Challenges of Ensuring Dietary Diversity and food density in developing regions

Peter Ngwatu, MBCHB, MMed, Fell Paed Gastro

Lecturer, Department of Pediatrics and Child Health, KenyattaUniversity, Kenya

P.O.Box 9715-00202, Nairobi

Email;pngwatu@yahoo.com

Abstract

Nutrition is a major component in human development and the influence on growth and development begins during pregnancy, through breastfeeding, during complementary feeding and family food .Pregnancy and the pediatric population are vulnerable to malnutrition due to their increased nutrient requirement and therefore a variety of foods in their diet is considered imperative in ensuring adequate nutrient intake.

Food security encompasses both physical and economic access to sufficient food which meets dietary needs for a productive and healthy life for all the people and at all times.

Dietary diversity reflects nutrient adequacy since no one food can meet 100% nutritional requirement for a person.

In sub- Sahara Africa, poor access to health services, limited resources and poor infrastructure are the major contributors to malnutrition and food insecurity.

With climate change, the frequency of drought and flash floods is expected to increase in both intensity and spread. Bearing in mind that Africa is predominantly practicing rain fed agriculture, this phenomenon of climate change will have a great impact on food availability.

Rising global fertilizer prices, high energy costs, globalization in addition to climate change are all having a major impact on food affordability. This therefore makes poor people be limited in food choices, further limiting their consumption and even shift to even less balanced diets and less frequent meals thereby affecting health and nutrition.

There are many sources of dietary information which has had great influence on food choices and has contributed to both under and overnutrition.This ranges from cultural practices passed down generation to generation, a growing multitude of both printed and electronic media, food industry, government and professional bodies.

Nutrition related behavior is greatly influenced by culture and environment, and the adoption of new ways of feeding depends on the ability to integrate the new practices into the already embedded knowledge systems. Hence understanding the local nutrition knowledge systems about dietary diversity becomes empirical in trying to formulate messages which would be accepted and this would go a long way in improving nutrition education.

Inadequate access to credit, poor marketing, transportation and distribution of food produce also affects overall food production and availability. 

Key words; Food security, food diversity, poor infrastructure, malnutrition

LITERATURE REVIEW

Nutrition is a major component in human development and the effects are seen in all stages of our lives, right from conception to old age. This influence on growth and development in essence begins during pregnancy, through breastfeeding, thereafter complimentary feeding and feeding of the older child. Therefore a nutritional challenge during pregnancy, breastfeeding, complimentary feeding and family foods has great impact on the fetus, infant and the child.

Dietary diversity reflects nutrient adequacy since no one food can meet 100% nutritional requirement of a person. A diet meeting energy requirement and all essential nutrients is essential for appropriate growth and development of the child (1). Pregnant women and the pediatric population have been considered vulnerable to malnutrition due to their increased nutrient requirement and therefore a variety of foods in their diet is considered imperative in ensuring adequate nutrient intake.

Food security entails a situation where all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life. (2)

 The challenge of malnutrition persists despite the number of people suffering from hunger and undernutrition globally having reduced significantly over the past 25 years. Globally, About 25% of under-fives are stunted, and almost 50%of the deaths in this cohort are due to effects of malnutrition, with majority of this occurring in developing countries. (3)Stunting, the impaired height for age, results from not eating enough or inadequate diet.

On the flip side, over nutrition rates are increasing rapidly in developing countries. At 42% prevalence of obesity among women, South Africa is leading in Sub-Sahara Africa (4).Obesity is recognized as one of the major risk factors of Non-communicable disease NCDs,as they contribute to 37% of all-cause mortality especially type 2 diabetes melitus,osteoarthritis,heart disease in South Africa(5).South Africa in the same breath battles with food insecurity and micronutrient deficiency;28% of population were at risk of hunger,26% of 1-3 year olds were stunted (6).

The changing systems and food environment immensely contributes to the rising prevalence of obesity. There is an increased supply of ultra- processed food products UPPs which are often energy dense, but nutrient poor (7).UPPs high content of fat, sugar, salt and additives make them highly palatable. The high palatability, omnipresence, desirable convenience and aggressive marketing make UPPs drivers of changing dietary patterns promoting NCDs (7).Concept of food has changed from means of nutrition to a marker of lifestyle and a source of pleasure.

In the last 30 years or so, the population of overweight/obese people in Africa and those with associated diet related chronic disease has significantly been on the rise and is also shifting towards groups of lower socioeconomic status. This is a result of nutrition transition, the increasing consumption of fats, sweeteners, energy dense foods, and highly processed food compared to traditional foods which has been occasioned partly by globalization. Globalization has made high calorie, nutrient poor foods more readily available, accessible and acceptable to a greater proportion of the world’s population. This in addition to increased opportunity to desire and consume such foods.

In Kenya, the scenario is much more reflective of the global trends, faced with a burden of both under nutrition and over nutrition; 26% of under five are stunted, 4% are wasted and 11% are underweight, and the  consumption of minimum acceptable diet among children aged 6-23 months dropped from 39% to 31% when comparing KDHS 2008 and 2014.(8).

