1:

Source: Comprehensive National Nutrition Survey 2016-2018, Ministry of Health and Family Welfare Govt. of India.

We propose a five-point plan to put nutrition-sensitive policy measures in place to combat the adverse effects of COVID-19:

1. Increase budget and coverage for essentials

Many state and national governments have gone beyond the entitlement provisions under the National Food Security Act – 2013 to announce a stimulus package, the key elements of which are grain and pulses, and cash transfers to lower-income households. While this is a necessary and commendable step, a much stronger nutrition-sensitive hunger mitigation and food programming scheme is crucial. A basic, nutritious diet, recommended by the EAT-Lancet Commission, would cost at least INR 33.69 per day. Accounting for a family of 4, cash transfer of INR 500 per month would only satisfy a family’s requirement for approximately four days a month! Most states’ announcement of transferring an additional INR 1,000 only satisfies their requirement for an additional eight days. India has surplus food grains to weather the current crisis. Universal access and 3x more rations, irrespective of possession of ration cards, will be effective in addressing hunger including the 70 million poor households who lack an identification document.

2. Address malnutrition through dietary diversity, supplementation, and fortification:

Current food supplies through the Targeted Public Distribution Systems (TPDS) are predominantly comprised of grain and pulses. In the current situation where farm supply chains are expected to take at least four months to be restored, essentials such as vegetables, milk, and eggs, could be sourced directly from the farmers and made available in the open markets, supplied through public distribution systems and provided as weekly take home supplies to children and PLW. A few state governments such as the Telangana government have directed Anganwadi workers to provide eggs to mothers and children. Scaling such initiatives to a national level will help improve nutrition outcomes during the pandemic.
 
The honorable Prime Minister of India, in his address to the nation, ‘Mann ki baat’ on 25th August 2019, announced fortification of rice that is distributed to India’s poor through the public distribution systems, Integrated Child Development Services (ICDS) and mid-day meals. This would be the right time to implement the policy and improve access to fortified products including salt, edible oil, flour, rice, and milk. The aforesaid initiative is critical in the current scenario when nutrient consumption is bound to be erratic due to cash and food shortages.

3. Create awareness about nutrition practices:

Increasing evidence suggests that malnutrition increases susceptibility to infections including COVID-19. We, therefore, need to create awareness about better nutrition practices. The National Nutrition Mission (POSHAN Abhiyaan)’s Jan Andolan movement is a platform to engage in civil society and engage people to be committed to better nutrition. The Jan Andolan initiative can be utilized to implement a social behavior change campaign addressing food safety and feeding practices at the household level. Second, front-line workers can be empowered to halt the rise of malnutrition. They can be trained and equipped with behavior change communication equipment on nutrition care during pandemics. Empowering them with the right information and communication technology (ICT) equipment will enable them to spread information through digital platforms while following social distancing norms.

4. Incentivize farmers and small enterprises to produce nutrition-rich crops and food:

The following initiatives can improve the livelihoods of small-scale farmers and enterprises while improving access to nutrition. Incentivize smallholder farmers to produce nutrition-rich crops and staple foods and thus improving access to safe and nutritious diets across the value chain. Micro small and medium enterprises (MSMEs) can be motivated to produce and process nutritious and culturally appropriate foods using millets and legumes such as lentils, chickpea, groundnut, ragi which contain many nutrients and can store for long periods. They can also be prepared by women self-help groups authorized to prepare take-home rations and then the ICDS channel can distribute these foods to PLW and young children.


5. Harness technology for better nutrition:

India has a successful history of using technology to improve socio-economic and public health outcomes. For example, the Arogya Setu app, recently developed by the National Informatics Centre, uses technology to track coronavirus infections, thus providing a valuable tool in the fight against the pandemic. The government can similarly engage entrepreneurs to develop technologies to forecast the trend and pattern of disease burden in future months, rectify supply chain management of key food and nutrition supplies, revitalize already introduced software in public distribution systems to monitor food supplies.
 
