Combating Micronutrient Deficiencies: Food-based Approaches

Combating Micronutrient Defi ciencies: Food-based Approaches

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Combating Micronutrient Defi ciencies:
Food-based Approaches
Edited by
Brian Thompson
Senior Nutrition Offi cer
Nutrition and Consumer Protection Division
Food and Agriculture Organization of the United Nations
and
Leslie Amoroso
Food and Nutrition Security Consultant
Published by
and

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Library of Congress Cataloging-in-Publication Data
Combating micronutrient deficiencies : food-based approaches / edited by Brian Thompson and Leslie
Amoroso.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-84593-714-0 (alk. paper)
1. Malnutrition--Prevention. 2. Trace elements in nutrition. 3. Enriched foods. I. Thompson, Brian, 1953-
II. Amoroso, Leslie, 1977- III. Food and Agriculture Organization of the United Nations. IV. C.A.B.
International.
[DNLM: 1. Nutrition Disorders--prevention & control. 2. Micronutrients. 3. Nutritional Physiological
Phenomena. WD 100]
RA645.N87C655 2011
362.196'39--dc22
2010026020
Published jointly by CAB International and FAO
Food and Agriculture Organization of the United Nations (FAO)
Viale delle Terme di Caracalla, 00153 Rome, Italy
website: www.fao.org
ISBN-13: 978 1 84593 714 0 (CABI)
ISBN-13: 978 92 5 106546 4 (FAO)
The designations employed and the presentation of material in this publication do not imply the
expression of any opinion whatsoever on the part of the Food and Agricultre Organization of the United
Nations concerning the legal status of any country, territory, city or area or of its authorities, or
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endorsed or recommened by the FAO in preference to others of a similar nature that are not mentioned.
The views expressed herein are those of the authors and do not necessarily represent those of FAO.
Commissioning editor: Nigel Farrer
Production editor: Fiona Chippendale
Typeset by SPi, Pondicherry, India.
Printed and bound in the UK by the MPG Books Group.

Contents
Foreword ix
Preface xi
Acknowledgements xv
About the Editors xvii
Contributors xix
Introduction 1
B. Thompson and L. Amoroso
1. Strategies for Preventing Multi-micronutrient Defi ciencies: a Review of 7
Experiences with Food-based Approaches in Developing Countries
R.S. Gibson
2. Addressing Micronutrient Malnutrition to Achieve Nutrition Security 28
P. Shetty
3. Agricultural Interventions and Nutrition: Lessons from the Past 41
and New Evidence
M. Arimond, C. Hawkes, M.T. Ruel, Z. Sifri, P.R. Berti, J.L. Leroy, J.W. Low,
L.R. Brown and E.A. Frongillo
4. A 3-year Cohort Study to Assess the Impact of an Integrated Food- and 76
Livelihood-based Model on Undernutrition in Rural Western Kenya
J. Fanzo, R. Remans, P.M. Pronyk, J. Negin, J. Wariero, P. Mutuo, J. Masira, W. Diru,
E. Lelerai, D. Kim, B. Nemser, M. Muñiz, C. Palm, P. Sanchez, S. Ehrlich Sachs
and J.D. Sachs
5. Food-based, Low-cost Strategies to Combat Micronutrient Defi ciencies: 92
Evidence-based Interventions in Lesotho and Malawi
J.M. Aphane, N. Pilime and N.J. Saronga
v

vi Contents
6. Animal-source Foods as a Food-based Approach to Address Nutrient 117
Defi ciencies and Functional Outcomes: a Study among Kenyan
Schoolchildren
C.G. Neumann, N.O. Bwibo, C.A. Gewa and N. Drorbaugh
7. Small-animal Revolving Funds: an Innovative Programming Model 137
to Increase Access to and Consumption of Animal-source Foods
by Rural Households in Malawi
A.C. MacDonald, B.J. Main, R.H. Namarika, M.E. Yiannakis and A.M. Mildon
8. Aquaculture’s Role in Improving Food and Nutrition Security 150
B. Thompson and R. Subasinghe
9. A Home Gardening Approach Developed in South Africa to Address 163
Vitamin A Defi ciency
M. Faber and S. Laurie
10. AVRDC – The World Vegetable Center’s Approach to Alleviate Malnutrition 183
M.L. Chadha, L.M. Engle, J. d’A. Hughes, D.R. Ledesma and K.M. Weinberger
11. Introducing Vegetables into the India Mid-day Meal (MDM) Programme: 198
the Potential for Dietary Change
E. Muehlhoff, R. Ramana, H. Gopalan and P. Ramachandran
12. Developing Micronutrient-rich Snacks for Pre-conception and Antenatal 214
Health: the Mumbai Maternal Nutrition Project (MMNP)
D. Shivashankaran, S. Gurumurthy, S.H. Kehoe, P.S. Chheda, B.M. Margetts,
P. Muley- Lotankar, A. Agarwal, N. Brown, S.A. Sahariah, V. Taskar, C.H.D. Fall
and R.D. Potdar
13. Approaches and Lessons Learned for Promoting Dietary Improvement in 224
Pohnpei, Micronesia
L. Englberger, A. Lorens, M. Pretrick, B. Raynor, J. Currie, A. Corsi, L. Kaufer, R.I. Naik,
R. Spegal and H.V. Kuhnlein
14. A Food Systems Approach to Increase Dietary Zinc Intake in Bangladesh 254
based on an Analysis of Diet, Rice Production and Processing
A.B. Mayer, M.C. Latham, J.M. Duxbury, N. Hassan and E.A. Frongillo
15. Combating Iron Defi ciency: Food-based Approaches 268
B. Thompson
16. Human Micronutrient Defi ciencies: Linkages with Micronutrient 289
Defi ciencies in Soils, Crops and Animal Nutrition
M. Nubé and R.L. Voortman
17. Nationwide Supplementation of Sodium Selenate to Commercial Fertilizers: 312
History and 25-year Results from the Finnish Selenium Monitoring
Programme
G. Alfthan, P. Aspila, P. Ekholm, M. Eurola, H. Hartikainen, H. Hero,
V. Hietaniemi, T. Root, P. Salminen, E.-R. Venäläinen and A. Aro
18. Leaf Concentrate and Other Benefi ts of Leaf Fractionation 338
M.N.G. Davys, F.-C. Richardier, D. Kennedy, O. de Mathan, S.M. Collin, J. Subtil,
E. Bertin and M.J. Davys

Contents vii
19. Disability-adjusted Life Years (DALYs): a Methodology for Conducting 366
Economic Studies of Food-based Interventions such as Biofortifi cation
S. Pérez Suárez
Index 381
FAO’s Publications on Food-based Approaches to Prevent
and Control Micronutrient Defi ciencies – Covers

The importance of food-based approaches for the prevention and control of micronutrient
defi ciencies as well as for the improvement of nutrition in general is fully recognized by the
Food and Agriculture Organization of the United Nations (FAO). FAO, a specialized UN
agency, has as its mandate the raising of levels of nutrition and ensuring humanity’s freedom
from hunger by promoting sustainable agricultural and rural development. Focusing on the
unique relationship between agriculture, food and nutrition, FAO works actively to protect,
promote and improve established food-based systems as the sustainable solution to ensure
food and nutrition security and, by doing so, to achieve the nutrition-related Millennium
Development Goals (MDGs). FAO is committed to supporting the promotion of the produc-tion
and consumption of micronutrient-rich foods as the sustainable solution to micronutrient
malnutrition. This activity clearly falls under the Organization’s mandate, and the Nutrition
and Consumer Protection Division, under whose direction this publication has been prepared,
plays an important role in its implementation.
Inadequate attention has so far been paid to food-based approaches in achieving sustain-able
improvements in the micronutrient status of vulnerable populations. The Nutrition and
Consumer Protection Division has therefore undertaken the preparation of this publication to
provide more emphasis on these strategies. For the first time in one volume, Combating
Micronutrient Deficiencies: Food-based Approaches brings together available knowledge, case
studies on country-level activities, lessons learned and success stories showing that food-based
approaches are the only viable and sustainable solution to micronutrient malnutrition.
The purpose of this publication is to provide policy makers, agronomists, food and nutri-tion
security planners, programme implementers and health workers with the information
needed to better understand, promote, support and implement food-based strategies to com-bat
micronutrient deficiencies in their respective countries. This book will appeal to profes-sionals
in the sectors of food security, nutrition, public health, horticulture, agronomy, animal
science, food marketing, information, education, communication, food technology (preserva-tion,
processing and fortification) and development.
The book is designed as a useful supplementary source for Bachelor, Master and PhD
courses on public health; human nutrition (including nutrition education and communication
courses); micronutrient deficiency interventions, programmes and policies, and food and
nutrition security policy interventions and programmes; and food and agriculture in agricul-tural
research.
Foreword
ix

x Foreword
A varied diet is the key to solving micronutrient deficiency problems. The elimination of
micronutrient deficiencies on a sustainable basis will only be possible when the diets of vulner-able
populations provide all required nutrients in adequate amounts. Programmes in several
countries show that comprehensive, well-designed food-based strategies can improve the diets
of vulnerable populations in a relatively short period of time and that these improvements can
be sustained. A number of countries demonstrate that problems of micronutrient deficiencies
can be resolved when government policies and programmes are directed to the goal of increas-ing
production of and access to vitamin- and mineral-rich foods, in combination with market-ing
and education activities to improve the consumption of such foods. FAO support to
food-based approaches also extends to fortification where it is seen as part of an overall strategy
for a total food and total diet approach.
Currently, the combined effects of prolonged underinvestment in nutrition, food and agri-culture,
the recent food price crisis and the economic downturn have led to increased hunger
and poverty, jeopardizing the progress achieved so far in meeting the MDGs. According to
FAO, there were 105 million more hungry people in 2009 than in the previous year; the number
of malnourished people now stands at 1.02 billion. This book shows how food-based approaches
can not only reduce the prevalence of micronutrient malnutrition, but also improve the nutri-tional
status of all populations and mitigate one of today’s greatest public health problems.
It is hoped that Combating Micronutrient Deficiencies: Food-based Approaches will be a catalyst
for continuing the process of dialogue and information exchange to support, promote and
implement food-based strategies to reduce micronutrient deficiencies.
Ezzeddine Boutrif
Director
Italy

We are proud to bring you the first edition of the publication Combating Micronutrient
Deficiencies: Food-based Approaches. This book aims at documenting the benefits of food-based
approaches, particularly of dietary improvement and diversification interventions, in control-ling
and preventing micronutrient deficiencies. The focus of the publication is on practical
actions for overcoming micronutrient malnutrition in a sustainable manner through increasing
access to and availability and consumption of adequate quantities and variety of safe, good-quality
food. The book is unique in this area as it is the first to gather a variety of relevant
articles under one cover to encourage and promote further attention, importance and invest-ment
in food-based strategies to combat micronutrient deficiencies.
Although the most severe problems of micronutrient malnutrition are found in develop-ing
countries, people of all population groups in all regions of the world can be affected by
micronutrient deficiencies. Approximately two billion people – about a third of the world’s
population – are today deficient in one or more micronutrients. This is one of the most serious
impediments to socio-economic development, contributing to the vicious cycle of malnutri-tion,
underdevelopment and poverty. Micronutrient malnutrition has long-ranging effects on
health, learning ability and productivity, leading to high social and public costs, reduced work
capacity in populations due to high rates of illness and disability and tragic loss of human
potential. Therefore, overcoming micronutrient deficiencies is a precondition for ensuring
rapid and appropriate development.
National, regional and international efforts to improve micronutrient status worldwide
have been guided by recommendations made during international meetings and high-level
conferences. At the International Conference on Nutrition (ICN), jointly convened by the Food
and Agriculture Organization of the United Nations (FAO) and the World Health Organization
(WHO) in Rome in 1992, delegates of participating countries pledged ‘to make all efforts to
eliminate … iodine and vitamin A deficiencies’ and ‘to reduce substantially … other important
micronutrient deficiencies, including iron’ before the end of the decade. Linked to the World
Declaration was the Plan of Action for Nutrition which recommended that governments give
priority to food-based approaches to combat micronutrient malnutrition.
The Plan of Action of the World Food Summit 1996 re-affirmed the ICN goals ‘govern-ments,
in partnership with all actors of civil society … will implement the goals of preventing
and controlling specific micronutrient deficiencies as agreed at the ICN’. Furthermore, the
Declaration of the World Food Summit: five years later in 2002 recognized ‘the importance of
interventions to tackle micronutrient deficiencies which are cost-effective and locally
xi
Preface

xii Preface
acceptable’. Addressing micronutrient deficiencies will also help bring the international com-munity
closer to achieving the Millennium Development Goals by 2015.
Food-based approaches promote the consumption of foods that are naturally rich in
micronutrients or are enriched through fortification. To be successful they require a sound
scientific basis and need to be built on practical experiences in nutrition; agricultural sciences,
including horticulture, agronomy, animal science and food marketing; information, education
and communication; food technology related to preservation, processing and fortification; and
in problem assessment, programme management and monitoring and evaluation.
FAO strongly emphasizes that food-based approaches, which include food production,
dietary diversification and food fortification, are sustainable strategies for improving the
micronutrient status of populations. Increasing access to and availability and consumption of
a variety of micronutrient-rich foods not only have a positive effect on micronutrient status but
also contribute to improved nutrition in general. In addition to its intrinsic nutritional value,
food has social and economic significance which, for many people, especially those living in
developing countries, is commonly mediated through agriculture and agriculture-related
activities that sustain rural livelihoods. The multiple social, economic and health benefits asso-ciated
with successful food-based approaches that lead to year-round availability, access and
consumption of nutritionally adequate amounts and varieties of foods are clear. The nutri-tional
well-being and health of individuals is promoted, incomes and livelihoods supported,
and community and national wealth created and protected.
However, progress in promoting and implementing food-based strategies to achieve
sustainable improvements in micronutrient status has been slow. They were often over-looked
as governments, researchers, the donor community and health-oriented international
agencies sought approaches for overcoming micronutrient malnutrition that had rapid start-up
times and produced quick and measurable results. Much effort to control the three major
deficiencies of public health concern – i.e. vitamin A, iron and iodine deficiencies – has
focused on supplementation. Although supplementation has saved many lives and much
suffering has been avoided as a result of these efforts, and while supplementation remains
necessary for groups at high risk and as a short-term emergency measure, it fails to recognize
the root causes of micronutrient malnutrition and to assist communities and households to
feed and nourish themselves adequately. Supplementation simply cannot provide the over-all
long-term economic benefits of economy and sustainability that food-based approaches
can deliver.
The idea for this publication originated during the First International Meeting of the
Micronutrient Forum held in Istanbul, Turkey, in April 2007. With very few posters and little
discussion on food security and dietary diversification, the Istanbul meeting highlighted the
lack of attention to and information on this important aspect of the fight against micronutrient
malnutrition. On that occasion, FAO discussed with interested individuals the possibility of
putting together this publication for which support was received.
Subsequently, a ‘call for papers’ was prepared and widely circulated through different
Internet sites and web forums. Expertise from the nutrition community, including programme
managers and researchers from universities, research institutions, food industries and enter-prises
at various levels and disciplines, non-governmental organizations (NGOs) and interna-tional
organizations were invited to submit articles. Papers were welcomed from a wide
diversity of relevant disciplines including nutrition, agriculture, horticulture, education, com-munication
and development.
The publication has been as inclusive as possible and has benefited from the contribution
of 100 authors. We have captured and included many different views and analyses and created
an interesting and rich combination of knowledge and experience.
Effective correspondence and communication with the authors was maintained through-out
the preparation process of the publication. A peer review panel was established to provide
technical inputs to, comments on and suggestions for the papers. The hard work of the

Preface xiii
reviewers and their dedicated efforts in providing feedback to the authors was critical in ensur-ing
the high quality of the contributions.
Many developing countries, international agencies, NGOs and donors are beginning to
realize that food-based strategies that promote diet diversity are a viable, cost-effective and
sustainable solution for controlling and preventing micronutrient malnutrition. We hope that
this book will serve as the basis for future dialogue, debate and information exchange and
facilitate wider support for an international movement committed to the implementation of
effective, long-term food-based solutions to undernutrition and for combating micronutrient
deficiencies, thus allowing the world population to achieve its full human and socio-economic
potential.
Brian Thompson
Leslie Amoroso

Acknowledgements
The editors would like to express their appreciation to the many individuals who contributed
to the preparation of this publication. First and foremost we wish to thank all the authors for
their expertise and hard work in preparing their chapters as well as their collaboration, dedica-tion
and patience in meeting our numerous requests.
All of the chapters were peer-reviewed. A special acknowledgment is due to William
D. Clay, Ian Darnton-Hill, Saskia De Pee and Suzanne Harris, whose constructive and valuable
technical comments, inputs and suggestions have helped to improve the quality of the
chapters.
Our gratitude goes to Ezzeddine Boutrif, Director of the Nutrition and Consumer
Protection Division, Food and Agriculture Organization of the United Nations (FAO), for his
continuing support to the realization of this work.
Our special thanks go to Jayne Beaney, Nutrition and Consumer Protection Division, FAO,
for her invaluable assistance in providing secretarial support and checking the final submis-sions.
We would also like to show our appreciation to Rachel Tucker, Office of Knowledge,
Exchange, Research and Extension, FAO, for liaising between FAO and CABI on the develop-ment
of the project into book form and giving support on copyright-related issues.
xv

About the Editors
BRIAN THOMPSON
Nutrition Security and Policy Group
Rome, Italy
E-mail: Brian.Thompson@fao.org
Brian Thompson, MSc in Human Nutrition, London School of Hygiene and Tropical Medicine, UK, is
a nutritionist with over 30 years of international development experience. He is Senior Nutrition Officer
in the Nutrition and Consumer Protection Division of FAO dealing with Nutrition Security and Policy.
Working initially for ICRC, WFP and UNICEF with the NGO community in Asia over five years, he
led nutrition surveys, provided clinical treatment, designed and evaluated emergency relief and
recovery programmes including feeding programmes, supported health prevention and promotion
activities and coordinated the provision of comprehensive humanitarian aid to refugees and other
vulnerable communities. He joined FAO Headquarters in Rome in 1987 and advises Member
Countries on the development and implementation of policies, strategies and plans of action for
promoting and improving food and nutrition security in both emergency and development contexts.
LESLIE AMOROSO
Nutrition Security and Policy Group
Rome, Italy
E-mail: Leslie.Amoroso@fao.org
Leslie Amoroso has a Master’s in Urban and Regional Planning for Developing Countries with
emphasis on food and nutrition security and livelihood issues from the Istituto Universitario di
Architettura di Venezia (IUAV), Venice, Italy. She has extensive international experience in food and
nutrition security policy and programme-related activities, with childhood, gender and HIV/AIDS
components, in Ethiopia, The Gambia and Nicaragua. Since 2007, she has been working as a
Nutrition Consultant in the Nutrition Security and Policy Group, Nutrition and Consumer Protection
Division, FAO, where she provides advice and support to policy, strategy, capacity building, advocacy
and programme activities aimed at improving food and nutrition security among vulnerable
population groups. Ms Amoroso also collaborates on several initiatives designed to strengthen
linkages between food and nutrition security assessment and decision making at policy and
programme level.
xvii

Contributors
Anjana Agarwal completed an MSc in Food and Nutrition from GB Pant University, Pantnagar,
followed by a PhD from the University of Delhi. She has worked on an All-India coordi-nated
project studying the dietary patterns of North Indian populations. She worked as a
nutritionist on the pilot phase of Mumbai Maternal Nutrition Project and is currently a
lecturer at SNDT University teaching undergraduate and postgraduate food and nutrition
courses. Contact: Mumbai Maternal Nutrition Study, Centre for the Study of Social
Change, Roy Campus, Bandra East, Mumbai, India. E-mail: anjana_d1@rediffmail.com
Georg Alfthan is a biochemist affiliated with the National Institute for Health and Welfare,
Helsinki, and is an Adjunct Professor in Nutritional Biochemistry at the University of
Helsinki. His research on various aspects of selenium began in 1980 with the topics meth-odology
of selenium, clinical interventions, metabolism and epidemiology of selenium in
chronic diseases. He has been involved in international collaboration in the field of clinical
nutrition since the 1980s. In the 1990s, he supervised the PhD thesis of Dacheng Wang on
the biogeochemistry of selenium in natural water ecosystems. He is a member of the
Selenium Working Group responsible for monitoring the human selenium status. Contact:
National Institute for Health and Welfare, Helsinki, Finland. E-mail: georg.alfthan@thl.fi
Juliet M. Aphane is a Nutrition Officer working with the Food Security and Policy Group,
Nutrition and Consumer Protection Division, Food and Agriculture Organization of the
United Nations (FAO). She has extensive experience in rural development working in the
area of nutrition, specifically in household food security and community nutrition, infant
and young child nutrition, and nutrition in agriculture. She served as Chief Technical
Advisor for the project ‘Protecting and Improving Food and Nutrition Security of Orphans
and HIV/AIDS Affected Children, in Lesotho and Malawi’. The contents and material
used in Chapter 5 are almost entirely based on information from this project. Ms Aphane
has worked for the Nutrition and Consumer Protection Division of FAO, Rome, Italy since
July 1995. Contact: Nutrition and Consumer Protection Division, Food and Agriculture
Organization of the United Nations, Rome, Italy. E-mail: Juliet.Aphane@fao.org
Mary Arimond joined the University of California, Davis, Program in International and
Community Nutrition as a research analyst in 2009. Prior to 2009 she was a scientist at the
International Food Policy Research Institute, with research interests in maternal and child
nutrition, dietary diversification and other food-based approaches to improving micronu-trient
nutrition, and programme monitoring and evaluation. She has also worked as a
consultant with the World Health Organization, the United Nations Children’s Fund and
xix

xx Contributors
non-governmental organizations. Contact: Program in International and Community
Nutrition, University of California, Davis, USA. E-mail: marimond@ucdavis.edu
Antti Aro is specialist in internal medicine and endocrinology, Emeritus Professor in Clinical
Nutrition and Research Professor at the National Institute for Health and Welfare. His
research on selenium includes clinical interventions, metabolism and epidemiology of
selenium in chronic diseases and includes European collaboration. He has been involved
for two decades in work on the Nordic Nutrition Recommendations regarding selenium
and other nutrients. In the 1990s he supervised the PhD thesis of Dacheng Wang on the
biogeochemistry of selenium in natural water ecosystems. He has been Secretary and
Member of the Selenium Working Group since it was appointed in 1983. Contact: National
Institute for Health and Welfare, Helsinki, Finland. E-mail: antti.aro@thl.fi
Pentti Aspila is an animal nutrition specialist by training and did extensive research at the
University of Helsinki on selenium supplementation to animals in the 1980s. His PhD thesis
focused on selenium metabolism in lactating dairy cows and goats. These studies provided
essential background data in deciding the form and level of supplementing fertilizers with
selenium in Finland in 1984. Since 2000, he has been serving as an expert on the European
Food Safety Authority’s FEEDAP panel to decide on proper selenium supplementation
levels to animals. Currently he is Director of Services at MTT Agrifood Research Finland.
Contact: MTT Agrifood Research Finland, Jokioinen, Finland. E-mail: pentti.aspila@mtt.fi
Peter R. Berti is the Deputy Director and Nutrition Advisor of HealthBridge, a Canadian non-governmental
organization that works with partners worldwide to improve health and
health equity through research, policy and action. He has conducted research and man-aged
programmes in food fortification, nutritional assessment, and risk analysis and man-agement,
and in the integration of food and nutrition interventions into agriculture
interventions. Contact: HealthBridge, Ottawa, Canada, E-mail: pberti@healthbridge.ca
Eric Bertin is Professor of Nutrition at the University of Reims, Champagne, France. He is the
Coordinator of APEF’s (Association pour la Promotion des Extraits Foliaires en nutrition)
Scientific Committee. Contact: University of Reims, Champagne-Ardenne, France. E-mail:
ebertin@chu-reims.fr
Lynn R. Brown, a food policy economist, is currently employed by the World Food Programme,
working on food security and social protection. She worked with The World Bank for 12
years, largely in agriculture and rural development, but also spending two years manag-ing
The World Bank’s nutrition engagement in Bangladesh. She has previously worked
with the International Food Policy Research Institute and is the author/co-author of
numerous articles on food, nutrition and gender issues. Contact: World Food Programme,
Rome, Italy. E-mail: Lynn.Brown@wfp.org
Nick Brown FRCPCH, MSc, DTM, H, is a paediatrician and epidemiologist based at Salisbury
District Hospital, UK. He was involved in developing and coordinating the pilot study
of the Mumbai Maternal Nutrition Project. Contact: University of Southampton,
Southampton, UK. E-mail: n_janbrown@yahoo.co.uk
Nimrod O. Bwibo, Professor Emeritus at the Department of Pediatrics, University of Nairobi,
Kenya, served as the former Kenyan Principal Investigator for the ‘Role of Animal Source
Foods to Improve Diet Quality and Growth and Development in Kenyan School Children’
study. Contact: Department of Pediatrics, University of Nairobi, Nairobi, Kenya. E-mail:
thebwibos@wanachi.com
Madan L. Chadha is an international scientist with over 35 years’ experience in vegetable crops
research and development, currently based at Hyderabad, India, as the Director of the Regional
Center for South Asia, AVRDC – The World Vegetable Center. Contact: AVRDC – The World
Vegetable Center, Shanhua, Tainan, Taiwan. E-mail: madan.chadha@worldveg.org
Purvi S. Chheda completed her BSc in Food Science and Nutrition from SNDT University,
Mumbai. From 2006 to 2008, she worked as a nutritionist with the Mumbai Maternal
Nutrition Project and Coordinator for Sneha–MRC, a networking organization for Indian

Contributors xxi
researchers interested in the developmental origins of health and disease. Contact: Mumbai
Maternal Nutrition Study, Centre for the Study of Social Change, Roy Campus, Bandra
East, Mumbai, India. E-mail: always_smileying@yahoo.co.in
Simon M. Collin, MSc, is an Epidemiologist and Research Associate in the Department of
Social Medicine of the University of Bristol, UK. From 1988 to 1990, he worked for the
non-governmental organizations (NGOs) Find your Feet and Leaf for Life on projects in
Mexico and Nicaragua (the latter with the Nicaraguan NGO Soynica). Contact: Department
of Social Medicine, University of Bristol, Bristol, UK. E-mail: simon.collin@bristol.ac.uk
Allison Corsi, MPH, Emory University, USA, is a global health consultant who has worked for
Cornell University, the World Health Organization, the Global Fund to Fight Aids, Tuberculosis
and Malaria, focusing on multiple methodology research, behavioural assessments, policy
development and analysis and the development of a micronutrient program assessment
guide for implementation planning and analysis. She worked in Pohnpei, Federated States of
Micronesia, leading a food behaviour formative study along with the Island Food Community
of Pohnpei and other inter-agency collaboration. Contact: Global Health Consultant, Ithaca,
NY, USA. E-mail: allisoncorsi@hotmail.com
Jim Currie, Master of Professional Study, Cornell University, USA, is an agriculturalist with
extensive experience in agricultural research management and extension, project imple-mentation
and evaluation, working with governmental and non-governmental organiza-tions
and universities. He has worked in the Pacific Islands for over 20 years and is
currently Vice-President of Cooperative Research and Extension at the College of
Micronesia–FSM. Contact: College of Micronesia–FSM, Kolonia, Pohnpei, Federated States
of Micronesia. E-mail: jimc@comfsm.fm
Jacqueline d’A. Hughes is the Deputy Director General for Research of AVRDC – The World
Vegetable Center. A virologist by training, she assists and advises on the Center’s research
priorities and strategies, facilitating multi-institutional research and development activities,
identifying strategic alliances, designing research matrices for rolling plans, and forging
strong internal research teams as well as partnerships with collaborators. Contact: AVRDC –
The World Vegetable Center, Shanhua, Tainan, Taiwan. E-mail: jackie.hughes@worldveg.org
M. John Davys, BEng, PhD, is an independent consultant, formerly Head of Environment for
Total UK Ltd. In 1990–1991, he spent one year in Nicaragua working on the Find your Feet/
Soynica project. Contact: Independent Consultant, Hove, Sussex, UK. E-mail: johndavys@
yahoo.co.uk
M.N. Glyn Davys was the engineer in N.W. Pirie’s team at Rothamsted Experimental Station
(UK) from 1958 to 1972. He was an honorary technical advisor to the non-governmental
organization Find your Feet from 1971 to 1995, in which capacity he was responsible for
planning and supervising leaf concentrate projects in Asia, Africa and Latin America. He
has been retired since 1996 and is now an active member of APEF, based in France. Contact:
APEF (Association pour la Promotion des Extraits Foliaires en nutrition), Paris, France.
E-mail: glyn.judith.davys@wanadoo.fr
Olivier de Mathan is an engineer and from 1970 to 1993 was the Director of Research and
Development of the France-Luzerne (FL) Group. He designed and developed FL’s extrac-tion
plants. He is a Co-Founder of APEF. Contact: APEF (Association pour la Promotion des
Extraits Foliaires en nutrition), Paris, France. E-mail: olivier.de_mathan@club-internet.fr
Willy Diru is currently serving as Agriculture and Environment Coordinator in Sauri Millennium
Village Project. He joined the Kenya public service in 1976 in the Ministry of Agriculture
serving in different capacities in various regions in the country, acquiring experience in
public administration, public finance, budgeting, management and working with various
groups in society. In 1994–1998, he served as Manager, Technical Services, in the project
coordination and management unit for the second Coffee Improvement Project funded by
The World Bank, which provided credit to smallholder coffee farmers and for coffee factory
construction. Willy has a BSc in Agriculture and a Postgraduate Diploma in Irrigation and

xxii Contributors
has served at national level in different capacities; in 1989–1993 as national Head, Farmer
Training Services and in 1998–2005 as Deputy Director of Agriculture responsible for the
promotion of crop production in Kenya. Contact: Millennium Development Goals Centre
for East and Southern Africa, The Earth Institute at Columbia University, Nairobi, Kenya.
E-mail: w.duru@cgiar.org
Natalie Drorbaugh is a Public Health Nutrition Consultant, and holds an MA and an MPH from
the University of California at Los Angeles. Contact: Public Health Nutrition Consultant,
Los Angeles, California, USA. E-mail: ndrorbau@ucla.edu
John M. Duxbury, PhD, is a soil scientist who specializes in increasing agricultural productivity
in developing countries using sustainable approaches and in improving crop quality to
address micronutrient malnutrition. Contact: Department of Crop and Soil Sciences, Cornell
University, Ithaca, New York, USA. E-mail: jmd17@cornell.edu
Sonia Ehrlich Sachs is a paediatrician, endocrinologist and public health specialist. She joined
The Earth Institute, Columbia University, in 2004, taking her current position as the
Director of Health for the Millennium Villages Project, overseeing all health-related inter-ventions
and research. Contact: The Earth Institute at Columbia University, New York,
New York, USA. E-mail: ssachs@ei.columbia.edu
Päivi Ekholm was born in Central Finland. She received her BSc in Chemistry and her MSc in
Food Chemistry from the University of Helsinki. Her dissertation considered the effects of
selenium fertilization on the selenium content of foods and the average dietary selenium
intake of the Finnish population. Her postdoctoral research topics have been inter alia the
interaction of dietary fibre, minerals and trace elements. She works at the University of
Helsinki at the Department of Applied Chemistry and Microbiology as a lecturer in chem-istry.
She is a member of the Selenium Working Group responsible for monitoring dietary
selenium intake. Contact: Department of Food and Environmental Sciences, University of
Helsinki, Finland. E-mail: paivi.ekholm@helsinki.fi
Lois Englberger, PhD, University of Queensland, Australia and Master of Nutritional Science,
Cornell University, USA, is a public health nutritionist and food composition specialist
who follows an ethnographic approach in her research and has worked for over 35 years
in developing countries. Since 1980 she has worked in the Pacific Islands. She has been
assisting the Island Food Community of Pohnpei in its leadership as the only full-time
officer since its formation. Contact: Island Food Community of Pohnpei, Kolonia, Pohnpei,
Federated States of Micronesia. E-mail: nutrition@mail.fm
Liwayway M. Engle (retired) is formerly Geneticist and Head of Genetic Resources and Seed
Unit with AVRDC – The World Vegetable Center. She coordinated projects on the conser-vation
and promotion for utilization of indigenous vegetables in South-East Asia and led
activities to improve conservation of and access to the genebank collection of the Center.
Contact: AVRDC – The World Vegetable Center, Shanhua, Tainan, Taiwan. E-mail: bing_
engle@yahoo.com
Merja Eurola has an MSc in Food Science and is a Research Scientist at the MTT Agrifood
Research Finland. She is responsible for the mineral and trace element research and anal-yses,
especially selenium research since the 1980s. She has studied selenium emissions
from fossil fuels and thereafter the effects of selenium fertilization on basic foods first at
the University of Helsinki and currently at MTT. Merja Eurola is a member and secretary
of the Selenium Working Group responsible for monitoring of the selenium contents of
cereals and basic foods and the analytical quality control program. Contact: MTT Agrifood
Research Finland, Jokioinen, Finland. E-mail: merja.eurola@mtt.fi
Mieke Faber is a nutritionist and senior specialist scientist at the South African Medical
Research Council. Her research focus is on community-based nutrition interventions
to address micronutrient malnutrition, particularly in infants and small children.
She conducts research at the interface of human nutrition and agriculture, and is a member
of the steering committee of the Vitamin A for Africa initiative. Mieke and Sunette Laurie

