Food Systems Interventions for Nutrition: Lessons from 6 Program Evaluations in Africa and South Asia.

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.

How Livelihood Change Affects Food Choice Behaviors in Low- and Middle-Income Countries: A Scoping Review.

Livelihoods have changed dramatically over the past decade in low- and middle-income countries (LMIC). These shifts are happening in tandem with shifts in individual and household food choice behaviors. This scoping review aimed to identify and characterize mechanisms through which livelihood changes could affect food choice behaviors in LMIC, including behaviors relating to food production, acquisition, preparation, distribution, and consumption. A literature search was conducted using 4 databases: PubMed, PsycInfo, AGRICOLA, and Embase. The search was further enhanced by expert solicitations. Studies were included if they measured or focused on a livelihood change, described or assessed a change in ≥1 food choice behavior, and focused on LMIC. Studies were excluded if they focused on migration from LMIC to a high-income country. Of the 433 articles that were identified, 53 met the inclusion criteria. Five mechanisms of how livelihood change can affect food choice were identified: occupation, locality, time, income, and social relations. Changes in occupation altered the balance of the availability and affordability of foods in local food environments compared with individual food production. Changes in location, time use, and income influenced where food was purchased, what types of foods were acquired, and how or where foods were prepared. Additionally, changes in social relationships and norms led to expanded food preferences, particularly among urban populations. Time limitations and higher discretionary income were associated with consumption of ultraprocessed foods. Understanding the relationships between the changes in livelihood occuring in LMIC and food choices of households in these countries can inform the development of policies, programs, and other actions to promote sustainable healthy diets and planetary health.

Identifying and understanding barriers to optimal complementary feeding in Kenya.

Optimal complementary feeding between the ages of 6 and 23 months provides children with the required range of nutritious and safe foods while continuing to be breastfed to meet their needs for essential nutrients and develop their full physical and cognitive potential. The rates of exclusive breastfeeding in the first 6 months of life have increased from 32% in 2008 to 60% in 2022 in Kenya. However, the proportion of children between 6 and 23 months receiving a minimum acceptable diet remains low and has declined from 39% in 2008 to 31% in 2023. The Kenyan Ministry of Health, GAIN and UNICEF collaborated to understand the drivers of complementary feeding practices, particularly proximal determinants, which can be directly addressed and acted upon. A secondary analysis of household surveys and food composition data was conducted to outline children's dietary patterns within the different regions of Kenya and the extent to which the affordability of animal-source foods could be improved. Ethnographic data were analyzed to identify socio-cultural barriers to optimal complementary feeding. Furthermore, we outlined the critical steps for developing user-friendly and low-cost complementary feeding recipes. The results of all the analyses are presented in five of the six papers of this Special Issue with this additional paper introducing the Kenyan context and some of the critical findings. The Special Issue has highlighted multidimensional barriers surrounding the use and availability of animal-source foods. Furthermore, it emphasizes the need for a multi-sectoral approach in enacting policies and programmes that address these barriers.

Modelling policies to improve affordability and consumption of nutritious foods for complementary feeding in Kenya.

In Kenya 26% of children under age 5 experience stunted growth, 4% are wasted and 11% are underweight. In pregnant women, the prevalence of iron deficiency is 36% and iron-deficiency anaemia prevalence is 26%. Previous studies have identified affordability as a key barrier to the intake of nutrients, particularly from animal-source foods (ASFs). Thus, this study analyzes to what extent the affordability of ASF in Kenya can be improved. It focuses on four ASFs: eggs, milk, chicken and beef. Using a computable general equilibrium model, three policy simulations were undertaken to establish the impact of potential changes on nutritious ASF availability and affordability: a 20% increase in total factor productivity (TFP) for the four products; a 20% TFP increase plus a 25% reduction in trade and transportation margins; and a 20% TFP increase for ASF and maize (a key input in animal feed). Simulations suggest increasing the productivity of the four ASF products would increase their availability and lower consumer prices (up to 17% lower). Household consumption of the four commodities would increase, resulting in improved household dietary diversity. Rural households would gain more compared with urban households. Poor households (the lowest 40%) would register larger welfare (Equivalent Variation) gains than other households in both urban and rural areas. The richest 20% of the population would neither lose nor gain following the policy changes. Reducing transportation costs and trade margins and increasing maize productivity could further reduce the price of ASFs through lower production costs and increased consumption.