Nutrition is a great equalizer. It can create the right environment to stimulate growth, economic development, and progress of an entire generation, thus propelling India on a path towards excellence. India has demonstrated early successes in managing the pandemic through strict isolation measures, innovative use of technology, and public health services. As we fight a pandemic of epic proportions, accounting for the nutritional needs of the world’s most vulnerable will not only give us the strength and immunity to fight COVID-19 but also save lives and give more babies the healthy start they deserve, irrespective of their socio-economic status.
 

The Role of Nutrition in the Immune System

Should we pay more attention? Part I of II

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As the coronavirus (COVID-19) is spreading rapidly across the globe, it is important to take note of the approaches that can help prevent and fight infections, particularly viral infections. Evidence already suggests that viral infections are one of the world’s greatest public health challenges (WHO, 2020). The World Health Organization (WHO) estimates seasonal influenza results in 3-5 million cases annually. Today we understand hygiene and social distancing play a key role in protecting yourself and others from contracting a virus while also slowing the spread of infections. Here are a few simple ways to reduce your risk to infections:

– Wash your hands regularly for 20 seconds with soap and water or alcohol-based hand rub.
– Cover your nose and mouth when you sneeze or cough with a disposable tissue or flexed elbow.
– Avoid close contact with people who are sick.
– Stay at home and self-isolate from others if you feel unwell.

Incorporating nutrition

Good nutrition is fundamental to improving immunity. The immune system is the body’s defense against disease and infection and it has long been established that several factors influence the function of the immune system including stress, sleep and nutrition (Song et al, 2019; Patel et al 2012 and Gombart et al 2020). The WHO guidance on diet, especially during the current pandemic states that “good nutrition is crucial for health, particularly in times when the immune system might need to fight back” (WHO, 2020). Providing a diet high in nutritious foods rich in vitamins and minerals supports optimal function of the immune system by providing antioxidants to slow damage of cells caused by free radicals (Lobo 2010) or assisting in T-cell production (Cohen 2017). 

Although, presently, we do not have data concerning nutritional factors in relation to the risk and severity of viral diseases such as COVID-19 the role of nutrition in immunity has been well established. For example, a study on the role of vitamin A in the treatment of measles in children found a reduced risk of mortality and pneumonia when vitamin A was administered over two days (D’Souza and D’Souza, 2002). The European Journal of Clinical Nutrition concluded that “Without adequate nutrition, the immune system is clearly deprived of the components needed to generate an effective immune response” (Marcos et al, 2003). Good nutrition is thus important in supporting an optimum immune system which can reduce the risk of viral infections (Beck and Levander, 2000).

It is now recognized that the complex, integrated immune system requires several micronutrients that have essential, often synergistic roles at every phase of the immune response (Gombart et al, 2020). In fact, even marginal deficiencies in certain nutrients have been shown to impair the immune system (Gombart et al, 2020). Micronutrients are believed to work collectively to support an optimum immune system. Based on a variety of systematic and clinical data, vitamins AB6, B12C, D, E, folate, zinc, iron, copper, and selenium (read our Vitamin and Mineral: a brief guide) are particularly important to boosting immune response.

The chart below identifies the role of these vitamins in immunity and shares recommended amounts and sources in the diet. In a forthcoming post, we will highlight the important minerals supporting the immune system and the work Sight and Life has achieved over the past 30 years to ensure access to vital nutrients, especially for children and women of childbearing age.

*Current advice on supplementation concludes that consuming a balanced diet provides all the necessary nutrition required but where there are challenges in meeting dietary recommendations, supplements are a useful addition in helping meet our nutritional needs (EUFIC, 2020).

*Please note these are approximate values and can vary based on recommended reference values employed.

Interested in learning more, read Part II HERE.