Contributors xxiii
jointly developed a manual to assist organizations in implementing the home garden
approach in South Africa. Contact: Nutritional Intervention Research Unit, Medical
Research Council, Cape Town, South Africa. E-mail: mieke.faber@mrc.ac.za
Caroline H.D. Fall is Professor of International Paediatric Epidemiology and Consultant in
Child Health at the University of Southampton. Her main research interest is the develop-mental
origins of type 2 diabetes and cardiovascular disease. She is Co-Principal Investigator
with the Mumbai Maternal Nutrition Project. Contact: University of Southampton,
Southampton, UK. E-mail: chdf@mrc.soton.ac.uk
Jessica Fanzo is a Senior Scientist for Nutrition at Bioversity International, one of the Consultative
Group on International Agricultural Research (CGIAR) centres in Rome, Italy. Before coming
to Bioversity, Jessica served as the Nutrition Coordinator for the Millennium Villages Project
and the Nutrition Director for the Center for Global Health and Economic Development
(CGHED) at The Earth Institute, Columbia University in New York City from 2007 to 2010.
In 2009, she was also the Regional Nutrition Advisor for East and Southern Africa at the
Millennium Development Goal Centre at the World Agroforestry Centre in Nairobi, Kenya.
From 2004 to 2007, Jessica was the Program Officer for Medical Research at the Doris Duke
Charitable Foundation focusing on HIV/AIDS programmes in sub-Saharan Africa. Her
PhD in Nutrition was completed in 2000 from the University of Arizona, and was a Stephen I
Morse Immunology Postdoctoral Fellow at Columbia University until 2004. Contact:
Bioversity International, Rome, Italy. E-mail: j.fanzo@cgiar.org
Edward A. Frongillo has received graduate training in nutrition, human development and
biometry. His research concerns problems of under- and overnutrition of populations glo-bally,
with interests in child growth, development and feeding; family stress and parent-ing;
household food insecurity; policy and programmes for improving nutrition and
development; and design and analysis of longitudinal studies. Contact: Department of
Health Promotion, Education, and Behavior, University of South Carolina, Columbia,
South Carolina, USA. E-mail efrongillo@sc.edu
Constance A. Gewa, MS in Applied Human Nutrition from the University of Nairobi and
MPH and PhD in Public Health at the University of California, Los Angeles, is Assistant
Professor at the Department of Global and Community Health, George Mason University,
Fairfax, USA. Contact: Department of Global and Community Health, George Mason
University, Fairfax, Virginia, USA. E-mail: cgewa@gmu.edu
Rosalind S. Gibson, a Research Professor in Human Nutrition at the University of Otago,
Dunedin, New Zealand, has had a life-long interest in international nutrition, initially
working in the Ethio-Swedish Children’s Nutrition Unit in Ethiopia, and subsequently in
collaborative research studies on micronutrients in Papua New Guinea, Guatemala,
Ghana, Malawi and, more recently, Thailand, Cambodia, Mongolia, Zambia and Ethiopia.
One focus has been on sustainable food-based strategies to combat micronutrient deficien-cies.
She is the author of a standard reference text, Principles of Nutritional Assessment
(Oxford University Press, 2005). Contact: Department of Human Nutrition, University of
Otago, Dunedin, New Zealand. E-mail: Rosalind.Gibson@Stonebow.Otago.ac.nz
Hema Gopalan is a nutrition research scientist working at Nutrition Foundation of India. Contact:
Nutrition Foundation of India, New Delhi, India. E-mail: hemasgopalan@gmail.com
Subbulakshmi Gurumurthy completed her MSc and PhD from MS University, Baroda and
post-doctoral work at the Central Food Technology Research Institute, Mysore. She has
worked as a nutritionist, teacher, educational administrator and researcher and is particu-larly
interested in community health and nutrition. Contact: Mumbai Maternal Nutrition
Study, Centre for the Study of Social Change, Roy Campus, Bandra East, Mumbai, India.
E-mail: subbulakshmi_g@hotmail.com
Helinä Hartikainen is Professor in Soil and Environmental Chemistry at the University of
Helsinki. Since the end of the 1980s, her studies on selenium have dealt with the biogeo-chemistry
of selenium in agricultural soils and its impact on the quantity and quality of

xxiv Contributors
plant products. Versatile physiological roles of this trace element, such as anti- and pro-oxidative
effects, its defending role against various internal and external stressors and
promoting impact on the accumulation of energy reserves, have been investigated with
various plant species. Currently she is leading a project targeted to develop an extraction
test appropriate to monitor the fertilization-induced changes in the selenium reserves in
Finnish soils. Contact: Department of Food and Environmental Sciences, University of
Helsinki, Helsinki, Finland. E-mail: helina.hartikainen@helsinki.fi
Nazmul Hassan, MA, MS, PhD, is a Professor at the Institute of Nutrition and Food Science,
University of Dhaka, Bangladesh. Contact:Institute of Nutrition and Food Science, University
of Dhaka, Bangladesh. E-mail: nhassan@bangla.net
Corinna Hawkes is an independent consultant focused on identifying and analysing policies
and processes needed to address the global shift towards unhealthy diets, overweight/
obesity and diet-related chronic diseases. Her clients include international organizations,
national governments, foundations and non-governmental organizations. She is also a
Visiting Research Fellow at the Centre for Food Policy, City University, London, and has
formerly worked at the International Food Policy Research Institute and the World Health
Organization. Contact: Independent Consultant, Le Pouget, France. E-mail: corinnahawkes@
aliceadsl.fr
Heikki Hero took a degree in Inorganic Chemistry in 1973. His focus during his entire career
has been fertilizer chemistry. Supplementing inorganic fertilizers with selenium became
of interest in Finland as early as the late 1970s. Heikki Hero acted as quality and develop-ment
manager in Kemira Oy, Kemira Agro Oy and Kemira GrowHow Oyj for more than
30 years. One of his specific areas was use, availability and safety of selenium in manufac-turing
of compound fertilizers. He retired in 2007. Contact: Kemira Growhow Oyj (Yara Oy),
Helsinki, Finland. E-mail: heikki.hero@yara.com
Veli Hietaniemi is an organic chemist from the University of Turku. He has been a laboratory
manager of MTT Laboratories since 1998. His research focuses mainly on organic contami-nants
of food and feedstuffs and bioactive components of foodstuffs. Since 1998, he has
been Chair of the Finnish Selenium Working Group which was set up by the Finnish
Ministry of Agriculture and Forestry in 1983. The task of the Group has been to assess the
effects of selenium fertilization and to report and make proposals concerning the selenium
situation in Finland. The Group is directed by MTT Agrifood Research Finland, which
coordinates monitoring activities between the various research facilities. Contact: MTT
Agrifood Research Finland, Jokioinen, Finland. E-mail: veli.hietaniemi@mtt.fi
Laura Kaufer, MSc in Human Nutrition, McGill University, worked in Pohnpei, Federated
States of Micronesia, guiding the project to evaluate the Pohnpei Traditional Food for
Health Study, led by the Centre for Indigenous Peoples’ Nutrition and Environment
(CINE), McGill University, Canada. She carried out this research as part of her require-ments
for completing an MSc in Human Nutrition. Contact: Centre for Indigenous Peoples’
Nutrition and Environment, Macdonald Campus of McGill University, Ste. Anne de
Bellevue, Quebec, Canada. E-mail: laura.kaufer@gmail.com
Sarah H. Kehoe obtained a BSc in Physiology and Psychology and an MSc in Public Health
Nutrition at the University of Southampton, UK. After completing the MSc, she joined
the Medical Research Council’s Epidemiology Resource Centre in Southampton and is
currently registered for a PhD with the University of Southampton. She also works as a
research assistant on a programme of research investigating the developmental origins
of chronic disease in India. She works as a nutritionist with the Mumbai Maternal
Nutrition Project. Contact: University of Southampton, Southampton, UK. E-mail: sk@
mrc.soton.ac.uk
David Kennedy, MSc, is the Founder and Director of Leaf for Life, based in Kentucky, USA.
He has initiated and coordinated numerous leaf concentrate projects in Latin America.
Leaf for Life promotes the use of leaf concentrate as part of a wider programme of

Contributors xxv
education concerned with the improved utilization of green leaves. Contact: Leaf for Life,
Berea, Kentucky, USA. E-mail: leafforlife@yahoo.com
David Kim graduated from Duke University in 2007 with a BSc in Biology and completed his
Master in Public Health Nutrition at Columbia University in 2009. He worked with the
Millennium Village Project for a year for his master’s thesis. He will be attending medical
school in the autumn of 2010 in the USA. Contact: Institute of Human Nutrition, Columbia
University, New York, New York, USA. E-mail: daviddkim84@gmail.com
Harriet V. Kuhnlein, PhD, RD, FASN, LL D (Hon), is Founding Director, Centre for Indigenous
Peoples’ Nutrition and Environment (CINE), McGill University, Canada. She is trained as
a dietician and nutritionist, and has worked with indigenous peoples in many parts of the
world on research and development topics related to documentation of indigenous peo-ples’
food systems and health promotion. She chairs the Task Force on Indigenous Peoples’
Food Systems and Nutrition of the International Union of Nutritional Sciences. Contact:
Centre for Indigenous Peoples’ Nutrition and Environment, Macdonald Campus of McGill
University, Ste. Anne de Bellevue, Quebec, Canada. E-mail: harriet.kuhnlein@mcgill.ca
Michael C. Latham, OBE, MD, MPH, FFCM, DTM&H, is a medical doctor and nutritionist,
with degrees also in Public Health and Tropical Medicine. He has worked extensively
overseas, particularly in East Africa, but also in Asia. He has been a Professor at Cornell
University since 1968, and has published extensively, particularly on nutritional problems
of low-income countries. Contact: Division of Nutritional Sciences, Cornell University, Ithaca,
New York, USA. E-mail: mcl6@cornell.edu
Sunette Laurie is working as plant breeder and senior researcher at the South African
Agricultural Research Council. Her research includes the sweet potato breeding pro-gramme
and the food-based approach to address vitamin A deficiency. She is part of
a research team that is at the forefront of biofortification of orange-fleshed sweet potato in
sub-Saharan Africa and is one of the collaborators in the Sweetpotato for Profit and Health
initiative. Since 2001, she has coordinated technology transfer in several community
projects over seven provinces in South Africa on home gardens with vitamin A-rich veg-etables
linked to nutrition education. Contact: Agricultural Research Council, Roodeplaat
Vegetable and Ornamental Plant Institute, Pretoria, South Africa. E-mail: slaurie@arc.
agric.za
Dolores R. Ledesma is currently the Biometrician of AVRDC – The World Vegetable Center.
She has extensive experience in experimental design and data analysis, and conducting
biometrics training and reviewing scientific papers. Contact: AVRDC – The World Vegetable
Center, Shanhua, Tainan, Taiwan. E-mail: didit.ledesma@worldveg.org
Eliud Lelerai graduated from Maseno University with a BSc in Applied Statistics in 2003. He
is finalizing his MSc in Applied Statistics in Maseno University this year (2010). He worked
as a statistician intern in the Research Support Unit of the World Agroforestry Centre
(ICRAF) in 2004. He later joined the Millennium Villages Project in 2005 where he worked
as a Database Manager for Sauri Millennium Village until 2009. He is currently working as
a consultant with The Earth Institute of Columbia University supporting data management
and analysis in Dertu and Sauri Millennium Villages. Contact: Millennium Development
Goals Centre for East and Southern Africa, The Earth Institute at Columbia University,
Nairobi, Kenya. E-mail: e.lelerai@cgiar.org
Jef L. Leroy is a research fellow at the Poverty, Health and Nutrition Division of the
International Food Policy Research Institute (IFPRI). Prior to IFPRI, he was a research
associate at the Center for Evaluation Research and Surveys at the National Institute of
Public Health in Mexico. He studies the impact of large-scale integrated programmes on
child nutrition and health, household food consumption and women’s weight. He fur-ther
conducts research on child mortality. Contact: Poverty, Health and Nutrition Division,
International Food Policy Research Institute, Washington, DC, USA. E-mail: j.leroy@
cgiar.org

xxvi Contributors
Adelino Lorens, Diploma in Tropical Agriculture, Vudal Agricultural College, Papua New
Guinea, worked as Pohnpei Chief of Agriculture and related areas for 30 years. He is a
traditional leader in the community of U Municipality in Pohnpei and a leader in the
Catholic Church. He serves on the Pacific Agriculture Plant Genetic Resources Network
steering council and has assisted in leading the Island Food Community of Pohnpei since
its formation. Contact: Phonpei Agriculture of the Office of Economic Affairs, Kolonia,
Pohnpei, Federated States of Micronesia. E-mail: pniagriculture@mail.fm
Jan W. Low is an agricultural economist with a strong research interest in food-based
approaches to combating micronutrient malnutrition. Much of her work in this area dur-ing
the past 15 years has focused on developing and testing effective delivery strategies
that utilize provitamin A-rich sweet potato. She is currently working for the International
Potato Center, based in Nairobi, Kenya, where she is serving as the leader of the 10-year
‘Sweetpotato for Profit and Health Initiative for Sub-Saharan Africa’. Contact: International
Potato Center, Nairobi, Kenya. E-mail: j.low@cgiar.org
A. Carolyn MacDonald is the Nutrition Advisor for World Vision International (WVI) and
Director of WVI’s Nutrition Centre of Expertise. She has worked extensively in international
nutrition in both programming and operational research focusing on integrating multiple
sectors to address malnutrition, including health and food-based approaches. She has man-aged
nutrition programmes in Ethiopia, DRC, and the Sudan and conducted fortification
research in Malawi, and since 1996 has been based in Toronto with World Vision. She holds
a PhD in Nutrition from the University of Guelph. Contact: World Vision International,
based at Mississauga, Ontario, Canada. E-mail: carolyn_macdonald@worldvision.ca
Barbara J. Main is a nurse-midwife with extensive experience supporting maternal and child
health and nutrition programming in several countries of Africa and Asia, including nine
years based in Cambodia. She holds a Master of Public Health from Curtin University of
Technology, Australia, and since 2003 has been based in Mississauga, Ontario, as World
Vision Canada’s Public Health Specialist. Contact: World Vision Canada, Mississauga, Ontario,
Canada. E-mail: barbara_main@worldvision.ca
Barrie M. Margetts holds a BSc in Anatomy and Human Biology, an MSc in Human Nutrition
and a PhD in Epidemiology from the University of Western Australia. He is now Professor
of Public Health Nutrition at the University of Southampton, UK. He is a consultant nutri-tionist
with the Mumbai Maternal Nutrition Project. Contact: University of Southampton,
Southampton, UK. E-mail: B.M.Margetts@soton.ac.uk
Jessica Masira is the Deputy Team Leader/Community Development Coordinator for the
Millennium Villages Project in Sauri, Kenya. She holds an MSA in International Development
(Andrews University, Michigan, USA), a BSc in Agriculture and Home Economics (Egerton
University, Kenya), a Diploma in Management in the Agricultural Sector (Nordic Agricultural
College, Denmark) and a PhD in Planning Continuing. She has over 15 years’ experience in
development and relief, having worked as Head for the Women and Youth programme in the
Ministry of Agriculture, Livestock Development and Marketing, Development Coordinator
with ADRA Kenya, Monitoring and Evaluation Officer on World Food Programme Kenya
Emergency Operations, and was instrumental in initiating the Community-Based Food Aid
Targeting System (CBFTD) as the Health and Nutrition Coordinator in USAID Title 11 project.
Contact: Millennium Development Goals Centre for East and Southern Africa, The Earth
Institute at Columbia University, Nairobi, Kenya. E-mail: j.masira@cgiar.org
Anne-Marie B. Mayer, BSc, MSc, PhD, is a nutritionist; she received her PhD from Cornell
University in 2004. The study presented in Chapter 14 was undertaken as part of her PhD.
Her present research concerns the links between agriculture, food security, nutrition and
health in sub-Saharan Africa. She has worked in Asia and Africa on assessments of the
causes of malnutrition and has developed new survey approaches for nomadic pastoral-ists.
Contact: Centre for Epidemiology and Biostatistics, Faculty of Medicine and Health,
University of Leeds, Leeds, UK. E-mail: abm17@cornell.edu

Contributors xxvii
Alison M. Mildon is a Registered Dietitian specializing in international nutrition. As a
Nutrition Programme Manager at World Vision Canada (based in Mississauga, Ontario)
she has experience in providing technical and management support to nutrition pro-grammes
in a variety of contexts. Contact: World Vision Canada, Mississauga, Ontario,
Canada. E-mail: alison_mildon@worldvision.ca
Ellen Muehlhoff is Senior Nutrition Officer in the Nutrition and Consumer Protection Division,
Food and Agriculture Organization of the United Nations. She heads the Division’s
Nutrition Education and Consumer Awareness Group which works to improve the diets
and nutritional well-being of populations by developing and disseminating science-based
dietary guidance. The Group gives direct technical assistance to countries in the develop-ment
and implementation of nutrition education policies and programmes for the general
public, children and youth, with the aim of changing food environments, creating demand
for healthy diets and stimulating sustainable agricultural development. Contact: Nutrition
Education and Consumer Awareness Group, Nutrition and Consumer Protection Division,
Food and Agriculture Organization of the United Nations, Rome, Italy. E-mail: Ellen.
Muehlhoff@fao.org
Priyadarshini Muley-Lotankar completed an MSc in Food Science and Nutrition and a Master
in Education both at SNDT University, Mumbai, India. She then taught Home Science and
Nutrition to junior and postgraduate students, respectively. She worked as Nutrition
Manager with the Mumbai Maternal Nutrition Project from 2004 to 2006. Contact: Mumbai
Maternal Nutrition Study, Centre for the Study of Social Change, Roy Campus, Bandra
East, Mumbai, India. E-mail: PriyadarshiniMuley-Lotankar@dsm.com
Maria Muñiz (MPA, MSc) is the Data Team Coordinator for the Millennium Villages Project
Monitoring and Evaluation Team, with a focus on data management and field systems,
impact assessment, and research on poverty measurement and livelihoods. Ms Muñiz
received an MPA from the University of Michigan and an MSc in Development Management
from the London School of Economics. Contact: The Earth Institute at Columbia University,
New York, New York, USA. E-mail: mmuniz@ciesin.columbia.edu
Patrick Mutuo is the Science Coordinator and Team Leader of the first Millennium Villages
Project site in Sauri, Kenya, a position he has held since September 2004. Dr Mutuo serves
as the focal person for the Millennium Villages Project at the Cluster Programme level,
ensuring proper programme and financial management and scientific and technological
support required to achieve the Millennium Development Goals at the community level.
He also provides oversight of the technical aspects of the project, including data collection
and analysis, while establishing and managing partnerships with a variety of collabora-tors.
Contact: Millennium Development Goals Centre for East and Southern Africa, The
Earth Institute at Columbia University, Nairobi, Kenya. E-mail: p.mutuo@cgiar.org
Rupesh I. Naik, MPH, Emory University, worked in Pohnpei, Federated States of Micronesia,
guiding the project to assess the development of small-scale local food processing. He car-ried
out this research as part of his requirements for completing a Master of Public Health.
Contact: Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. E-mail:
rupe.naik81@gmail.com
Rose H. Namarika (retired) holds a Master of Community Health from the University of
Liverpool, UK. She was Programme Director of the MICAH (MICronutrient and Health)
programme in Malawi from 1995 to 2006 and was the Senior Health and Nutrition Manager
of World Vision Malawi, based in Lilongwe, Malawi. Contact: World Vision Malawi, Lilongwe,
Malawi. E-mail: rosenamarika@yahoo.com
Joel Negin is Lecturer in International Public Health at the University of Sydney and a Research
Fellow at the Menzies Centre for Health Policy. His research focuses on multi-sectoral
development in sub-Saharan Africa as well as aid effectiveness in the Pacific. Joel has lived
and worked throughout Africa on research and projects with African governments, United
Nations agencies and non-governmental organizations. He maintains an ongoing

xxviii Contributors
affiliation with The Earth Institute at Columbia University where he previously worked.
Contact: Sydney School of Public Health, University of Sydney, Sydney, New South Wales,
Australia. E-mail: joel.negin@sydney.edu.au
Bennett Nemser is the Health Research Manager for the Millennium Villages Project with
primary focus on health data analysis, survey instruments and field systems, as well as
the vital statistics/verbal autopsy reporting. Mr Nemser received an MPH from the
Epidemiology Department at Columbia University’s Mailman School of Public Health in
2007. In addition to his public health experience, Mr Nemser has an MBA and a back-ground
in governmental finance and budgeting. Contact: The Earth Institute at Columbia
University, New York, New York, USA. E-mail: bnemser@ei.columbia.edu
Charlotte G. Neumann, MD, MPH, Professor at the Departments of Community Health
Sciences and Pediatrics at the University of California, Los Angeles’ Schools of Public
Health and Nutrition, has pioneered and directed research in maternal and child health
and development for over five decades in India and Africa that demonstrates the interac-tion
of nutrition, infection and the identification of unique, practical ways to improve the
nutritional status of children and mothers with limited food resources. Her recent research
has documented the role of animal foods in ameliorating multiple micronutrient deficien-cies
and improving growth, activity and development. Contact: Departments of Community
Health Sciences and Pediatrics, Schools of Public Health and Medicine, University of
California, Los Angeles, California, USA. E-mail: cneumann@ucla.edu
Maarten Nubé is a nutritionist whose specific areas of expertise concern the relationships
between poverty and malnutrition, analysis of gender inequalities in nutrition in both
children and adults. Large-scale household surveys and their analysis have also been a
continuing area of research. More recent areas of research include food aid and studies
which relate to the occurrence of micronutrient deficiencies, both in agriculture and in
human nutrition. Contact: Centre for World Food Studies (SOW-VU), VU-University,
Amsterdam, the Netherlands. E-mail: m.nube@sow.vu.nl
Cheryl Palm is the Science and Research Director of the Millennium Villages Project and a
Senior Research Scientist at The Earth Institute at Columbia University. Dr Palm received
a PhD in Soil Science from North Carolina State University after completing her bach-elor’s
and master’s degrees in Zoology at the University of California, Davis. Her research
focuses on land-use change, degradation and rehabilitation, and ecosystem services in
tropical landscapes. She led a major effort quantifying carbon stocks, losses and net green-house
gas emissions following slash-and-burn and alternative land-use systems in the
humid tropics in the Brazilian and Peruvian Amazon, Indonesia and the Congo Basin. She
has spent much of the past 15 years investigating nutrient dynamics in farming systems of
Africa, including options for land rehabilitation. She was elected a Fellow of the American
Society of Agronomists in 2005. Contact: The Earth Institute at Columbia University, New
York, New York, USA. E-mail: cpalm@ei.columbia.edu
Salomón Pérez Suárez is an economist trained at the Universidad del Valle, Cali, Colombia,
with a specialization in International Cooperation and Social Management from the
Universidad de San Buenaventura, Cali, Colombia. He is presently studying for a
Master in Economics at the Pontefician Javeriana University in Cali, Colombia. He has
been associated with Centro Internacional de Agricultura Tropical (CIAT) since 2004,
first as Economist of the CLAYUCA Consortium and since 2006 in the AgroSalud
Project. Contact: Centro Internacional de Agricultura Tropical (CIAT), Cali, Colombia.
E-mail: s.p.suarez@cgiar.org
Nerisa Pilime holds a master’s degree in Nutrition and Health, specializing in Public Health
Nutrition (Wageningen University and Research Centre, The Netherlands), and a BSc
degree in Nutritional Sciences (University of Zimbabwe). She has supported several nutri-tion
interventions as nutritionist with the Food and Agriculture Organization of the United
Nations (sub-regional office in Harare and Rome, Italy). In Zimbabwe she served within

Contributors xxix
Catholic Relief Services, Central Statistical Office and the University of Zimbabwe in col-laboration
with the University of California, San Francisco. Nerisa conducted research in
northern Ghana on factors predicting the intention to consume cowpeas among school-children.
In addition she participated in the facilitation of training on HIV, agriculture and
nutrition training modules in Arusha Tanzania. Nerisa is currently employed as a Nutrition
Advisor within USAID (United States Agency for International Development), South
Africa. Contact: Health Office, USAID Southern Africa, Pretoria, South Africa. E-mail:
npilime@usaid.gov
Ramesh D. Potdar is Head of the Pediatrics Department, Port Trust Hospital and Co-Principal
Investigator of the Mumbai Maternal Nutrition Project. He also heads the Centre for the
Study of the Social Change, a non-governmental organization which works for the empow-erment
of women in urban slums. Contact: Mumbai Maternal Nutrition Study, Centre for
the Study of Social Change, Roy Campus, Bandra East, Mumbai, India. E-mail: rdpotdar@
snehamrc.com
Moses Pretrick, BSc, Park University, USA, is an environmental health specialist who has
worked for the Federated States of Micronesia (FSM) National Government and related
agencies for over 10 years and is presently overseeing the FSM National Food Safety
Program. He has been serving as Vice-Chairman for Island Food Community of Pohnpei
for two years. Contact: Environmental and Community Health Section, Department of
Health and Social Affairs, Palikir, Pohnpei, Federated States of Micronesia. E-mail:
mpretrick@ fsmhealth.fm
Paul M. Pronyk (MD, FRCP, PhD) is an infectious disease physician and public health practi-tioner,
and is currently the Director of Monitoring and Evaluation for the Millennium
Villages Project at The Earth Institute, Columbia University. He has worked extensively in
sub-Saharan Africa, publishing on a range of issues including clinical and structural inter-ventions
for HIV/AIDS; tuberculosis epidemiology and prevention; interventions for the
prevention and mitigation of gender-based violence; nutrition and child health; the health
and social impacts of economic development programmes including microfinance; social
capital, health systems development and public health ethics. Contact: The Earth Institute at
Columbia University, New York, New York, USA. E-mail: ppronyk@ei.columbia.edu
Prema Ramachandran is Director of the Nutrition Foundation of India (NFI). Prior to her cur-rent
position she was Adviser (Health, Nutrition and Family Welfare) of India’s Planning
Commission. She has three decades of research experience in maternal and child nutrition.
Working as Director, NFI, she has contributed to the evaluation and improvement of the
Mid-Day Meal (MDM) programme in Delhi. Contact: Nutrition Foundation of India, New
Delhi, India. E-mail: premaramachandran@gmail.com
Rajeswari Ramana is doing her PhD at Delhi University. She is interested in assessing the
impact of nutrition education in primary-school children. She was involved in the intro-duction
of vegetables in the Mid-Day Meal (MDM) programme.Contact:NutritionFoundation
of India, New Delhi, India. E-mail: rajeshwari.ramana@gmail.com
Bill Raynor, MSc, University of Hawaii at Manoa, USA, is a professionally trained agroforester
who has lived and worked in the Federated States of Micronesia for 26 years. He currently
is the Micronesia Program Director for The Nature Conservancy, and is a recognized
expert on environmental issues in the region. He is a Founding Board Member of the
Island Food Community of Pohnpei and has been active in the organization since its incep-tion.
Contact: The Nature Conservancy–Micronesia Program. Kolonia, Pohnpei, Federated
States of Micronesia. E-mail: braynor@tnc.org
Roseline Remans, PhD, is a Marie Curie Postdoctoral Research Fellow at Leuven Sustainable
Earth of the KU Leuven, Belgium and at The Earth Institute of Columbia University, USA.
She has a PhD in Bioscience Engineering from the KU Leuven and has research experience
in a diversity of institutions that focus on smallholder agricultural systems, including the
Center for Genomic Sciences in Mexico, the International Center for Tropical Agriculture in

xxx Contributors
Colombia, the National Soils Institute in Cuba, the Weizmann Institute of Science in Israel
and the Millennium Villages Project. Her current research focuses on linkages between agri-culture
and nutrition in the Millennium Villages Project and in the Consortium for Improving
Agriculture-based Livelihoods in Central Africa (CIALCA). Contact: The Earth Institute at
Columbia University, New York, New York, USA. E-mail: rremans@ei.columbia.edu
F.-Christophe Richardier has been a volunteer for a number of years in Africa and Asia and a
consultant in the health sector for the Ministry of Health of Timor-Leste and for various
non-government organizations. He is now the Secretary of APEF. Contact: APEF
(Association pour la Promotion des Extraits Foliaires en nutrition), Paris, France. E-mail:
fcr270@yahoo.fr
Tarja Root is an animal nutritionist working in feed control as a senior officer and head of
section at the Finnish Food Safety Authority, Evira. As member of the Selenium Working
Group, she is responsible for selenium surveillance of feeds. Contact: Finnish Food Safety
Authority, Evira, Helsinki, Finland. E-mail: TARJA.ROOT@EVIRA.FI
Marie T. Ruel has been Director of the Poverty, Health and Nutrition Division at the
International Food Policy Research Institute (IFPRI) since 2004. She has worked for more
than 20 years on issues related to policies and programmes to alleviate poverty and child
malnutrition in developing countries. She has published extensively on maternal and
child nutrition, agricultural strategies to improve diet quality and micronutrient nutrition
with a focus on women’s empowerment, urban livelihoods, food security and nutrition.
Before joining IFPRI in 1996, she was head of the Nutrition and Health Division of the
Institute of Nutrition of Central America and Panama/Pan American Health Organization.
Contact: Poverty, Health and Nutrition Division, International Food Policy Research
Institute, Washington, DC, USA. E-mail: m.ruel@cgiar.org
Jeffrey D. Sachs is the Director of The Earth Institute, Quetelet Professor of Sustainable
Development, and Professor of Health Policy and Management at Columbia University. He
is Special Advisor to United Nations Secretary-General Ban Ki-moon. From 2002 to 2006, he
was Director of the United Nations Millennium Project and Special Advisor to United
Nations Secretary-General Kofi Annan on the Millennium Development Goals. Dr Sachs is
also President and Co-Founder of the Millennium Promise Alliance. Contact: The Earth
Institute at Columbia University, New York, New York, USA. E-mail: sachs@columbia.edu
Sirazul A. Sahariah completed an MD in Community Medicine at Gauhati University and
worked as a research officer at the All-India Institute of Medical Sciences, New Delhi for 4
years. He has been working as project manager on the Mumbai Maternal Nutrition Project
since 2005 and is registered for a PhD with the University of Southampton. Contact:
Mumbai Maternal Nutrition Study, Centre for the Study of Social Change, Roy Campus,
Bandra East, Mumbai, India. E-mail: drsahariah@yahoo.com
Pirjo Salminen took her MSc in Horticulture at the University of Helsinki. She is working as
Ministerial Adviser in the Ministry of Agriculture and Forestry and is a member of the
Selenium Working Group responsible for legislation concerning selenium in fertilizer
products. Contact: Ministry of Agriculture and Forestry, Helsinki, Finland. E-mail: pirjo.
salminen@mmm.fi
Pedro Sanchez is the Director of the Tropical Agriculture and the Rural Environment Program,
Senior Research Scholar, and Director of the Millennium Villages Project at The Earth
Institute at Columbia University. Dr Sanchez was Director-General of the World
Agroforestry Centre (ICRAF) headquartered in Nairobi, Kenya from 1991 to 2001, and
served as Co-chair of the United Nations Millennium Project Hunger Task Force. He
received his BS, MS and PhD degrees in Soil Science from Cornell University. His profes-sional
career has been dedicated to help eliminate world hunger and absolute rural pov-erty
while protecting and enhancing the tropical environment. Dr Sanchez is the 2002
World Food Prize Laureate and 2004 MacArthur Fellow. Contact: The Earth Institute at
Columbia University, New York, New York, USA. E-mail: psanchez@ei.columbia.edu

Contributors xxxi
Naomi J. Saronga holds a Bachelor of Science degree in Home Economics and Human Nutrition
(Sokoine University of Agriculture, Tanzania) and a master’s degree in Nutrition and Health,
specializing in Public Health Nutrition (Wageningen University and Research Center, The
Netherlands). She has worked as a nutritionist for the Tanzania Muhimbili National Hospital
in Dar-es-Salaam, and for Tanzania Episcopal Conference, in the Department of Health as
National Assistant Coordinator for an HIV project. She is currently working as a Research
Scientist for the IFAKARA Health Institute in Dar-es-Salaam. Contact: IFAKARA Health
Institute, Dar-es-Salaam, Tanzania. E-mail: nsaronga@ihi.or.tz
Prakash Shetty, MD, PhD, FFPH, FRCP, is Professor of Public Health Nutrition at the Institute
of Human Nutrition, University of Southampton, UK and Editor-in-Chief of the European
Journal of Clinical Nutrition. Until 2005 he served as Chief, Nutrition Planning, Assessment
and Evaluation Service in the Food and Nutrition Division (now Nutrition and Consumer
Protection Division) of the Food and Agriculture Organization of the United Nations
(FAO) in Rome, Italy. Before joining FAO he was Professor of Human Nutrition at the
London School of Hygiene and Tropical Medicine (London University). Contact: Institute
of Human Nutrition, University of Southampton School of Medicine, Southampton, UK.
E-mail: P.Shetty@soton.ac.uk
Devi Shivashankaran completed a BSc in Nutrition at SNDT University, Mumbai. She now
works as a nutritionist with the Mumbai Maternal Nutrition Project, currently studying
for an MSc in Dietetics and Food Service Management from the Indira Gandhi National
Open University, New Delhi. Contact: Mumbai Maternal Nutrition Study, Centre for the
Study of Social Change, Roy Campus, Bandra East, Mumbai, India. E-mail: devu_480@
rediffmail.com
Zeina Sifri is a Public Health Nutritionist with over ten years’ experience in development.
Since 2006 she had been undertaking consultancies on micronutrient malnutrition, home-stead
food production, food security and project management. Prior to that, she worked
with Helen Keller International as a Country Director in Burkina Faso, then as a Deputy
Director for Child Survival, and then as the Regional Coordinator for Africa. Prior to that,
she worked as an Associate Professional Officer and then as a consultant for the Food and
Agriculture Organization of the United Nations in Rome, Bangkok and Bhutan. Contact:
Independent Consultant, Vienna, Virginia, USA. E-mail: sifriz@hotmail.com
Robert Spegal, MPH, University of Hawaii at Manoa, MBBS (Hon), a long-time resident of
Pohnpei State, Federated States of Micronesia (FSM), is the Head of the Micronesia Human
Resource Development Centre, an FSM-chartered non-government organization addressing
regional health concerns, including diabetes, HIV/AIDS and tuberculosis. His former posi-tions
include teacher, medical school administrator, Pohnpei State Director of Health Services
and FSM National Health Planner. Contact: Micronesia Human Resource Development
Center, Kolonia, Pohnpei, Federated States of Micronesia. E-mail: opalpac@mail.fm
Rohana Subasinghe, a former teacher at the University of Colombo and the Universiti Putra
Malaysia, is Senior Aquaculture Officer at the Fisheries and Aquaculture Department of
the Food and Agriculture Organization of the United Nations (FAO). He is specialized in
aquaculture development and aquatic animal health management. Since graduating from
the University of Colombo, Sri Lanka, in 1980, he has worked all over the world. He joined
FAO in 1994 and has been responsible for implementing projects on aquaculture and
aquatic animal health at national, regional and global levels. He is also responsible for
analysis of trends in aquaculture development. He earned his PhD from Stirling University.
He is responsible for initiating major policy changes in aquatic health management in rela-tion
to aquaculture, especially in Asia. He currently serves as the Technical Secretary to the
Sub-Committee on Aquaculture of the Committee on Fisheries of the FAO, the only global
inter-governmental forum on aquaculture. Contact: Fisheries and Aquaculture Resources
Use and Conservation Division, Food and Agriculture Organization of the United Nations,
Rome, Italy. E-mail: Rohana.Subasinghe@fao.org

xxxii Contributors
Jacques Subtil was President of the France-Luzerne Group from 1968 to 1991. He is Co-Founder
and President of APEF. Contact:APEF (Association pour la Promotion des Extraits Foliaires
en nutrition), Paris, France. E-mail: jacques.subtil@wanadoo.fr
Vijayalaxmi R. Taskar completed a medical degree (MBBS) at Bombay University. She is now
the President of Streehitkarini, a non-governmental organization providing healthcare
and education to women living in the slums of Mumbai. She was involved with coordinat-ing
the pilot study of the Mumbai Maternal Nutrition Project. Contact: Streehitkarini,
Lokmanyanagar Compound, Mumbai, India. E-mail: vijayataskar@hotmail.com
Brian Thompson, MSc in Human Nutrition, London School of Hygiene and Tropical Medicine,
UK, is a nutritionist with over 30 years of international development experience. He is
Senior Nutrition Officer in the Nutrition and Consumer Protection Division of the Food
and Agriculture Organization of the United Nations (FAO) dealing with Nutrition
Security and Policy. Working initially for the International Committee of the Red Cross,
the World Food Programme and the United Nations Children’s Fund within the non-governmental
organization community in Asia over five years, he led nutrition surveys,
provided clinical treatment, designed and evaluated emergency relief and recovery pro-grammes
including feeding programmes, supported health prevention and promotion
activities and coordinated the provision of comprehensive humanitarian aid to refugees
and other vulnerable communities. He joined FAO Headquarters in Rome in 1987 and
advises Member Countries on the development and implementation of policies, strate-gies
and plans of action for promoting and improving food and nutrition security in both
emergency and development contexts. Contact: Nutrition and Consumer Protection
Division, Food and Agriculture Organization of the United Nations, Rome, Italy. E-mail:
Brian.Thompson@fao.org
Eija-Riitta Venäläinen, PhD, is a chemist working as a senior researcher at the Finnish Food
Safety Authority, Evira in the Unit of Chemistry and Toxicology. She is a member of the
Selenium Working Group responsible for the analysis of selenium in foodstuffs of animal
origin. Contact: Finnish Food Safety Authority, Evira, Helsinki, Finland. E-mail: eija-riita.
venalainen@evira.fi
Roelf L. Voortman is a land resource ecologist specializing in agro-ecological characterization
and assessment for agricultural development planning with emphasis on parent material–
climate–vegetation–soil chemistry relationships and their implications for fertilizer tech-nologies.
Contact: Centre for World Food Studies (SOW-VU), VU-University, Amsterdam,
the Netherlands. E-mail: r.l.voortman@sow.vu.nl
James Wariero is a pharmacist and public health practitioner. He schooled at the University of
Nairobi’s College of Health Sciences and graduated with a degree in Pharmacy in 2001. He
has worked for the Ministry of Health in Kenya in HIV Care, and in training and mentor-ship
programmes for the Ministry’s HIV Programme in care provision and management.
He has been the Health Coordinator of the Millennium Villages Project in Sauri, Kenya,
since 2006. Contact: Millennium Development Goals Centre for East and Southern Africa,
The Earth Institute at Columbia University, Nairobi, Kenya. E-mail: jwariero@cgiar.org
Katinka M. Weinberger is a socio-economist and formerly Global Theme Leader for ‘Postharvest
Management and Market Opportunities’ at AVRDC – The World Vegetable Center. Her
research interests included high-value supply chains for poor farmers and related aspects
of postharvest and food safety, nutritional health and gender. Contact: Center for
International Forestry Research, Bogor, Indonesia. E-mail: k.weinberger@cgiar.org
Miriam E. Yiannakis is a nutritionist with experience in programme management and techni-cal
support in several countries in Southern Africa, Asia and Pacific Regions, including
seven years with the MICAH (MICronutrient and Health) programme in Malawi. She
now works for World Vision International by advising and developing global nutrition
capacity-building initiatives. Contact: World Vision International, based at Mississauga,
Ontario, Canada. E-mail: miriam_yiannakis@worldvision.ca