Improving complementary feeding practices, programs and policies for optimal early childhood nutrition in Kenya: What would work?

Complementary feeding practices are greatly influenced by local contexts. Therefore, national home-grown evidence, policies and guidelines are critical to improving infant and young children's diets. This Special Issue has provided a comprehensive, evidence-based analysis of the situation, gaps and context-specific opportunities for improving young children's diets in Kenya. The primary research findings of the Special Issue supported the identification of a set of recommendations articulated across the four systems (food, health, water, sanitation and hygiene [WASH] and social protection) to improve food availability and accessibility in Kenya at the national and subnational levels. It is anticipated that the decentralised government functions seen in Kenya provide a strong opportunity to develop and mainstream context-specific recommendations into action. This Special Issue recommends adopting a multi-sectoral systems approach, including a shared vision, joint planning, implementation and monitoring, towards improving young children's diets with a focus on service delivery as well as scaled-up community social behaviour change interventions. In particular, the approach should entail advocacy for policy revisions for service delivery that support complementary feeding and development of costed implementation strategies in support of the same, across four critical systems-food, health, WASH and social protection, along with, the strengthening of national coordination, monitoring and accountability structures as per the Kenya Nutrition Action Plan. Finally, the development of a legal framework for enhanced accountability from all relevant sectors towards sustainable, nutritious, safe and affordable children's diets. These recommendations provide a clear direction in addressing the complementary feeding challenges, which the primary research of this Special Issue has presented.

Leveraging Emotion for Behavior Change: Lessons from Implementation of the "Emo-Demo" Behavior Change Technique in Rural Mozambique.

Innovative social behavior change communication (SBCC) can help improve child nutrition, but little is known about the process of implementing innovative nutrition SBCC strategies in resource-poor settings and associated challenges. This research study examines emotional demonstrations (Emo-Demos), interactive game-like group activities that aim to spark behavior change by pulling emotional levers. It seeks to determine whether they are feasible and acceptable for implementers and targeted community members in rural Mozambique, aiming to draw lessons for the application of similar highly interactive SBCC approaches in resource-poor settings-a key equity issue. This is done through a series of structured observations of the approach being delivered in seven communities as well as interviews with facilitators and participants. Results show the Emo-Demos were generally feasible to implement as planned and largely acceptable for both facilitators and participants. However, facilitators did not always understand the theory behind them, the importance of them being interactive, and the exact steps that needed to be followed to do them correctly. Participants universally reported enjoying the sessions and understood the lessons taught, and were able to translate them into potential behavior changes. However, few reported the expected emotional reaction to the sessions, and some had difficulty understanding the symbolic use of props in the exercises. The results underline the importance of strong training of SBCC facilitators, including on underlying theory; adapting approaches to local realities; and considering the incentives for participants to attend. These steps can help ensure high-quality SBCC that functions even in resource-poor settings, increasing intervention equity.

The state of food systems worldwide in the countdown to 2030.

This Analysis presents a recently developed food system indicator framework and holistic monitoring architecture to track food system transformation towards global development, health and sustainability goals. Five themes are considered: (1) diets, nutrition and health; (2) environment, natural resources and production; (3) livelihoods, poverty and equity; (4) governance; and (5) resilience. Each theme is divided into three to five indicator domains, and indicators were selected to reflect each domain through a consultative process. In total, 50 indicators were selected, with at least one indicator available for every domain. Harmonized data of these 50 indicators provide a baseline assessment of the world's food systems. We show that every country can claim positive outcomes in some parts of food systems, but none are among the highest ranked across all domains. Furthermore, some indicators are independent of national income, and each highlights a specific aspiration for healthy, sustainable and just food systems. The Food Systems Countdown Initiative will track food systems annually to 2030, amending the framework as new indicators or better data emerge.

How Perspectives on Food Safety of Vendors and Consumers Translate into Food-Choice Behaviors in 6 African and Asian Countries.