References

Beck,MA and Levander, OA (2000) Host Nutritional Status and Its Effect on a Viral Pathogen The Journal of Infectious Diseases, Volume 182, Issue Supplement_1, Pages S93–S96 [Online] Available at: https://academic.oup.com/jid/article/182/Supplement_1/S93/2191642) (Accessed on 1st April 2020)

Cohen S, Danzaki K, MacIver NJ. Nutritional effects on T-cell immunometabolism. Eur J Immunol. 2017;47(2):225–235. doi:10.1002/eji.201646423

Charan, J; Goyal JP; Saxena, D and Yadav, P (2012) Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. J Pharmacol Pharmacother.3(4): 300–303. [Online] Available at:http://www.jpharmacol.com/article.asp?issn=0976-500X;year=2012;volume=3;issue=4;spage=300;epage=303;aulast=Charan (Accessed on 30th March 2020)

D’Souza RM and D’Souza R(2002). Vitamin A for treating measles in children. Cochrane Database Syst Rev.(1) [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/11869601 (Accessed on 8th April 2020)

EUFIC (2020) Food and coronavirus (COVID-19): what you need to know [Online] Available at: https://www.eufic.org/en/page/food-and-coronavirus-covid-19-what-you-need-to-know (Accessed on 2nd April 2020)

Gombart AFPierre A and Maggini S (2020). A Review of Micronutrients and the Immune System-Working in Harmony to Reduce the Risk of Infection. Nutrients, Vol 12 (1) [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/31963293. (Accessed on 29th March 2020)

Gysin DV, Dao D, Gysin CM, Lytvyn L, Loeb M (2016). Effect of vitamin D3 supplementation on respiratory tract infections in healthy individuals: a systematic review and meta-analysis of randomized controlled trials. PloS one.11(9).[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025082/ (Accessed on 1st April 2020)

Hemilä H, Louhiala P (2013). Vitamin C for preventing and treating pneumonia. Cochrane database of systematic reviews (Issue 8) [Online] Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005532.pub3/abstract (Accessed 2nd April 2020)

Song, H  Fall,K; Fang,F; Erlendsdóttir,H; Lu, D; Mataix-Cols, D; Fernández de la Cruz, L;  D’Onofrio; BM; Gottfreðsson,M; Almqvist, C; Unnur A Valdimarsdóttir (2019) Stress related disorders and subsequent risk of life threatening infections: population based sibling controlled cohort study. BMJ 367: l5784 [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812608/ (Accessed of 7th April 2020)

Charan, J; Goyal JP; Saxena, D and Yadav, P (2012) Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. J Pharmacol Pharmacother.3(4): 300–303. [Online] Available at:http://www.jpharmacol.com/article.asp?issn=0976-500X;year=2012;volume=3;issue=4;spage=300;epage=303;aulast=Charan  (Accessed on 30th March 2020)

Lee, GY and Nim Han, S (2018) The role of Vitamin E in Immunity. Nutrients 10(11): 1614 [Online] Available at :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6266234/ (Accessed on 2nd April 2020)

Lobo V, Patil A, Phatak A, Chandra N. Free radicals, antioxidants and functional foods: Impact on human health. Pharmacogn Rev. 2010;4(8):118–126. doi:10.4103/0973-7847.70902

Marcos, A., Nova, E. & Montero, A (2003). Changes in the immune system are conditioned by nutrition. Eur J Clinical Nutrition 57, S66–S69 [Online] Available at: https://www.nature.com/articles/1601819 (Accessed on 7th April 2020)

Meydani SN1, Han SN, Wu D. Vitamin E and immune response in the aged: molecular mechanisms and clinical implications. Immunol Rev.205pp:269-84.[Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/15882360 (Accessed on 8th April 2020)

Mikkelsen K., Apostolopoulos V. (2019) Vitamin B12, Folic Acid, and the Immune System. In: Mahmoudi M., Rezaei N. (eds) Nutrition and Immunity. Springer, Cham

Moriguchi S and Muraga M (2000) Vitamin E and immunity. Vitam Horm.(Vol 59) pp:305-36 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/10714244  (Accessed on 1st April 2020)