Introduction
B. Thompson* and L. Amoroso**
Nutrition Security and Policy Group, Nutrition and Consumer Protection Division,
Food and Agriculture Organization of the United Nations, Rome, Italy
This publication contains 19 chapters, each of
which, with a diverse and unique emphasis
and focus, shows the benefits – and in some
cases the limitations – of food-based
approaches for preventing and controlling
micronutrient malnutrition. The purpose of
this introductory chapter is to set the scene
for the publication, briefly synthesizing the
crucial aspects of each article. One hundred
authors with different backgrounds have con-tributed
to this volume, which brings together
for the first time under one cover available
knowledge, success stories and lessons
learned on country-level activities that help
to demonstrate that food-based app roaches
are viable, sustainable and long-term solu-tions
to overcoming micronutrient malnutri-tion.
Furthermore, the book is an exceptionally
rich source of references on the subject.
Chapters 1 and 2 present an overview of
current developments in food-based app-roaches
and examine some of the studies
and programmes applying these strategies.
Chapter 1, ‘Strategies for Preventing Multi-micronutrient
Deficiencies: A Review of
Experiences with Food-based Approaches in
Developing Countries’ by Rosalind Gibson,
observes the importance of coexisting multiple
micronutrient deficiencies is gaining recogni-tion
prompted by disappointing outcomes
frequently found with single micronutrient
supplements. Concerned about the feasibility
and sustainability of supplementation in poor
resource settings, the chapter discusses the
growing emphasis on food-based approaches
including fortification, dietary diversifica-tion
and modification, and biofortification.
A summary is provided of new developments
in food-based approaches, their advantages
and limitations, and some of the efficacy stud-ies
and programmes utilizing food-based
strategies to combat micronutrient malnutri-tion
are examined. Chapter 2, ‘Addressing
Micronutrient Malnutrition to Achieve
Nutrition Security’ by Prakash Shetty, shows
that combating micronutrient deficiencies
requires short-, intermediate- and long-term
sustainable approaches. The article empha-sizes
that, in addition to micronutrient sup-plementation
and fortification, we need to
promote sustainable food-based approaches
to enable adequate intakes of micronutrients
by much of the population including through
dietary diversification strategies and agricul-ture-
based approaches. By ensuring food and
nutrition security and reducing the wide-spread
problem of micronutrient malnutrition,
the Millennium Development Goals may be
* Contact: Brian Thompson: Brian.Thompson@fao.org
** Contact: Leslie Amoroso: Leslie.Amoroso@fao.org
©FAO 2011. Combating Micronutrient Deficiencies: Food-based Approaches
(eds B. Thompson and L. Amoroso) 1

2 B. Thompson and L. Amoroso
reached. While agricultural approaches have
the potential to significantly impact nutritional
outcomes in a sustainable way, Chapter 3,
‘Agricultural Interventions and Nutrition:
Lessons from the Past and New Evidence’ by
Mary Arimond et al., notes that there is insuf-ficient
understanding of the evidence base on
how best to achieve this potential. Looking at
the available evidence linking agricultural
interventions to nutrition outcomes, the chap-ter
describes the pathways through which
agricultural interventions impact nutrition
and reviews the types of studies that have pro-vided
insights on the links between agriculture
and nutrition. Two case studies are presented
that show how well-designed interventions
can successfully diversify diets and/or impact
on micronutrient intakes and nutritional status
outcomes and can have impact at scale. Finally,
lessons for the design of future interventions
are provided including cost-effectiveness, scal-ing
up and sustainability.
Chapters 4 and 5 show how multi-sectoral
programmes with food-based approaches com-ponents
can alleviate undernutrition and
micronutrient malnutrition. The impact of a
comprehensive multi-sectoral approach in
reducing morbidity and mortality tends not to
be as well documented as single interventions
and hence evidence for the effectiveness of this
approach remains inconclusive. Chapter 4,
‘A 3-year Cohort Study to Assess the Impact of
an Integrated Food- and Livelihood-based
Model on Undernutrition in Rural Western
Kenya’ by Jessica Fanzo et al., aims to correct
this by evaluating the impact of an integrated
food- and livelihood-based model on nutrition-related
outcomes in rural western Kenya. A
3-year prospective cohort study was conducted
collecting data on wealth, socio-economic sta-tus,
health, food and nutrition security, food
consumption and dietary diversity, anthro-pometry
and blood chemistry. Encouraging
evidence is presented that a multi-sectoral
food- and livelihood-based model can improve
diet quality, enhance food security and posi-tively
affect childhood nutritional outcomes.
The wider application of this approach to a
diversity of agro-ecological zones in sub-Saha-ran
Africa is currently being assessed. Chapter
5, ‘Food-based, Low-cost Strategies to Combat
Micronutrient Deficiencies: Evidence-based
Interventions in Lesotho and Malawi’ by Juliet
M. Aphane et al., shows it is possible to enable
resource-poor, HIV- and drought-affected com-munities
to combat micro nutrient deficiencies
through food-based approaches. The project
carried out interventions in food and nutrition
security, health, education and social welfare
but mainly the food and nutrition security
component is discussed. Several strategies
were used including institution building,
human resource development, participatory
approaches, bio-intensive methods of agri-culture,
and crop and diet diversification.
Communities produced more and had greater
access to a variety of micronutrient-rich foods,
including animal-source foods, all year round.
Nutrition education and improved techniques
in food production, processing, preservation
and storage and preparation increased the con-sumption
of micronutrient-rich foods.
Increased intake of animal-source foods
improves nutritional status in populations
with high levels of nutrient deficiencies.
However, the identification of effective
strategies to increase access to and consump-tion
of animal-source foods by vulnerable
populations has proven challenging. The ben-efits
of animal-source foods in combating
micronutrient deficiencies are discussed in
Chapters 6 to 8. Chapter 6, ‘Animal-source
Foods as a Food-based Approach to Address
Nutrient Defi ciencies and Functional Out-comes:
A Study among Kenyan School children’
by Charlotte G. Neumann et al., shows how
food-based approaches, particularly utilizing
animal-source foods, offer potentially sustain-able
solutions to multiple deficiencies. Looking
at school feeding, a causal link was found
between intake of animal-source foods and
micronutrient nutrition, growth and cognitive
and behavioural outcomes, including physical
activity, initiative, arithmetic test and leader-ship
behaviours. Differences in meat versus
milk consump tion and between animal-source
foods and plant-based snacks on children’s
functional outcomes were found. Chapter 7,
‘Small Animal Revolving Funds: An Innovative
Programming Model to Increase Access to and
Consumption of Animal-source Foods by
Rural Households in Malawi’ by A. Carolyn
MacDonald et al., looks at a community-based
intervention to increase household access to

Introduction 3
and consumption of animal-source foods,
implemented as part of a comprehensive,
9-year nutrition and health programme in
Malawi. Small animals were given to poor
households accompanied by training on ani-mal
husbandry and intensive nutrition educa-tion
to promote consumption of the animal
products as part of a broader anaemia- control
strategy which included iron supplementation
and malaria control. The intervention increased
access to and consumption of animal-source
foods and the prevalence of anaemia in women
decreased. However, the authors admit that
the potential contribution of animal-source
foods in the diet cannot be separated from the
potential impact of the integrated programme.
Chapter 8, ‘Aquaculture’s Role in Improving
Food and Nutrition Security’ by Brian
Thompson and Rohana Subasinghe, describes
the benefits of aquaculture, which provides
almost half of the total worldwide food fish
supply, for improving the diets of even the
very poor through increased consumption of
protein, fatty acids, vitamins and minerals.
The authors argue that aqua culture policies
and plans need to ensure that the small-scale
fisheries sector in developing countries bene-fits
from improvements in this sector, as aqua-culture
is not only an essential source of
nutrition, but also a key sector that can decrease
poverty and alleviate malnutrition, including
micronutrient deficiencies. They conclude that
small-scale aquaculture has to be developed
as a responsible and sustainable entrepre-neurial
activity that is financially viable so as
to assure its efficacy in poverty reduction and
nutrition improvement, including the increase
in the micronutrient status of vulnerable
populations.
Fruits and vegetables are a fundamental
part of a balanced diet and a good source of
vitamins and minerals. Chapters 9 to 13
describe the benefits of vegetables and fruits
in preventing and combating micronutrient
malnutrition. Chapter 9, ‘A Home Gardening
Approach Developed in South Africa to
Address Vitamin A Deficiency’ by Mieke
Faber and Sunette Laurie, describes a home
garden strategy that integrates gardening
activities with nutrition education, using
community-based growth monitoring as an
entry point in South Africa. A positive effect
on maternal knowledge of vitamin A nutri-tion,
dietary intake of provitamin A-rich
vegetables, child morbidity as reported by
the caregiver and vitamin A status of chil-dren
is reported. Non-participating house-holds
within the project area were exposed
to the promotion activities and benefited
from the spill-over effect. Provitamin A-rich
vegetables and fruits contributed signifi-cantly
towards achieving the recommended
dietary intake of vitamin A and other micro-nutrients.
The chapter concludes that home
gardening is a long-term strategy that con-tributes
to combating vitamin A and other
nutritional deficiencies. Constraints experi-enced
with vegetable gardens and their pos-sible
solutions are discussed. The World
Vegetable Center (AVRDC) conducts research
and development activities to increase access
to and improve consumption of diverse and
nutrient-rich vegetables, particularly in areas
where malnutrition is prevalent. In Chapter
10, Madan L. Chadha et al. describe ‘AVRDC –
The World Vegetable Center’s Approach to
Alleviate Malnutrition’, which focuses on
increasing vegetable productivity, availabil-ity
and consumption; improving the nutri-ent
content and phytochemical density of
vegetables; and enhancing the bioavailabil-ity
of nutrients from vegetables. The impact
of vegetable consumption on health and eco-nomic
development, as well as the health
benefits of consuming vegetables high in
bioactive compounds, are discussed. Schools
are increasingly recognized as important
settings for promoting healthy nutrition and
eating practices in children. Chapter 11,
‘Introducing Vegetables into the India Mid-day
Meal (MDM) Programme: The Potential
for Dietary Change’ by Ellen Muehlhoff
et al., reviews current literature on school-based
fruit and vegetable initiatives. The
chapter describes the process and the results
of a pilot intervention in urban Indian
schools to promote increased vegetable con-sumption
through the Mid-day Meal (MDM)
programme and to create awareness among
teachers and children on the health benefits
of vegetables. Adequate nutrition is crucial
during childhood and a diet rich in micronu-trients
is vital for good physical growth,
mental development and prevention of

infectious diseases. The chapter shows that
the introduction of vegetables into MDM is
feasible and sustainable if adequate funds
are allocated. The authors conclude that, if
used effectively, the MDM has the potential
to become a major tool for improving vege-table
consumption among school-age chil-dren
both in urban and rural areas of India.
Poor maternal micronutrient status resulting
from poor-quality diets before and during
pregnancy impairs fetal growth and
development. Chapter 12, ‘Developing
Micronutrient-rich Snacks for Pre-conception
and Antenatal Health: the Mumbai Maternal
Nutrition Project (MMNP)’ by Devi
Shivashankaran et al., describes how the
development of locally produced food sup-plements
improves the quality of the diet of
young women living in Mumbai slums,
India. A cooked snack of green leafy vegeta-bles,
fruit and milk which could be distrib-uted
daily to women was developed. The
authors conclude that it is possible to develop
palatable, culturally acceptable and safe
micronutrient-rich food supplements using
a low-technological app roach and locally
available fresh and dehydrated ingredients.
The Pacific island state of Pohnpei,
Micronesia, has experienced much change in
diet and lifestyle since the 1970s: traditional
local foods have been neglected and there
has been a shift to rice and imported proc-essed
foods which, at the same time, have
been accompanied by the emergence of
serious micro nutrient deficiencies and non-communicable
diseases. Chapter 13, ‘App-roaches
and Lessons Learned for Promoting
Dietary Improvement in Pohnpei, Micronesia’
by Lois Englberger et al., des cribes an aware-ness
campaign on the benefits of growing
and consuming local food, especially carote-noid-
rich bananas, for nutrition. As yellow-fleshed
carotenoid-rich foods (banana, taro,
pandanus and breadfruit varieties) were
identified and promoted, banana and taro
consumption increased as did the number
of the varieties consumed. The awareness
campaign was considered a success and the
authors suggest its application in other
Pacific Islands.
Chapters 14 and 15 describe the benefits
of food-based approaches for overcoming
single specific micronutrient deficiencies. Chapter
14, ‘A Food Systems Approach to Increase
Dietary Zinc Intake in Bangladesh Based on
an Analysis of Diet, Rice Production and
Processing’ by Anne-Marie B. Mayer et al.,
suggests that an understanding of the zinc
content of rice at different stages of the proc-ess
from field to fork may be used to identify
and plug ‘nutrient leaks’ in the food system.
In villages in Bangladesh, the potential for
intakes of zinc increases if soil zinc is above
the critical level and adjustments are made to
milling, cooking and local variation in the
zinc content of rice varieties, in that order. It is
suggested that if all these changes are imple-mented,
dietary zinc could increase by more
than 50%. Iron deficiency is the most preva-lent
dietary deficiency worldwide affecting
almost two billion people. Chapter 15,
‘Combating Iron Deficiency: Food-based
Approaches’ by Brian Thompson, describes
the requirements for iron and related micronu-trients
and the prevalence and geographic and
socio-economic distribution of anaemia. The
chapter outlines the public health consequences
of anaemia on both the individual and society
and discusses the determining factors that
can lead to or hinder their alleviation. The
chapter describes policies and intervention
programmes that can effectively alleviate
micronutrient deficiencies and highlights the
commitment of the Food and Agriculture
Organization of the United Nations to place
food-based strategies for preventing micro-nutrient
deficiencies high on the development
policy agenda. The chapter concludes that
increasing the availability and consumption
of a nutritionally adequate diet is the only
sustainable long-term solution, not only for
combating iron-deficiency anaemia, but also
for preventing and controlling other micro-nutrient
deficiencies.
Chapters 16 to 18 discuss food fortifica-tion.
Chapter 16, ‘Human Micronutrient
Deficiencies: Linkages with Micronutrient
Deficiencies in Soils, Crops and Animal
Nutrition’ by Maarten Nubé and Roelf L.
Voortman, discusses the connection between
micronutrient deficiencies in soils, crops,
animal and human nutrition. The chapter
asks whether the application of micronutri-ents
as fertilizer is realistic and feasible for

Introduction 5
addressing human micronutrient deficien-cies.
Evidence for direct quantitative rela-tionships
between micronutrient deficiency
in soils and human nutrition is clearly avail-able
for iodine and selenium, and possibly
also for zinc. Addition of these micronutri-ents
to soils can substantially increase crop
micronutrient content and thus contribute
to ameliorating human micronutrient
deficiencies. While recognizing the potential
for developing new crop varieties through
plant breeding and genetic manipulation
(gene tically modified organisms), for some
micronutrients there appears to be evidence
that micronutrient fertilization in some
cases may be an alternative approach. For
example, worldwide the element selenium
is un equally distributed in the soil. For cli-matic
and geochemical reasons Finland is
one of the low-selenium regions in the
world. To improve the quality of Finnish
foods and animal health and to increase the
selenium intake of the population, it was
decided in 1984 to supplement compound
fertilizers with selenium. Chapter 17,
‘Nationwide Supplementation of Sodium
Selenate to Com mercial Fertilizers. History
and 25-year Results from the Finnish
Selenium Monitoring Pro gramme’ by Georg
Alfthan et al., describes the effects of the
supplementation of selenium in commercial
fertilizers on soils, feeds, basic foodstuffs,
dietary selenium intake, human tissues and
environment. In Finland, where the geo-chemical
conditions are relatively uniform,
the nationwide supplementation of fertiliz-ers
with selenium has proved to be an effec-tive,
safe and controlled way of bringing
selenium intake of populations up to the
recommended level. Chapter 18, ‘Leaf
Concentrate and Other Benefits of Leaf
Fractionation’ by M.N. Glyn Davys et al.,
describes the nutritional qualities of leaf
concentrate, providing the technical details
of leaf fractionation at domestic and inter-mediate
scales of production. It reviews the
evidence for the effectiveness of leaf concen-trate
in improving human nutritional status
and the factors that have slowed down its
adoption on a larger scale. The authors pro-pose
how these may be overcome and argue
the possible wider role of leaf concentrate in
combating human malnutrition, including
its use as a locally produced ready-to-use
therapeutic food.
In conclusion, Chapter 19 describes how
the disability-adjusted life years (DALYs) meth-odology
can be a useful approach for econom-ically
assessing cost-effectiveness in terms of
the nutritional impact of interventions. The
development of biofortification programmes,
for example in Nicaragua, can complement
traditional food-based strategies, but their
applicability and continued development
ought to be strengthened with an accurate
assessment of cost-effectiveness and their
economic impact. The DALYs methodology
could be a good approach for this. Chapter
19, ‘Disability-Adjusted Life Years (DALYs):
a Methodology for Conducting Economic
Studies of Food-based Interventions such as
Biofortification’ by Salomón Pérez Suárez,
describes the DALYs methodology which is
used to evaluate interventions in health and
nutrition (biofortification) in economic
terms, and then applies it in the case of iron-biofortified
beans in Nicaragua. The DALYs
are a useful approach for the economic
assessment of nutritional interventions such
as biofortification, but the author points out
that the principal constraint is the availabil-ity
and quality of the information required
for its application.
The chapters have been selected and the
publication compiled to showcase and docu-ment
the impact of food-based approaches on
nutrition, drawing as much as possible on
evidence-based experiences. This has been
achieved with the contributions from this
diverse and learned group of researchers and
experts who all point to the need for viable,
long-term and sustainable interventions and
programmes for the alleviation of micronutri-ent
deficiencies among vulnerable population
groups. What the chapters also point out is
the need for better documentation of the
impact of agricultural development pro-grammes
and food-based interventions on
people, and specifically on their ability to
produce, acquire and consume better diets in
terms of quantity, quality and variety of nutri-ent-
rich foods for improving nutrition in
general and for alleviating micronutrient
deficiencies in particular. We need to keep in

mind that Ministries of Finance, investment
banks and donors all require firm evidence
from development strategists and agricul-tural
planners that the approach proposed
has an impact, and that this impact can be
measured in a way that can lend itself to anal-ysis
of its cost-effectiveness. Con sequently,
we need to make further efforts to better doc-ument
and collect the scientific evidence to
demonstrate the impact and effectiveness of
food-based approaches for preventing and
controlling micronutrient malnutrition.

1 Strategies for Preventing
Multi-micro nutrient Deficiencies: a Review
of Experiences with Food-based
Approaches in Developing Countries
R.S. Gibson*
Department of Human Nutrition, University of Otago, Dunedin, New Zealand
Abstract
The importance of coexisting micronutrient deficiencies in developing countries is gaining recognition,
prompted by the disappointing responses often observed with single micronutrient supplements. Further,
of concern is the feasibility and sustainability of supplementation as a mode of delivery in poor resource
settings. Consequently, there is increasing emphasis on food-based approaches: fortification, dietary diver-sification
and modification, and biofortification. Novel delivery approaches exist for fortifying comple-mentary
foods in the household using tablets, sprinkles and fat-based spreads. These are all designed to
supply micronutrients without any changes in feeding practices, and irrespective of the amount of food
consumed. A version of the fortified spread is also used as a ready-to-use therapeutic food for treating
malnourished children. Dietary diversification and modification, in conjunction with nutrition education,
focus on improving the availability, access to and utilization of foods with a high content and bioavailabil-ity
of micronutrients throughout the year. The strategies are designed to enhance the energy and nutrient
density of cereal-based porridges; increase the production and consumption of micronutrient-dense foods
(especially animal-source foods); incorporate enhancers of micronutrient absorption; and reduce the
phytate content of cereals and legumes through germination, fermentation and soaking.
In the future, biofortification via processes such as agronomic practices, conventional plant breeding
or genetic modification holds promise as a sustainable approach to improve micronutrient adequacy in the
diets of entire households and across generations in developing countries. This review summarizes new
developments in food-based approaches, their advantages and limitations, and examines some of the
efficacy studies and programmes utilizing food-based strategies to alleviate micronutrient deficiencies.
Key words: complementary food supplements, fortification, household dietary strategies, biofortification
Introduction
The existence of multiple micronutrient defi-ciencies
in developing countries is gaining
increasing recognition (1). Their aetiology is
multi-factorial: inadequate intakes and genetic,
parasitic and infectious diseases may all play a
role (2,3). Inadequate intakes of certain micro-nutrients
such as iodine, selenium and zinc
can also be exacerbated by environmental
factors, as their content in plant-based foods
is dependent on soil trace element levels (4).
* Contact: Rosalind.Gibson@Stonebow.Otago.ac.nz

8 R.S. Gibson
Micronutrient deficiencies can have major
adverse health consequences, contributing to
impairments in growth, immune competence,
mental and physical development, and poor
reproductive outcomes (1,5) that cannot always
be reversed by nutrition interventions.
Clearly, there is an urgent need for pro-grammes
to alleviate micronutrient deficien-cies
in developing countries. Strategies
commonly used are supplementation and
food-based approaches, preferably in conjunc-tion
with public health interventions such as
promotion and support of breastfeeding and
control of infectious and parasitic diseases.
Several efficacy trials employing multi-micronutrient
supplements have been con-ducted
on selected population groups in
developing countries. Results have been
mixed, depending on the combination of
micronutrients included, age or life-stage
group, baseline nutritional status of the sub-jects
(including HIV status), study setting and
duration, and the outcomes measured (6–12).
Such discrepancies have highlighted that a
cautious approach is needed with regard to
routine use of micronutrient supplements,
especially when they contain large doses of
iron taken in a single dose in malaria-endemic
areas (13). Distribution and sustainability of
supplementation programmes are additional
concerns in poor resource settings. As a conse-quence,
increasingly, food-based approaches
involving fortification, improving dietary
quality through diversification/modification
and nutrition education, and biofortification
are being pursued. Some of these new devel-opments,
especially appropriate for poor
resource settings, are discussed below.
New Approaches for Fortifying
Complementary Foods
Inadequacies in several micronutrients, nota-bly
iron, zinc and calcium, and sometimes
vitamin A, vitamin B6 and riboflavin, have been
reported in complementary foods in many
developing countries (14–16). Such deficits
arise in part because unrefined cereals are often
used as a basis for complementary foods in
poor resource settings. These staples contain
high levels of phytic acid and/or polyphenols,
components known to inhibit absorption of
iron, zinc and calcium (15). Unfortunately,
addition of animal-source foods, especially red
meat and organ meats which are rich sources of
absorbable iron and zinc, vitamin B6, riboflavin,
vitamin B12 and in some cases vitamin A, is often
not feasible in complementary foods given to
infants living in poor resource settings.
Use of complementary food supplements
In an effort to reduce risk of these micronutri-ent
inadequacies during the complementary
feeding period, complementary food supple-ments
(CFSs) have been developed. At
present, three types of CFS are available:
(i) crushable or water-soluble micronutrient
tablets – termed foodlets; (ii) micronutrient
powders – termed sprinkles; and (iii) micro-nutrient
lipid-based fortified spreads – termed
lipid-based nutrient supplements (LNSs).
They have been summarized in detail by
Nestel et al. (17). The CFSs have been designed
to supply vitamins and minerals at the level
of one or two recommended dietary allow-ances,
without any changes in feeding prac-tices
and irrespective of the amount of
complementary food consumed. A modified
version of micronutrient sprinkles containing
a lower amount of iron per serving is now
available for use in malaria-endemic areas in
an effort to avoid the potential adverse effects
of a large bolus of iron taken in a single dose.
This modified sprinkles formulation also con-tains
lower amounts of zinc, vitamin A and
iodine, copper and added vitamin K, and can
be added to family foods as well as home-prepared
complementary foods (13).
Unlike the foodlets or sprinkles, the LNSs
also provide a source of energy, protein and
essential fatty acids – linoleic acid and a-linolenic
acid. A modified version of the forti-fied
spread – termed ready-to-use therapeutic
food (RUTF) – is used for treating acutely mal-nourished
children in health centres and
home-based care. RUTFs do not have to be
cooked before consumption and have a low
water content, so that risk of interactions
among micronutrients, as well as bacterial
contamination during home storage, is low (18).

Strategies for Preventing Multi-micronutrient Deficiencies 9
Typically, malnourished children consume
the RUTF directly from the jar, without dilut-ing
it or mixing it with other foods, although
it can also be added to a traditional cereal- or
legume-based porridge when used for feed-ing
infants aged 6 to 12 months, who may
find the thick paste difficult to swallow.
Acceptable clinical outcomes have been
achieved among malnourished children in
Malawi using either imported (18,19) or
locally produced RUTFs (19,20).
LNSs have also been used for the preven-tion
of malnutrition in infants and young chil-dren.
Efficacy trials in sub-Saharan Africa have
reported improvements in linear growth and a
reduction in the incidence of severe stunting
among 6- to 18-month-old breastfed infants
provided with small daily doses of comple-mentary
LNS (21,22). There is some evidence
that this positive impact on stunting may be
sustained post intervention (23), although
more studies are needed to confirm these find-ings.
In the future, it is anticipated that spe-cially
formulated LNSs designed to meet the
needs of infants and young children and preg-nant
and lactating women will be incorporated
in the food packages supplied in emergency
settings; more details are available in Chaparro
and Dewey (24).
Some concern has been raised about pos-sible
antagonistic interactions that might
occur in complementary foods fortified with
multi-micronutrients, arising from competi-tion
for a common absorptive pathway.
However, some data suggest that these risks
are low in fortified foods because the dietary
ligands released during digestion of the forti-fied
foods chelate the trace minerals, which
are then absorbed by different pathways (25).
Nevertheless, the bioavailability of iron, zinc
and calcium fortificants may still be compro-mised
if the complementary foods are based
on cereals and legumes high in phytic acid,
polyphenols and oxalates (26).
Several efficacy trials of CFSs mixed with
home-prepared complementary foods have
been completed; details are summarized in
Dewey et al. (27). Significant positive effects on
haemoglobin concentrations and/or iron
status have been observed in most of these
studies (28–32). In contrast, of the four trials
that have measured serum/plasma zinc
(29,30,32,33) only the South African study (30)
observed a significant decrease (P < 0.05) in the
incidence of low plasma zinc concentrations in
those receiving a daily micronutrient crusha-ble
foodlet mixed with the porridge compared
with the placebo group.
The effects of the CFSs on growth have
been inconsistent, and dependent on the type
of CFS consumed. Significant gains in length
and/or weight have been reported in
Ghanaian (21) and Malawian (33) infants fed
fortified spreads, but not in those receiving
micronutrient sprinkles (21,29,31) or foodlets
(21,30). The essential fatty acid content of the
fat-based fortified spreads may account for
the improved length gain, whereas the
increased energy intake may be associated
with greater weight gain (21).
Consuming all three types of CFS for
6 months has been reported to result in a
higher proportion of Ghanaian infants walk-ing
independently by 12 months compared
with non-intervention infants (21), but no
positive effects on morbidity. Indeed, only
one multi-micronutrient sprinkles study
among 6- to 12-month-old Pakistani infants at
high risk for diarrhoea has shown a signifi-cant
reduction in morbidity (34). Future stud-ies
of CFSs should include an assessment of
biomarkers for all micronutrients and func-tional
health outcomes such as growth, body
composition, morbidity, motor milestones
and cognitive function. Consideration should
also be given to the addition of acid-resistant
phytase enzyme to the fortificant premixes to
hydrolyse phytate in high-phytate comple-mentary
foods; these enzymes hydrolyse
phytic acid during digestion in the stomach.
Effectiveness studies of CFSs are limited.
World Vision has been involved in two large-scale
effectiveness programmes of micronu-trient
sprinkles, one in conjunction with
nutrition education in Mongolia (35) and a
second with fortified wheat/soy blend in
rural Haiti (36). In both programmes, signifi-cant
reductions in anaemia were reported
among those children receiving sprinkles,
which in Haiti were sustained 7 months after
completion of the 2-month sprinkles inter-vention
period; growth outcomes were not
reported. To date, there have been no effec-tiveness
trials of foodlets or LNSs mixed with

10 R.S. Gibson
complementary foods for the prevention of
malnutrition.
Use of centrally processed,
micronutrient-fortified cereal-based
complementary foods
There have been several efficacy trials of cen-trally
processed micronutrient-fortified com-plementary
foods based on cereal blends;
results have been summarized by Dewey and
Adu-Afarwuah (37). Some biochemical and/
or functional health outcomes, most notably
growth, have been investigated, but again
results have been mixed. In some of these
studies, results of the fortified group have
been compared with a control group receiv-ing
the same product but unfortified with
micronutrients (38,39), whereas in others
(40,41) the comparison children have con-sumed
their usual home diets, making com-parisons
among the studies difficult. Two of
the randomized controlled trials (38,39)
reported a significant and positive effect of
the fortified complementary food on haemo-globin
and/or iron status. However, there has
been no significant increase in serum/plasma
zinc observed, perhaps attributed to the low
bioavailability of zinc in high-phytate-based
complementary foods. Moreover, no signifi-cant
effects on weight or length gain were
reported in three of the studies (38–40),
although in India weight but not linear
growth improved significantly compared
with the comparison group during the
8-month intervention (41). Of the other func-tional
outcomes investigated in some of these
efficacy trials (i.e. morbidity, psychomotor
and/or motor development), only the South
African study by Faber et al. (39) reported sig-nificantly
higher motor development in the
fortified compared with the unfortified group.
No reductions in morbidity from infections
have been observed. Indeed, in the study in
India (41), morbidity increased in the group
receiving the fortified complementary food,
possibly in part due to contamination during
the preparation of the food, a decrease in
breastfeeding rates and/or differential over-reporting
of morbidity in this group.
A few large-scale effectiveness pro-grammes
have included a micronutrient-fortified
cereal-based complementary food,
notably the Food and Nutrition Program
(PANN) in Ecuador (42), which distributed
Mi Papilla (with education) for families, and
the National Fund of Development and Social
Compensation (FONCODES) Project in Peru
in which children received Ali Alimentu, a
pre-cooked (extrusion) instant fortified food
(43). Only the PANN programme in Ecuador
showed a significant increase in haemoglobin
(P < 0.0001) and ponderal growth (P = 0.03),
with a marginally significant improvement in
linear growth (P = 0.08) compared with the
control group, although improvements in
micronutrient intakes were reported in the
FONCODES Project in Peru (43).
Use of other micronutrient-fortified
food products by young children
The effects of micronutrient fortification of
other food products such as biscuits, spreads,
milk and other beverages consumed by young
children have also been investigated, in some
cases in schools (44–46). Results of several of
these efficacy studies have been promising.
Reductions in anaemia (47–50), biochemical
micronutrient deficiencies (45,47–51) and
morbidity (46,47,52) have been reported.
Improvements in some aspects of cognitive
function (short-term learning and memory
and attention span) (46,47,51) and sometimes
in body weight (48–50) and height (49) have
also been observed.
Effectiveness trials with fortified food
products are limited. In an effectiveness
programme in Mexico, children aged 10 to 30
months from low-income families were sup-plied
(400 ml/day) with Nutrisano – distributed
as whole cow’s milk powder fortified with
iron (ferrous gluconate), sodium ascorbate,
folic acid and zinc oxide. Sig nificant reduc-tions
in anaemia prevalence and improve-ments
in iron status after 6 months were noted
in the children receiving the fortified versus
unfortified milk, but there were no differences
in mean serum zinc concentrations (53).
Powdered whole cow’s milk is also fortified

with iron, copper, vitamin C and zinc in Chile
and used for feeding children aged >6 to 18
months of age. Although studies have shown
increases in the amount of absorbed iron and
zinc from this fortified milk, and improve-ments
in iron status among 18-month-old male
children (n = 42) receiving the fortified pow-dered
cow’s milk for at least 6 months, no com-parable
effect on their biochemical zinc status
has been reported; growth was not measured
in this study (54). Such inconsistencies may be
associated, at least in part, with the form and/
or dose of the fortificants and the composition
of the food vehicle, as well as the earlier factors
discussed in relation to micronutrient supple-mentation.
Additionally, constraints on growth
may be linked to infection, poor child feeding
practices (55,56), long-term effects of prenatal
malnutrition and/or intergenerational effects
of maternal malnutrition. The impact of the
latter emphasizes the critical need for sustain-able
strategies to enhance both energy and
micronutrient adequacy of the plant-based
diets of the entire household in developing
countries and across generations; some of
these dietary strategies are outlined below.
Household Dietary Strategies
Use of CFSs and processed fortified foods
may have limited lasting benefits in poor
resource households in developing countries
because of problems with accessibility,
affordability and their reliance on continuing
donor support. In such circumstances, die-tary
diversification and modification,
designed and implemented through a forma-tive
research process, may be the preferred
strategy. The approach involves changes in
food selection patterns and traditional house-hold
methods for preparing and processing
indigenous foods, with the overall goal of
enhancing the availability, access to and utili-zation
of foods with a high content and bio-availability
of micronutrients throughout the
year. Factors that must be considered when
designing and implementing effective die-tary
strategies include knowledge of dietary
patterns, availability and cost of foods, data
on their nutrient and anti-nutrient content,
information on food beliefs, preferences and
taboos, impact on cooking time and work-loads
of the caregivers, and the inclusion of
nutrition education and social marketing to
foster behaviour change.
Dietary diversification and modification
have the potential to prevent multiple micro-nutrient
deficiencies simultaneously without
risk of antagonistic interactions, while at the
same time being culturally acceptable, eco-nomically
feasible and sustainable, even in
poor resource settings. The strategies have the
added advantage of enhancing the
micronutrient adequacy of diets of the entire
household and across generations. Several
additional non-nutritional benefits may also
be achieved through the community-based
nature of dietary diversification/ modification.
These may include empowerment of women
in the community, training and income gener-ation.
To be successful, a multidisciplinary
team of specialists in nutrition, epidemiology,
agriculture, rural extension, adult education,
psychology and community health is essential
to assist with the design, implementation,
monitoring and evaluation of dietary diversifi-cation/
modification strategies.
Possible household dietary strategies
include: (i) increasing the energy and nutrient
density of cereal-based porridges; (ii) increas-ing
the production and consumption of
micronutrient-dense foods; (iii) incorporating
enhancers of micronutrient absorption in
household diets; and (iv) employing germi-nation,
fermentation and/or soaking to
reduce the phytate content of unrefined cere-als
and legumes by enzyme-induced hydrol-ysis
of phytate and/or passive diffusion of
water-soluble phytate. Each of these strate-gies
is discussed briefly below; the reader is
referred to the following reviews for more
details (26,57–59).
Increasing the energy and nutrient density
of cereal porridges for infant and young
child feeding
The energy (and micronutrient) density of
porridges used for infant and young child
feeding can be increased by using thicker por-ridges
prepared with 20–28% dry matter, a