Similar to other parts of the world, Non communicable diseases NCDs are an increasing public health concern in Kenya accounting for more than 50% of total hospital admissions and over 55% of hospital deaths(8).

Ensuring healthy diets will be the cornerstone of long term sustainable practices for overcoming malnutrition.

The median month in pregnancy at first Antenatal clinic ANC visit is 5.1 months, and only 20% of pregnant mothers present before 4 months. And of those who attend ANC, only 58% make the recommended 4 visits during pregnancy. With regards to micronutrient supplementation during pregnancy, 60% took iron supplementation and of these 50% took for less than 60 days and only 8% took for more than 90 days. This is despite the fact that of those who manage to attend ANC, 90% of them are seen by a skilled health care provider, this being a doctor, nurse or midwife.(8).

With the understanding that optimal nutrition is critical for the mother and her developing fetus, in the face of late presentation, low uptake of services for those who make for the visits thendietary counselling and supporting interventions through focused antenatal care which is an essential package for improving nutrition will not have desired impact.

Of the mothers 15-49 years interviewed, 37% cited low finances and 23% reported distance to the health facility, while 11% reckoned not wanting to go alone contributed to their inability to access health facility for medical advice and care during pregnancy.

The low uptake of Antenatal care services is compounded by the fact that only 60% of mothers deliver in health care facilities, about 52% of these born in health facility do not receive postnatal checkups,49% of women received postnatal care from a doctor, nurse or a midwife and only 60% exclusive breastfeeding rate. The categories of infants exclusively breastfed decreases sharply from 84 % of infants age 0-1 month to 63 %of infants age 2-3 months and, further, to 42% of infants age 4-5 months. Improving the mother’s knowledge, incomes, information access, quality of antenatal and postnatal care service, are important to improving the exclusive breastfeeding. This can be achieved by increased access to health facility for both antenatal and post-natal care.

The skill level of the person who provides the first postnatal checkup has important implications for maternal and neonatal health.

Nutritionists and dieticians are the cadre of healthcare professionals trained to provide nutritional care and dietary advice with the ultimate goal of achieving optimal health. The numbers of this special cadre of health care providers is limited in the health care facilities hence majority of mothers attending antenatal and postnatal care services, will be majorly served by the nursing staff. (9) Nurses were perceived as having the necessary expertise in maternal care and also a trusted source of nutrition information and advice by pregnant mothers. 

A study on knowledge of maternal nutrition, attitude and practices among nurses working at Kenyatta national hospital showed that despite their knowledge on maternal nutrition being above average and having a positive attitude towards maternal nutrition care, their practices seemed to contradict their knowledge and attitude revealing a missing link. (10)

Adequate nutrition during breastfeeding helps a mother maintain her health and also optimize on nutrients for the dependent infant.A healthy diet during breastfeeding also helps establish healthy eating habits for the whole family including the baby who will soon be transitioning through complementary foods to family.

The nutrients in breastmilk are sourced from maternal diet or maternal stores.The carbohydrate, protein, fat, calcium and iron levels in breastmilk are more or less constant, and these are maintained even at the expense of the mother. Such that if maternal diet is not well managed then the mother will end deficient and this puts her health and that of the next pregnancy at risk of poor growth and development. A mother whose diet is deficient in thiamine and vitamins A and D, however, produces less of these in her milk. The mother should be given advice on consuming a mixed diet. At each postnatal visit, both the mother and the baby should be examined, and advice on the diets of both mother and infant should be provided.

Considering that only about 42% of infants will be exclusive breastfeeding at 4-5 months age, it follows then about 60% will already have initiated complementary feeding, much earlier than the recommended 6 months age of initiation. The Kenya Demographic Health Survey 2014 reports that only 22%of infants are fed in accordance with Infant and Young child feeding practices; so they initiate earlier than recommended and still about 80% did not meet the set standards.(8)

The achievement of national food security is to be a key objective of the agricultural sector. Food security in this case is defined as “ a situation in which all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life” (11).In the recent years, and especially starting from 2008, the country has been facing severe food insecurity problems. These are depicted by a high proportion of the population having no access to food in the right amounts and quality. In Kenya about 52% of the population is poor, predominantly an agricultural country which relies mainly on agriculture for its development and livelihood. This sector confronted by a host of problems among them occasional droughts which affect small scale farmers 'access to food(12)

The current food insecurity problems are attributed to several factors, including the frequent droughts in most parts of the country, high costs of domestic food production due to high costs of inputs especially fertilizer, displacement of a large number of farmers in the high potential agricultural areas following the post-election violence which occurred in early 2008, high global food prices and low purchasing power for large proportion of the population due to high level of poverty.

Food security has a major impact on ability to provide dietary diversity to the population. Food security here being defined as a situation in which all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life (11). In the last 10 years, Kenya has been facing severe food insecurity problems, this being depicted by a high proportion of the population having no access to food in the right amounts and quality. 