Patel SRMalhotra AGao XHu FBNeuman MIFawzi WW (2012) A prospective study of sleep duration and pneumonia risk in women. Sleep1;35(1):97-101 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/22215923(Accessed on 8th April 2020)

Rall LC  and Meydani SN (1993) Vitamin B6 and immune competence. Nutr Rev. Vol 51(8):217-25 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/8302491 (Accessed on 2nd April 2020)

Tamure; J; Kubota,K; Murakami H; Sawamura, M; Matsushima T; T;Tamura, Saitoh, T; Kurabayshi, H and Naruse, T(1999)  Immunomodulation by vitamin B12: augmentation of CD8+ T lymphocytes and natural killer (NK) cell activity in vitamin B12-deficient patients by methyl-B12 treatment Clin Exp Immunol Vol 116(1): 28–32.[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1905232/ (Accessed on 13th April 2020)

WHO (2020) Food and Nutrition tips during self-quarantine [Online] Available at: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/food-and-nutrition-tips-during-self-quarantine  (Accessed on 2nd April 2019)

World Health Organization (2020) WHO launches new global influenza strategy [Online] Available at: https://www.who.int/news-room/detail/11-03-2019-who-launches-new-global-influenza-strategy (Accessed on April 7th2020)

WHO (1998) Vitamin and mineral requirements in human nutrition Second edition. https://apps.who.int/iris/bitstream/handle/10665/42716/9241546123.pdf?ua=1

Zhiyi Huang;Yu Liu;Guangying Qi; David Brand and Song Guo Zheng (2018) Role of Vitamin A in the Immune System. J Clin Med  7(9): 258. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162863/(Accessed on 28th March 2020)

Zhou, Jian MD*; Du, Juan MD*; Huang, Leting MD; Wang, Youcheng MD; Shi, Yimei MD; Lin, Hailong MD(2018) Preventive Effects of Vitamin D on Seasonal Influenza A in Infants – A Multicenter, Randomized, Open, Controlled Clinical Trial The Pediatric Infectious Disease Journal Vol 37 (8) pp 749-754 [Online] https://journals.lww.com/pidj/fulltext/2018/08000/Preventive_Effects_of_Vitamin_D_on_Seasonal.5.aspx (Accessed on 2nd April 2011)

Opinion: Engaging nutrition to improve pregnancy outcomes

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On December 17, 2019, Devex published “Opinion: Engaging nutrition to improve pregnancy outcomes” by Klaus Kraemer, managing director of Sight and Life and adjunct associate professor at the Johns Hopkins Bloomberg School of Public Health. The full article can be read here on Devex.

Abstract

Good nutrition sets off a ripple effect. It can dismantle inequity, poverty, and poor health and drive progress at every stage in life. It supports physical and cognitive development, helps prevent a number of medical conditions — from spina bifida to diabetes — and saves lives.

During and after pregnancy, nutrition demands are greater — as are the consequences of not meeting them. For mothers, ensuring a healthy pregnancy limits the risk of life-threatening complications. And for their children, good nutrition during pregnancy can be the difference between being born healthy and being born physically or mentally disadvantaged.

It is critical that we sustain our momentum on nutrition, a task that requires greater investment in cultivating a cadre of leaders to take us there, argues Klaus Kraemer, director at Sight and Life.

While diet diversity remains the preferred means for women to meet nutrient requirements during pregnancy, many nutrient needs cannot be met through diet alone, especially in resource-constrained settings. As such, it is imperative that we reach women and girls with effective interventions for improving maternal nutrition that are ready for global scale-up now. Multiple micronutrient supplementation, or MMS, during pregnancy could be one way to help meet maternal nutrition needs.

Read the full article on Devex here.