12 R.S. Gibson
practice that can be facilitated by the addition
of small amounts of germinated cereal flours
to the cooked porridges. The a-amylase in the
germinated cereals hydrolyses amylose and
amylopectin to dextrins and maltose, reduc-ing
the viscosity of thick porridges to an easy-to-
swallow semi-liquid consistency suitable
for infant and child feeding, without dilution
with water (26).
Five efficacy trials have employed the
addition of amylase (either produced indus-trially
or by traditional methods) to enhance
the energy density of complementary foods;
details are given in Dewey and Adu-Afarwuah
(37). Of these, only two significantly enhanced
ponderal and/or linear (60,61) growth. Only
the trial in the Congo collected morbidity
data (61), and reported significantly greater
(P < 0.05) rates of cough and rhinitis (but not
diarrhoea or fever) in the intervention com-pared
with the control group. Differences in
breastfeeding practices did not account for
this finding. Instead, although not confirmed,
the intervention group may have had a
greater intake of microbial-contaminated
complementary food. No effectiveness stud-ies
or programmes employing the addition of
amylase have been reported.
Increasing the production and/or
consumption of micronutrient-dense foods
To increase the micronutrient content of diets,
small livestock production and aquaculture
can be promoted, and consumption of meat,
poultry, fish and eggs encouraged ensuring
they are not sold for cash but targeted to those
household members at high risk of micronu-trient
deficiencies. Incorporation of some
animal-source foods, especially cellular ani-mal
protein, into predominantly plant-based
porridges used for infant and young child
feeding has several advantages. Cellular ani-mal
foods have a high energy density and are
good sources of high-quality protein, readily
available haem iron and zinc, as well as vita-mins
B6, B12, B2, and in liver, vitamin A, all
micronutrients frequently limiting in plant-based
diets (62). Incorporation of dried meat
and fish has the added advantage of not
requiring refrigeration. Further, dried fish can
be consumed in countries where religious
and/or cultural beliefs prohibit the consump-tion
of meat, and when prepared from small,
whole, soft-boned fish, provides a good
source of readily available calcium.
At least six studies have either supplied
or vigorously promoted the consumption of
animal-source foods such as chicken livers
(63) and/or eggs (63–65), red meat (65–67) or
fish (38,65) among infants and/or young chil-dren;
details are summarized in Table 1.1.
Increases in weight (63–65), length (63,64),
head circumference (67) and behaviour index
score (67) have been reported but no reduc-tions
in morbidity (38,66), perhaps because of
small sample sizes. Results of the studies con-ducted
in Peru (63) and China (64), in which
stunting was significantly reduced, empha-sized
the beneficial effects of including key
educational messages to promote the con-sumption
of animal-source foods together
with enhanced feeding and caring practices.
The addition or promotion of animal-source
foods in the diets of schoolchildren
and women of reproductive age in develop-ing
countries also has the potential to have a
positive impact on micronutrient status,
growth and cognitive function. In a 2-year
randomized controlled efficacy study among
Kenyan schoolchildren, despite no significant
increase in biochemical indices except for
plasma vitamin B12 concentrations (68),
improvements in weight (69) (but not height)
and certain domains of cognitive functioning
(70) were reported in those receiving a meat-based
snack compared with the control group.
An increase in height was also observed in
those children who received a milk-based
snack and had a lower baseline height-for-age
Z score (£−1.4) compared with their coun-terparts
in the control group (69). In two later
reports, growth among all the children was
shown to be positively predicted by average
daily intake of energy from animal-source
foods and those nutrients provided in high
amounts and in a readily available form from
meat and milk (i.e. haem iron, calcium, vita-min
B12, vitamin A) (71). Improved cognitive
test scores were significantly related to intakes
of available iron, available zinc, vitamin B12
and riboflavin, after controlling for potential

Table 1.1. Studies that have supplied or promoted the consumption of animal-source foods among infants and toddlers.
Country
(reference)
Intervention strategies
Design Methods
Outcomes
Supplied
ASFs
Nutrition
education
Target
groups
KAP and dietary
intake Nutritional status
Ghana (38) Yes No Healthy
breastfed
infants
≥2.5 kg at
birth
(Efficacy
study)
RCT for 6 months,
with 4 treatments:
Weanimix (W); W
plus vitamins &
minerals (WVM);
W plus fish
powder (WF); koko
with fish power
(KF); compared
with non-intervention
group
(NI) (n = 464)
Monthly 24-h
recalls for 3 days
(6 to 12 months);
12-h weighed
records for 50%
of subjects;
morbidity;
anthropometry;
Hb, Hct, CRP,
plasma Zn,
serum retinol,
serum ferritin,
TIBC, RBC B-2
• No differences in
intakes between W,
WF and KF groups
except at 7 months
when Zn and Fe
intakes higher in KF
than W group
(P < 0.05)
• No significant differences in
morbidity outcomes, weight,
length, HC, MUAC, skin folds,
AFA or AMA, or plasma Zn,
Hb, Hct, transferrin saturation
or RBC B-2, between 4
groups at any time
•WAZ and LAZ scores of NI
group were lower (P < 0.05)
than combined intervention
group at 6 and 9 months of age
• Significant increase in
percentage with low ferritin
between 6 and 12 months in
W, WF and KF groups but not
in WVM group (P < 0.05)
• Change in plasma retinol was
significantly greater in WVM
between 6 and 12 months
than in other 3 groups
combined (0.14 ± 0.3 versus
−0.04 ± 0.3 μmol/l, P = 0.003)
• No effect on morbidity after
3 months
Continued

14 R.S. Gibson
Table 1.1. Continued.
Country
(reference)
Design Methods
Outcomes
Supplied
ASFs
Nutrition
education
Target
groups
KAP and dietary
Bangladesh
(65)
No Yes Malnourished
children
(WAZ
61–75% of
NCHS
median)
aged 6–24
months
(n = 189)
(Efficacy
study)
RCT for 3 months,
with 2 treatments:
Grp 1 (n = 93)
received supple-mental
food for 6
days/week) (cereal
blends) plus
intensive nutrition
education that
promoted inclusion
of egg, meat or
fish in CFs; Grp 2
(n = 90) was
control, received
normal services
Anthropometry,
morbidity
• Greater change in WAZ and
WLZ but not LAZ in
intervention versus control
(P < 0.05) after 3 months
USA (67) Yes No Exclusively
breastfed,
healthy,
infants
followed
from ~6 to
12 months
(Efficacy
study)
RCT: puréed beef
(n = 46) versus
iron-fortified infant
rice cereal (n = 42)
as first CF at ~6
months; plus fruits
and vegetables as
desired. 9 months
follow-up
2 × 3-day diet
records/month for
4 visits); rating
scale of infant’s
acceptance to
CF; anthropom-etry;
developmen-tal
testing (Bayley
scores); Hb, Hct,
serum ferritin,
somatomedin,
plasma Zn
• Mean protein and Zn
intakes higher but Fe
intake lower in meat
than cereal group at 5
and
7 months (P < 0.001)
• No difference in mean
energy intakes
• Tolerance and
acceptance for beef
and cereal
comparable
• Greater increase in HC for
meat than cereal group; Zn
and protein significant
predictors of head growth
• No biochemical differences
in Fe or Zn status between
groups
• Trend for higher behaviour
index at 12 months in meat
than cereal group (P = 0.08)

Denmark
(66)
Yes No Healthy,
term,
partially
breastfed
infants,
aged 8
months
(n = 41)
(Efficacy
study)
Randomized trial;
low meat group
(LMG) 10 g meat/
day (n = 20)
versus high meat
group (HMG) 27 g
meat/day (n = 21).
2 months follow-up
Food records:
24-h weighed
food record 1/wk;
anthropometry;
Hb, serum ferritin,
TfR; morbidity
(frequency of
illness)
• Despite higher meat
intakes, NSD in total
Fe intakes: HMG 3.1
(0.4–6.2) mg/day
versus LMG 3.4
(1.4–6.1) mg/day, P >
0.05
• Zn intakes not
measured
• Change in Hb: LMG –4.9
(–12.9, 5.6) g/l versus HMG
–0.6 (–12.1, 7.3) g/l,
P = 0.008
• NSD in change in serum
ferritin or TfR
• No differences in serum Zn
at follow-up or morbidity
between LMG and HMG
China (64) No Nutrition
education and
counselling
visits to
increase BF
and quality
plus quantity
of CFs from 4
months of
age, e.g. give
egg yolk daily
after 4–6
months
Infants aged
4–12
months
from rural
China
(Efficacy
study)
Quasi-experimental
design with
non-equivalent
controls. Pre/post
intervention,
1-year follow-up;
intervention group
(n = 250) versus
control group
(n = 245)
Weight and length;
single 24-h
recall; FFQ; KAP
(infant feeding
and health-related
behav-iours);
Hb
measures
• Intervention group
had greater nutrition
knowledge, higher BF
rates (83% versus
75%, P = 0.034) and
better reported infant
feeding practices
versus controls
(P < 0.05)
• Greater number eggs
fed/day to children
4–9 months in
intervention versus
controls
• NSD in growth between 2
groups before age of 12
months
• At 12 months, WAZ in
intervention group was –1.17
versus –1.93 for controls
(P = 0.004), HAZ was –1.32
versus –1.96 for controls
(P = 0.022) and prevalence
of anaemia was 22% versus
32% for controls (P = 0.008)
Continued

16 R.S. Gibson
Country
(reference)
Design Methods
Outcomes
Supplied
ASFs
Nutrition
education
Target
groups
KAP and dietary
Peru (63) No Nutrition
education to
increase intake
of thick purées
and ASFs and
increase
practice of
responsive
feeding.
Demonstrations
of CF
preparation.
Accreditation
system in
government
health facilities
Birth cohort:
infants
from a
poor,
peri-urban
area,
followed
from 0 to
18 months
(Efficacy
study)
Cluster-randomized
trial (non-blinded),
pre/post interven-tion;
intervention
(n = 187) versus
control (n = 190).
18-month
follow-up
Home interviews
and observations
for SES, hygiene
and feeding
practices; weight
and length;
24-h recalls on
intake of CFs at
6, 9, 12, and 18
months; morbidity
(over past 24 h)
at same visits
Intervention versus
control group:
• more caregivers
received nutrition
education (16/31
(52%) versus 9/39
(24%); P = 0.02)
• more infants were fed
nutrient-dense thick
purées at 6 months
(31% versus 20%,
P = 0.03)
• higher intake of
energy from ASFs at
15 months
(P = 0.082) and 18
months (P = 0.001)
• fewer children failed to
meet requirements for
energy (8 and 12
months), Fe (8 and 9
months) and Zn
(9 months) (P < 0.05)
• Intervention group had
higher housing and hygiene
scores, education level and
body weight than controls at
baseline: analysis performed
without and with adjustment
• Stunting at 18 months:
intervention 5% versus
control 16% (P = 0.02;
adjusted OR = 3.04; 95% CI,
1.21, 7.64)
• Adjusted mean changes in
WAZ and LAZ better in
intervention than in control
group at 18 months
(P < 0.05)
AFA, arm fat area; AMA, arm muscle area; ASF, animal-source food; BF, breastfeeding; CF, complementary food; CI, confidence interval; CRP, C-reactive protein; FFQ, food-frequency
questionnaire; HAZ, height-for-age Z score; Hb, haemoglobin; HC, head circumference; Hct, haematocrit; KAP, knowledge, attitudes and practices; LAZ, length-for-age Z score; MUAC, mid-upper
arm circumference; NCHS, National Center for Health Statistics; NSD, non-significant difference; OR, odds ratio; RBC B-2, red blood cell B-2 (riboflavin) concentration; RCT, randomized controlled
trial; SES, socio-economic status; TfR, serum transferrin receptor; TIBC, total iron-binding capacity; WAZ, weight-for-age Z score; WLZ, weight-for-length Z score.

confounders (72). Among women of child-bearing
age, promotion of consumption of
animal-source foods has also resulted in
improvements in iron status (73) and/or hae-moglobin
(73,74); no data on functional health
outcomes were reported in these studies.
Orange/yellow fruits (e.g. mangoes,
papayas) and vegetables (carrots, pumpkin,
orange-fleshed sweet potatoes), and to a
lesser extent dark-green leafy vegetables, pro-vide
food sources of provitamin A caroten-oids
(75) which can also contribute effectively
to improving vitamin A intakes on a year-round
basis, provided appropriate pre-servation
strategies are adopted (76). The
carotenoids in orange and yellow fruits and
vegetables are dissolved in oil droplets in
chromoplasts and are more readily extracted
during digestion, so that the efficiency with
which they are absorbed and converted to their
active form is much higher than that from dark
green leafy vegetables, where the b-carotene is
bound to proteins in the chloroplasts. Several
studies have confirmed the use of yellow veg-etables,
orange-red fruits and/or orange
sweet potatoes with or without fat supple-mentation
to be efficacious in improving the
vitamin A status of children (57,77,78).
Incorporating enhancers of micronutrient
absorption in household diets
Besides providing a rich source of micronutri-ents
often limiting in plant-based diets, cellu-lar
animal protein also enhances the absorption
of non-haem iron and zinc from plant-based
foods (26,79). Even small amounts of meat
(³50 g) can significantly increase non-haem
iron absorption from meals low in vitamin C
and rich in phytate (80). The mechanism of
this effect in different types of meals remains
uncertain (81).
Plant-based foods rich in ascorbic acid
including certain fruits (e.g. citrus fruits and
other fruits: guava, mango, papaya, kiwi,
strawberry) and vegetables (e.g. tomato,
asparagus, Brussels sprouts, spinach, etc.)
have long been known to be enhancers of
non-haem iron absorption (26). Nevertheless,
in a study in rural Mexico, no improvement
in biochemical iron status was observed
among iron-deficient women receiving 25 mg
ascorbic acid from fresh lime juice twice daily,
6 days/week, for 8 months, compared with
those receiving a placebo (82), despite a two-fold
increase in iron absorption, based on ear-lier
stable isotope results (83). Ascorbic acid
may also enhance the bioavailability of folate
by increasing its stability during food process-ing
and digestion. Other organic acids (e.g.
citric and lactic acid) produced during fer-mentation
may also enhance non-haem iron
and possibly zinc absorption to some degree,
possibly by forming soluble ligands in the
gastrointestinal tract, thus preventing the for-mation
of insoluble compounds with phytate
(26), while simultaneously generating an
optimal pH for the activity of any endo genous
phytases in cereal or legume flours (84).
However, the magnitude of the enhancing
effect, if any, of organic acids on iron and zinc
absorption is uncertain. Improvements in
protein quality have also been documented
after fermenting some blended mixtures of
plant-based complementary foods (85,86).
Such improvements may be associated with
the destruction of protein inhibitors that
interfere with nitrogen digestibility by micro-bial
enzymes, or from the ability of starter
cultures to synthesize certain amino acids.
Oilseeds and nuts provide a source of fat
necessary for enhancing absorption of the
fat-soluble vitamins and provitamin A carote-noids
in plant-based diets.
Reducing inhibitors of micronutrient
absorption in plant-based diets
The adverse effect of some of the organic
components in plant-based diets on micro-nutrient
bioavailability can be reduced by
certain household food preparation and
processing practices; they are summarized
in Gibson et al. (26).
The strategies involve inducing enzymatic
hydrolysis of phytic acid by endogenous cereal
and/or microbial phytases through germina-tion
and fermentation, respectively, or soaking
to reduce the phytic acid content of some
cereal and legume flours by passive diffusion

18 R.S. Gibson
because their phytic acid is stored in a rela-tively
water-soluble form; some polyphenols
that inhibit iron absorption may also be lost
via soaking. Several in vivo isotope studies in
adults have reported improvements in both
iron (87) and zinc (but not copper) (88) absorp-tion
in cereal-based porridges with a reduced
phytate content.
Only a few efficacy trials have been under-taken
to assess the impact of these phytate-reducing
strategies on zinc absorption (89,90),
nutrient adequacy (91,92) and biochemical
and/or functional outcomes in infants and
children (93–97). In a small hospital-based
study in Malawi, phytate reduction of a corn-plus-
soy porridge via commercial phytase
enzyme (Aspergillus niger) increased fractional
zinc absorption and decreased endogenous
zinc losses only in children recovering from
tuberculosis but not in the apparently well
children (89). Restriction of this response to the
children experiencing catch-up growth sug-gests
that zinc absorption may be up-regulated
by Zip4 in response to the high zinc require-ments
for catch-up growth. Zip4 is the princi-pal
zinc transporter responsible for regulation
of zinc absorption across the apical membrane
of the enterocyte.
In a large community-based, double-blind
randomized controlled trial in Tanzania
in which a processed complementary food,
based on soaked and germinated finger mil-let
and kidney beans, with roasted peanuts
and mango purée, and an identical unproc-essed
blend were fed to 6-month-old infants
(n = 309) for 6 months, there were no signifi-cant
differences between the two groups at
the end of the study in anaemia, iron status as
measured by haemoglobin and zinc protopor-phrin,
hair zinc concentrations, or growth
(95,96). Failure to observe any positive
response may be in part because there was
only a 34% reduction in the phytate content of
the processed complementary food (95).
Results of these efficacy trials empha-size
the importance of an integrated
approach that combines a variety of the
strategies discussed above to improve the
energy, micronutrient content and bioavail-ability
of plant-based diets. We have under-taken
two such community-based efficacy
trials among infants and young children in
rural Malawi; details of the strategies used
and their implementation have been pub-lished
earlier (59,91,92,94,97). The efficacy
of these dietary strategies was evaluated by
determining knowledge, trial and adoption
of the new practices, and by comparing die-tary
quality and adequacy of the energy and
nutrient intakes of the intervention and con-trol
groups post-intervention (91,92,94,97).
In the study of young children, changes in
growth and body composition, morbidity,
and haemoglobin and hair zinc concentra-tions
were also investigated (94). In both tri-als,
improvements in the adequacy of energy,
protein, calcium and available zinc were
observed in the diets of the intervention
compared with the control group, associ-ated
with significantly higher intakes of
animal-source foods (mainly fish). In the
children, however, the adequacy of iron
intakes did not differ between the interven-tion
and control groups post-intervention,
in part because fish, rather than meat, was
the major source of cellular animal food
consumed and the estimates of iron bioa-vailability
did not take into account the
impact of the phytate-reduction strategies
on non-haem iron absorption. These find-ings
were also accompanied by a signifi-cantly
enhanced anthropometric index of
lean body mass and a lower incidence of
both anaemia and common illnesses in the
intervention compared with the control
group (97). Our results indicate that a com-bination
of household food-based strategies
can be designed to be feasible and acceptable
to caregivers of infants and children in sub-sistence
farming settings, although ongoing
nutrition education and social marketing
efforts are essential to enhance their adoption
and to empower the community to sustain
them. In the future, a new technique based
on goal programming may become available
to health professionals for the development
of realistic and sustainable complementary
feeding recommendations for interventions
in developing countries, based on habitual
dietary practices (98).
An integrated food-based approach has
been adopted by programmes implemented
by Helen Keller International (HKI) and World
Vision (WV) Malawi, although strategies to

reduce the phytate intakes were not included
in these programmes. The Home stead Food
Production (HFP) programme of HKI inte-grates
animal husbandry with home garden-ing
and nutrition education, with the aim of
enhancing the production, availability and
consumption of animal-source foods by
women and children (99). This integrated HFP
programme was implemented first in
Bangladesh, but has now been expanded into
Nepal, Cambodia and the Philippines. Results
of the evaluation for the HFP programme in
Bangladesh showed significantly higher
intakes of animal-source foods, specifically
eggs, poultry, other meat, milk or milk prod-ucts,
and dark green leafy vegetables at end
point compared with baseline among children
aged 6 to 59 months from target households,
whereas intakes in the control group were
almost unchanged (99). In addition, more of
the target households earned income from gar-dening
and poultry activities, showed
improvements in poultry-rearing practices
and a higher involvement of women in deci-sion
making than control households. A decline
in the prevalence of anaemia among non-pregnant
women and children from HFP
households compared with controls was also
reported in Nepal and Bangladesh, but not in
Cambodia (100,101).
The Micronutrient and Health Pro-gramme
(MICAH) of WV Malawi is another
example of an integrated programme that
included public health interventions (e.g.
promotion and support of breastfeeding;
control of infectious diseases, malaria and
parasites), vitamin A and iron supplementa-tion
for young children, nutrition and health
education, and dietary diversification strate-gies.
As a result of a small animal revolving
fund set up by World Vision (102), increases
in both production and consumption of
guinea fowl, chickens, rabbits, eggs and
goat’s milk were observed in the MICAH
intervention households compared with the
comparison group (102). Modest but signifi-cant
reductions in stunting and anaemia
among the children and anaemia in the
women from the MICAH households were
also achieved compared with the trends
observed in the comparison group house-holds
(103).
Biofortification
In the long term, biofortification of staple cere-als,
involving strategies to enhance both their
micronutrient content and bioavailability, may
become a feasible option for improving the
micronutrient status of the entire household
and across generations in poor resource set-tings.
Unlike fortification at the national level,
biofortification does not depend on a food
vehicle being centrally processed. Hence,
biofortification has the potential to fill the
gap in coverage left by mass fortification
because it can be more accessible to the rural
poor who consume staple foods from local
or self-production. Biofortification can be
achieved by three processes: (i) agronomic
practices; (ii) conventional plant breeding; and
(iii) genetic modifications involving gene
insertions or induced mutations.
Minimum target levels have been set for
increasing the micronutrient content of bio-fortified
staple food crops, taking into
account the usual daily intake of the staple
food crop, the loss of micronutrients from
the seed, root or tuber during processing
(e.g. milling) and cooking, and the bioavail-ability
of the micronutrient from the staple
food as consumed in the habitual diet (104).
Adoption rate estimates for these new crop
varieties in Africa and Asia have been made,
and range from 20–40% for Africa, where
seed systems are less well developed, to
30–60% for Asia which has more developed
seed systems (105).
Agronomic practices
Fertilizers can be applied to the foliage to
enhance its iron content and to the soil to
improve the content of zinc, selenium and
iodine content of staple food crops (e.g. wheat,
maize, rice, sorghum, beans) when grown in
trace-element deficient soils, as has been prac-tised
for low-zinc soils in Turkey (106) and
India (107) and low-selenium soils in Finland
(108). Nevertheless, care is needed because
too high amounts can have negative effects
on plant growth and soil microorganisms
(109). Further, the response to the application

20 R.S. Gibson
of fertilizer varies, depending on the crop,
genotypes of the same crop and environmen-tal
conditions, making it difficult to extrapo-late
to all situations.
Conventional plant breeding
Conventional plant breeding can also be
used to increase iron and zinc concentrations
in seeds of common beans (Phaseolus vulgaris
L.), rice (especially aromatic varieties) and
wheat (especially Tritium dicoccum Schrank
species), with no negative correlations
between grain yield and iron and zinc den-sity
in the seeds and grains. The effect of
processing on the content and bioavailability
of iron and zinc in these seeds is under
investigation.
Research is also underway to produce
varieties of cassava roots, sweet potatoes,
maize and bananas that are high in b-carotene
using selective plant breeding. Genotypes
containing the highest amount of b-carotene
have been found in the Amazonian regions of
Brazil and Columbia. However, processing
techniques influence the final b-carotene con-tent
of these foods, with some genotypes
being more stable to various types of process-ing
than others. Hence, any effects of process-ing
must also be taken into account in any
breeding programme.
So far, efficacy studies employing con-ventional
plant-breeding methods of biofor-tification
are limited. A stable isotope study
in Mexican adult women compared the
amount of zinc absorbed from tortillas pre-pared
with biofortified (4.0 mg Zn/100 g)
and control (2.3 mg Zn/100 g) wheat flours.
Zinc absorption from the tortilla meals pre-pared
with biofortified wheat flour was sig-nificantly
higher (0.5 mg Zn/day; P < 0.05)
than from the control wheat, confirming that
increases in zinc absorption can be achieved
from biofortification of wheat with zinc
(110). The efficacy of consuming high-iron
rice (3.21 mg Fe/kg) compared with a local
variety (0.57 mg Fe/kg) has been assessed in
a 9-month randomized, double-blind, con-trolled
feeding trial involving 192 religious
sisters living in ten convents around Metro
Manila, the Philippines (111). A modest
increase in serum ferritin (P = 0.10) and total-body
iron (P = 0.06) was reported among the
subjects overall, but no increase in haemo-globin.
For non-anaemic subjects, the corre-sponding
responses were significantly
greater: serum ferritin, P = 0.02 and total-body
iron, P = 0.05. These results confirm the
efficacy of biofortified rice in enhancing iron
stores of women consuming habitual diets
with a low content and bioavailability of
iron. The efficacy of orange- fleshed sweet
potato, developed by selective plant breed-ing,
for increasing intakes of vitamin A and
serum retinol among young children in rural
Mozambique has also been confirmed (112),
emphasizing that such an approach has the
potential to enhance the vitamin A status of
young children in other similar areas of sub-
Saharan Africa.
Genetic modifications
For some crops (e.g. oilseed rape and rice),
genetic engineering is the only way to
enhance the content and in some cases the
bioavailability of b-carotene (113,114).
Indeed, in the Philippines, 5000 ha of a new
variety of genetically modified Golden Rice
containing a yellow daffodil gene that is rich
in b-carotene were planted in 2004 (115).
Genetic modification can also be used to
alter simultaneously the amounts of absorp-tion
modifiers in plant foods. Possible
approaches include producing new varieties
of cereal grains with an increased content of
methionine and cystine to promote zinc
absorption; and a reduced phytic acid con-tent
(116). In vivo stable isotope studies have
demonstrated increases in both iron (117)
and zinc (118,119) absorption when adults
were fed tortillas or polenta prepared from
low-phytate hybrids of maize compared
with those with their native phytate.
Transgenic approaches are also being
used to express microbial-source, heat-stable
phytase from Aspergillus fumigatus into the
endosperm of wheat, and to introduce a gene
that codes for a sulfur-rich metallothionein-like
protein into rice (Oryza sativa), a protein
that increases the resorption-enhancing effect
of iron from the small intestine (120).

Conclusions
More attention is urgently required to
develop sustainable multiple micronutrient
interventions suitable for poor resource set-tings.
In such circumstances, dietary deficits
in energy and multiple micronutrients often
coexist together with infections, especially
among infants (>6 months) and young chil-dren,
so that provision of micronutrients
alone is unlikely to prevent growth faltering
during childhood. As a result, an integrated
approach that combines a variety of public
health, nutrition education and dietary strat-egies
is probably the best strategy to over-come
the dietary deficits and improve the
growth and development of infants and
young children. In settings where inclusion
of animal-source foods is especially difficult,
fortification of complementary foods, either
at the household level using CFSs or at the
national level, should be explored, provided
the energy densities of the fortified comple-mentary
foods are adequate. Care must be
taken to ensure that the fortificants selected
are bioavailable, effective, and added at
levels that do not induce any adverse micro-nutrient
interactions or influence the orga-noleptic
qualities and shelf-life of the food
vehicle. In the future, biofortification may be
the most sustainable approach to improve
the micronutrient adequacy of plant-based
diets of entire households and across genera-tions
in developing countries, especially if a
full range of bioavailable micronutrients can
be achieved in a single staple plant species.
Finally, to maximize their effectiveness,
attention must always be given to the deliv-ery
and utilization of any programme based
on food-based strategies.
Acknowledgements
Special thanks are given to Nancy Drost,
Elaine Ferguson, Christine Hotz, Lara
Temple and Fiona Yeudall who contributed
to the work in Malawi. Thanks also to our
co- investigators from the University of
Malawi, the late Professor T. Cullinan and
Dr Beatrice Mtimuni, our federal collabora-tors
at the Ministries of Health, Agriculture
and Community Services, and all our
Malawian programme staff.
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116. Raboy, V., Below, F.E. and Dickinson, D.B. (1989) Alterations of maize kernel phytic acid levels by recur-rent
selection for protein and oil. Journal of Heredity 80, 311–315.
117. Mendoza, C., Viteri, F.E., Lonnerdal, B., Young, K.A., Raboy, V. and Brown, K.H. (1998) Effect of geneti-cally
modified low phytic acid maize on absorption of iron from tortillas. American Journal of Clinical
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absorption from a low-phytic acid maize. American Journal of Clinical Nutrition 76, 556–559.
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cereals to improve iron and zinc content and bioavailability. Journal of Nutrition 132, 514S–516S.

2 Addressing Micronutrient Malnutrition
to Achieve Nutrition Security
P. Shetty*
Institute of Human Nutrition, University of Southampton School of Medicine,
Southampton, UK
Abstract
The poor quality of the habitual diet and the lack of dietary diversity in much of the developing world
contribute to deficiencies of micronutrients. Micronutrient malnutrition is a global problem much bigger
than hunger and imposes enormous costs on societies in terms of ill health, lives lost, reduced economic
productivity and poor quality of life. Addressing the global challenge of micronutrient malnutrition
requires the need for many strategies – both short- and intermediate-term and long-term sustainable
approaches. In addition to the conventional approaches of micronutrient supplementation and fortifica-tion,
promoting sustainable food-based approaches to enable adequate intakes of micronutrients by much
of the population includes dietary diversification strategies and agriculture-based approaches. Dietary
diversification is possible by the promotion of homestead food production, which includes home garden-ing,
small livestock rearing and fishing as well as the processing and preservation of food. Agriculture and
agricultural biotechnology offer the opportunity of increasing crop yields and have the potential to
improve the micronutrient content of staple foods and cereal crops, thus contributing to better nutrition of
populations and thereby helping to achieve nutrition security. By ensuring food and nutrition security and
by reducing the widespread problem of micronutrient malnutrition we may hope to achieve the targets set
for the Millennium Development Goals.
Key words: nutrition security, food security, micronutrient deficiencies, dietary diversification, home
gardening, homestead food production, agricultural biotechnology
Introduction
While the objectives of food security are
focused on increasing agricultural production
and the availability and access to food, nutri-tion
security has emphasized more the physi-ological
needs for nutrients and the role of
health and the environment in determining
good health and nutrition of communities.
Nutrition security is thus broader than food
security as it incorporates additional aspects
such as biological utilization, which refers to
the ability of the human body to ingest food
and metabolize nutrients and meet the needs
of essential nutrients required by the body (1).
Nutritious and safe diets, an adequate biologi-cal
and social environment, and proper nutri-tion
and health care ensure adequate utilization
of food in order to promote health and prevent
disease. Consequently, good nutrition or
nutritional status, i.e. nutrition security, is a
function of both food intake and health status.
* Contact: P.Shetty@soton.ac.uk
28 (eds B. Thompson and L. Amoroso)

Addressing Micronutrient Malnutrition 29
Food and water are what people eat and
drink to achieve an adequate nutritional status,
i.e. maintain life and physical, cognitive and
social development. It has to meet physiologi-cal
requirements in terms of quantity and qual-ity,
and be safe and socially and culturally
acceptable. Accordingly, nutrition security has
been defined as ‘adequate nutritional status in
terms of protein, energy, vitamins, and miner-als
for all household members at all times’ (2).
The necessity to incorporate nutrition into
food security evolved over time and food and
nutrition security is said to have been achieved
‘if adequate food (quantity, quality, safety,
socio-cultural acceptability) is available and
accessible for and satisfactorily utilized by all
individuals at all times to achieve good nutri-tion
for a healthy and happy life’ (3,4). Food
and nutrition security are fundamental to the
achievement of the Millennium Development
Goals (MDGs) (5) and incorporating nutri-tional
goals alongside the goals of food secu-rity
provides a holistic approach towards
achieving the targets set out in the MDGs (6).
Micronutrient Malnutrition
Micronutrient malnutrition or ‘hidden hun-ger’
is an important dimension of food and
nutrition security from a global perspective
and is caused by the lack of adequate micronu-trients
(vitamins and minerals) in the habitual
diet. Micronutrient deficiencies are common in
populations that consume poor-quality diets
lacking in dietary diversity, as their habitual
diet is often deficient in these nutrients. Diets
deficient in micronutrients are relatively high
in intakes of staple food and cereal crops, but
low in the consumption of foods rich in bioa-vailable
micronutrients such as animal and
marine products, fruits and vegetables.
Deficiencies of micronutrients are there-fore
common in developing country popula-tions
that habitually consume largely
cereal-based, monotonous diets. For example,
for iron, the amount of bioavailable iron is
dependent on the content and source of iron in
the diet and on iron absorption during the
digestive process. The absorption of iron of
plant origin into the body is relatively low and
is considered to be a major factor in the causa-tion
of iron-deficiency anaemia. The exception
is soybean, which is a good source of dietary
iron (7). Cereals also contain high concentra-tions
of phytic acid, a potent inhibitor of iron
(and zinc) absorption. Foods that enhance non-haem
iron absorption such as fruits and vegeta-bles,
which are rich in ascorbic acid, are often
not consumed in adequate amounts in devel-oping
countries. Haem iron, which is relatively
well absorbed by the human intestine, is found
primarily in animal products such as meat, but
animal sources of food are usually limited in
the diets of the poor in developing countries
owing to cost and availability. Widespread
infections such as malaria and hookworm
infestation also contribute to the risk of iron
deficiency (8). In general, cereal grains contain
low concentrations of carotenoid compounds
which are precursors to vitamin A. Consequently,
vitamin A deficiency often occurs where the
diet is predominantly cereal-based and indi-viduals
have poor and irregular access to foods
rich in provitamin A carotenoids. The bioavail-ability
of vitamin A also varies with the source
of the carotenoids in the diet (9). Zinc and iodine
deficiencies are the other major micronutrient
deficiencies in the developing world and are
essentially caused by the low levels of these
micronutrients in the diet.
Globally, there are nearly two billion
people who suffer deficiencies of micronutri-ents
such as iron, iodine, zinc and vitamin A
(10). Micronutrient deficiencies are therefore
important from a public health perspective
and exceed current estimates of global hun-ger
and food insecurity. Micronutrient defi-ciencies
impair cognitive development and
lower resistance to disease in children and
adults (11). They increase the risk of morbid-ity
and mortality of both mothers and infants
during childbirth and in early childhood, and
impair the physical ability and economic pro-ductivity
of adults. The costs of these defi-ciencies
in terms of lives lost and reduced
quality of life are enormous, not to mention
the economic costs to society. They lower
school performance of children, while in
adults they compromise work output,
productivity and earning capacity (12).
They impair immunity and increase suscepti-bility
to infectious diseases and mortality,

30 P. Shetty
particularly among vulnerable groups such
as pregnant women and children. Deficiencies
of vitamin A and zinc together are estimated
to contribute to one million deaths of children
while iron deficiency as a risk factor for
maternal mortality adds an additional 115,000
deaths. The analysis of co-exposure to these
nutrition-related factors shows that, together,
they are estimated to be responsible for about
35% of child deaths and 11% of the total global
disease burden (13).
Intervention Strategies to Tackle
The global prevalence of vitamin and mineral
deficiencies is remarkably high and it is esti-mated
that a third of the world’s population
does not meet its physical and intellectual
potential because of micronutrient deficien-cies
(11), in addition to having increased risk
of morbidity and mortality related to infec-tious
disease. The most vulnerable groups are
infants and children, women in their repro-ductive
age and the elderly. Micronutrient
deficiencies are sufficiently widespread to
warrant action as they cause enormous health,
economic and social costs. As the problem is
worldwide and poses numerous challenges,
several intervention programmes have been
initiated in developing countries in order to
improve the current situation with regard to
micronutrient malnutrition of their popula-tions.
The time-tested strategies universally
promoted to combat micronutrient malnutri-tion
have hitherto focused on supplementa-tion
and fortification of commonly consumed
foods with micronutrients.
Supplementation of specific nutrients
helps to meet the immediate deficits of vul-nerable
groups; an example is the provision
of iron and folate supplements to all pregnant
mothers attending antenatal clinics in pri-mary
health care centres in several develop-ing
countries. Despite iron deficiency being a
major public health problem, there has been
very little progress in its control in the devel-oping
world (13). This is attributable to the
low compliance with iron supplementation,
insufficient targeted interventions for infants
and young children, and lack of integration of
nutritional interventions with other national
programmes. The recent controversies regard-ing
the safety of iron interventions related to
the interaction between malaria and iron
metabolism, and those pertaining to the role
of iron in oxidative damage, have not helped
(13). On the other hand, there has been a lot of
progress with vitamin A supplementation
with a threefold increase in effective coverage
over the last 10 years and it has been esti-mated
that 70% of all pre-school children
receive at least one mega-dose of vitamin A
(14). However, shortfall of the supplement
and sustainability of vitamin A supplementa-tion
programmes are major challenges. Zinc
supplementation to young children in at-risk
populations is expected to have a high impact
and a course of zinc supplements in
conjunction with oral rehydration solution is
currently recommended by the World Health
Organization/United Nations Children’s
Fund for the treatment of acute diarrhoea
(15). Recent evidence from Bangladesh shows,
however, that few eligible children are receiv-ing
zinc in response to diarrhoeal attacks.
Despite the well-documented benefits of zinc
supplementation of high-risk groups, there
are currently no formal recommendations for
programmes for the preventive supplementa-tion
for zinc.
Fortification of food items in the daily diet
is another successful intervention strategy
that has been widely adopted to deal with
specific nutritional problems or nutrient defi-ciencies.
A good example is the fortification of
common salt with iodine (iodized salt) to
tackle the problem of iodine deficiency and
goitre; one of the most successful strategies
that has helped reduce the burden of iodine
deficiency disorders globally. Success in pre-vention
of iodine deficiency rests on the effec-tiveness
of universal salt iodization and
currently approximately 80% of the 130 coun-tries
with a significant problem have imple-mented
legislation on salt iodization since the
late 1990s. Iron fortification programmes have
usually been poorly designed with largely
ineffective forms of iron used, and their suc-cess
has been limited. Zinc fortification of sta-ple
foods and of special foods targeted at
specific subpopulations is being implemented.