Background: Consumption of unsafe foods increases morbidity and mortality and is currently an issue, particularly in low- and middle-income countries. Policy actions to ensure food safety are dominated by mitigation of biological and chemical hazards through supply-side risk management, lessening the degree to which consumer perspectives of food safety are considered. Objectives: This study aimed to provide an in-depth understanding, from vendor and consumer perspectives, of how food-safety concerns of consumers translate into their subsequent food-choice behaviors in 6 diverse low- and middle-income countries. Methods: Six Drivers of Food Choice projects (2016-2022) provided transcripts from 17 focus group discussions and 343 interviews conducted in Ghana, Guinea, India, Kenya, Tanzania, and Vietnam. Qualitative thematic analysis was used to identify emerging themes important to food safety. Results: The analysis suggests that consumers constructed meaning about food safety through personal lived experience and social influences. Community and family members contributed knowledge about food safety. Concerns about food safety were influenced by reputations of and relationships with food vendors. Consumers' mistrust of food vendors was amplified by purposeful adulteration or unsafe selling practices and new methods used to produce food. Moreover, consumers were reassured of food safety by positive relationships with vendors; meals cooked at home; implementation of policies and following regulations; vendor adherence to environmental sanitation and food-hygiene practices; cleanliness of vendors' appearance; and vendors' or producers' agency to use risk mitigation strategies in production, processing, and distribution of food. Conclusions: Consumers integrated their meanings, knowledge, and concerns about food safety to achieve assurance about the safety of their foods when making food-choice decisions. The success of food-safety policies hinges on consideration of consumers' food-safety concerns in their design and implementation, alongside actions to reduce risk in food supply.

Friend or Foe? The Role of Animal-Source Foods in Healthy and Environmentally Sustainable Diets.

Scientific and political discussions around the role of animal-source foods (ASFs) in healthy and environmentally sustainable diets are often polarizing. To bring clarity to this important topic, we critically reviewed the evidence on the health and environmental benefits and risks of ASFs, focusing on primary trade-offs and tensions, and summarized the evidence on alternative proteins and protein-rich foods. ASFs are rich in bioavailable nutrients commonly lacking globally and can make important contributions to food and nutrition security. Many populations in Sub-Saharan Africa and South Asia could benefit from increased consumption of ASFs through improved nutrient intakes and reduced undernutrition. Where consumption is high, processed meat should be limited, and red meat and saturated fat should be moderated to lower noncommunicable disease risk-this could also have cobenefits for environmental sustainability. ASF production generally has a large environmental impact; yet, when produced at the appropriate scale and in accordance with local ecosystems and contexts, ASFs can play an important role in circular and diverse agroecosystems that, in certain circumstances, can help restore biodiversity and degraded land and mitigate greenhouse gas emissions from food production. The amount and type of ASF that is healthy and environmentally sustainable will depend on the local context and health priorities and will change over time as populations develop, nutritional concerns evolve, and alternative foods from new technologies become more available and acceptable. Efforts by governments and civil society organizations to increase or decrease ASF consumption should be considered in light of the nutritional and environmental needs and risks in the local context and, importantly, integrally involve the local stakeholders impacted by any changes. Policies, programs, and incentives are needed to ensure best practices in production, curb excess consumption where high, and sustainably increase consumption where low.

Limitations of the Food Compass Nutrient Profiling System.

Nutrient Profiling Systems provide frameworks to assess the healthfulness of foods based on food composition and are intended as inputs into strategies to improve diets. Many Nutrient Profiling Systems are founded on a reductionist assumption that the healthfulness of foods is determined by the sum of their individual nutrients, with no consideration for the extent and purpose of processing and its health implications. A novel Nutrient Profiling System called Food Compass attempted to address existing gaps and provide a more holistic assessment of the healthfulness of foods. We propose that the chosen algorithm is not well justified and produces results that fail to discriminate for common shortfall nutrients, exaggerate the risks associated with animal-source foods, and underestimate the risks associated with ultraprocessed foods. We caution against the use of Food Compass in its current form to inform consumer choices, policies, programs, industry reformulations, and investment decisions.