Changing the Standard

Why Multiple Micronutrient Supplements in Pregnancy Are an Ethical Issue

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On 9 July 1999, the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the United Nations University (UNU) held a technical workshop at the UNICEF headquarters in New York to address widespread micronutrient deficiencies and high rates of anemia among pregnant women. Looking beyond iron and folic acid (IFA), the workshop designed a comprehensive prenatal supplement – or multiple micronutrient supplement (MMS) –that would be tested in effectiveness trials among pregnant women in low- and middle-income countries (LMICs). Thus, the United Nations International Multiple Micronutrient Antenatal Preparation – now commonly known by its acronym, UNIMMAP – was born.

Women, Family, children

The group at the workshop was, in many ways, before its time. They identified access to MMS as an inequity issue as stated in a report the group published after the workshop: “The high [micronutrient] needs of pregnancy are almost impossible to cover through dietary intake [alone] – in most industrialized countries, it is common for women to take multiple micronutrient supplements during pregnancy and lactation.” And the group discussed how MMS could impact other at-risk groups, particularly adolescent girls.
 
They also considered the needs of the women most in need – and reflected on the information at their fingertips. The UNIMMAP formulation consisted of1 RDA (Recommended Dietary Allowance for women 19-50 years during pregnancy and lactation) for 15 essential vitamins and minerals. But they correctly predicted that 1 RDA underestimated the requirements for populations in LMICs because they were based on dietary reference intakes from populations in the US and Canada, where nutritional statuses are stronger. In April, results from the JiVitA-3 study in rural Bangladesh (the largest ever trial comparing prenatal MMS to IFA) showed that 1 RDA, while reducing risks of preterm birth, low birth weight and still birth, and while improving micronutrient status, failed to eliminate deficiencies. Might 2 RDAs have had a greater effect on birth outcomes in an environment where poverty, poor diets and frequent infections prevail?

The bigger picture

Malnutrition – undernutrition, overweight, obesity, and micronutrient deficiencies – is a driver of intergenerational inequity, poverty, and poor health. It represents a significant barrier to equitable and sustainable social and economic development, in high- and low-income countries alike. However, many women and girls lack access to essential antenatal and postnatal care services, including micronutrient supplementation. This is especially true for women living in LMICs. While 62% of pregnant women globally receive at least four antenatal care visits, in regions with the highest rates of maternal mortality – such as sub-Saharan Africa and South Asia – only 52% and 46% of women in the respective regions receive the same services. Further coverage disparities exist between poor and rich, and rural and urban households. In South Asia and sub-Saharan Africa, the urban-rural gap in coverage of antenatal care visits exceeds 20 percentage points in favor of urban areas, and the richest 20% of the population are more likely to receive antenatal care than poorer women. Good nutrition and equitable rights for all women are mutually reinforcing, and with improved gender equality leading in turn to improved nutrition.

We see this uneven and sub-optimal maternal care reflected in infant birthweight. A new study by the London School of Hygiene & Tropical Medicine (LSHTM), the WHO, and UNICEF finds that there has been minimal progress on reducing the number of babies born low birthweight (LBW), meaning they weigh less than 2,500 grams (5.5 pounds) at birth – a cause for alarm given that LBW increases the risk of newborn death, stunted growth, developmental delays, and conditions such as heart disease and diabetes later in life. As the mother’s micronutrient requirement increases during pregnancy in order to support the growth of the fetus, maternal undernutrition during pregnancy is closely linked with LBW.In 2015, 14.6% of all births worldwide, or 20.5 million babies, were born with LBW, the majority in sub-Saharan Africa and South Asia. Urgent action is needed to get the world on track to meet global goals on LBW, and maternal nutrition must be at the center of this effort.

Time for a change

To help meet women’s increased nutritional demands during pregnancy, the WHO recommends IFA as the current standard of care for pregnant women – but the policy has not changed in 50 years. The most recent 2016 WHO Antenatal Care (ANC) Guidelines, however, opened a window for MMS. The guidelines counsel against the use of MMS due to “some evidence of risk, and some important gaps in evidence,” but stipulate that “policymakers in populations with a high prevalence of nutritional deficiencies might consider the benefits to outweigh the disadvantages [such as cost], and may choose to give multiple micronutrient supplements that include iron and folic acid.”
 