Zinc fortification of complementary foods is
expected to have an impact on the health of
young children. While there appear to be no
technical barriers to including zinc in existing
food fortification programmes, there is a need
for well-designed trials to determine their
efficacy.
Food fortification is increasingly recog-nized
as an effective means of delivering
micronutrients, with the objective being to
deliver micronutrients to remote and impov-erished
populations in an affordable and sus-tainable
manner. Commercially marketed
fortified complementary foods and home-based
fortification of complementary foods,
as well as the fortification of staple foods such
as cereal flours, cooking oils and dairy prod-ucts,
have made a positive impact (16). Proper
choice of the fortificant and processing meth-ods
can ensure the stability and bioavailabil-ity
of the nutrient in the food vehicle. The
level of fortification needs to take into account
variations in food consumption and ensure
safety for those at the higher end of the scale
while having an impact on those at the lower
end. Fortification requires food regulations
and labelling, quality assurance and monitor-ing
to ensure compliance and the desired
impact. A growing number of large-scale for-tification
programmes in different parts of the
world are beginning to demonstrate impact
towards eliminating several micronutrient
deficiencies; however, food fortification con-tinues
to be an underutilized opportunity in
many developing countries where micronu-trient
malnutrition remains a public health
problem (16).
Supplementation and fortification are
intervention strategies that have been aimed
at the immediate or short-term amelioration
of the situation and often address the symp-toms
and not the underlying causes of micro-nutrient
deficiencies. Other complementary
interventions include public health measures
such as water and sanitation, and treatment
of parasitic infestations, which often are
important contributors to micronutrient defi-ciencies
such as that of iron. While both these
strategies have been tried with varying
degrees of success and continue to play an
important role in improving the nutrition of
communities, increasingly more emphasis is
being placed by international agencies on
food fortification strategies (16) since they can
be categorized as food-based approaches and
hence probably sustainable in the long term.
Food-based Approaches to Combat
The International Conference on Nutrition
(ICN) Declaration (17) advocating a strategy
to combat micronutrient malnutrition stated:
‘… ensure that sustainable food-based strate-gies
are given first priority particularly for
populations deficient in vitamin A and iron,
favouring locally available foods and taking
into account local food habits’. Food-based
intervention strategies include attempts to
improve the nutrition of households by ena-bling
families to have access to and to con-sume
a diversified diet rich in micronutrients.
Food-based strategies to address micronutri-ent
malnutrition encompass a wide variety of
interventions that aim to increase the produc-tion,
availability and access to micronutrient-rich
foods, promote the consumption of foods
rich in micronutrients and enhance the bio-availability
of these micronutrients in the
diet. Strategies, which are food-based and are
sustainable, alter behaviour and include
nutrition education and the promotion of
dietary diversity through investment in access
to a diversified diet.
Food-based strategies to address micro-nutrient
malnutrition pose their own set of
challenges. Food-based approaches aimed at
improving vitamin A status by increasing the
intake of fruits and vegetables have been
shown to improve vitamin A status in many
studies. However, the challenge posed relates
to the bioavailability of dietary carotenoids
and their conversion to retinol, which appear
to be influenced by a host of other factors (18).
The availability of dietary iron is low in pop-ulations
consuming monotonous plant-based
diets with little meat, since most dietary iron
is non-haem and its absorption is usually less
than 10% (19). The absorption of non-haem
iron is increased by meat and ascorbic acid,
but inhibited by phytates, polyphenols and
calcium. Because iron is present in many

32 P. Shetty
foods, and its intake is directly related to
energy intake, the risk of iron deficiency is
highest when iron requirements are greater
than what can be met by meeting the energy
needs. Zinc deficiency, now recognized as a
micronutrient malnutrition of significant
importance in developing countries, is related
more to the role of inhibitors of zinc absorp-tion
such as phytates in the largely cereal-based
diets rather than inadequate intakes in
the diet (20).
Dietary diversification and modification
Food-based strategies focusing on dietary
modification and diversification to enhance
intakes and bioavailability of micronutrients
at the household level have been summarized
elsewhere (21) and are dealt with thoroughly
in Chapter 1 of this book. While promoting
the addition of animal and marine foods to
the predominantly cereal- or plant-based
diets of populations in developing countries
may be the ideal, recognizing the socio-economic
circumstances and being sensitive
to the cultural and religious beliefs of those
who live there is important. Gibson and Hotz
(21) have enumerated strategies that do not
involve substantial changes in habitual diets.
Home gardening, horticulture and home-stead
food production have been promoted
for a long time in order to provide low-cost
variety in the diet. Although home gardening
as an activity has been extensively promoted
in developing countries by international
agencies such as the Food and Agriculture
Organization of the United Nations (FAO)
and non-governmental organizations like
Helen Keller International, it is only now that
they are being evaluated for their impact; and
there are a few evaluations of its proven ben-efits
and sustainability (22). A study in rural
South Africa has shown how effective home
gardening can be and provides insights into
what activities ensure success and sustaina-bility
in the community (23). These include
the integration of community-based monitor-ing
of children’s growth, the active participa-tion
and involvement of women and their
consequent empowerment. It also facilitates
maternal awareness of vitamin deficiencies
through nutrition education. This study
showed that locally produced vegetables and
promotion of the consumption of vitamin-rich
foods, such as orange-fleshed sweet pota-toes,
can provide households with direct
access to foods rich in b-carotene and that
home gardens can make a valuable contribu-tion
towards vitamin A intake and, ultimately,
the alleviation of vitamin A deficiency (24).
Evaluation of the promotion of home-stead
gardening programmes in Bangladesh
revealed that the active households on the
gardening programmes improved the pro-duction
and consumption of vegetables year-round
(25). Over a 3-month period, these
households produced a median of 135 kg and
consumed a median of 85 kg of vegetables,
while the control households produced a
median of only 46 kg and consumed a median
of only 38 kg. The active-participant house-holds
also generated a higher garden income
which was spent mainly on food compared
with the control households. It was also
shown to be sustainable over several years
while increasing the economic contribution
and empowerment of women in the house-holds
with the predictable increase in the use
of health care facilities and schooling, espe-cially
for female children. The development
and expansion of the Bangladesh homestead
gardening programme has successfully
increased the availability and consumption of
foods rich in vitamin A and has been expanded
nationally (26). Several reviews have high-lighted
the effectiveness of home gardening
interventions, especially when combined
with promotional and education interven-tions,
in improving vitamin A intake and
nutrition (27). Food-based approaches to
addressing malnutrition and food and nutri-tion
security should necessarily include edu-cational
inputs and the promotion of the
awareness of nutrition-related health
problems.
Interventions that promote small animal
husbandry and fishponds can promote and
ensure the increased intake of cheap sources
of animal products. They also have a positive
impact by helping to control iron deficiency
in communities (27). Thus, alongside the pro-motion
of home gardening aimed at dietary

diversification are other related household or
community strategies broadly considered as
homestead food production. These include
the promotion of small livestock production,
encouragement of integration of aquaculture
into farming systems, and the investment at
community level in village-based technolo-gies
for refrigeration, drying and preserva-tion
of food (21). The contribution of foods
from animal sources by the promotion of
small livestock production in the homestead
can help to combat micronutrient malnutri-tion
and provide the range of micronutrients
that are deficient in a wholly cereal or plant-based
diets. Such foods diversify the diet and
enhance its nutritional quality by providing a
good source of protein, fat and a number of
key micronutrients like iron and zinc that are
more readily bioavailable from these sources.
Homestead food production is of particular
benefit to vulnerable segments of the popula-tion
such as infants and children, pregnant
and lactating women, female-headed house-holds
and the elderly.
Several intervention and community
development programmes have used live-stock
promotion to achieve improvements in
nutrition and health (28). FARM-Africa pro-moted
livelihoods projects, the objectives of
which included the improvement of family
welfare through the generation of increased
income and diversified food consumption.
Goats need less space than cows and goats’
milk is highly nutritious. Through breeding
goats and selling the milk, households can
increase their income and these are activities
that women traditionally undertake. The
Dairy Goat Project in Ethiopia and Kenya
adopted an integrated approach and increased
the productivity of local goats managed by
women. It demonstrated an increase in milk
and meat products in local diets, and a consid-erable
improvement in the nutritional status
and family welfare of participant households
(29). The VAC programme (V = Vuon, i.e.
garden; A = Ao, i.e. pond, C = Chuong, i.e. cattle
shed) in Vietnam is another homestead food
production intervention whose aim was to
provide diversified agricultural products to
meet the range of nutritional needs of commu-nities
(30). V has been extended to mean all
kinds of land farming; A involves all activities
consisting of intensive exploitation of water
areas; and C refers to all animal husbandry
activities including raising cattle and poul-try.
Subsequent nutritional surveys showed
that the population’s dietary intake had
improved in terms of both quality and quan-tity
and the consumption of foods such as
meat, fish and fruit was much higher than
before the VAC was introduced. The preva-lence
of child malnutrition and chronic
energy deficiency in women of reproductive
age decreased and there was a remarkable
increase in incomes and the health and nutri-tion
of the rural populations in Vietnam (30).
The Vietnamese government now considers
this to be an effective solution for the allevia-tion
of poverty, dietary improvement and
the prevention of malnutrition. National
programmes in Thailand have also priori-tized
the production of livestock by the poor,
resulting in improvements in the quality of
their diets and better nutrition and health.
Integration of these programmes with
national policies for poverty alleviation is
now recommended to ensure long-term
sustainability (31).
The Nutrition Collaborative Research
Support Programme (NCRSP) reported on
three parallel longitudinal studies in dispa-rate
ecological and cultural parts of the world,
i.e. Egypt, Kenya and Mexico. Strong associa-tions
between the intake of foods from animal
sources and better growth, cognitive function
and physical activity in children, better preg-nancy
outcomes and reduced morbidity due
to illness were found (32). Access to foods of
animal origin through the promotion of small
livestock is thus considered a strategic
intervention for avoiding the poverty–
micronutrient–malnutrition trap (33).
Fish is considered a good source of ani-mal
protein although its role as a source of
vitamins and minerals in the diet of popula-tions
in developing countries is often over-looked.
In poor, rural households, mean fish
intake was between 13 and 83 g raw, whole
fish per person per day; the frequency of
intake of small fish was high and made up
50–80% of all fish eaten during the fish pro-duction
season in rural Bangladesh and
Cambodia (34). Many small fish are eaten
whole and therefore are a rich source of

34 P. Shetty
calcium; some are also rich in vitamin A, iron
and zinc. However, the results of randomized
control trials using small fish in Bangladesh
have been disappointing, showing no changes
in biochemical indicators of vitamin A status
in children following a 9-week feeding trial
(35), but may reflect the short timespan of the
study, or more likely the type of fish con-sumed.
Where fish is consumed, use of small
dried whole fish eaten with the bones is
encouraged. As fish flour or relish they can be
used to enrich cereal-based foods for infants
and children.
Gibson and Hotz (21) identify food-based
strategies more specifically targeted at infants
and children such as the use of soaking to
enhance micronutrient availability; the use of
fermentation which decreases phytate – an
inhibitor of mineral absorption – and thus
enhances micronutrient availability; and the
use of germinated cereals and legumes to
increase nutrient density and bioavailability
of nutrients in prepared foods. Hence a vari-ety
of home-based food processing techniques
can be used to either increase the bioavailabil-ity
of micronutrients or to ensure their reten-tion
during preparation, cooking, processing
or preservation, while in the case of others the
challenge is to extend the availability of
micronutrient-rich foods beyond the season
in which they are in abundance (27). This can
be achieved through solar drying or the pro-duction
of concentrates. In the case of iron
from plant sources (non-haem iron) the objec-tive
is to increase its bioavailability.
Home processing techniques such as ger-mination,
fermentation and amylase treat-ment
are effective in reducing the amount of
inhibitors like phytates and in promoting the
absorption of iron. Avoiding tea and coffee
during the meal and the addition of citrus
fruits (rich in ascorbic acid) are other effective
approaches to improve non-haem iron bio-availability.
It has also been suggested that
cooking in iron pots increases the intake of
bioavailable iron in the foods and improves
iron status. However, it is unsure whether
there are benefits to the use of cooking in iron
pots as a strategy as some studies have shown
(36), while others have not (37) and some oth-ers
indicate that while the iron added to foods
cooked in iron pots is bioavailable, the amount
obtained through this process is insufficient
to replenish depleted iron stores (38).
Role of agriculture and agricultural
biotechnology
A sustainable solution to the problem of
micronutrient malnutrition can only be
achieved when their concentration in the
major staple crops is adequate (39) and the
agricultural approaches to increase quantity
also attempt to improve the quality of the
food at the same time. This is particularly true
of cereals given that a major proportion of the
diet of vulnerable populations in the develop-ing
world is cereal-based. For example, rice
alone contributes 23% of the energy consumed
worldwide and countries that rely on rice as
the main staple often consume up to 60% of
their daily energy from this cereal (40).
Agricultural approaches to improve the
nutrient content of crops have included field
fortification strategies, which enhance the
micronutrient and trace element content of
crops by applying enriched fertilizers to the
soil. There is good evidence that deficiencies
and excesses of micronutrients and trace ele-ments
in soils have a profound impact on the
well-being of plants and animals that depend
on soil to thrive. Increase in the micronutrient
and trace element content of cereal grains has
been attempted by enrichment of soil with
fertilizers fortified with these minerals and
trace elements. This appears to influence the
selenium, iodine and zinc content in the cereal
grain and, in the case of iron, to enhance the
iron content of the leaves. However, the best
studies showing this to be an effective strat-egy
have been with the soil fortification of
zinc through fertilizers. Gibson and col-leagues
(41) have demonstrated an increase
of almost double the zinc intake of children in
north-east Thailand achieved through the
application of zinc fertilizer to rice fields defi-cient
in the element.
The advent of modern biotechnology
has generated new opportunities in agriculture
to address the global problem of micronutri-ent
malnutrition. Agricultural biotechnology
strategies can help improve the amount and

availability of a range of nutrients in plant
crops and provide an important opportunity
to do so in a sustainable manner. The strate-gies
include simple plant selection for varie-ties
with high nutrient concentration in the
seeds, cross-breeding for incorporating a
desired trait within a plant, and genetic engi-neering
to manipulate the nutrient content of
the plant (42). In agriculture, biotechnologi-cal
or molecular-biology-based approaches
are used primarily in one of two ways:
(i) genetic engineering to create transgenics
or genetically modified organisms by manip-ulating,
deleting or inserting genes in order
to change the organism; and (ii) marker-assisted
selection to speed up conventional
crop and animal breeding. Both can and have
played a part in providing biotechnology-based
solutions to improve the nutritional
quality of agricultural products and can thus
address the challenge of micronutrient
malnutrition.
Genetic engineering
The production of Golden Rice was a major
event involving the transfer of the genes nec-essary
for the accumulation of carotenoids
(vitamin A precursors) in the endosperm that
are not available in the rice gene pool. As the
endosperm of rice does not contain any pro-vitamin
A, the initial objective was to intro-duce
the entire biochemical pathway for its
synthesis. The transgenics developed were
based on daffodil genes which resulted in
substantial increases in provitamin A, visible
as a ‘golden’ colour of different intensities in
different lines (43,44). The best provitamin A
line had 85% of its carotenoids as b-carotene.
Other lines had less b-carotene, but high lev-els
of lutein and zeaxanthin, both substances
of nutritional importance because they have
other positive nutritional effects (43). The
first-generation Golden Rice with a gene from
daffodil and a common soil bacterium drew
considerable criticism as a technological solu-tion
to a problem associated with poverty and
hunger. It was argued that Golden Rice would
encourage people to rely on a single food
rather than the promotion of dietary diversi-fication.
Detractors also noted that a normal
serving of Golden Rice contained only a small
fraction of the Recommended Daily Allowance
(RDA) of b-carotene. However, the develop-ment
of Golden Rice 2 by replacing the daf-fodil
gene with an equivalent gene from
maize increased the amount of b-carotene by
about 20-fold, resulting in about 140 g of the
rice providing a child’s RDA for b-carotene
(45). It has also been recently demonstrated
that b-carotene from Golden Rice is effectively
converted to vitamin A in humans (46).
Another approach with similar objec-tives
was to increase the availability of iron
while reducing the inhibitor content or add-ing
a resorption-enhancing factor. Only 5% of
the iron in the rice plant is in the seed and
hence an attempt was made to create a sink
for iron storage within the endosperm by
expressing a ferritin gene from Phaseolus
which resulted in a 2.5-fold increase in iron
content of the endosperm. Feeding studies
with peptides from muscle tissue showed
that cystein-rich polypeptides enhance iron
resorption. A metallothionein-like gene
achieved a sevenfold increase in endosperm
cystein (47). Since interference with the phos-phate
storage may affect germination, expres-sion
of a phytase gene had to be achieved in
such a manner as not to interfere with germi-nation.
The enzyme was hence excreted into
the extracellular space and one transgenic
line that was developed expressed the phytase
to levels 700-fold higher than endogenous
phytase. However, the transgenic enzyme in
this line had lost its thermo-tolerance and did
not refold properly after cooking and was
therefore ineffective. New transgenic plants
aimed at targeting the enzyme-to-phytase
storage vesicles to reduce the phytate content
directly were developed to overcome the loss
of the enzyme during cooking. These three
genes, which influence iron availability and
absorption, are combined with the provita-min
A genes by crossing (47). The addition of
provitamin A genes was justified by the obser-vation
that vitamin A deficiency indirectly
interferes with iron metabolism (48) and
higher intakes of b-carotene (converted to
retinol after ingestion) may promote absorp-tion
of iron.
Work supported by FAO and the
International Atomic Energy Agency, as well
as by other investigators, has approached this

36 P. Shetty
problem in a different manner, aimed at agri-cultural
improvement by induced mutation
using nuclear techniques (49). The aim here is
to produce strains of cereals with higher con-centrations
of micronutrients and improve-ment
of their bioavailability by reduction in
the concentration of phytic acid. Raboy (50)
has developed low phytic acid (or lpa) mutant
varieties of maize, rice and barley using these
techniques. The phytic acid content of lpa
seeds was reduced by 50–80% compared with
non-mutant seeds, but the total amount of
phosphorus remained the same as the phytic
acid was replaced by inorganic phosphorus.
This does not bind trace minerals, thus allow-ing
them to be potentially available for
absorption. Unfortunately, unless the phytate
levels are reduced below 5% of that of the
wild type, the strong inhibitory effect on
absorption of iron persists (51).
Marker-assisted selection
The composition of nutrients in a range of
food crops such as rice, cassava, beans and
maize shows wide variations. Kennedy and
Burlingame (52) have shown a wide range in
the micronutrient content of rice varieties
grown throughout the world. There is sub-stantial
useful genetic variation in the germ-plasm
of key crops which may be exploited
by conventional plant breeding but this takes
a long time. Using molecular markers associ-ated
with specific traits, i.e. marker-assisted
selection, the process can be speeded up. A
strategy of breeding plants that contain a high
concentration of minerals and vitamins in
their edible parts has the potential to reduce
substantially the recurrent costs associated
with fortification and supplementation. But
this will be successful only if farmers are will-ing
to adopt such varieties, if the edible parts
of these varieties are palatable and acceptable
to consumers, and if the incorporated micro-nutrients
can be absorbed by the human body
(53). According to Bouis (53), for a plant-breeding
strategy to combat micronutrient
deficiency to work and to be universally
adopted, particularly in developing coun-tries,
five crucial questions need to be
addressed. They are: (i) Is it scientifically fea-sible
to breed micronutrient-dense staple food
varieties? (ii) What are the effects on plant
yields and will farmers adopt such varieties?
(iii) Will micronutrient density change the
characteristics of the staple for the consumer?
(iv) Will the extra micronutrients in staple
foods be bioavailable to humans? (v) Are
there other cheaper or sustainable strategies
for reducing micronutrient malnutrition?
Thus the ICN goal of promoting sustain-able
‘food-based strategies’ to enable ade-quate
consumption of micronutrients in the
developing world can be achieved by the
introduction of ‘biofortified’ crops, which are
varieties bred for their qualitative aspects
and not merely to improve yields. The feasi-bility
of plant-breeding approaches for
improving the micronutrient content of sta-ple
crops is real (54). This is an approach that
uses both classical plant breeding and mod-ern
biotechnology. Breeding programmes can
readily manage nutritional quality traits,
which for some crops are highly heritable,
simple to screen for and offer the possibility
of increasing the content of several micronu-trients
in the same variety. The desirable traits
are sufficiently stable across a wide range of
growing environments and, in addition, these
traits for quality and high nutrient content
can be combined with the traits for which sta-ples
are specifically bred e.g. superior agro-nomic
characteristics and high yields.
Biotechnology enables the identification of
markers and thus facilitates marker-assisted
selection that will enable transfer of these
desirable traits through conventional plant
breeding.
There is considerable progress in this
new area of biofortification of staple food
crops (55). Good examples are iron-rich rice
(International Rice Research Institute (IRR),
Philippines), maize with improved quality
protein (International Maize and Wheat
Improvement Centre (CIMMYT), Mexico),
high-carotene orange-fleshed sweet potato
(International Potato Center (CIP), Peru) and
high-carotene cassava (International Center
for Tropical Agriculture (CIAT), Colombia)
(56). Orange-fleshed sweet potato has been
shown to be an efficacious source of vitamin
A both in Mozambique (57) and South Africa
(58). Studies in Mozambique have not only
shown that biofortified orange-fleshed sweet

potatoes are adopted by farmers and con-sumed
by children (57), but also that their
integrated promotion is an effective food-based
approach to improving the vitamin A
status of children (59).
It is important to note that, while the
potential for the breeding of biofortified crops
by the agricultural community is high, it is
quite some way from establishing the efficacy
and sustainability of the nutritional benefits
of many of these crops. The major advantage
of the biofortification approach is that this
strategy does not depend much on the change
in behaviour of the producer (farmer),
although there may be implications for
acceptability of these staple foods on the part
of the consumer (53). Already existing high-yielding
varieties can be used and these are
widely consumed. The increase in nutrient
content is a natural variation and hence breed-ing
specifically for these qualities need not
necessarily alter appearance, taste, texture or
cooking qualities, which influence consumer
behaviour. Combining nutritional quality
traits with those for high yield or pest or
drought resistance ensures ready adoption by
the farmer and market success. An added
advantage is the increasing recognition that
high levels of trace minerals in seeds also aid
plant nutrition and may thus contribute to
better growth and yields of staple crops.
Because trace minerals are important not only
for human nutrition but also for plant and
animal nutrition, plant breeding has great
promise for making a significant, low-cost,
sustainable contribution to reducing micro-nutrient
deficiencies even among livestock
and other agricultural food products (60). It
may thus have other important spin-off effects
for environmentally beneficial increases in
farm productivity for developing countries
and may thereby contribute to agricultural
trade from the South.
Conclusions
Promoting sustainable ‘food-based strategies’
to promote nutrition security and enable ade-quate
consumption of micronutrients to
reduce the global problem of micronutrient
malnutrition can be achieved by micronutri-ent
supplementation and fortification, dietary
diversification and modification strategies
and the introduction of biofortified crops.
Dietary diversification strategies, which
include home and homestead gardening,
small livestock production, aquaculture and
other related activities such as nutrition edu-cation,
are sustainable strategies that provide
rural employment and active participation of
women, furthering their empowerment as
well as contributing to increase awareness of
nutrition and health.
Another sustainable long-term approach
to reducing micronutrient malnutrition
among vulnerable populations in developing
countries is to enrich major staple food crops
with micronutrients through plant-breeding
strategies assisted by biotechnology, which
can offer direct and indirect benefits to
producers and consumers in developing
countries (61). Breeding nutrient-dense staple
foods can make a major contribution to reduc-ing
the global problem of micronutrient defi-ciencies
and, at the same time, to achieving
food and nutrition security. Improving the
micronutrient composition of plant foods
may become a sustainable strategy to combat
deficiencies in human populations, comple-menting
or even replacing other strategies
such as food fortification or nutrient supple-mentation
(62). Plant breeding has thus a
great potential to emerge as a long-term sus-tainable
agricultural strategy for improving
not only the quantity but also the quality of
the daily diet, thus contributing to achieving
nutrition security for all.
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3 Agricultural Interventions and
Nutrition: Lessons from the Past and
New Evidence*
M. Arimond,**1 C. Hawkes,2 M.T. Ruel,3 Z. Sifri,4 P.R. Berti,5 J.L. Leroy,3 J.W. Low,6
L.R. Brown7 and E.A. Frongillo8
1Program in International and Community Nutrition, University of California, Davis,
California, USA; 2Independent Consultant, Le Pouget, France; 3Poverty, Health and
Nutrition Division, International Food Policy Research Institute, Washington, DC, USA;
4Independent Consultant, Vienna, Virginia, USA; 5HealthBridge, Ottawa, Ontario, Canada;
6International Potato Center (CIP), Nairobi, Kenya; 7The World Food Programme, Rome,
Italy (formerly with The World Bank); 8Department of Health Promotion, Education, and
Behavior, University of South Carolina, Columbia, South Carolina, USA
Abstract
Globally, many poor households rely on agriculture for their livelihoods, and this remains true even when
livelihoods are diversified. Poor households are also most vulnerable to undernutrition, including lack of
micronutrients. Over the last decades, a variety of organizations have aimed to harness agriculture for nutri-tion.
Agricultural approaches have the potential to substantially impact nutritional outcomes in a sustainable
way, but there is insufficient understanding of the evidence base for this potential impact and of how best to
achieve this potential. This chapter aims to consolidate the available evidence linking agricultural interven-tions
to nutrition outcomes. First, the chapter describes five pathways through which agricultural interven-tions
can impact nutrition: consumption of own production; increases in income; reductions in market prices;
shifts in consumer preferences; and shifts in control of resources. Second, we review four types of studies that
provide insights about links between agriculture and nutrition: early studies of agricultural commercializa-tion;
studies of women in agriculture; studies of horticultural interventions; and studies of livestock and
aquaculture interventions. Consistent themes include the importance of integrating well-designed behav-iour-
change communications and careful consideration of gender dimensions. Third, we present two case
studies that show how well-designed interventions can successfully diversify diets and/or impact micronu-trient
intakes and nutritional status outcomes; the second case study illustrates impact at scale. The review
yields lessons for design of future interventions and for evaluation design, and identifies critical areas for
future work, which include investigations of cost-effectiveness, scaling up processes and sustainability.
Key words: nutrition, agriculture, micronutrients, gender, interventions
* Partial support for this work came from the Agriculture and Rural Development Department of The World Bank
and from the International Livestock Research Institute through the United States Agency for International
Development Linkage Funds grant programme to Cornell University. This chapter draws from and extends
material developed by the authors for World Bank Report No. 40196-GLB, From Agriculture to Nutrition.
Pathways, Synergies and Outcomes. The findings, interpretations and conclusions expressed do not necessarily
reflect the views of the Executive Directors of The World Bank or the governments they represent.
** Contact: marimond@ucdavis.edu

42 M. Arimond et al.
Background
International development agencies, govern-ments
and non-governmental organizations
(NGOs) have been designing strategies and
interventions1 linking agriculture and nutri-tion
since the 1960s. Initially, efforts to har-ness
agriculture for nutrition were focused on
increasing agricultural production and small-holder
incomes to improve food security, with
food security narrowly defined as food avail-ability
and household-level access to suffi-cient
food energy. Late in the last century
definitions of food security evolved to incor-porate
new knowledge about the wide preva-lence
and public health importance of
micronutrient deficiencies, and the following
definition was adopted at the World Food
Summit in 1996 (1):
Food security exists when all people, at
all times, have physical and economic
access to sufficient, safe, and nutritious
food to meet their dietary needs and food
preferences for an active and healthy life.
Inclusion in the definition of sufficient, safe,
and nutritious food broadened the focus beyond
food energy. The emphasis on all people implic-itly
recognized that food security is deter-mined
by distribution both within
communities and within households. For
young children – a vulnerable group targeted
by many nutrition interventions – access to
sufficient, safe and nutritious food is contin-gent
on their receiving adequate care and
1 We define ‘agricultural interventions’ broadly to
mean changes purposefully introduced into an
existing agricultural system to promote new crops,
technologies, management practices, production
and marketing methods and other innovations.
Such interventions usually include an implicit
objective of behaviour change; some interventions
address this explicitly with programme elements.
Commonly, sets of activities in the agriculture sec-tor
are referred to as ‘projects’, while ‘programme’
is more commonly used in the public health and
nutrition sectors. For the purposes of this document
we use both ‘interventions’ and ‘programmes’
interchangeably to refer to planned sets of activities
undertaken by an organization or organizations in
order to achieve defined results.
feeding. In most societies this is conditional
on the power of women within households
and, specifically, their control over resources
to both secure sufficient quality food and give
it to children according to need.
Despite consensus around this broad
definition of food security, outside the
nutrition community dialogues about food
security often remain focused on household-level
access to sufficient food energy, indicat-ing
a need for increased communication
between nutritionists, agriculturalists, advo-cates
and policy makers. At the same time,
and supported by several international agen-cies
and donors, a number of agricultural
approaches to improving diet quality and
micronutrient intakes have emerged (2,3).
These agricultural approaches have the
potential to substantially impact nutritional
outcomes (as well as food security) in a sus-tainable
way, but there is insufficient under-standing
of the evidence base for this potential
impact and of how best to achieve this
potential.
Objective, Scope and Conceptual
Framework
This review summarizes and integrates les-sons
learned from a range of past agricultural
interventions that provide evidence about
nutrition outcomes. The aim was to identify
lessons that can inform the design of future
interventions. Although much of this mate-rial
has been previously reviewed, we build
on this work by bringing together and inte-grating
information from these reviews,
describing a wide range of interventions and
synthesizing lessons learned for design and
for future evaluations. We supplement previ-ous
reviews with two case studies of well-designed
interventions. These case studies
highlight the potential of agriculture to
improve micronutrient nutrition.
Several different types of literature are
included in the review. The primary focus is
on studies linking agricultural change or
intervention to individual-level nutrition
outcomes (dietary intakes and/or nutritional
status indicators). Current best practice in

Agricultural Interventions and Nutrition 43
designing agricultural interventions for nutri-tion
is also informed by decades of research
regarding the role of women in agriculture;
therefore, we provide a selective review of
this research. Women perform most of the
work of food production in the developing
world, and have been shown to spend a large
proportion of their income on food and health
care for children and on household consump-tion
goods (4,5). They therefore play a key
role in translating available household
resources into nutrition improvement for vul-nerable
household members. While studies of
women in agriculture do not necessarily pro-vide
information on nutrition outcomes per
se, they do provide critical insights into how
the benefits of agricultural interventions are
distributed and whether it is possible to
achieve nutrition gains.
Agricultural interventions have the
potential to influence nutrition, including
micronutrient intakes and status, through a
variety of pathways. The evidence summa-rized
in this review illustrates five main path-ways
toward impact:
1. Increases in food availability and access at the
household level through production for the
household’s own consumption – this can also
include filling seasonal gaps.
2. Increases in income through production for
sale in markets, and hence potential to
increase food purchases and/or purchases of
higher-quality food as well as acquire other
goods and services that influence nutrition.
3. Reductions in real food market prices asso-ciated
with increased agricultural production
(again impacting potential to purchase more
or different types of food).
4. Shifts in consumer preferences, for example
when intervention programmes include ele-ments
of behaviour-change communication
(BCC).
5. Shifts in control of resources within house-holds
and communities – in particular, inter-ventions
that shift resources (income, time,
other) towards women provide an additional
pathway towards impact on nutrition.
These pathways are not mutually exclusive.
For example, even in areas with poor market
access, subsistence-oriented households are
likely to sell part of their crop production to
meet other needs. This is particularly true for
high-value micronutrient-rich fruits, vegeta-bles
and animal products. Which pathway
dominates in determining impacts on nutri-tion
depends on a variety of factors, includ-ing
market access and integration, potential
for surplus production within a given agro-ecological
setting, pre-existing nutrition
knowledge, and consumer preferences and
demand.
In addition, impacts on nutrition through
the first pathway depend on the types (i.e.
nutrient content) of crop/livestock produced.
Impacts through the second pathway depend
on who controls any new income generated.
For all pathways, the extent to which nutri-tion
improvement for any particular individ-ual
actually occurs depends on a series of
intra-household factors and processes, includ-ing
women’s status, education, knowledge,
practices and decision making, as well as
access to and use of health and sanitation
services and other key inputs into nutrition.
Methods
The review is based on systematic searches of
recently published literature and a limited
search of unpublished documents, as well as
personal contacts with project officers and
international agency staff. The searches pri-marily
aimed to identify studies of agricul-tural
interventions that had evaluated
individual-level nutrition outcomes, such as
child nutritional status, individual food or
nutrient intakes and diet quality. Some stud-ies
also documented household-level impacts
on food consumption. In most cases, these
interventions had explicitly included nutri-tion
improvement among their objectives. We
did not exclude studies lacking such objec-tives,
however, so long as nutrition outcomes
were measured. Details about search meth-ods
and results are published elsewhere (6).
Several thousand published articles were
reviewed for relevance.
We drew on previous reviews (7–16)
with the purpose of synthesizing them. Much
of the analysis related to interventions pro-moting
animal production was taken from