Engaging men in maternal, infant and young child nutrition in rural Tanzania: Outcomes from a cluster randomized control trial and qualitative study.

There is growing recognition that engaging men in maternal, infant and young child nutrition (MIYCN) interventions can benefit child health and disrupt harmful gender norms. We conducted a cluster-randomized controlled trial in Tanzania, which engaged men and women in behaviour change via mobile messaging (short message service [SMS]) and traditional interpersonal communication (IPC), separately and in combination. Here, we evaluate intervention effects on individual-level men's MIYCN knowledge and discuss barriers to male engagement. Eligible clusters were dispensary catchment areas with >3000 residents. Forty clusters were stratified by population size and randomly allocated to the four study arms, with 10 clusters per arm. Data on knowledge and intervention exposure were collected from 1394 men through baseline and endline surveys (March-April 2018 and July-September 2019). A process evaluation conducted partway through the 15-18-month intervention period included focus group discussions and interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. Male participants in the short message service + interpersonal communication (SMS + IPC) group reported higher exposure to IPC discussions than IPC-only men (43.8% and 21.9%, respectively). Knowledge scores increased significantly across all three intervention groups, with the greatest impact in the SMS + IPC group. Qualitative findings indicated that the main barriers to male participation were a lack of interest in health/nutrition and perceptions that these topics were a woman's responsibility. Other challenges included meeting logistics, prioritizing income-earning activities and insufficient efforts to engage men. The use of a combined approach fusing IPC with SMS is promising, yet countering gender norms and encouraging stronger male engagement may require additional strategies.

Impact Investing Holds Promise for Nutrition If Guided by Evidence.

There is a widely recognized need to increase funding available for improving nutrition in low- and middle-income countries and to move beyond traditional grants from development agencies and private foundations. This includes the so-called innovative financing approaches, such as impact investment (i.e., investing with the intent to generate positive social impact). Impact investment is no substitute for much-needed public funding to support direct nutrition interventions, but such approaches could make sense where supporting nutrition entails a "business case" that could create profit for a business-thus fostering the positive returns needed by investors. This includes some food-based approaches, as most households purchase food from for-profit companies and entrepreneurs. Investment in firms that produce nutritious foods for local markets could be profitable and-if it were to improve food affordability, accessibility, or desirability-could help improve diet quality. In this Perspective, we describe these innovative financing mechanisms and discuss their potential for supporting nutritious foods. We note that doing so would require a simple yet evidence-based approach to screening nutritious foods for potential investment, and we describe our experience operationalizing this through a novel nutrition impact investment mechanism: the Nutritious Foods Financing Facility. We conclude by highlighting remaining gaps to explore the potential of impact investment in nutrition and what the nutrition community can do to help fill them-and to mitigate the risk of such approaches being applied in ways that do not lead to positive social impact for nutrition.

Diets of infants and young children in two counties of Kenya: Key drivers and barriers to improvement.

Infant and young child feeding (IYCF) practices are influenced by many context-specific factors related to local food systems as well as social and cultural practices. Understanding these local contextual perspectives is essential for designing effective programs and policies. This paper uses focused ethnographic study methods to examine challenges experienced by mothers related to IYCF in two counties in Kenya, a country with considerable heterogeneity in agriculture, food systems, and cultures. A two-phase qualitative study was undertaken in each of Kilifi County and West Pokot County, entailing interviews and rating activities with mothers, health workers, and vendors. Interviews were audio-recorded, transcribed, translated into English, coded, and analysed by topic. Results show low levels of dietary diversity in both counties; in West Pokot, the level of adequate meal frequency is also low. Core foods in young child diets included maize porridge and family foods such as ugali (stiff maize porridge), vegetables, beans, fish, and plantains. Food safety, acceptability, and acquisition ease were the main drivers of food choice. Mothers generally felt that all core foods fed to young children are healthy and safe, but there was more variability regarding child acceptance, acquisition ease, cost, and convenience. Common barriers to feeding nutrient-dense foods to children included child illness, economic constraints, and limited knowledge of modification strategies, skills, or tools to make the foods suitable for young children. Potential actions to address these barriers include sharing information on child-appropriate recipes; raising awareness on local, affordable nutrient-dense foods; and improving WASH practices to reduce illness frequency.