Since 2016, the scientific community has met all the WHO’s concerns regarding risk and evidence. Compelling scientific evidence shows that taking MMS during pregnancy reduces the risk of maternal anemia and reduces the likelihood of a child being born LBW and too small. Anemic and underweight women benefit even more from MMS and have reduced risk of infant mortality and preterm births compared with mothers taking only IFA. Furthermore, recent research shows that MMS can reduce the gender imbalance in terms of the survival of female neonates compared with IFA supplementation alone, and that it represents an opportunity to invigorate maternal nutrition by putting women at the center of antenatal care.

The push for progress

The Women Deliver Conference (Vancouver, 3–6 June 2019) will be the world’s largest conference on gender equality, so Sight and Life and other leading organizations are working to elevate MMS. At Women Deliver, Sight and Life has partnered with the Children Investment Fund Foundation (CIFF), Kirk Humanitarian, 1,000 Days, Vitamin Angels, and the Multiple Micronutrient Supplement Technical Advisory Group (MMS TAG) – to host a side-event to make the case for MMS and build support behind the movement to update the global recommendations on MMS. This event, named Power for Mothers, will capitalize on the gathering of global leaders, key influencers, decision-makers, civil society and donors as part of the Women Deliver conference.

I firmly believe that, after 20 years of research and some 20 studies and meta-analyses comparing IFA and MMS on birth outcomes, it is unethical to further withhold MMS from pregnant women in low-resource settings. The MMS TAG (to which I belong) has documented the clear scientific advantage of MMS over IFA and the safety of MMS for mothers and their children, and has shown that the provision of prenatal MMS is a cost-effective intervention. Not only is MMS cost-effective, but it has also achieved cost parity.
 
It is no wonder why some early-riser countries with widespread micronutrient deficiencies have requested implementation research and donations of MMS for the successful replacement of IFA in their health sector. The time is now to adapt global and national guidelines to the overwhelming evidence. Disparities in antenatal care including the provision of MMS are no longer acceptable.

Email: klaus.kraemer@sightandlife.org
 
 
 
 

Cracking the Egg Potential

Working to Reduce Child Stunting and Improve Rural Livelihoods

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Eggs are among “nature’s first foods”, designed to holistically support early life and development. They are among the richest sources of essential amino acids, protein, choline, and long- chain fatty acids (DHA).  They are also an important source of some vitamins and minerals, including vitamin A, B2, B5, B12, selenium, phosphorous and zinc, and contain other bioactive factors. In a symposium chaired by Chessa Lutter from RTI International and the University of Maryland School of Public Health and Saul Morris from the Global Alliance for Improved Nutrition (GAIN), and sponsored by the Child Investment Fund Foundation (CIFF) at the International Congress of Nutrition (ICN 2017) in Buenos Aires, the potential of eggs to improve child nutrition and rural livelihoods was debated. 

Eggs

The Science Behind the Egg

For a full-packed symposium hall, Lora Iannotti from Washington University, presented findings from the Lulun Project, a randomized controlled trial in Ecuador, where eggs were given to children 6 to 9 months of age.  After only 6 months, linear growth was improved and stunting was reduced by 47% in the group receiving eggs –  an effect larger than those of any other complementary feeding interventions to date. The trial also showed significant  improvements in concentrations of biomarkers associated with cognitive development including  choline, betaine, methionine and DHA.  Currently, a replication study is on its way in Malawi that also includes assessments of child development.

In rural Ghana, poultry-based income generation activities embedded in an integrated agricultural and nutrition education intervention also led to improved egg consumption, dietary diversity and linear growth among young children. Dr Grace Marquis from McGill University presented the preliminary results of this intervention, in which households with infants up to 12 months of age received multiple agricultural and infant feeding interventions, including education and training on poultry, home gardens and beekeeping. Dr Marquis and her team are currently working with district partners on the sustainability of the intervention by helping women form farmer associations, opening opportunities for access to credit from the local rural bank, and strengthening technical assistance from government health and agriculture extension services.