The frequent droughts in most parts of the country, high costs of domestic food production due to high costs of inputs especially fertilizer, high global food prices and low purchasing power for large proportion of the population due to high level of poverty are some of the major contributors of food insecurity.
Maize is the most important cereal crop in Kenya and is the main staple food of the country which provide more than one-third of the caloric intake

Wheat is the second most important staple food in Kenya, which accounted for 17% of staple food consumption. Beans are the third most important staple food nationally; accounting for 9% of staple food calories and 5% of total food calories in the national diet 

The major cause of the high prevalence of micronutrient deficiencies among low and middle income countries is low intake due to monotonous diets also known as staple diets.The availability of cheap cereal foods together with the loss of agricultural biodiversity has resulted in reduced dietary diversity (13). Hence the clamor to raise awareness and promote the role that agricultural biodiversity plays in the lives of people, particularly those in low income countries after the UN General assembly recognized 2010 as the international year of biodiversity (Food and Agriculture Organization (FAO) 2010) .The dietary intake of fats and oils in Africa meals tends to be low as refined oils and animal foods are expensive for the larger proportion of the population; fat consumption in Swaziland is 14% of total intake compared to 15-35 % as the recommended guidelines 15.(Huss-Ashmore and Curry 1994).

New maize varieties have been bio-fortified with pro-vitamin A, mainly a-carotene, which renders the grain yellow or orange.The main target beneficiaries of bio-fortified crops are poor rural farm households: their diets depend on home grown staples with low nutritional quality, they have little access to other sources of nutritious food, and they are hard to reach through other interventions. 

 Bio-fortified crops, bred for improved nutritional quality, can alleviate nutritional deficiencies if they are produced and consumed in sufficient quantities. Unfortunately the uptake of bio-fortified crops has been on the low uptake in Kenya, this is occasioned by lack of information to the farmers, availability of the improved seeds and the cost of the seeds too. Hence we stick to the staple crop whose yield is reducing yearly, poorer quality of protein and vitamin, and in the end result poor nutrient uptake and leading to malnutrition in the population

Soil micronutrient deficiencies including N,P,K ,Ca,Mg,Zn,Fe,Cu(Vanlauwe et al., 2015)limit crop productivity and nutritional quality of foods, which together affect nutrition and human health (Sanchez and Swaminathan, 2005).Mineral micronutrient fertilizer use is currently limited in developing countries due to general issues of cost and supply, weak infrastructure, the lack of information on micronutrient problems, a reliable fertilizer recommendation system, and the poor availability of micronutrient fertilizers. The resultant low crop productivity will manifest as food scarcity, and poor nutritional quality would consequently end up with malnutrition.

Dietary habits are influenced by a combination of various factors including, knowledge, social-cultural factors, psychological factors environmental context, and resources [8).Health behavior change has a wider influence circle as it often shaped by factors such as social and cultural context that are beyond the control of the individual, and therefor change goes beyond convincing people to act in a more rational manner.While traditional diets are often quite healthy [9], social, cultural and economic change in many places has led to dietary transitions associated with decreasing quality of diets [10). In study in Nigeria factor selected as having influence on food choice, 56% was food habit, followed by price of food at 34% and taste of food at 32%(10).

CONCLUSIONS
Understanding what constitutes healthy eating can help people to consume 
the right type, quality and quantity of foods. This should be a constant consideration when information on diet is disseminated to the people since

nutritional needs continuously change throughout the life cycle and hence family eating habits should be adapted to fit in with the needs of individual family member. 

The trickle down of information from the experts to the health care workers and eventual to the public would do lot of justice in taming malnutrition in our set up. The effort toward establishment of food based dietary guidelines will help on the public understanding health messages.

With Africa predominantly agricultural with reliance on rain fed agriculture, small scale farming, increasing cost of farm inputs and high post-harvest loss, there will be great need for bio fortification of seeds, ensuring food reserves are sustained for the population, and micronutrient food supplementation is encouraged.

References
1.National Food and Nutrition Security Policy of 2011.
2. World food summit 1996
3. UNICEF data monitoring the situation of children and women
4. Ng et al,2014
5. Puoane et al 2012
6. Shisana et al 2014
7. Monteiro et al 2013
8.The 2014 Kenya Demographic Health Survey (KDHS
9.Szwajcer, 2009, 
10.sitati A study on knowledge of maternal nutrition, attitude and practices among nurses working at Kenyatta national
11.(Kenya Food Security Steering Group, 2008).
12.(Ogutu, 2012).
13.(Frison et al. 2005)

8.Contento IR, Randell JS, Basch CE. Review and analysis of evaluation measures used in nutrition education intervention research. J Nutr Edu Behav. 2002;34:2–25. doi: 10.1016/S1499-4046(06)60220-0

9.Kuhnlein H. Introduction: why are indigenous Peoples’ food systems important and why do they need documentation? In: Kuhnlein HV, Erasmus B, Spigelski D, editors. Indigenous peoples’ food systems: the many dimensions of culture, diversity and environment for nutrition and health. Rome, Italy and Montreal: Food and Agriculture Organization of the United Nations and the Centre for Indigenous Peoples’ Nutrition and Environment; 2009.

10.Ngwu et al,Nutrition Knowledge, Quality of Diet and Factors Influencing Food Selection in a University Community ]HER Vol. 8, No. %&2, 2007, p. 224-232