Beliefs, values, and sociocultural patterns related to food safety in low- and middle-income countries: A synthesis of the descriptive ethnographic literature.

Foodborne disease is intimately connected to nutrition and causes considerable harm to health and economic wellbeing. Consumers play a key role in food safety, making it essential to understand the motivations, beliefs, and practices that shape their decisions. Ethnographic research methods are well suited to understanding such topics but have rarely been applied to food safety. This paper presents an evidence synthesis of ethnographic studies, with an emphasis on food safety beliefs, values, and related socio-cultural information, and a focus on consumers' purchasing behaviors. Vendor perspectives are also briefly considered. Key findings include the importance of trust, strategies to reduce risk, the effects of economic status and gender, and broader cultural concepts about foods that influence food purchasing. The synthesis demonstrates that there are numerous social and cultural factors that influence decision making related to food safety, offering insights for the design of interventions to reduce exposure to foodborne disease and improve nutrition.

Diagnosing the performance of food systems to increase accountability toward healthy diets and environmental sustainability.

To reorient food systems to ensure they deliver healthy diets that protect against multiple forms of malnutrition and diet-related disease and safeguard the environment, ecosystems, and natural resources, there is a need for better governance and accountability. However, decision-makers are often in the dark on how to navigate their food systems to achieve these multiple outcomes. Even where there is sufficient data to describe various elements, drivers, and outcomes of food systems, there is a lack of tools to assess how food systems are performing. This paper presents a diagnostic methodology for 39 indicators representing food supply, food environments, nutrition outcomes, and environmental outcomes that offer cutoffs to assess performance of national food systems. For each indicator, thresholds are presented for unlikely, potential, or likely challenge areas. This information can be used to generate actions and decisions on where and how to intervene in food systems to improve human and planetary health. A global assessment and two country case studies-Greece and Tanzania-illustrate how the diagnostics could spur decision options available to countries.

Food safety-related perspectives and practices of consumers and vendors in Ethiopia: A scoping review.

Despite being one of the first African countries to prioritize food safety, foodborne diseases are of acute concern in Ethiopia. This review aims to understand food safety-related perspectives and practices among consumers and food vendors in Ethiopia to identify motivations, beliefs, and values that shape and/or drive their practices. A well-defined search and review identified 116 relevant articles. These spanned eight of the ten regional states and two chartered cities, with most work focusing on urban areas and on a sample within one state or chartered city. Ninety-four studies focused on vendors or food handlers; fifteen articles examined both consumers and vendors, but only four assessed interactions between the groups. Meat, dairy products, and ready-to-eat (street) foods were the most studied food groups. Food service establishments were the most examined outlets. Forty-six studies examined generic food safety issues or concerns. Overall, 102 studies assessed food safety practices; 53 studies examined knowledge, and 19 studies assessed attitudes. A gap in vendors' observed practices versus knowledge and attitudes was noted. Consumer deductions of food safety were based on vendor practices. Both groups used physical attributes based on senses to assess quality and safety of animal-source foods, had their own 'coping' strategies to address food safety-related concerns, and had similar views on consumer choice motives. Analysis of food and the food handling environment revealed a high level of contamination. An additional study, included after the original search, identified training to be effective in influencing knowledge, attitudes, and practices - though results for attitudes and practices were not sustained in the long term. Future research should address consumers and consumer-vendor interactions and include the full triad of knowledge-attitudes-practices. It is also recommended to focus on nutrient-rich foods as well as on traditional markets and local eateries. Improving the quality of research will be critical to improve food safety in Ethiopia.

A subnational affordability assessment of nutritious foods for complementary feeding in Kenya.