Leroy and Frongillo (17). No primary search
was done to identify studies of women in
agriculture. Rather, key lessons regarding
women in agriculture already identified in
previous reviews (4,17–21) are summarized
here as these inform current thinking about
intervention design.
Results
Overview
Most of the studies identified in this review
documented nutrition impacts of agricultural
interventions along the first two pathways
described above, i.e. through increased house-hold
production and own consumption and/
or through increased income. Some studies
described interventions that included an
explicit BCC strategy. In addition, some stud-ies
took gender into account and disaggre-gated
results according to gender roles in
production and in the control of new resources
generated by the interventions.
Studies in this review are divided into
the following categories:
• Agricultural commercialization (early
‘cash crop’ studies).
• Women in agriculture.
• Horticultural interventions.
• Livestock and aquaculture interventions.
• Case studies with impact on micronutri-ent
nutrition.
The order of presentation is roughly chrono-logical.
Studies of agricultural commerciali-zation
were among the first to examine links
between agriculture and nutrition. Key
insights from these early studies still influ-ence
current thinking and intervention
designs. Notably, these studies were among
the first to highlight differential nutrition out-comes
depending on women’s control of new
resources. In the years that followed, a large
number of studies focused on women in agri-culture.
While these generally did not include
examination of nutrition outcomes per se,
they yielded many critical insights for pro-gramme
design and policies, which remain
relevant. Concurrent with this evolution in
general knowledge about optimal design,
agricultural interventions specifically aim-ing
to improve nutrition also evolved. With
recognition of the widespread prevalence of
micronutrient deficiencies, more recent
agricultural interventions have focused on
nutrient-dense horticultural crops and/or
animal-source foods (ASFs) from livestock
and aquaculture production interventions.
Finally, some recent interventions have
built on the existing knowledge base and
have demonstrated success in impacting
micronutrient malnutrition; the results of
two such interventions are presented here as
case studies.
Agricultural commercialization
Studies of agricultural commercialization
were motivated by early conceptual reviews,
which had suggested the potential for
negative impacts of commercialization on
nutrition through reduced household-level
access to food (see e.g. Fleuret and Fleuret
(22)). One early review showed mixed
impacts on nutrition, but also identified
methodological issues that constrained
interpretation and comparison (7). Given
these uncertainties, von Braun and col-leagues
designed and undertook a series of
micro-level case studies that included assess-ment
of nutrition outcomes as an explicit
objective (10). The case studies assessed the
impact of commercialization on energy
intakes rather than on diet quality or micro-nutrient
intake, consistent with the then-prevailing
idea that energy intakes were the
primary constraint in the diets of the poor
(23,24). In addition, young child nutritional
status (anthropometry) was assessed in most
of the studies. These studies also reported
results disaggregated by income group and
examined the role of control of income by
women as opposed to men.
Results from these and closely related
studies were synthesized in previous
reviews (8–10); results of individual studies
are summarized in Table 3.1. In sum, the
case studies documented fairly consistent
positive impacts on focus crop production,

Table 3.1. Summary of findings from selected studies of agricultural commercialization.
Country crop
(reference(s))
(publication
date(s))
Intervention or
technological
change Study design
Key findings
Production,
income,
marketing/salesa
HH energy
consumptiona
Individual energy
intakes and/or
nutritional status Gender dimensions
West Kenya
Irrigated rice
(25,26)b,c
(1988, 1994)
Two rice irrigation
schemes. Irrigated
land was expropri-ated
and redistrib-uted
to
smallholders for
rice production only.
Initially, all tenants
lived on scheme
but eventually some
moved off scheme.
No livestock and
only small rainfed
plots on scheme
Cross-sectional
survey comparing:
(i) resident
tenants;
(ii) non-resident
tenants;
(iii) individual rice
growers; and
(iv) non-rice
growers
• Total incomes
were similar
across all four
groups but sources
of income were
least diverse for
resident tenants
and most diverse
for individual rice
growers
• HH energy consump-tion
increased with
increasing diversity of
income sources
• Child energy intakes
were lowest and
nutritional status
(height-for-age) was
substantially worse
among resident
tenants. Other groups
fared better and were
similar
• In-depth follow-up
study among
resident tenant HHs
revealed higher per
capita food
expenditures from
income controlled
by women
Rwanda
Potatoes
(27,28)b,d
(1994, 1991)
Expansion of potato
production in
former forest
reserve, allowing
access to additional
land for food
production. During
reforestation, potato
production was
allowed to keep
weeds down.
However, potato
cultivation
expanded rapidly
and uncontrollably
Cross-sectional
survey comparing:
(i) farms with
access to and
(ii) farms without
access to ‘extra’
forest reserve
land under potato
(monocropped)
• Potatoes grown on
‘extra’ land were
the only crop
marketed to a
significant degree
but the amount
sold varied from
8% to 45% based
on wealth quartile;
potato production
expanded rural
wage labour
market
• A 10% increase in
income was associ-ated
with a 5%
increase in energy
consumption
• A lower degree of
commercialization
raised energy intakes
over and above price
and income effects
• Increases in HH energy
consumption were
associated with better
child nutritional status
(height-for-age and
weight-for-age) but this
effect was very small
• Child anthropo metry
was more strongly
related to health and
sanitation
• Female-headed
HHs consumed
more energy (per
unit); this effect was
strongest in poorest
HHs and did not
hold in wealthiest
Continued

Country crop
(reference(s))
(publication
date(s))
Intervention or
technological
change Study design
Key findings
Production,
income,
marketing/salesa
HH energy
consumptiona
Individual energy
intakes and/or
nutritional status Gender dimensions
Zambia
Hybrid
maize (29)b
(1994)
Introduction of
hybrid maize. A
number of
different varieties
were introduced
over a 1-year
period
Repeated HH
surveys
comparing: (i)
HHs in high- and
low-adopting
areas; and (ii)
adopters and non-adopters
• Incomes were
33–45% higher in
high-adoption areas
whether HH adopted
or not; incomes of
adopters were 25%
higher than non-adopters
• Per capita consump-tion
of energy and
other nutrients
followed same pattern
as income (higher
intakes among
adopters and in
high-adoption areas)
• Results for child
nutritional status were
mixed. Higher weight
but lower height in
high-adoption areas
(young children) and
lower weight among
older children. In
adopting HHs, young
child height was slightly
higher but weight and
height were lower
among older children
The Gambia
Irrigated rice
(30,31)b,c
(1988, 1994)
Large-scale rice
irrigation scheme.
Explicit attempt to
maintain
traditional use
rights of women
farmers through
giving women
priority during
registration of
plots. Production
technology in the
scheme was
heterogeneous
with varying levels
of water control
Repeated HH
surveys in area of
new state-owned
large-scale
rice irrigation
scheme, with 4
production
systems: (i)
traditional swamp
rice; (ii) small
pump irrigation; (iii)
partial water
control (rain or
tide); and (iv)
central irrigation
drainage
• New technology
resulted in substan-tially
increased yields
and allowed a second
crop, but did not have
large impact on
marketed surplus
• Substitution effects in
labour allocation
meant that increased
rice production was
accompanied by
decreases in other
cereals and
groundnuts (– $0.64
per $1.00 rice)
• Consumption (energy)
increased with
expenditure quartile in
both wet (hungry) and
dry seasons. A 10%
increase in expendi-ture
was associated
with a 5% increase in
energy (wet season)
• Consumption was not
correlated with HH
cereal production, but
was correlated with
women’s share of
cereal production
•Women’s seasonal
weight fluctuations
were buffered in HHs
with greater access to
new rice land
• Child height was
lowest in the lowest
expenditure quartile
(Q1) but similar across
Q2–Q4
• Child weight increased
with HH energy
intakes; access to new
rice land did not have
other independent
effects, positive or
negative
• Traditional swamp rice
was grown on
‘women’s land’. The
scheme sought to
assure women’s
access to new project
rice land; however, the
men changed the HH
classification resulting
in the land and crop
being controlled by
men
•Women’s control of
production and income
was decreased for
new higher-input and
higher-yielding rice

Mexico
Sorghum (32)c
(1990)
Adoption of sorghum
production in
areas formerly
dominated by
subsistence
agriculture (maize
and beans);
sorghum
production
increased to meet
increasing
demand for
livestock feed
Ethnographic
methods (partici-pant
observation
and informal
interviews)
followed by a HH
survey in 4
communities where
sorghum was
produced as a
cash crop.
Communities
represented range
of ecological
conditions,
landholding size,
irrigation, and
access to credit,
technical assist-ance
and markets
• Incomes were
highly diversified
• Access to
good-quality and
irrigated land
determined
income, rather
than participation
in cash cropping
(Neither food consump-tion
nor dietary
intake was
measured)
• There was no
relationship between
sorghum production
and child nutritional
status (height-for-age,
weight-for-age or
weight-for-height)
• Income was associ-ated
with child
nutritional status
(weight-for-age), but
only weakly
HH, household.
aIncome and HH consumption expressed per adult equivalent unit.
bIncluded in von Braun and Kennedy (10).
cIn DeWalt (9).
dIn Kennedy et al. (8).

household income and food expenditures,
but no substantial impacts on young child
anthropometry.
In relation to the original stimulus for
exploring impacts of commercialization on
nutrition – i.e. the hypothesized negative
impacts – DeWalt (9) concluded that a focus
on commercialization per se was misplaced
and that impacts on food consumption and
child nutrition were determined by control of
production and income, allocation of house-hold
labour, maintenance of subsistence pro-duction,
land tenure and pricing policies for
both food and non-food crops.
Overall, review authors made the follow-ing
nutrition-relevant conclusions:
• Participation in cash-crop schemes gen-erally
resulted in increased household
income.
• Increases in income were accompanied
by increases in food expenditures, but
impacts were also dependent on changes
in relative prices.
• Household dietary energy intakes
increased in most cases but decreased in
some, as food expenditures shifted to
more expensive items such as meat and
fruits – potential improvements in diet
quality were suggested but not
documented.
• Increases in women’s income were docu-mented
in some studies and were gener-ally
linked to increases in household
energy consumption – this effect was
most pronounced among the lowest-in-come
groups.
• Overall, commercialization did not have
a significant impact – negative or posi-tive
– on young child nutritional status.
Kennedy et al. (8) attributed the lack of impact
on child nutritional status to the generally
high levels of morbidity observed in inter-vention
areas. In addition to this factor, we
also note that the commercialization schemes
were not designed as nutrition interventions
and consequently did not include any BCC
relevant to nutrition objectives. As demon-strated
in subsequent sections, this may have
contributed to limited impact on nutrition.
Finally, many of the studies in Table 3.1
were weakly designed. Most were observa-tional
studies and randomization was not
possible. This is often the case, but a number
of these studies also lacked adequate control
groups and compared groups that had been
‘self-selected’. Some authors addressed this
analytically and explored differences between
adopters and non-adopters and, in one case,
between high- and low-adoption areas. Some
studies also lacked baseline information.
Overall, design constraints limited the
strength and/or generalizability of some con-clusions.
However, these early studies began
to illuminate links between agriculture and
nutrition and, in particular, the key role of
women.
Women in agriculture
Several of the commercialization studies
highlighted the role of women, and specifi-cally
the positive effect of women’s control of
income on household energy intakes.
Following on this work, additional studies
confirmed the positive association between
women’s income and food expenditures and
also demonstrated strong positive associa-tions
between women’s income/other
resources and child health and nutrition out-comes;
this evidence is summarized in
Quisumbing et al. (4), Peña et al. (19),
Quisumbing and Maluccio (33) and Kurtz
and Johnson-Welch (34).
In addition to documenting links between
women’s resources and positive nutrition
outcomes, studies of women in agriculture
have described a series of problems and con-straints
faced by women agriculturalists in
many contexts. These constraints include:
weak land rights; limited access to common
property resources; lack of equipment and
appropriate technology; limited contact with
agricultural extension; lack of access to finan-cial
services, markets and information; and
lower levels of education (4).
These constraints have conspired to sub-stantially
lower the productivity of women
farmers compared with male farmers even
from the same socio-economic bracket, result-ing
in high opportunity costs for households
and communities (18,20). In addition to affect-

Box 3.1. Characteristics of agricultural interventions targeting women farmers. (Adapted from
Peña et al. (19).)
Failed interventions often:
• did not take into account women’s needs, livelihoods or their context-specifi c constraints;
• did not consult participants regarding their preferences for new activities;
• lacked needed staff expertise;
• focused on traditional women’s activities with low economic returns; and
• provided inadequate training and technical inputs.
Successful interventions often:
• ‘mainstreamed’ gender in the intervention rather than treating it as a separate project or component;
• incorporated assessments of women’s pre-existing livelihood assets;
• considered women’s incentives to undertake new activities;
• considered women’s time constraints and multiple roles;
• listened to participants and their own assessment of needs;
• worked with groups of women;
• employed female extension specialists or trained male extension specialists to work with women;
• disaggregated monitoring data by gender;
• monitored participation and could adjust intervention to address identifi ed constraints as needed;
• provided leadership training to participants; and
• integrated well multiple components of intervention.
ing productivity, these constraints have lim-ited
women’s share of benefits flowing from
adoption of new technologies and have lim-ited
the share of household resources that
they can command and control.
The evidence suggests that specific
intervention strategies aimed at addressing
these constraints must be carefully designed.
Past experience is rich in examples of incom-plete
or failed attempts to address gender
dimensions (19,26,35), including examples
of interventions where new technologies for
‘women’s crops’ have shifted control of the
focus crop to men (10,17,36). Past studies
have also identified characteristics likely to
be associated with successful and failed
interventions (Box 3.1). Because of the
proven importance of women’s access to
and control of resources for food security
and child nutrition outcomes, these same
characteristics are relevant for the design of
any agricultural intervention aimed at
improving nutrition.
However, note that the constraints iden-tified
above operate at many levels and
involve many institutions; in some situations
the legal and institutional context in which
programmes operate may limit their potential
to increase women’s access to and control
over resources.
Horticultural interventions
Concurrent with the recognition of the role of
women in agriculture, new nutrition knowl-edge
generated recognition of the prevalence
and importance of micronutrient malnutri-tion.
This motivated new efforts to impact
micronutrient malnutrition through agricul-tural
interventions involving fruit and vegeta-ble
production. Despite the existence of a wide
variety of fruit and vegetable production sys-tems,
however, only homestead garden pro-duction
systems have been implemented and
evaluated with explicit nutrition objectives.
These interventions generally have been
designed to impact nutrition via the first path-way
described above (i.e. own production for
consumption) and sometimes, secondarily, via
increased income from sales.
Homestead gardens take a wide variety
of forms, in backyards, farmyards, kitchens,
containers, small patches of available land,
vacant lots, on rooftops and tabletops, and
along roadsides and the edges of fields. They
are generally close to a house and source of
water, and are managed by family members
using low-cost inputs. Their products include
fruits, vegetables, herbs, condiments and
sometimes secondary staples like legumes
and sweet potatoes, most of which are grown

for household consumption. The nutrition
impacts of homestead gardens have been
relatively well documented in previous
reviews (12–16).
In 1990 and 1991 the United States
Agency for International Development-funded
Vitamin A Field Support Project
(VITAL) carried out an assessment of past
and then-current household garden interven-tions
and their impacts on nutrition out-comes.
The aim was to inform the planning
of future research and initiatives. Focusing
on the effects of homestead gardens on the
intake of vitamin A-rich foods and improv-ing
vitamin A status, the review yielded a
number of recommendations on design, tar-geting
and evaluation of homestead gardens
as a means of strengthening their nutritional
impact. The main recommendation was that
interventions should focus on women and
provide nutrition education to promote
appropriate processing, storage and cooking
techniques for vitamin A-rich foods. They
should also promote a diverse variety of vita-min
A-rich foods to meet both subsistence
and marketing needs, and take into account
cultural preferences when selecting which
foods to introduce (13).
Gillespie and Mason (14) considered 13
programmes aimed at improving diet quality,
seven of which included homestead garden-ing.
Four of these were combined with social
marketing activities and all four exhibited a
number of indirect benefits such as increased
women’s income and social status. Yet only
one intervention, in Bangladesh, showed a
positive effect on vitamin A status in addition
to increased energy intakes and improve-ments
in the economic status of women.
Studies included in more recent reviews
are summarized in Table 3.2, which details
impacts on diets, nutritional status, knowl-edge,
practices and other outcomes. Table 3.2
includes a number of intervention studies that
reported increases in production and con-sumption
of fruits and vegetables. In summa-rizing,
Ruel (15) found that interventions that
did not include explicit BCC strategies (Box
3.2) (generally those conducted prior to the
mid-1990s) failed to achieve significant impacts
on nutritional outcomes. Subsequent interven-tions
that incorporated well-designed BCC
elements did demonstrate impacts. The review
also emphasized that using a gender-sensitive
approach to agricultural interventions could
strengthen their impact on nutrition.
Berti et al. (16) used a Sustainable
Livelihoods Framework and assessed whether
agricultural interventions had invested in dif-ferent
types of capital: human, physical,
social, environmental and financial.
Interventions that invested more broadly in
various types of capital, as was usually the
case with homestead gardening programmes,
tended to have a greater impact on nutrition
than did those that focused more narrowly on
production. Interventions with a strong gen-der
focus were classified as having made
investments in social capital; those with BCC
components were classified as having made
investments in human capital.
Although they employed different theo-retical
frameworks, the two reviews by Ruel
(15) and Berti et al. (16) led to a common con-clusion
that homestead gardening interven-tions
after the mid-1990s succeeded in
improving diets, nutrient intakes and/or
child nutritional status if they incorporated
communication and nutrition education
activities targeting behaviour change among
their audiences and if they incorporated gen-der
considerations in their design.
As noted with regard to the cash crop
studies, both reviews also reported that many
of the studies of horticultural interventions
had weak designs, which limited the strength
of conclusions and generalizability. While a
number of studies included control groups,
selection of appropriate comparison groups
remained challenging and/or poorly
described and inter-group differences were
not always accounted for in analyses. Baseline
information was also often unavailable.
Livestock and aquaculture interventions
Like homestead gardening interventions,
livestock and aquaculture interventions have
the potential to improve diet quality and
increase micronutrient intake. Livestock and
aquaculture interventions could impact
nutrition through any of the five pathways

Table 3.2. Summary of findings from horticultural interventions with nutrition objectives.
Country (reference(s))
(publication date(s)) Intervention(s) Study design
Key findings
Diets, nutrient intakes and/or
nutritional status
Other: Food production, KAP,
morbidity, gender dimensions
Bangladesh (37)a,b (1995) Homestead gardening with
provision of seeds,
farming education,
nutrition education
Pre/post, with control • Slight decrease in night blindness
indicating improved VA status
• Increase in % of HHs
growing vegetables and fruit
in both intervention and
control areas
• Increased knowledge of
function of VA
Bangladesh (38)a,b (1993) Homestead gardening with
vegetables, training on
agriculture, provision of
seeds, nutrition
education.
Pre/post, with control • Increase in vegetable consumption
per capita and children’s vegetable
intake
• Improvements in stunting and in
underweight
• Increase in vegetable
production, size of plot
cultivated, year-round
availability of vegetables
and income
• Intervention children had
fewer respiratory infections
• Increase in women’s control
over income
Bangladesh (39)a (1998) Vegetable production or
polyculture fish
production in HH-owned
or group-managed
ponds, and credit and
agricultural training;
some nutrition education
but primary objective
was not better nutrition
Pre/post, with 3 groups:
(i) adopters; (ii) potential
adopters (in non-intervention
villages);
and (iii) random
selection of HHs not in
(i) or (ii)
• No increase in consumption of fish
in fishpond group. Shift in
consumption from smaller to larger
fish, with possible negative impact
on micronutrient intakes
• Increase of vegetable intake in
vegetable group
• No change in Hb in any group,
implying no change in Fe status
• Increased production of fish
and vegetables; modest
increase in income for
adopters, compared with
potential adopters
• Demands on women’s time
relatively small
Ethiopia (40)a,b (1999) Training on agriculture,
food preparation
sessions, provision of
seeds; health and
nutrition education
Participants compared
with non-participants
• More diversified diets, higher VA
food frequency scores among
participants
• Lower prevalence of clinical signs
of VAD among participants
• More gardens
• Better KAP for VA
Continued

Key findings
nutritional status
Guatemala (41)b (1996) Provision of seeds,
extension services and
nutrition education for
the promotion of VA-rich
foods
Pre/post, with control • Control children without gardens
with VA-rich vegetables had more
VAD
India (42)a (2000) Homestead gardening and
nutrition and health
education
Pre/post • Weekly intake of VA-rich garden
produce more than doubled
• Decrease in ocular signs/
symptoms of VAD
growing vegetables
• 40% of HHs sold 10–25% of
produce
• Increased KAP on VA
Indonesia (43)a (1998) Social marketing with
mass-media and 1-on-1
communication to
increase intake of
targeted VA-rich foods
Pre/post • Increase in % of children and
mothers consuming at least 1 egg
in previous week; increase in
amount of vegetables prepared/
person per day
• Increased VA intakes from both
eggs and plants.
• Increased serum retinol with
increased egg consumption;
dose–response relationship
indicating improved VA status
Kenya (44)a,b (2001) Introduction of new
varieties of yellow- and
orange-fleshed sweet
potatoes and training in
food-processing
techniques; nutrition
education
Pre/post, with control • Higher VA food frequency scores
for children in intervention
(nutrition education plus agricul-tural
component) versus control
group (agricultural component
only)
• Unfamiliar yellow and
orange flesh colour did not
constrain adoption
Nepal (45)a,b (1995) Homestead gardening,
irrigation, agriculture
extension, seeds
Pre/post • Insufficient VA intake for mothers
and children both pre- and post-intervention
producing vegetables

Niger (46)a (1996) Promotion of home
production; multimedia
education campaign
promoting consumption
of VA-rich foods
Pre/post • Increased intake of VA-rich
vegetables (children), purchase and
consumption of liver (a food targeted
by the intervention to increase VA)
by women and children
• Increase in VA knowledge of
women
Peru (47)a (1998) Nutrition education in
community kitchen with
capacity building
Pre/post members/non-members
• Increased quality of diet and intake
of Fe-rich foods
• Increased intakes of VA, haem Fe
and proportion of absorbable Fe
• Reduction in prevalence of
anaemia
Philippines (48–50)b (1979,
1980, 1991)
Promotion of production of
VA-rich fruits and
vegetables with provision
of seeds and seedlings
and advice on agricul-tural
practices
Paired pre/post • Increase in children’s VA intake
• Improved weight-for-height and
decrease in severe wasting
• No change in serum retinol or
clinical eye signs of severe VAD,
implied no change in VA status
Philippines (51)b (1996) Promotion of homestead
gardens with some
target vegetables;
provision of seeds and
cuttings; mass media
campaigns, social
marketing and nutrition
education
Pre/post, with control • Increased vegetable consumption
• Increased VA intake in intervention
group; 48% decrease in VA intake
in control group
• Increased production of five
types of vegetables
Senegal (52)b (1989) Promotion of homestead
gardens and sale of
produce; nutrition
education and agricul-ture
education
Survey of those with and
without homestead
gardens (baseline;
10–12 years later)
• Consumption increased for some
nutrients, decreased for others
Tanzania (53)a,b (2000) Agriculture, promotion of
home production,
consumption and
storage of VA-rich foods;
health and nutrition
education
Intervention/control; post • Higher 7-day frequency of intake
of VA-rich foods
• Lower serum VA and higher
helminths in intervention area
• Higher intake of VA-rich foods
associated with higher serum VA
(both areas)
• Higher % of HHs with
homestead gardens and
producing VA-rich vegeta-bles
in intervention area
• Better KAP for VA, higher %
using solar driers for VA
foods
Continued

Key findings
nutritional status
Tanzania (54)a (2000) Promotion of solar driers;
nutrition and health
education
Pre/post, with control • VA food frequency score higher in
intervention group and among
adopters with increased intake of
animal products
• 8% women adopted solar
driers in intervention area
• No significant increase in %
selling or income from
selling dried vegetables
Thailand (55–57)a,b (1993,
1999, 1999)
Seed distribution, training
of women farmers,
promotion of gardens,
fishponds and raising
chickens; nutrition
education and social
marketing
Pre/post, with control • Increased VA intake; no change in fat
intake; increased Fe intake in some
targeted groups; increase in vitamin
C intake in lactating women
• Increased serum retinol,
decreased VAD (in school girls).
Increased mean Hb, decreased
anaemia and low serum ferritin
(NS) implied improved Fe status
Vietnam (58,59)a (1997, 1998) Homestead gardens,
fishponds, animal
husbandry; nutrition
education
Intervention/control; post • Higher fruit and vegetable intake in
intervention group
• Higher energy, protein and VA and
vitamin C intakes for children in
intervention areas
• Better growth in intervention group
• Better KAP in mothers of
intervention group
• Lower severity and
incidence of respiratory
infections in intervention
group
Vietnam (60)b (1994) Promotion of homestead
gardens with a focus on
VA-rich crops; nutrition
education for mothers
Pre/post • Increase in intake of energy,
protein and fat
• Clinical eye signs of severe VAD
decreased to almost zero implying
improved VA status
• Per capita vegetable
production increased
five-fold
Fe, iron; Hb, haemoglobin; HH, household; KAP, knowledge, attitudes and practices; NS, not significant; VA, vitamin A; VAD, vitamin A deficiency.
aIncluded in Ruel (15).
bIncluded in Berti et al. (16).

Box 3.2. Behaviour-change communication. (Adapted from Linkages (61) and United Nations
Children’s Fund (62).)
Behaviour-change communication:
• bridges the gap between information, knowledge, attitudes and subsequent behaviour;
• requires listening, understanding and then negotiating with individuals and communities for
long-term positive behaviour change;
• involves the use of an appropriate mix of communication channels, including interpersonal, group,
community and mass media; and
• recasts the role of ‘communicator’ as ‘facilitator’ rather than ‘expert’.
(i.e. consumption of own production, new
income from sales, changes in prices, shifts in
preferences or shifts in control of resources,
including women’s time). Animal production
interventions also have the potential to
impact nutrition through negative health
effects (i.e. via exposure to zoonoses), but
information on this link is scarce (17). Impacts
through the first pathway are potentiated
because certain micronutrients (e.g. iron and
vitamin A) are found in more bioavailable
forms in animal-source, as compared with
plant-source foods. However, unlike home-stead
gardens, livestock and aquaculture
interventions have often focused on income
generation through the sale of products,
rather than on own consumption. Also unlike
homestead gardens, which are often the
domain of women, resources from aquacul-ture
and large livestock are frequently con-trolled
by men.
A range of livestock and aquaculture
interventions have been evaluated with
respect to their impacts on nutrition (among
other outcomes). Leroy and Frongillo (17)
reviewed fifteen intervention studies, includ-ing
four on aquaculture, five on dairy pro-duction,
three on poultry and three in which
livestock production was one component of a
larger integrated intervention. The findings
concerning the impacts of these studies on
production, income and expenditure, dietary
intake, nutritional status and women’s income
and time use are summarized in Table 3.3.
Most of the studies showed a positive
impact on production of ASFs, despite the
large variety of promotional interventions.
Similarly, most interventions that measured
income or expenditures also reported
increases in these (Table 3.3).
Impacts on diets, nutrient intakes and
nutritional status, however, showed mixed
results. For aquaculture interventions, one
intervention may have actually decreased
dietary quality because it led to a switch from
consumption of small fish (which are con-sumed
whole and contain high levels of cal-cium
and vitamin A) to greater consumption
of larger fish with poorer micronutrient den-sity
(39). In another, there were no differences
in total fish consumption between the fish-producing
and non-fish-producing house-holds
(63). In a third study, intervention
households appeared to have consumed more
fish, but the analyses were not subject to sta-tistical
testing (64).
Similarly mixed results were found for
dairy interventions. In one intervention in
India, households in villages with milk coop-eratives
actually consumed less milk than
households in villages without cooperatives.
The overall nutrient consumption of house-holds
with cows in intervention villages did
rise, however, whereas nutrient consumption
among non-producing households fell (65). In
another intervention in India, children in
households that produced more than 5 litres
of milk daily had higher protein intakes than
those from non-producers (or smaller produc-ers)
(66). A third intervention in East Africa
found that households with cross-bred cows
consumed more energy, fat, protein, retinol
and iron than non-adopters (68). Finally, a
study in Kenya introducing cross-bred cows
and promoting fodder production found that
participating women increased their milk
consumption relative to baseline (69).
Poultry interventions in Bangladesh and
Egypt saw higher intakes of a range of nutri-ents
among participating households than

Table 3.3. Summary of findings from animal-source food interventions. (Adapted from Leroy and Frongillo (17), including notes to table.)
(publication date(s)) Intervention (s) Design
Key findings
Production, income,
expenditures
Diets, nutrient intakes
and/or nutritional status Gender dimensions
AQUACULTURE
Bangladesh (39) (1998) Polyculture fish
production in
HH-owned or
group-managed
ponds (or vegetable
production) to
improve income;
some nutrition
education was
provided, but primary
objective was not
better nutrition
Three groups: (i)
adopters; (ii) potential
adopters (in non-intervention
villages);
and (iii) random
selection of HHs not
in (i) or (ii)
• Positive but very
modest increase in
income in adopters
compared with potential
adopters
• No effect on fish
consumption; shift to
larger fish, i.e.
speculated that effect
on certain
micronutrient intakes
may be negative
• Pre-schoolers favoured,
particularly boys
• Programme effect on
anthropometric
indicators not estimated
• Demands on time
relatively small
Bangladesh (63) (2003) Poor farmers trained in
carp culture. HH
ponds were stocked
with carp and either
mola (species very
rich in VA) or other
small indigenous fish
species
Intervention/control;
post
• No difference in
production between
mola and small
indigenous fish species
ponds
• No difference in fish
intake between
producing and
non-producing HHs
• 47% of the mola was
consumed in the HH,
covering 21% of the
recommended VA
intake
Bangladesh (64) (2000) Aquaculture extension
(pond aquaculture).
HHs expected to
adapt monoculture of
tilapia or silver barb or
polyculture of native
and exotic carp
species using on-farm
resources
Intervention/control with
2 control groups:
(i) neighbouring HHs
in same village; and
(ii) others from other
area
• Both extension
recipients and
neighbours had higher
yields than control
farmers
• Returns on investments
higher in extension HHs
• Intervention and
neighbouring HHs
seemed to consume
more fish

DAIRY
India (65) (1987) Integrating rural HHs
into a market
economy by
increasing the use of
purchased inputs and
increasing the
marketed surplus.
Dairy cooperatives
were set up in the
villages
Intervention/control; pre/
post comparisons of
HHs in villages with
and without dairy
cooperatives
• Villages with coopera-tives
produced twice the
amount of milk as
control group (result of
> number of cross-bred
cows)
• Income and expenditure
increased in the
cooperative villages
• HHs in villages with
cooperatives con-sumed
less milk
• Nutrient consumption
of milk-producing HHs
in intervention villages
rose, that of non-pro-ducing
HHs fell
India (66) (1994) Dairy Development
Project of the Indian
government;
formation of dairy
cooperatives
post; 3 groups within
intervention: (i) large
(LP) (>5 l/day), (ii)
medium (MP) (2.5–5
l/d) and (iii) small
producers (SP) (<2.5
l/d)
N/A • Only children in the LP
met protein RDA
• LP children had the
highest energy intake
too (did not meet RDA)
• Overall, protein and
energy requirements
best met in LP and
worst in MP
Ethiopia (67,68) (1999,
2000)
Market-oriented dairying
for smallholder
mixed-crop and
livestock farmers; use
of cross-bred dairy
cows for milk
production and
traction; farmers with
cross-bred cows
encouraged to grow
fodder and received
training on improved
hygiene and restricted
grazing; also
veterinary and
breeding services
post
• Income of intervention
HHs 72% higher
• Higher income
associated with higher
food and non-food
expenditures
• Energy intake 19%
higher in participating
HHs
• Intake of fat, protein,
retinol and Fe also
higher
• Increase in maternal
income
• No apparent increase
in women’s labour
input
• Men’s incomes
benefited significantly
more from intensified
dairying than women’s
Continued

Kenya (69) (1996) National Dairy
Development Project:
intensive dairy
technology through
introduction of
cross-bred cows,
fodder production
Pre (recall)/post • Increase in HH income
• Increases in food
purchases, school fee
payments and book
purchases
• Increased milk
consumption
• Higher workload for
women
• Increase in maternal
income
POULTRY
Egypt (70) (1987) More and Better Food
Project: combined
activities promoting
plant production with
animal production
(poultry). 47% of
poultry farmers were
women
Intervention/control
(adopters/non-adopters)
Increase over time in
poultry production (and in
maize, groundnut and
wheat production) (not
clear whether for
adopters only)
• Fe, total protein and
animal protein intake
higher in adopting HHs
• Prevalence of
Fe-deficiency anaemia
dropped in school-aged
children during
the same time period
(in community)
Bangladesh (71) (2003) Saving schemes,
technical training for
poultry rearing and
credit programmes;
project beneficiaries
were all women
Pre/post • Chicken production
increased
• All reported improved
economic conditions
• Both food and non-food
expenditure increased
• % of income spent on
food decreased
• HH consumption of
eggs, chicken, fish,
meat and milk
increased
• Frequency of
vegetable consump-tion
did not change
• Grain consumption
increased
• Women gained
influence in deciding
on the use of income
Key findings
Production, income,
expenditures

Bangladesh (72) (1996) Participatory Livestock
Development Project
supporting semi-scavenging
poultry
production; loans and
technical assistance
provided through
women’s groups
post
• Egg production
significantly higher in
adopting HHs
• No difference in chicken
production
• Egg and chicken sales
significantly higher in
adopting HHs
• Egg and chicken
consumption not
different
• Women and girls in
adopting HHs ate
more fish
MIX OF
INTERVENTIONS
Ethiopia (40,73) (1999,
2003)
Women-focused goat
development project
without impact on
nutrition was
expanded to include
interventions to
promote VA intake,
including nutrition and
health education,
training in gardening,
food preparation and
distribution of
vegetable seeds;
school garden clubs
Intervention/control; 2
intervention groups:
(i) local goats or (ii)
cross-bred goats
• All of the newly started
vegetable gardens
during intervention
period in participating
HHs
• Participation signifi-cantly
associated with
vegetable garden
ownership
• No other data on
production
• Goat-owning HHs
consumed all
produced milk
• 87% by adults as
hojab; children in
participating HHs had
slightly more diversi-fied
diet; more likely to
consume milk >4×/
week
• Participating HHs
consumed egg at low
rate (0.46/week) but
significantly more than
controls (0.29)
• No impact on child
anthropometry; clinical
VAD lower in interven-tion
children
Vietnama (58) (1997) Fishponds; livestock;
home gardens;
nutrition education
post; only 1 interven-tion
and 1 control,
village, no
randomization
• Larger production of
fish, eggs, vegetables
and fruits in intervention
community
• Children in intervention
group had greater
intakes of vegetables,
fruits, energy, protein,
VA and Fe, and better
child growth
Continued

Thailand (56) (1999) Promotion of poultry
and rabbit-raising and
home gardens
through a community-based
intervention;
nutrition education;
school-based nutrition
programme targeted
to 10- to 13-year-old
schoolgirls; girls
received weekly iron
supplement of 60 mg
ferrous sulfate;
improved school
lunches; poultry
raising, fishponds
Intervention/control; pre/
post
Key findings
Production, income,
expenditures
N/A • Increased intake of VA
in both intervention
and control groups, but
greater in intervention
group
• Inconsistent findings
for Fe intake
• No increases in fat
intake
• Schoolgirls had
improved serum retinol
and serum ferritin
(double difference:
changes over time
compared between tx
and control)
Fe, iron; HH, household; N/A, not applicable; RDA, Recommended Dietary Allowance; VA, vitamin A; VAD, vitamin A deficiency.
aCould not obtain original report: Tilden, R. (1993) Impact of the FAO Vitamin A Nutritional Improvement Project in Rural Vietnam on: Rates of Xerophthalmia, Nutritional Status,
Maternal Attitude and Practices, Household Production and Consumption Patterns, and Children’s Dietary Practices. Food and Agriculture Organization of the United Nations, Rome.
bTraditional tea made of coffee pulp and leaves and preferably drunk with milk (73).