Creation of demand and overcoming social and cultural taboos preventing mothers and caregivers from giving eggs can be major barriers to overcome when promoting the use of eggs for young child feeding. A key element of the previously described RCT in Ecuador — an intensive social marketing strategy — was described by Carlos Andres Gallegos Riofrío of Washington University. The project was branded as “Lulun”, which translates into ‘egg’ in the local indigenous language, and symbolically tied the practice of giving eggs to young children with indigenous worldviews. The strategy followed a structured process targeting all the six P’s in successful marketing: people, product, place, price, promotion and policy change. Creating a successful brand, brand loyalty and empowerment of mothers and caregivers to take decisions on their child feeding were critical for the successful and continued behavior change and central to the success of the study in improving egg consumption and child growth.

Availability of Eggs

To make eggs available and affordable to low-income households, small holder poultry business models need to be viable. Klaus Kraemer of Sight and Life presented the findings from a scoping study in Kenya, Ethiopia, Malawi and India demonstrating the potential of four types of business models to be viable at-scale:  

(1)  Micro-Financing institutions that provide a small credit to underserved poultry entrepreneurs coupled with peer group support, technical, and business skill training. Such credit helps backyard poultry farmers set-up and operate micro-enterprises.

(2)  The Out-Grower Model: a partnership between smallholder poultry farmers and commercial players to improve the productivity of hens.  

(3)  In the Enterprise Development Model, an established local input supplier organizes smallholder farmers into groups and helps them invest in mid-size poultry enterprises. With relevant training, market support and funding, they manage businesses that not only generate profits, but also succeed in improving the availability of high quality eggs in their community.

(4)  The One-Stop Hub Model is a distribution and aggregation platform tailored for a rural environment. It is a combination of the above three models, and goes one-step further by providing a marketing channel for eggs to be accessible even in hard-to-reach rural areas.

All of these models were successful and in some contexts even hugely profitable. In Malawi, for instance, women farmers in the Enterprise Development Model, can each earn an average income of US$1130 per year!

Chicken

Finally, Emily Lloyd of the One Acre Fund demonstrated the importance of rigorous piloting before moving to scale to tackle issues with selection of the most appropriate chicken-breed in a particular setting, appropriate housing and vaccinations of chickens to prevent spread of poultry-related infectious diseases in the participating households, as well as distribution and financing challenges.

The Challenges

In a lively discussion, some important suggestions were raised by the audience. These included the potential to improve egg consumption in other vulnerable target-groups, in particular pregnant and lactating women, the need for behavioral change strategies and other interventions to prevent the spread of poultry-related infectious disease to the household, concerns about allergies, considerations of equity when rolling-out poultry business models and how to improve sustainability when these programs and interventions are further scaled-up.

Saul Morris, GAIN’s Director for Policy and Planning, concluded that the potential of egg and poultry interventions to impact child’s nutrition and improve rural livelihoods is ‘egg-citing’ and has been underexplored and appreciated. The symposium clearly demonstrated that together, interventions to improve young child egg intake and household and community egg production could radically reduce the global prevalence of stunting and improve livelihoods of the rural poor. The next challenge will be to bring these interventions to scale, and fulfill the promise that by 2020, 10 million eggs will be delivered to young children annually, as a key component of complementary feeding.

Watch the complete ‘Cracking the Egg’s Potential to Improve Child Growth and Development’ presentation from the 2017 ICN IUNS and access the linked research here on SecureNutrition’s website. For additional information on eggs read ‘Cracking the Egg Potential During Pregnancy and Lactation‘ featured in the Sight and Life magazine on Women’s Nutrition and ‘Eggciting Innovations‘ on our blog. 

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