Complementary feeding among children aged 6-23 months is a key determinant of micronutrient deficiencies and childhood stunting, the burdens of which remain high in Kenya. This study examines the affordability of complementary foods to increase young children's nutrient consumption across eight provinces in Kenya. We combined data from household surveys, food composition tables and published sources to estimate the cost of portion sizes that could meet half of the children's daily iron, vitamin A, calcium, zinc, folate, vitamin B12 and protein requirements from complementary feeding. These costs were compared to current household food expenditures. The selection of foods and price and expenditure data were stratified by province. Our analysis indicates that vitamin A, vitamin B12 and folate are affordable to most households in Kenya via liver, beans and in some provinces, orange-fleshed fruits and vegetables, avocado and small dried fish. Calcium, animal-source protein, zinc and iron were less affordable and there was more provincial variation. In some provinces, small dried fish were an affordable source of calcium, protein and zinc. In others (North Eastern, Central, Eastern, parts of Rift Valley and Coast), small dried fish were not commonly consumed and other foods were less affordable. Future research should consider interventions aimed at reducing prices, increasing availability and changing behaviours related to these foods. Solutions such as supplementation and fortification may be needed for iron and zinc in some locations. Food affordability presented the greatest barriers in North Eastern province, which had lower dietary diversity and may require additional targeted interventions.

Vendor Knowledge, Attitudes, and Practices Related to Food Safety in Low- and Middle-Income Countries: A Scoping Review.

ABSTRACT: Foodborne diseases are a significant cause of illness in low- and middle-income countries (LMICs). Poor infrastructure, lack of regulatory oversight, and environmental conditions can increase food safety risks, particularly in traditional markets. Food vendors in traditional markets shoulder a heavy responsibility to keep food safe under often challenging conditions. The ability of these vendors to ensure food is safe is shaped by their knowledge, attitudes, and practices (KAP). Hence, understanding vendor KAP is important when designing interventions to improve food safety. To date most research on food vendors in LMICs has focused on vendors of ready-to-eat street foods and not on vendors of fresh food commodities. To fill this gap, a scoping review was undertaken to compile existing research on food safety KAP of vendors of food commodities in LMICs. PubMed, Google Scholar, Ovid Medline, and institutional Web sites of major research organizations were searched for original research articles and reports. Of 17,483 titles screened, 84 relevant studies were identified. Of the studies included, most were conducted after 2014 and focused on urban and periurban Africa. Most studies had a cross-sectional design with mixed methods (e.g., quantitative and qualitative analyses of vendor KAP through interviews and observations) and had small sample sizes (<50 participants). Common food value chains studied were dairy, meat, and fruits and vegetables. Very few studies included more than one type of commodity or value chain. Food vendor knowledge typically ranged from little to none, which was evident from observations of vendors operating under unsafe and unhygienic conditions, such as poor food handling and storage practices. Poor compliance with existing food safety policies, laws, and regulations was evident in some cases primarily due to either limited awareness of their existence or limited knowledge of how to implement them. However, vendors generally had positive attitudes toward food safety. No significant gaps were found between food safety knowledge and actual practices, although this correlation was not always examined rigorously in the reviewed studies. KAP and gaps between food safety behavior did not differ with vendor age or gender, type of product sold, or geography. Local government staff were identified as key enabling actors, interacting with food market vendors to foster improved food safety practices.

"Sometimes You Get Good Ones, and Sometimes You Get Not-so-Good Ones": Vendors' and Consumers' Strategies to Identify and Mitigate Food Safety Risks in Urban Nigeria.

This paper uses detailed data from in-depth interviews with consumers (n = 47) and vendors (n = 37) in three traditional markets in Birnin Kebbi, Nigeria. We used observations from those markets to examine how consumers and vendors identify and avoid or manage food safety risks and whom they hold responsible and trust when it comes to ensuring food safety. At the level of the vendor, consumers mentioned seeking "clean" or "neat" vendors or stalls. Cleanliness was primarily related to the appearance of the vendor, stall, and surroundings; reliance on trusted, known vendors was also noted. Food products themselves were largely evaluated based on visual cues: insects, holes, and colors-with some reliance on smell, also. Similarly, vendors assessed safety of food from suppliers based on a visual assessment or reliance on trusted relationships. On the second research question, both consumers and vendors largely placed responsibility for ensuring food safety on government; when asked specifically, consumers also named specific steps that vendors could take to ensure food safety. Consumers and vendors also generally felt that they could limit many food safety risks through identifying the "good" products in the market or from suppliers. The paper discusses the implications of these results for behavior change interventions.