among non-participating households (70,71).
Another poultry intervention in Bangladesh
did not lead to increased egg or chicken
consumption, but participating households
did eat more fish, suggesting that the
intervention led to increased income and
subsequent positive dietary changes (72).
Three of the interventions focusing on
animal production incorporated nutrition
education and were combined with fruit and
vegetable production (see ‘mix of interven-tions’
in Table 3.3). In Ethiopia, children in
participating households had slightly more
diverse diets and were significantly more
likely to drink milk four or more times weekly
(40,73). In Vietnam the intervention group
had higher intakes of vegetables, fruits,
energy, protein, vitamin A and iron, and
exhibited higher growth rates among children
(58). It is not clear whether the animal pro-duction
per se caused the positive effects, as
the interventions were complex. In Thailand,
vitamin A intake increased in both interven-tion
and control groups, but the increase was
greater in the intervention group (56).
Leroy and Frongillo (17) also assessed
the impact of livestock and aquaculture inter-ventions
on maternal income and/or wom-en’s
control over income. The results were
quite mixed. For example, an intervention
involving intensified dairy farming in Kenya
(69) showed that an important share of the
additional income was controlled by women,
whereas in Ethiopia men’s incomes increased
significantly more than women’s (67).
Overall, the authors concluded that
women’s control over income from livestock
production activities has been very site-specific,
depending on the livestock or aquac-ulture
production system, the nature of the
intervention, and pre-existing cultural beliefs
and practices relating to gender. Even when
the intervention has been targeted to wom-en’s
livestock and aquaculture activities,
women have sometimes lost control over the
income generated by those activities.
The results relating to women’s control
of income serve as a cautionary note for pro-gramme
planners, but some interventions did
have positive impacts on nutrition. Leroy and
Frongillo (17) concluded that the interven-tions
associated with marked improvement
in dietary intake and nutritional status had
two key characteristics: women played a criti-cal
role in the intervention and/or the inter-ventions
included a BCC component. The
conclusion was entirely consistent with the
earlier reviews of horticultural interventions
(15,16).
The review also concluded that uncer-tainties
remain regarding which pathway
towards nutrition impact dominates in live-stock
and aquaculture interventions, i.e. direct
consumption, new income, changes in prices
or changes in control over resources. The
answer is likely to depend on a range of con-textual
factors and the studies reviewed did
not provide a systematic way to assess this.
Concerns with design limitations add a
final cautionary note and limit the strength of
the conclusions that can be drawn from these
studies. As with studies of cash cropping and
homestead gardening, many evaluations of
livestock and aquaculture interventions had
weak designs. Self-selection was an issue in a
number of studies, as was lack of baseline
information, small sample size and lack of
appropriate control for confounders in analy-ses.
As noted, few studies captured informa-tion
on unintended consequences related to
zoonoses. Taken together, the studies provide
sufficient information to suggest the potential
of well-designed animal production interven-tions;
in future, well-designed interventions
with equally well-designed evaluations may
confirm this potential.
Case Studies: Recent Agricultural
Interventions with Impact on
Micronutrient Nutrition
The studies summarized above yielded a
range of lessons for design of interventions.
Key and consistent conclusions include: care-ful
design around gender issues is crucial;
integrating BCC is necessary for ultimate
impact on nutrition outcomes; and grounded
understanding of livelihoods is more likely to
lead to successful interventions.
Recent interventions aiming to harness
agriculture for nutrition have benefited from
past experience, and programme planners

have incorporated many of these lessons. Two
case studies – not included in the previous
reviews – illustrate the potential for success
when interventions are carefully designed to
meet local needs. The first summarizes results
of a small-scale intervention in rural
Mozambique. Unlike the horticultural and
animal production interventions described
above, the Mozambique intervention focused
on a secondary staple food, sweet potato, in
an effort to improve vitamin A intakes and
decrease deficiency. The second case study, of
mixed homestead gardening and livestock
production in Asia, provides a rare example
of an agricultural intervention aimed at
improving nutrition that has gone to scale.
Case study 1: Introducing orange-fleshed
sweet potato production in rural
Mozambique1
Background and context
Unlike fruits, vegetables and ASFs, staple food
crops are generally not viewed as rich sources
of micronutrients. In fact, monotonous diets
heavily dominated by one or few staple foods
generally are associated with high risk for a
variety of micronutrient deficiencies among
vulnerable groups. Recently, efforts have been
undertaken to ‘biofortify’ staple food crops.
Biofortification is the process of breeding food
crops that are rich in bioavailable micronutri-ents.
Orange-fleshed sweet potato (OFSP) is
the first biofortified staple crop with fairly
wide dissemination in several countries (pri-marily
in sub-Saharan Africa).
OFSP has been selected as a focus crop in
a number of efforts to improve vitamin
A intakes, including the Vitamin A for Africa
(VITAA) partnership2 and the HarvestPlus
biofortification programme.3 OFSP is promis-ing
for a number of reasons. It contains very
1 Information for this case study was drawn from the
following sources: Towards Sustainable Nutrition
Improvement webpage, http://www.aec.msu.edu/
fs2/tsni/index.htm (accessed 27 February 2007);
Low et al. (74–76).
2 VITAA website: http://www.cipotato.org/vitaa/.
3 HarvestPlus website: http://www.harvestplus.org/.
high levels of carotenoids (vitamin A precur-sors),
is well accepted by the young children
who are usually targeted, is easy to cultivate,
propagates vegetatively and is fairly drought-resistant
once established. It is also a good
source of energy for children and adults.
Sweet potato is less labour-intensive than
most other staple crops and this is particu-larly
helpful to labour-constrained house-holds,
such as those affected by HIV/AIDS. It
can be planted over a broad range of time
without considerable yield loss, and can fill
some seasonal gaps in energy and vitamin A
intakes. These qualities also make sweet
potato an excellent food security crop.
Finally, root production varies in size
and quality. Usually a significant amount of
production is ‘unmarketable’, resulting in
roots available for home consumption during
the production season and drying of chips for
consumption in the off-season. Therefore,
OFSP has the potential to improve micronu-trient
intakes directly in producing house-holds,
through the first pathway towards
impact of agriculture on nutrition. To the
extent that marketing of OFSP roots and proc-essed
products occurs and is affordable, other
community members may also increase
intakes.
In many developing countries, however,
and including sub-Saharan Africa, dominant
sweet potato varieties are white-fleshed
(WFSP) and contain no carotenoids. Hence,
breeding and adaptive testing of OFSP
varieties have been undertaken to ensure that
new orange-fleshed varieties can compete
agronomically and meet local consumer
preferences.
This case study reports on the results of a
2-year intervention research project, the
‘Towards Sustainable Nutrition Improvement
Project’ in rural Mozambique (74–76). The
intervention was implemented in drought-prone
areas of Zambezia Province. The area is
characterized by very high levels of young
child malnutrition, a monotonous diet with
cassava as the primary staple and a very poor
resource base. Vitamin A deficiency is preva-lent
in rural Mozambique and in the study
area (58% at baseline). WFSP varieties were
already widely cultivated (69% of households)
and consumed in the area. The primary aim

4 Districts were selected if they: (i) were within
the implementing partner’s area of operation; (ii)
had high levels of malnutrition; (iii) had a com-mon
dominant language; (iv) were outside major
flood plains; and (v) allowed reasonable distances
between sites (i.e. feasible for research activities).
of the research was to establish whether a
food-based, integrated agriculture–nutrition
intervention, with OFSP as the key ‘entry point’,
could lead to improvements in young child
nutrient intake and serum retinol.
Intervention design, elements and scope
The theoretical model underlying design of
the intervention held that three elements –
each necessary and none sufficient alone –
would need to be addressed to achieve
sustainable impact:
• Increase farmers’ access to improved
OFSP vines and roots.
• Increase nutrition knowledge and create
demand for OFSP.
• Ensure sustainability through market
development.
The intervention purposefully built on les-sons
learned from an earlier OFSP interven-tion
in Kenya (77). The Kenya experience, like
others reviewed above, had focused on
women and had underscored the critical
importance of inclusion of BCC. Accordingly,
the Mozambique intervention included inte-grated
agriculture and nutrition extension by
pairs of male and female extension specialists
who lived in study areas for the duration of
the intervention. The BCC component did not
present OFSP as a ‘magic bullet’ to solve mal-nutrition
among young children, but rather
used the OFSP intervention as an opportunity
to deliver a range of nutrition messages. For
example, the nutrition extension package
included strong support for breastfeeding,
another key source of vitamin A for infants
and young children.
To design and implement the interven-tion,
partnerships were developed between
researchers (led by Michigan State University);
the implementing NGO, World Vision
Mozambique; the Nutrition Division of the
Ministry of Health and Helen Keller
International (HKI), for BCC strategies and
materials; and the National Institute for
Agronomic Investigation (Mozambique) and
the Southern African Root Crops Research
Network. World Vision had extensive prior
experience and pre-existing relationships in
Zambezia Province.
Intervention activities included:
• Varietal trials and ‘taste testing’ of prod-ucts
with farmers and their children.
• Distribution of free OFSP vines via farm-ers’
associations (as per government
extension practice at the time).
• Stimulation of demand through BCC
using multiple communication channels
– community theatre and radio spots and
a visible presence at local markets – as
well as nutrition extension.
• Agricultural extension services support-ing
production, storage, processing, com-mercialization
and marketing.
• Nutrition extension aimed to improve
infant and young child feeding
practices.
• Development of a grading/pricing
scheme in partnership with a trader,
rewarding quality.
• Development and marketing of proc-essed
products (‘golden bread’, dough-nuts
and OFSP juice).
Approximately 1000 farmers participated in
53 groups; 70% of participating farmers were
women. Men, women and older household
members (grandparents) were all encouraged
to participate in nutrition extension
activities.
Assessing impact: evaluation design
and data collection
The evaluation employed a prospective,
quasi-experimental design. The objective was
to measure the impact of the intervention on
children’s vitamin A status (using serum reti-nol)
and to document changes in the interme-diate
factors leading to nutritional impact, i.e.
changes in knowledge, OFSP production and
consumption, and vitamin A intake. Two
intervention districts and one control district
were purposively selected.4 Within districts,
villages were stratified by distance to services

and other characteristics and randomly
selected within strata. Intervention villages
were selected first, and control villages were
then selected to match as closely as possible
on agro-ecological conditions. Within villages,
all households with age-eligible children
were invited to participate; in intervention
areas, study participation also entailed par-ticipation
in local farmers’ groups. A series of
nine surveys was undertaken. Information
was gathered on socio-economic and demo-graphic
characteristics of households, agri-cultural
production, child morbidity, adult
and child anthropometry, parental nutrition
knowledge, food frequency, dietary intakes
and biochemical indicators. In addition, sweet
potato plots were measured annually and
market prices were monitored monthly.
Evaluation results5
There was a marked decrease in the preva-lence
of low serum retinol (an indicator of
vitamin A deficiency) among children in
intervention households (60 to 38%); preva-lence
remained unchanged in control com-munities.
This was accompanied by large
changes in every step along the pathway
towards impact. There were large differences
in production of OFSP (90% of intervention
households compared with 11% of controls)
and increases in sales (30% of households
compared with 13% at baseline, among pro-ducers).
Mean sweet potato plot size increased
more than tenfold in intervention households
and agronomic performance was acceptable,
with yields similar to WFSP. Both women and
men showed positive changes in nutrition
knowledge, relative to baseline and relative
to controls. Intervention children were ten
times more likely to eat OFSP frequently.
Vitamin A intakes among intervention chil-dren
were eight times higher than in controls;
energy intakes and intakes of several other
micronutrients were also higher. Finally, by
the end of the study, OFSP was the cheapest
source of vitamin A (per retinol unit) in local
markets.
5 Evaluation results are reported in Low et al. (75).
Strengths and limitations of the evaluation
The primary strengths of the evaluation
component included its prospective design
and the comprehensive series of surveys,
which documented a wide range of interme-diate
as well as final outcomes. One design
limitation was that participation in interven-tion
areas was restricted to those willing to
join farmers’ groups, which precluded a full
exploration of determinants of adoption.
This also raised the possibility of a self-selection
bias, but this threat to internal
validity was addressed in the analysis. A sec-ond
limitation was that the time frame for
the study did not allow an assessment of
sustainability; the authors identified several
issues of relevance to sustainability (below).
Finally, this pilot intervention was relatively
small. Nevertheless, the study results have
provided ‘proof of concept’ and support the
relevance and the potential for impact of the
larger VITAA, biofortification and other
efforts.
We also note that because the agriculture
and nutrition extension activities were deliv-ered
as a full package to all participants, it is
not possible to attribute results to any one
component or to assess the necessity of the
full package. This was by design; based on
evidence from the past, the intervention
model assumed that both agricultural and
nutrition extension, as well as market devel-opment,
were necessary elements to achieve
desired impacts.
Lessons for intervention design
Key features of intervention planning and
implementation, which are believed to have
contributed to success, include the following:
• Careful selection of a focus crop (agro-nomic
characteristics, role/potential role
in diet, gender considerations).
• Integration of agriculture and nutrition
components at every stage of planning
and implementation.
• Links established between researchers
and communities, through implement-ing
partners.
• Identification, selection and adaptive
breeding of nutrient-dense varieties that

also addressed the needs of farmers and
the preferences of consumers.
• Grounding in thorough knowledge of
context.
• Consideration to the roles of women and
the constraints they face as farmers.
• Strong BCC and demand creation com-ponents,
using multiple channels and
targeting multiple audiences.
• Development of local markets for OFSP, to
increase the likelihood of sustainability.
The project also identified several issues and
questions for follow-up. First, distribution of
free vines reduced farmers’ incentives to pre-serve
vines for planting the next season; sus-tainability
will depend on future ability and
willingness of farmers to invest in improved
vine conservation and multiplication, and/or
their willingness to pay for vines. Also related
to sustainability, further research is needed to
determine if adoption of OFSP is maintained
without continual input on the demand crea-tion
side. Finally, the extension package was
relatively intensive; more operational research
is needed to identify the lowest cost and most
cost-effective package of interventions that
can achieve public health impacts.
Case study 2: Homestead gardening in Asia6
Background and context
Unlike the newer approach of biofortification,
interventions with fruits, vegetables and live-stock
have been promoted for some time for
their potential to improve nutrition. The review
of past interventions showed mixed results, but
confirmed the potential. This case study exam-ines
one of the largest efforts to date to use
homestead gardening integrated with livestock
production to improve nutrition for poor and
vulnerable households. The approach was
developed, documented and scaled up to
national level in Bangladesh, and has since been
replicated elsewhere in Asia. This has been a
6 Information for this case study was drawn from the fol-lowing
sources: Bloem et al. (78); Talukder et al. (79);
Helen Keller International (38,80–82); Bushamuka
et al. (83); Helen Keller International (84).
multi-decade programme; early published
results were included in previous reviews.
Additional monitoring and evaluation results
have subsequently been published (79–84).
Homestead gardening in Bangladesh is a
seasonal activity, and vegetable and fruit pro-duction
satisfies less than 30% of national
demand. To gain a better understanding of
pre-existing gardening practices, HKI con-ducted
an assessment in north-west
Bangladesh in 1988. Based on the findings,
HKI developed a pilot programme among
1000 households between 1990 and 1993. The
aims were to: (i) explore the feasibility of pro-moting
low-cost vegetable gardens combined
with nutrition education; and (ii) identify
constraints that might prevent increased pro-duction
and consumption of vitamin A-rich
foods among poor households.
The pilot programme provided a wealth
of information on successes and challenges
and gave HKI both justification and neces-sary
information for scaling up. Encouraging
results suggested that household production
of fruits and vegetables could be possible
throughout the year with some technical
assistance and support. A mid-term evalua-tion
in 1992 (38) confirmed that the integrated
homestead gardening and nutrition educa-tion
programme, targeted to women, had had
a very positive impact on vegetable consump-tion
among women and young children.
The evaluation also identified constraints
and information needs, which were addressed
when the pilot was scaled up. In the pilot,
households were unable to sustain change
without a regular supply of quality seeds and
other inputs. It was also noted that scaling up
would require greater understanding of cul-tural
beliefs about child feeding, maternal
food intake during pregnancy, intra-house-hold
food distribution and the role women
played in programme activities. Management
and human resource needs for scaling up
were also defined.
Based on this work and beginning in
1993, the pilot was expanded in collaboration
with local NGOs and the government of
Bangladesh into the ‘NGO Gardening and
Nutrition Education Surveillance Project’
(78). Eventually, the programme was scaled
up to national-level coverage, supporting

900,000 households (4.5 million beneficiaries),
at a cost of approximately US$8/household
per annum (82). In addition, based on success
in Bangladesh, the intervention was repli-cated
by HKI in Cambodia, Nepal and the
Philippines, and adapted to Niger (81,83).
As new information emerged concerning
the bioavailability of vitamin A from various
sources and the limited bioavailability in
plant sources (85), HKI developed a pilot
‘homestead food production’ programme,
integrating animal husbandry into the ongo-ing
homestead gardening programme in
Bangladesh. The success of this 2002 pilot led
to its expansion in 2003–2005 to other regions
of Bangladesh.
Intervention design, elements and scope
Both gardening and nutrition education
activities were linked with the ongoing devel-opment
programmes of local NGOs. Strong
links were established with participating
communities to ensure sustainability. The
NGOs’ work with women’s groups helped
them to address the social and cultural con-straints
faced by women in Bangladesh. These
NGOs were supported technically and finan-cially
by HKI for the first 3 years of the inter-vention.
The establishment of village-level
nurseries and homestead gardens was con-ducted
by the NGOs in conjunction with
community groups. The village nurseries
served as a community support service net-work,
where demonstrations and training on
low-cost, low-risk gardening practices were
conducted and where seeds, seedlings and
saplings were produced and distributed.
Most of the village nurseries in the pro-gramme
operated as small enterprises.
Each NGO was encouraged to form 45
village nurseries per sub-district. Five to ten
working groups of approximately 20 women
each were linked to each nursery. A group
leader was identified to develop and manage
the nursery. The group leader also facilitated
nutrition and health education through peer
education among the women’s groups. HKI
provided training and technical assistance to
the partner NGOs and, together with them,
provided technical assistance based on the
needs of the households and nursery owners.
Gender was an important focus of inter-vention
activities. Women in rural Bangladesh
have traditionally managed seasonal home-stead
gardening, from sowing to harvesting
and storing seeds. Thus the programme
actively targeted women in an effort to pro-vide
them with new income-generating oppor-tunities
related to homestead gardening.
To incorporate ASFs in the intervention,
interested village nursery owners became vil-lage
model farmers who provided training,
demonstration and other support services to
household food producers. The focus foods
were poultry, eggs, milk and fish. Nutrition
education focused on dietary diversity, micro-nutrient
consumption, and maternal and
child nutrition (80).
Monitoring and evaluation methods
The HKI programme had an integrated moni-toring
system that was an essential part of
implementation and was particularly impor-tant
in scaling up. Quarterly monitoring was
used to identify problems and priorities and
develop solutions through collaboration
between programme staff and beneficiaries.
Each local NGO used the quarterly monitor-ing
system to generate information on pro-gramme
progress. The data were collected
using a simple questionnaire on seed produc-tion,
vegetable and fruit production and con-sumption,
and income. In addition to
responding to monitoring information, HKI
staff regularly supervised NGO field and
management staff.
To assess economic and social impacts in
Bangladesh, a cross-sectional survey was con-ducted
in February and March 2002 (83). The
survey also aimed to capture information
about the potential for sustainability. The sur-vey
covered three groups of 720 households
each, representing active programme partici-pants,
former programme participants and
control households. Because of targeting,
participants and former participants gener-ally
were landless or land-poor (<0.2 ha), with
a day labourer as household head. Control
households were selected from similar geo-graphic
areas within targeted sub-districts,
but in sub-divisions (unions) where the
programme had not yet been implemented.

The selected control households were also
landless or land-poor.
Structured questionnaires were used,
and the homestead caretaker estimated gar-den
production in kilograms. Additional
information was collected on the adoption of
year-round production practices, consump-tion
of garden produce, the amount of cash
generated, changes in the ability of women to
contribute to household livelihoods and other
developments.
Monitoring results
Monitoring data showed that the programme
increased the production and consumption of
fruits and vegetables in the areas it covered
and increased the number of varieties con-sumed.
Between 1997 and 1998, the propor-tion
of households without a homestead
garden decreased from 25% at baseline to less
than 2%. After 1 year of participation, the pro-portion
that practised year-round (devel-oped)
gardening increased from 3% to 33%.
The number of varieties and the volume of
vegetables produced in developed gardens
were three times higher than in traditional
gardens. Seventy-three per cent of the gar-dens
were managed by women, and women
were the main decision makers regarding
gardening practices and use of the income
from sales of garden produce (79).
Monitoring data also showed that chil-dren
in households with developed gardens
consumed 1.6 times more vegetables. The
risk of night blindness was lower for at-risk
children7 when their house had a homestead
garden (79).
Finally, monitoring data also suggested
income effects. Participating households
earned, on average, the equivalent of US$8 on
a bimonthly basis selling fruits and vegeta-bles.
The main uses of this income were food
purchases and investments in seeds, seed-lings,
saplings, poultry, or other income-generating
activities. Nearly 10% of households
saved income generated from the garden (79).
7 Children were considered at risk if they were 12–59
months of age and had not received a vitamin A
capsule in the 6 months prior to the survey.
Households with improved or developed
homestead gardens consumed micronutrient-rich,
non-cereal foods more frequently than
other households. These foods, such as lentils
and animal products, were not produced in
the gardens, but were purchased using income
generated from sales of garden produce (80).
Evaluation results
The cross-sectional study in 2002 confirmed
monitoring results related to production, and
showed that households participating in the
intervention produced a median of 135 kg of
vegetables and 24 kg of fruit in the preceding
3 months, compared with 46 kg of vegetables
and 14 kg of fruits during the same period for
control households. Three years after with-drawal
of programme support, formerly par-ticipating
households maintained higher
production of vegetables (120 kg) and fruits
(24 kg), relative to controls. Similarly, income
from gardening remained more than twice as
high in formerly participating households,
compared with controls. Such results suggest
that the approach may lead to sustainable
improvements for vulnerable households,
and also illustrate a role in improving food
security (83).
Strengths, limitations and conclusions
Very few agricultural interventions with
nutrition objectives have been successfully
scaled up. The Bangladesh model, including
the scaling-up process, is well documented
and has been replicated in Cambodia and
Nepal. As with the OFSP intervention, infor-mation
on intermediary outcomes (produc-tion,
participation by women, sales and use of
new income) supports results, illuminating a
pathway towards impact on nutrition
outcomes.
While the evaluation design lacked base-line
information, the presence of the rich
monitoring data documenting change across
the life of the intervention, in combination
with the cross-sectional post-intervention
survey, provides plausible evidence of impact.
Efforts to identify comparable control house-holds,
in comparable environments, also
strengthen the evaluation results.

Finally, this example is also one of the
few to provide information on cost and evi-dence
of sustainability, at scale. The pro-gramme
continues to expand in Bangladesh
into new areas and to additional households
in the current working areas. In 1997, HKI
started the phase-out of technical and finan-cial
support to NGOs that had already
received one year of support. Monitoring
information from these areas one year later
showed that households were maintaining
their improved gardening practices and con-tinued
to consume fruits and vegetables more
regularly. The evaluation results reported
above also show evidence of sustainable
impacts on production and income.
Discussion
Lessons for design of interventions
Decades of research on the nutritional bene-fits
of agricultural interventions have yielded
a number of consistent lessons for interven-tion
design. These include: the importance of
careful attention to gender dimensions; the
necessity of incorporating BCC strategies and
elements; and a variety of process-related les-sons
that enable grounded design, taking into
account livelihoods and vulnerabilities.
Partnerships with local NGOs and other civil
society organizations can ground programmes
and improve prospects for sustainability.
Such partnerships, along with careful pilot
studies and systematic high-quality monitor-ing,
were also crucial to scaling up to national
level in the one case study where this
occurred.
Early commercialization studies identi-fied
the critical role of women in ensuring
nutritional benefits from agricultural inter-ventions,
especially for vulnerable household
members. This role was confirmed in the dec-ades
that followed and it is now widely
accepted that gender dimensions must be
addressed in agricultural interventions, both
for agricultural success and to achieve
improvements in food security and nutrition.
Research on women in agriculture has also
shown, however, that a number of attempts
to target and improve the status of women
have failed. One recent institutional study
(86) documented constraints to integration of
gender perspectives into agricultural inter-ventions
and concluded that development
planners and practitioners had limited expe-rience
with actually using gender methodolo-gies:
‘everyone “knows” gender but they
don’t know what to do with it’ (87, p. 17).
Including gender in design and monitoring
and evaluation systems clearly increases costs
and complexity and, hence, is often dropped
due to insufficient financial and human
resources. But previous work has identified
key elements of successful approaches
(Box 3.1). Mainstreaming gender into effec-tive
programming requires continued capac-ity
strengthening within implementing
organizations but success can be achieved
and tools are available (5,88,89). Successful
programmes may also depend on continued
advocacy to address ‘higher level’ constraints
related to land tenure and market systems.
The early studies also documented lack
of impact on young child nutritional status,
even when production and household
incomes (and sometimes household-level
energy consumption) increased substantially
as a result of agricultural commercialization.
There are a number of possible explanations
for the lack of impact, including the fact that
agricultural interventions alone are unlikely
to affect all of the proximal determinants of
childhood undernutrition. These may include
intra-household food distribution favouring
adult males, inadequate child feeding and
caregiving practices, unaddressed micronu-trient
deficiencies, and other constraints on
child nutrition such as high infectious disease
burden and poor access to health care. This
last determinant can only be addressed
through coordination with other sectors.
But many of the other determinants of
child nutrition involve behaviours that can be
changed within households. Our review has
shown that agricultural interventions that
seek to improve nutrition must include strong
BCC strategies to ensure that increased access
to food and increased income translate into
changed behaviours and nutrition improve-ment
for vulnerable individuals. This insight
has been confirmed in both horticultural and

animal production interventions: only those
interventions that attended to gender and/or
to BCC succeeded in impacting micronutrient
nutrition outcomes. The case studies confirm
strong potential for success when well-designed
interventions attend to both.
Finally, to enable planners to design suc-cessful
interventions including the elements
above, thorough and grounded knowledge of
context is essential. This, too, has long been
recognized; the successful interventions
included in this review suggest some proc-esses
for achieving it. One key strategy is
investment in developing strong partnerships
with local organizations and linking these
upwards to relevant actors in ministries,
international NGOs and agricultural research
institutes. Many organizations have also
found it useful to incorporate livelihoods
frameworks into planning processes, in order
to ensure that existing livelihoods, vulnera-bilities
and opportunities are identified. A
wide range of tools has been developed to
facilitate this.8
Lessons for evaluation design
Previous reviews have identified a range of
problems with evaluation designs. Common
problems have included absent, inappropriate
or poorly described comparison groups; self-selection
of participants/adopters of innova-tions
as the study group; small sample sizes;
and lack of baseline data. In addition, studies
have not always been controlled analytically
for differences between groups, even when
this was possible. Weak designs, together with
inconsistent results, have contributed to scep-ticism
about the potential for agricultural
interventions to impact nutrition.
We argue that sufficient evidence exists
to document potential for impact, but the
evidence base is still limited. To contribute to
this evidence base, future studies of agricul-tural
interventions should:
8 See e.g. a range of resources at: http://www.fao.org/
sd/pe4_en.htm; http://www.livelihoods.org/; http://
www.ifad.org/sla/; http://www.odi.org.uk/plag/
RESOURCES/sustainablelivelihoodsseries.html.
• Work from a conceptual framework/pro-gramme
theory that articulates pathways
between intervention inputs, processes
and activities, intermediate outcomes
and final impact objectives, and use this
framework to design data collection
activities.
• Gather baseline data before the interven-tion
is implemented.
• Include appropriate control groups
whenever possible, and clearly describe
how groups are defined and selected –
when this is not possible, include full
information about the characteristics of
study groups and compare these with
those to the general population.
• Use statistical methods to account for
inter-group differences in characteristics
resulting either from inherent population
differences or from differential selection
into the sample.
• Design simple monitoring systems that
include useful aggregation of informa-tion
to support evaluations – monitoring
systems must also serve programme
managers’ needs for timely information
for trouble-shooting and programme
improvement, and can inform efforts to
scale up programmes.
• In monitoring systems and in impact
assessment surveys, collect data on inter-mediate
outcomes according to the pro-gramme
theory – this will strengthen the
plausibility of positive results and help
explain negative or null results.
Future studies of agricultural interventions
can also fill several other information voids.
To date, very limited information is available
regarding the cost of interventions. Policy
makers and programme planners and man-agers
urgently need this information for deci-sion
making. Related to this, much work
remains to be done to characterize minimum
cost/minimum intensity extension and BCC
packages, in various contexts and for various
objectives. This was identified as a critical
next step following the OFSP work in
Mozambique.
Next, even though it has been suggested
that agricultural solutions to nutrition prob-lems
are more sustainable than some other

approaches (e.g. supplementation), informa-tion
on demonstrated sustainability is
extremely limited. Policy makers and pro-gramme
planners need information on sus-tainability
of both new agricultural practices
and improved nutrition-related behaviour.
Ongoing monitoring as in the HKI example
and/or follow-up studies will be very valua-ble
in this regard.
Finally, because scaling up has been
extremely rare, very little information is avail-able
to inform future efforts. Therefore, when
such efforts occur, partnerships, processes,
failures and successes should be well docu-mented
and this information disseminated.
Agriculture for nutrition: limitations
and potential
This review has documented the potential for
well-designed agricultural, horticultural and
livestock interventions to improve micronu-trient
nutrition for vulnerable individuals.
The complexity of agriculture interventions
may suggest that in many cases other
approaches – for example, micronutrient sup-plements
and/or fortified products – may be
more cost-effective in the short run. Whether
or not this is so, even in the short run, will
depend on underlying levels of micronutrient
deficiencies, health infrastructure, access to
commercially fortified products and many
other factors. For certain vulnerable groups,
such as infants and young children (6–23
months of age) and pregnant and lactating
women, it is very difficult, if not impossible,
to meet all micronutrient needs from family
foods/dietary diversification and supple-ments
and/or fortified products may be
needed to fill gaps. However, agricultural
interventions can complement supplementa-tion
and fortification programmes (75,90).
Interventions that succeed in increasing
intakes of fruits, vegetables and/or ASFs for
the poor deliver more than one or several
micronutrients. Unlike supplements and for-tified
products, diverse diets including fruits,
vegetables and ASFs deliver a range of macro-and
micronutrients, fibre and phytochemi-cals,
all related to human health (91). For this
reason, all national dietary guidelines include
objectives related to dietary diversity. Diverse
diets are also needed in order to truly achieve
food security, in its full sense, which recog-nizes
diet quality and preferences.
Further, although sustainability is not yet
well documented, we argue that agricultural
interventions do have the potential to improve
diets in a sustainable way, and this has been
demonstrated in the few instances where it
has been examined (53,82). If long-term costs,
effectiveness and sustainability are all docu-mented
and considered by policy makers,
agricultural approaches may find their place
in integrated strategies to improve nutrition
for vulnerable individuals.
In designing agricultural interventions
for nutrition, however, it is important to rec-ognize
that the simple pathway of production
for own consumption does not always domi-nate,
even when this is the intention of the
intervention design. Household decision
making about use of new resources is com-plex
and planners should consider which
pathway (e.g. own consumption, sale) is
likely to dominate, given conditions in the
intervention area. Design of effective BCC
strategies and their success will depend on
careful consideration of the factors involved
in these household decisions.
Finally, to fulfil the potential of agricul-ture
to improve micronutrient nutrition, part-nerships
across disciplines are required. Such
partnerships were evident in the case studies,
in which agriculture and nutrition were
closely integrated. Planners of agricultural
interventions are accustomed to careful con-sideration
of the agronomic characteristics of
the crops they introduce or promote.
Characteristics such as drought tolerance,
disease resistance, ‘fit’ within existing crop-ping
patterns and role in filling seasonal food
gaps are routinely considered. To impact
nutrition, agriculturalists, in partnership with
nutritionists, must supplement this with
information about deficits in local diets and
micronutrient intakes, as well as information
concerning the motivations and constraints
that determine household consumption deci-sions.
Agricultural and nutrition extension
and communication packages must be
designed to address these realities. When

they are, the potential to meaningfully impact
micronutrient malnutrition can be realized.
Acknowledgements
We thank the Agriculture and Rural
Development Department of The World Bank,
and particularly Nwanze Okidegbe and Chris
Delgado, for their support of this work. We
thank Harold Alderman, Bruce Cogill, James
Garrett, Beatrice Rogers and Meera Shekar
for their reviews and helpful comments on
previous drafts of the source material. M.A.,
C.H. and Z.S. performed literature searches
and M.A., C.H., M.T.R., Z.S. and L.R.B. wrote
sections of the source document; P.R.B., J.L.L.
and J.W.L. provided extensive comments on
the source document; M.A. reorganized,
adapted and extended material for this man-uscript;
all authors reviewed, commented on
and approved the manuscript.
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4 A 3-year Cohort Study to Assess
the Impact of an Integrated
Food- and Livelihood-based Model on
Undernutrition in Rural Western Kenya
J. Fanzo,*1, 5** R. Remans,*1, 6 P.M. Pronyk,*1 J. Negin,*2 J. Wariero,3 P. Mutuo,3 J. Masira,3
W. Diru,3 E. Lelerai,3 D. Kim,4 B. Nemser,1 M. Muñiz,1 C. Palm,1 P. Sanchez,1
S. Ehrlich Sachs1 and J.D. Sachs1
1The Earth Institute at Columbia University, New York, New York, USA; 2Sydney
School of Public Health, University of Sydney, Sydney, New South Wales, Australia;
3Millennium Development Goals Centre for East and Southern Africa, Earth Institute
at Columbia University, Nairobi, Kenya; 4Institute of Human Nutrition, Columbia
University, New York, New York, USA; 5Bioversity International at Rome, Italy; 6Leuven
Sustainable Earth at Katholieke Universiteit Leuven, Leuven, Belgium
Abstract
Reducing extreme poverty and hunger is the first Millennium Development Goal (MDG). With undernutri-tion
contributing to one third of all child deaths, improving nutrition is a precondition for accelerating progress
towards other MDG targets. While the role of technical interventions such as micronutrient fortification and
supplementation in reducing morbidity and mortality has been well documented, evidence to support more
comprehensive multi-sectoral approaches remains inconclusive. This chapter aims to evaluate the impact of
an integrated food- and livelihood-based model on nutrition-related outcomes in rural western Kenya.
A 3-year prospective cohort study was undertaken among 300 randomly selected wealth-stratified house-holds.
Detailed socio-economic and health surveys were conducted. A nutrition module assessed household
levels of food security, food consumption frequency and diet diversity. This was complemented by anthropo-metric
measurement and assessments of serum levels of vitamin A among children under 5 years old.
The average food insecurity score decreased from 5.21 at baseline to 4.13 at follow-up (P < 0.0001).
Average diet diversity scores for daily, weekly and monthly time periods increased from 6.7 to 7.3; from
10.7 to 11.2; and from 12.4 to 12.6, respectively (P < 0.0001). Daily consumption for 14 out of 16 food groups
increased significantly. For children under 2 years of age, underweight and stunting decreased from 26.2%
to 3.9% (P= 0.002) and from 62.3% to 38.3% (P = 0.014), respectively. Vitamin A deficiency as measured by
serum vitamin A levels decreased from 70.0% to 33.3% (P = 0.007) for children under 5 years old.
This study presents encouraging evidence that a multi-sectoral food- and livelihood-based model can
improve diet quality, enhance food security and positively affect childhood nutritional outcomes. The
wider application of this approach to a diversity of agro-ecological zones in sub-Saharan Africa is currently
being assessed.
Key words: diet diversity, multi-sectoral, food security, vitamin A, stunting, food-based
* Share first co-authorship.
** Contact: j.fanzo@cgiar.org

Undernutrition in Rural Western Kenya 77
Introduction
Globally, undernutrition contributes to roughly
half of the 8.8 million child deaths that take
place each year (1), representing nearly one-third
of the global burden of disease among
children (2). Micronutrient deficiencies weaken
the health, growth and productivity of over
two billion people worldwide, placing con-straints
on the development potential of
households, communities and countries (3).
The number of undernourished children has
increased in many countries over the past dec-ade,
with reductions in levels of child mortal-ity
levelling off or increasing in a number of
countries (4). This disturbing trend has been
compounded recently by global food crises
and an economic downturn that have compro-mised
fragile gains and plunged many more
households into a state of vulnerability and
deprivation (5). Decisive action is required to
address interdependent relationships between
undernutrition and wider Millennium
Development Goal (MDG) targets including
poverty reduction, maternal mortality and
child survival. Despite this urgency, interna-tional
action in support of new innovations
and strategic partnerships to address under-nutrition
has been limited (6).
The first 1000 days of a child’s life (minus
9 months to 2 years) is considered the ‘critical
window of opportunity’ where the potential
exists to affect not only child growth and
nutritional status, but also cognitive develop-ment
(7). However, nutrition throughout the
life cycle is of critical importance. Although
the significance of this time period has been
well documented, interventions to improve
early childhood nutrition have been frag-mented
and narrowly focused. Prevailing
approaches have generally emphasized sup-plementation
and fortification, relying heav-ily
on the external delivery of target nutrients
(8). Broader strategies to address the complex
challenges associated with the determinants
and consequences of undernutrition remain
poorly understood or embraced. Food- and
livelihood-based models that enhance the
security and quality of the diet through local
production, processing and storage of foods,
the promotion of agricultural biodiversity, all
complemented with community education
and development, which often falls outside
the traditional scope of clinical nutrition, have
been under-researched and under-developed.
As a consequence, well-defined scalable food
and livelihood interventions linked to
improvements in maternal or child health
outcomes have been less embraced by the
development community (9).
Recent calls for greater attention to
nutrition – including the United Nations’
Millennium Project, the recently formed High-
Level Task Force on the Global Food Security
Crisis, the reform of the World Committee on
Food Security and the establishment of the
High-Level Panel of Experts on Food Security
and Nutrition and the Policy Brief on ‘Scaling
up Nutrition: A Framework for Action’ – high-light
the importance of integrating technical
interventions with wider efforts to address its
underlying causes, incorporating perspec-tives
from agriculture, water and sanitation,
infrastructure, gender and education (10–14).
Such approaches would build on the knowl-edge
and capacities of local communities to
transform and improve the quality of diets for
better child health and nutrition. Recent
research has documented potential synergies
between health and economic interventions,
suggesting multi-sectoral approaches may
generate a wider range of benefits than
approaches of a single sector acting alone
(11,15). While these findings may seem intui-tive,
the testing of complex multi- and cross-sectoral
interventions to improve child
nutrition and health remains at an early stage
of development. Further operational research
is urgently required if the benefits of improved
food security and economic development are
to be expanded and channelled into conven-tional
health and nutrition intervention
programmes.
The Millennium Villages Project (MVP)
involves the systematic delivery of a package
of health and development interventions with
the aim of accelerating progress towards the
MDG targets (16,17). The project implements
a concurrent package of scientifically proven
interventions in agriculture, health, educa-tion,
water and sanitation, and infrastructure
at an annual cost of US$110 per person
per year sustained over a 5- to 10-year period.
The interventions were recommended as

78 J. Fanzo et al.
important components in achieving the
MDGs by the United Nations’ Millennium
Project (11,12). The MVP operates in 14 sites
in ten sub-Saharan African countries with
project sites drawn from a diversity of
agro-ecological zones in ‘hunger hot-spots’
where rates of child undernutrition exceed
20% (17).
The nutrition strategy adopted within the
Millennium Villages centres upon an inte-grated
food- and livelihood-based approach.
The model has three main components
(Fig. 4.1). Clinical interventions are introduced
to prevent and mitigate macro- and micronu-trient
deficiencies among infants and young
children. School-based interventions work to
improve health, nutrition, school attendance
and learning outcomes among primary-school
children. Community- and household-based
interventions foster increased agricultural pro-duction,
greater diet diversity and enhanced
livelihood security to address longer-term
nutritional needs.
We conducted a prospective evaluation
of the MVP site in rural western Kenya to
assess effects of this multi-sectoral approach
on undernutrition over a 3-year project
period. Our aim was to test the hypothesis
that a food- and livelihood-based model can
enhance household food security and diet
diversity, increase vitamin A levels, and lead
to improvements in anthropometric indica-tors
among children.
Methods
Setting
In December 2004, the MVP was launched in
collaboration with the Kenyan government in
the Sauri village of the western Nyanza
Province. This rural community of 63,500 per-sons
is located in the Kenya highlands, 1400–
1500 m above sea level and 30 km north of
Lake Victoria with annual rainfall of 1800 mm
(18). The main occupations are subsistence
farming, consisting primarily of maize, sor-ghum
and cassava and animal husbandry,
including goats, chickens and cattle. Before
the project started, 79% of the population
lived on less than US$1/day and 90% on less
than US$2/day. The infant mortality rate was
149 per 1000 live births, the under-five child
mortality rate was 95 per 1000 live births, and
63% of children under 5 years of age tested
positive for malaria (16,18).
Integrated multi-sectoral approach
to improving nutrition
The major aim of the nutrition programme is
to assist communities to eliminate hunger
and improve nutrition security. The three
components of the strategy are outlined in
Fig. 4.1. Interventions were implemented
concurrently over a 3-year period with the
agriculture and health initiatives being iden-tified
by community members at project com-mencement
as the most urgent.
Clinical interventions focused on persist-ent
macro- and micronutrient deficiencies in
children, including vitamin A supplementa-tion,
treatment of severe acute malnutrition
and regular growth monitoring. For cases of
moderate malnutrition, families received
InstaFlour (United States Agency for
International Development) or locally made
nutrient-rich flour consisting of millet, soybean,
sorghum, cassava and groundnuts. In addition,
basic maternal health interventions such as
antenatal care and institutional delivery were
supported by efforts to promote adequate
weight gain and improve coverage with iron
and folic acid supplementation.
School-based interventions included
home-grown school meals, gardens and nutri-tion
activities after school, along with de-worming
campaigns. Balanced school meals
have been demonstrated both to increase
school attendance as well as improve learning
outcomes (19). Currently, 20,584 children –
nearly all those of primary-school age –
receive a home-grown school meal consisting
primarily of maize and beans complemented
with vegetables such as tomatoes and leafy
greens.
Household- and community-based inter-ventions
engaged longer-term issues of food
and livelihood security. Interventions include
subsidized seed and fertilizer to increase

Antenatal iron and folic acid supplementation
Vitamin A supplementation of U5 children
Child growth monitoring
Zinc supplementation in the management of
diarrhoea
Treatment of severe acute malnutrition
School meals programme and school gardens
School health with deworming and nutrition education
CLINIC-BASED SCHOOL-BASED
ALLEVIATE HUNGER AND
MALNUTRITION
HOUSEHOLD- AND
COMMUNITY-BASED
Promotion of breastfeeding and improved complementary feeding
Community-based management of acute malnutrition
Improved seeds and fertilizer for staple crops
Crop diversification for income and diet diversity
Livestock, animal rearing and fish farming
Food processing, storage and cooking
Fig. 4.1. Nutrition strategy of the Sauri Millennium Village (U5, under 5 years of age).
agricultural productivity; the introduction of
high-value crops; agro-processing initiatives;
and microfinance programmes to stimulate
small-business development. Taken together,
these efforts were an attempt to enhance
nutritional intake and diet diversity, while
affording households the additional income
required to address nutritional needs in a sus-tainable
fashion. This was complemented by
a community health worker programme to
promote exclusive breastfeeding and locally
appropriate complementary feeding, home-based
fortification and proper food storage
techniques.
Study population
Detailed household mapping was conducted
prior to the initiation of interventions. This
process included a population census, Global
Positioning System coordinates for most
dwellings and the generation of a household
wealth score. Following this process, propor-tional
sampling was used to represent the
geographic spread of the sub-administrative
units within the village. From these adminis-trative
units, a total of 300 wealth-stratified
households were randomly selected to
undergo detailed periodic assessments.
Consenting households were followed longi-tudinally
over 3 years. In the event of refusals
or household attrition, random replacement
from baseline wealth strata was conducted to
maintain the sample size. This chapter com-pares
baseline data taken in June 2005 with
those from an assessment conducted after 3
years of intervention exposure, in June 2008.
Within each participating household, indi-viduals
were recruited for study inclusion
based on the results of preliminary demo-graphic
assessment. Household members were
defined as those who have lived in the house-hold
for at least three of the past 12 months and
who ‘normally eat from the same pot’.

80 J. Fanzo et al.
Within each household, specific demo-graphic
groups were sampled. Household
heads provided information on household
demography, education, employment, agri-cultural
and non-agricultural sources of
income, assets, expenditure, consumption
and access to basic services including water
and sanitation, energy, transport and com-munication.
Surveys were administered to
adults in the household aged 13–49 years
old and assessed health-related MDG indi-cators,
nutrition and food security, alongside
common causes of child mortality including
diarrhoea, pneumonia and malaria, and
health-seeking behaviour. Further, biologi-cal
data were collected on adults and chil-dren
and anthropometry data for children
under 5 years of age. A full explanation of
the study procedures, purpose, risks and
benefits were explained to participants dur-ing
the informed consent process. The study
received ethical approvals from the
Institutional Review Board at Columbia
University and the Kenya Medical Research
Institute.
Study procedures and generation
of indicators
Indicators, their definitions and sources of
data within this project are listed in Table 4.1.
Food insecurity
A Food Security Questionnaire (FSQ) was
administered to the head of each household
and/or the person primarily responsible for
preparing and serving food in the household.
Surveys were administered in the same time
period of the agriculture season, before the
harvest of the crop from the main rainy sea-son,
which corresponds to the hunger period.
The FSQ consisted of 11 questions on
food insecurity and coping aimed at assess-ing
the household’s access to food, as a meas-ure
of food insecurity. The questions were
locally modified from Food and Nutrition
Technical Assistance Project (FANTA) ques-tions
(20). For each of the 11 questions, the
percentage of individuals answering ‘yes’ to
that question was determined. A Food
Insecurity Score (FIS) was calculated as the
total number of food insecurity questions
answered with ‘yes’, indicating that the sub-ject
had to deal with that specific food short-age
situation. All questions were treated with
equal weight for FIS calculation.
Consumption frequency and diet diversity
A food-frequency questionnaire (FFQ) was
administered to household heads and/or the
person primarily responsible for preparing
and serving food at both baseline and year 3.
Similar to the FSQ, surveys were adminis-tered
in the preharvest period. The FFQ con-tained
121 locally available food items, for
which frequency of consumption (times per
day, week, month or year) was assessed.
A Consumption Frequency Score (CFS) for
each food item was calculated as the number
of times the food item was consumed per
week. A frequency of once weekly received a
score of 1, consumption of once daily
received a score of 7, with other values scaled
accordingly (21).
Food items were grouped into 16 food
groups based on the Food and Agriculture
Organization of the United Nations (FAO)/
FANTA Household Dietary Diversity
Questionnaire and Guidelines (22). The 16
food categories were: cereals; vitamin-A rich
vegetables and tubers; white tubers and
plantains; green leafy vegetables; all other
vegetables; legumes; nuts and oily fruits;
vitamin A-rich fruit; all other fruit; meat;
eggs; milk; fish; oils and fats; sweets; and
spices and condiments. No distinction was
made between organ meat and flesh meat in
the list of 121 food items used for the FFQ.
The CFS for each food group was calculated
as the sum of CFSs of food items in the
respective food group (21).
Food items and food groups were cate-gorized
for consumption frequency ‘at least
daily’, ‘at least weekly’ or ‘at least monthly’,
with criteria for CFS set at 7, 1 and 0.25,
respectively, based on the CFS scoring strat-egy
(21). For each food group, the percentage
of individuals consuming the food group on a
daily basis was determined.
Individual Diet Diversity Scores (DDS)
were generated for daily, weekly and monthly

Table 4.1. Indicators.
Indicator
No. of items for
composite indices Source
Food insecurity Answered YES to Food Insecurity Question X, with X being one of 11 food
insecurity questions
N/A FSQ
Food Insecurity Score (FIS) (total number of food insecurity questions
answered with YES; possible range 0–11)
11 FSQ
Food consumption
frequency and diet
diversity
Consumption Frequency Score (CFS) for food item X (= times consumed per
week; e.g. once weekly = 1, twice weekly = 2, once daily = 7, once monthly
= 0.25), with X being one of 121 FFQ items
N/A FFQ
CFS for food group Y (= sum of consumption frequency scores of food items in
food group Y), with Y being one of 16 food groups
N/A FFQ
Consumes food group Y on a daily basis (i.e. consumption frequency score of
food group Y is 7 or above)
N/A FFQ
Food Variety Score (FVS) – day (number of food items consumed on a daily
basis; i.e. CFS of food item X is 7 or above; possible range 0–121)
121 FFQ
FVS – week (number of food items consumed on at least a weekly basis; i.e.
CFS of food item X is 1 or above; possible range 0–121)
121 FFQ
FVS – month (number of food items consumed on at least a monthly basis; i.e.
CFS of food item X is 0.25 or above; possible range 0–121)
121 FFQ
Diet Diversity Score (DDS) – day (number of food groups consumed on a daily
basis; i.e. CFS of food group Y is 7 or above; possible range 0–13)
13 FFQ
DDS – week (number of food groups consumed on at least a weekly basis; i.e.
CFS of food group Y is 1 or above; possible range 0–13)
13 FFQ
DDS – month (number of food groups consumed on at least a monthly basis;
i.e. CFS of food group Y is 0.25 or above; possible range 0–13)
13 FFQ
Anthropometry Underweight (weight-for-age Z score ≤−2) N/A Anthropometric
measurements
Stunting (height-for-age Z score ≤−2) N/A Anthropometric
measurements
Wasting (weight-for-height Z score ≤−2) N/A Anthropometric
measurements
Vitamin A deficiency Vitamin A deficient (serum vitamin A level <20 μg/dl) N/A Serum sample analysis
Received vitamin A supplementation during the last 6 months N/A Children and Women
Health Questionnaire
N/A, not applicable; FSQ, food security questionnaire; FFQ, food-frequency questionnaire.

82 J. Fanzo et al.
time periods based on 13 food categories. As
recommended by FAO/FANTA (22), sweets,
spices and condiments, and beverages were
excluded for this purpose and legumes, nuts
and oily fruits were combined as one food
group. DDS per day, DDS per week and DDS
per month were calculated as the number of
food groups (of 13 in total) consumed on a
daily, weekly or monthly basis, respectively.
In addition, Food Variety Scores (FVS),
including FVS per day, FVS per week and
FVS per month, were calculated as the
number of food items (out of 121 food items)
consumed on a daily, weekly or monthly
basis, respectively.
Anthropometry
Body weight was obtained in two separate
measures using an electronic balance (Seca,
Hanover, Maryland, USA) or on a hanging
spring scale (Salter Ltd, Tonbridge, UK) read
to the nearest 0.1 kg. Standing height (for
children aged >24 months) or recumbent
length (for infants aged 0–24 months) was
read to the nearest 0.1 cm on a steel tape
attached to a wooden board with a foot-plate
and sliding head block (Shorr Productions,
Woonsocket, Rhode Island, USA). All anthro-pometry
measures were done by standard
practices (23). Anthropometric indices were
calculated with Stata macros provided by
the World Health Organization (WHO) with
use of the new growth references (24).
Underweight, stunting and wasting were
defined as weight-for-age Z score (WAZ)
£−2, height-for-age Z score (HAZ) £ −2
and weight-for-height (WHZ) Z score £−2,
respectively. Extreme Z scores, WAZ £ −6 or
³5 for underweight, HAZ £ −6 or ³6 for
stunting and WHZ £ −5 or ³5 for wasting,
were excluded as outliers, as suggested by
the WHO protocol. In this chapter, we com-pare
data on children under 2 years of age at
follow-up, who were conceived or born dur-ing
the intervention period, to the same age
range at baseline.
Vitamin A deficiency
Individual serum samples were collected
from children under 5 years old and women
between the ages of 13 and 49 years to
determine vitamin A deficiency. Aliquots of
100 ml from five individuals were pooled to
represent a single sample, resulting in a total
of 30 pooled serum samples (from 150 indi-viduals)
for baseline and 23 samples for year
3 follow-up. The same pooling was done for
women, resulting in a total of 30 serum
samples from both baseline and the year 3
analysis (25).
The levels of vitamin A were measured
by high-performance liquid chromatography
(Shimadzu Corporation, Kyoto, Japan).
Vitamin A was de-proteinized from the
serum/plasma sample using ethanol and
extracted with hexane. The extract was dried,
re-dissolved with ethanol and injected into
the chromatograph. Retinyl acetate was used
as the internal standard. This assay was
standardized using calibrators from the
National Institute of Standards and
Technology. The minimum required volume
for this assay is 150 ml. Vitamin A deficiency
was defined as a level <20 mg/dl (26).
A health questionnaire was administered
to adult women, above 13 years, to assess
women’s and children’s health status and
access to health care. In this questionnaire, it
was asked if the child under 5 years of age
received a vitamin A dose in a capsule during
the last 6 months. The percentage of children
for whom vitamin A supplementation was
reported was determined from these data.
Statistical analysis
Data from questionnaires were entered elec-tronically
using CSPro data entry software
(US Census Bureau, Washington, DC, USA)
and cleaned for structural and logical errors in
both CSPro and Stata version 10 (StataCorp.,
College Station, Texas, USA). All statistical
analyses were performed with Stata. Normal
distribution was checked by Shapiro–Wilk
tests. Differences between means were checked
by two-sample t tests. Two-proportion z tests
were used to test for differences between pro-portions.
Percentage change was calculated as
the difference between year 3 and baseline
divided by the value at baseline.

Three hundred households were surveyed at
baseline and follow-up. The study population
for each component of the evaluation is detailed
in Fig. 4.2. Results are summarized in Table 4.2.
The decrease in average FIS at year 3 compared
with baseline indicated improved food secu-rity
in the community (Table 4.2). For eight of
the 11 food insecurity questions, the percent-age
of individuals coping with the respective
food shortage situation reduced significantly
from baseline to year 3 (P < 0.01) (Table 4.3). In
contrast to the results of the other food coping
strategies, the proportion of the population
that ‘changed the family diet to cheaper or
less-preferred foods in the past week’ was
higher at year 3 (75.2%) than at baseline (56.9%;
P < 0.0001). The proportion of the population
who borrowed food or money for food from
others due to insufficient food did not change
over the course of the three years. Further, the
average number (95% confidence interval) of
daily meals increased significantly from 2.56
(2.50, 2.62) to 2.70 (2.63, 2.77) (P = 0.036).
Consumption frequency and diet diversity
Higher average DDS and FVS were observed
for daily, weekly and monthly time periods
at year 3 as compared with baseline, indicat-ing
improved dietary diversification in the
community (Table 4.2). Figure 4.3 shows
changes between baseline and year 3 in daily
consumption for 16 food groups. For 14 out
of the 16 food groups, consumption on a
daily basis increased from baseline to year 3.
Most pronounced was the increased con-sumption
14.6% at baseline to 44.3% by year 3 (P < 0.0001).
This can be explained by the increased con-sumption
maize-and-beans dish and beans alone (data
not shown).
The consumption of animal-source pro-tein
increased including fish, milk and milk
products, eggs and meat (P < 0.01 for each of
these food groups). For vitamin A-rich plant-based
food products, including vitamin
A-rich vegetables and tubers, vitamin A-rich
fruits and green leafy vegetables, daily
consumption was high at baseline (96.5%)
and no change was observed by year 3
(96.1%; P= 0.756) (Table 4.2). Some shifts of
food items within the vitamin A-rich plant
group were noted, including a decrease in
consumption of vitamin A-rich fruits (par-ticularly
in consumption of some dark-green leafy
vegetables (particularly kale, black night-shade,
amaranthus and spiderweed) and
vitamin A-rich vegetables and tubers
(carrots, pumpkin) (data not shown).
Consumption of vitamin A-rich animal-based
food products increased from 55.6% to 68.2%
(P < 0.0001) (Table 4.2).
TOTAL SAMPLE SIZE
Baseline: 300 households
Year 3: 300 households
of legumes, which increased from
frequency of common beans as a
guava and papaya) and an increase
ANTHROPOMETRY
Baseline: 272 U5 children
61 U2 children
Year 3: 142 U5 children
SERUM ANALYSIS
Baseline: 150 U5 children
150 adult women
Year 3: 115 U5 children
FFQ
Results
Food insecurity
Baseline: 768 individuals
Year 3: 440 individuals
FSQ
Baseline: 869 individuals
Year 3: 440 individuals
51 U2 children 150 adult women
Fig. 4.2. Sampling design (FSQ, Food Security Questionnaire; FFQ, food-frequency questionnaire; U5,
under 5 years of age; U2, under 2 years of age).

84 J. Fanzo et al.
Table 4.2. Outcome measures.
Indicator Baseline Year 3 % change P value
Food insecurity Mean FIS (95% CI) 5.21 (5.04, 5.38) 4.13 (3.92, 4.30) −20.7 <0.0001
Food consumption
frequency and diet
diversity
Mean FVS – day (95% CI) 9.6 (9.4, 9.9) 11.8 (11.3, 12.3) 22.1 <0.0001
Mean FVS – week (95% CI) 31.8 (31.1, 32.5) 35.5 (34.5, 36.5) 11.7 <0.0001
Mean FVS – month (95% CI) 56.7 (55.8, 57.6) 63.0 (61.8, 64.3) 11.2 <0.0001
Mean DDS – day (95% CI) 6.67 (6.54, 6.80) 7.33 (7.17, 7.50) 9.9 <0.0001
Mean DDS – week (95% CI) 10.66 (10.56, 10.76) 11.17 (11.04, 11.29) 4.8 <0.0001
Mean DDS – month (95% CI) 12.37 (12.30, 12.44) 12.63 (12.57, 12.69) 2.1 <0.0001
Consuming vitamin A-rich plant products on a daily
741/768 (96.5%) 423/440 (96.1%) −0.4 0.756
basis
Consuming vitamin A-rich animal products on a daily
basis
427/768 (55.6%) 300/440 (68.2%) 22.5 <0.0001
Anthropometry Children aged 0–2 years underweight 16/61 (26.2%) 2/51 (3.9%) −85.0 0.002
Children aged 0–2 years stunted 33/53 (62.3%) 18/47 (38.3%) −38.5 0.014
Children aged 0–2 years wasted 3/56 (5.4%) 1/45 (2.2%) −58.5 0.386
Vitamin A deficiency Children aged 0–5 years vitamin A deficient 21/30 (70.0%) 8/24 (33.3%) −52.4 0.0073
Women aged 13–49 years vitamin A deficient 1/30 (3.3%) 0/30 (0%) −100.0 0.3132
Children aged 0–5 years who received vitamin A
168/235 (71.5%) 156/225 (69.3%) −3.2 0.613
supplementation during the last 6 months
FIS, Food Insecurity Score; CI, confidence interval; FVS, Food Variety Score; DDS, Diet Diversity Score.

Table 4.3. Detailed outcome measures of food security from Food Security Questionnaire.
Indicator Baseline Year 3 % change P value
Food insecurity Because of insufficient food:
Had a day without eating anything in the past week 289/869 (33.2%) 101/440 (23.0%) −33.0 <0.0001
Reduced the size and/or number of meals eaten in the past week 632/869 (72.7%) 280/440 (63.6%) −12.5 0.0007
Changed the family diet to cheaper or less-preferred foods in the past
494/869 (56.8%) 331/440 (75.2%) 32.3 <0.0001
week
One or more children from the HH discontinued school in order to
save money or to work for additional income in the past 12 months
179/872 (20.5%) 43/440 (9.8%) −52.4 <0.0001
One or more of the HH went to another neighbourhood, village, town
or city to find work in the past 12 months
393/872 (45.1%) 122/440 (27.7%) −38.5 <0.0001
Used money that was intended for investing in small business in the
past 12 months
541/872 (62.0%) 204/440 (46.4%) −25.3 <0.0001
Sold some household possessions, agricultural tools or productive
tools in the past 12 months
218/872 (25.0%) 39/440 (8.9%) −64.6 <0.0001
Borrowed food or money for food from relatives, friends, neighbours,
bank or money lenders in the past 12 months
582/872 (66.7%) 290/440 (65.9%) −1.2 0.7626
Sold or consumed seeds meant for planting next season’s crops in
the past 12 months
486/872 (55.7%) 122/439 (27.8%) −50.1 <0.0001
Sold livestock in the past 12 months 643/872 (73.7%) 257/440 (58.4%) −20.8 <0.0001
Sold or pledged land or house in the past 12 months 78/872 (8.9%) 26/440 (5.9%) −33.9 0.0546
HH, household.

86 J. Fanzo et al.
*
Cereals
Other veg
Green leafy veg
Fat & oil **
VitA fruits
Sweets
*
**
Nuts & oily fruits
Spices tea coffee
Other fruits
Milk
Food group
**
**
**
White tubers
Fish
Legumes
**
**
**
Eggs
Meat
VitA veg & tubers
*
**
*
0 20 40 60 80 100
Percentage of individuals consuming food group on daily basis (%)
Fig. 4.3. Daily consumption of 16 food groups at baseline ( ) and year 3 ( ). Bars represent percentage of
the population consuming the food group on a daily basis, with 95% confidence interval represented by
error bar. Number of individuals: n = 768 at baseline and n = 440 at year 3. Percentage value was
significantly different from that at baseline: *P < 0.05, **P < 0.01 (vitA veg & tubers, vitamin A-rich
vegetables and tubers; veg, vegetables; vitA fruits, vitamin A-rich fruits).
Anthropometry
The results of the anthropometric assess-ment
are presented in Fig. 4.4. For children
under 2 years of age, the proportion of those
underweight and stunted was reduced by
85% and 39%, respectively. Levels of wast-ing
were relatively low at baseline (5.4%)
and remained unchanged by year 3 (2.2%;
P = 0.431).
Vitamin A deficiency
The proportion of children under 5 years old
with vitamin A deficiency was reduced by
52.4% over the study period (P = 0.0073)
(Table 4.2). Compared with children under 5
years of age, vitamin A deficiency among
adult women was low at baseline (3.3%) and
did not change. Between baseline and follow-up,
the proportion of children who received
vitamin A supplementation in the past 6
months remained nearly identical at approxi-mately
70% (Table 4.2).
Discussion
We assessed the effects of an integrated food-and
livelihood-based model on nutrition-related
outcomes in rural western Kenya.
Over a 3-year study period, we observed
improvements in diet diversity and food
security, both essential for long-term nutri-tion
gains (3). At follow-up, the number of
children who were vitamin A deficient was
reduced by half, and levels of stunting and
underweight were reduced by 39% and 85%,
respectively. These changes among children
under the age of 2 years are critical for
longer-term growth, cognitive development
and lifetime health (7). Taken together, these

**
*
80
60
40
20
0
Underweight Stunting Wasting
Percentage of children <2 years (%)
Fig. 4.4. Underweight, stunting and wasting of children under 2 years of age at baseline ( ) and year 3
( ). Bars represent the percentage of children under 2 years old with the nutritional deficit, with 95%
confidence interval represented by error bar. Number of individuals: n = 61 at baseline and n = 51 at year
3. Percentage value was significantly different from that at baseline: *P < 0.05, **P < 0.01.
findings provide encouraging evidence that
an integrated food- and livelihood-based
approach can generate rapid progress
towards the first MDG on reducing hunger
and undernutrition.
While this assessment followed a cohort
of households over a sustained period,
employed previously validated tools and
assessment methods, and measured changes
in a series of objective pathway and outcome
variables, there are also important limitations
to underscore. The use of historical controls
makes it difficult to separate the effect of the
intervention from wider secular changes that
may have taken place in the study site in the
absence of the intervention. Indeed, a number
of important contextual factors may have
affected nutrition-related outcomes during
the period of study. During 2007 and 2008, the
second and third year of the intervention,
the world witnessed an unprecedented
increase in global food and fertilizer prices,
pushing many marginal households deeper
into poverty, with profound effects in sub-
Saharan Africa (27). Accompanying this was
a wave of post-election political violence in
Kenya, from December 2007 to March 2008,
which had its most direct consequences in the
western region of the country where the study
site is located (28,29). This instability took
place several months before the follow-up
surveys were conducted for this assessment.
The combined effect of these factors served to
exacerbate economic and food insecurity in
much of the region. While further experimen-tal
research is clearly warranted, we suggest
that it is likely that the programme provided
an important buffer against these crisis events
and that the results of our assessment are
likely to underestimate the effects of the inter-vention
package.
The results of this study point to major
reductions in children stunted or under-weight,
which are important findings for a
number of reasons. First, chronic undernutri-tion
is a major public health challenge in
Kenya and the Millennium Villages study site
had substantially higher baseline levels than
the national average. While levels of moder-ate
or severe underweight (26.2%) were com-parable
to the 20% national figure, the levels
of stunting observed at baseline (62.3%) were
twice the 30% national average (30). Notably,
the study was unable to detect changes in

88 J. Fanzo et al.
wasting, where prevalence at baseline was
already low and in line with national figures.
Second, the changes in stunting and under-weight
were observed in children under 2
years old – those conceived and born after the
initiation of the intervention. As noted earlier,
maximizing gains during this period has the
potential to lead to longer-term nutritional
and developmental benefits and make the
greatest contribution to lifetime health (31).
There is evidence to suggest that damage
done to a child’s physical or cognitive devel-opment
during this period may be irreversi-ble.
Previous research in rural western Kenya
has demonstrated that the prevalence of
underweight and stunting was highest in
children 3–24 months of age, whereas in chil-dren
over 24 months of age, underweight and
stunting stabilized, but they remained below
the reference median (32).
In a complex multi-component approach
to address undernutrition, it is difficult to
make definitive statistical statements regard-ing
the underlying mechanisms through
which changes in growth outcomes were
observed. However, the design of the study
and results of our assessment do offer a
number of potential explanations. First,
changes in child growth took place alongside
parallel shifts in a number of theoretically
grounded pathway indicators (33), including
improvements in food security, diet diversity
and micronutrient levels. It has been previ-ously
demonstrated that dietary diversity
predicts diet quality particularly among
infants and young children (34). Second, there
is an association between the diversity of a
child’s diet and his/her nutritional status that
is independent of socio-economic factors,
with dietary diversity potentially associated
with diet quality (35). Our data indicate a sig-nificant
positive correlation between the
weight for age Z score of children under
2 years of age and the monthly DDS (P = 0.02)
(data not shown). Other studies have con-firmed
this as well (36). Yet multivariate mod-els
controlling for socio-economic factors are
critical to further analyse and interpret these
associations. Finally, the extent to which food
security results in good nutrition depends on
a set of non-food factors such as sanitary con-ditions,
water quality, infectious diseases and
access to primary health care (3,37). Although
not described in this chapter, other improve-ments
in the infrastructure and health system
of Sauri have taken place, perhaps contribut-ing
to the improved nutrition status.
Positive shifts in diet diversity were also
likely to be the potential mechanism through
which changes in vitamin A levels were
observed. While the clinical component of the
intervention involved vitamin A supplemen-tation,
this intervention was initiated prior to
the onset of our project, with proportions of
children who had received vitamin A in the
past 6 months being high (70%) and nearly
identical between baseline and follow-up. It
is also important to note that clinical trials
have not found an association between vita-min
A supplementation and growth (38–40).
We suggest that in this study, improvements
in micronutrient deficiency may be a biologi-cal
outcome of more complex changes in diet
quality and diversity. Previous research has
examined the association of dietary vitamin A
intake with growth and the incidence of
recovery from stunting, and demonstrated
that dietary carotenoid intake was associated
with a greater incidence of reversal of stunt-ing,
with the greatest impact on children
under 2 years old (41–43).
Documentation of the portfolio of inter-ventions
undertaken during the initial study
period lends further support to the potential
role and importance of food- and livelihood-based
approaches in contributing to changes
in nutritional status. Subsidized hybrid maize
seeds and fertilizers were provided in the ini-tial
stages of the project to improve food
yields and boost food security. In two years,
the maize yield tripled from 2.0 t/ha to 6.2 t/
ha (17). Since 2006, the community worked
with agricultural extension officers to diver-sify
their crops for markets and to improve
household nutrition. Farmers also engaged in
other income-generating activities such as
livestock for dairy production, poultry, fish
farming and bee keeping. Taken together, this
portfolio of interventions, when viewed
alongside documented shifts in pathway var-iables,
lends support to the contribution of
food- and livelihood-based strategies to
observed growth improvements among
children less than 2 years old.

A recent series reviewed the evidence on
mainly child-focused interventions proven to
reduce stunting, micronutrient deficiencies
and child mortality (9,44). The spectrum of
interventions reviewed generally reflected
single, stand-alone health-focused interven-tions
that were amenable to experimental
design. Little previous research has assessed
the potential impact of more complex ‘pack-ages’
that combine clinical with food- and
livelihood-based interventions. Even less
research has been done on strategies to
enhance delivery systems to improve
coverage.
The United Nations’ commitment to end-ing
food insecurity, as affirmed by the High-
Level Task Force on the Global Food Security
Crisis and the Alliance for a Green Revolution
in Africa, has generated renewed attention to
the need of making our world more food
secure. This study suggests that integrated
food- and livelihood-based models offer one
potential approach. We demonstrated that
such a model is feasible to deliver, with inter-vention
components generating complemen-tary
and potentially synergistic effects. The
project site in western Kenya covered 63,500
people, which is sufficiently large to extract
lessons for district-wide scale up. Certainly
any scale up would benefit from economies of
scale and greater integration into district or
national systems. More research is underway
to assess the potential for similar gains to be
observed in other MVP sites in sub-Saharan
Africa, which will ultimately enhance the
external validity and ability to generalize
the findings presented here. We hope that the
approach and evidence from this study can
provide lessons of replicability, scale up and
transfer to other contexts.
Acknowledgements
The authors are grateful to Walter Willett,
Richard Deckelbaum and Roger Sodjinou for
their support in the design and implementa-tion
of this project. The authors declare that
they have no conflict of interest. The Lenfest
Foundation, the Bill and Melinda Gates
Foundation and Millennium Promise sup-ported
this work. R.R. is supported by an FP7
Marie Curie International Outgoing
Fellowship from the European Commission.
The funders had no role in study design, data
collection and analysis, decision to publish or
preparation of the manuscript.
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5 Food-based, Low-cost Strategies
to Combat Micronutrient Deficiencies:
Evidence-based Interventions in Lesotho
and Malawi
J.M. Aphane,*1 N. Pilime2 and N.J Saronga3
1Nutrition and Consumer Protection Division, Food and Agriculture Organization
of the United Nations, Rome, Italy; 2Health Office, United States Agency for
International Development – Southern Africa, Pretoria, South Africa; 3Ifakara Health
Institute, Dar-es-Salaam, Tanzania
Abstract
The combined effects of HIV infection, food insecurity and malnutrition have fuelled adult death rates
across southern Africa, causing an alarming increase in the number of orphans. The long illness commonly
associated with HIV infection affects productivity, drains family resources and erodes livelihoods, leaving
households and communities stressed, both nutritionally and socio-economically, and vulnerable to fur-ther
deterioration. Regular intake of nutritionally adequate diets, including micronutrient-rich foods, is
essential for boosting the immune system and maintaining good health. Lesotho and Malawi were piloted
for a food security and nutrition project that included dietary diversification, aimed at improving micro-nutrient
intakes among HIV-affected communities.
The project’s overall objectives included: protecting and promoting the nutritional well-being of
HIV/AIDS-affected children; improving livelihoods and food and nutrition security among HIV-affected
households; and strengthening the capacity of communities to provide support to HIV-affected
households and children. This chapter restricts itself to showing it is possible to enable resource-poor,
HIV- and drought-affected communities to combat micronutrient deficiencies through food-based
approaches.
Multiple strategies – including institution building, human resource development, use of participa-tory
approaches, promoting bio-intensive methods of agriculture, and crop and diet diversification – were
used in the implementation process.
These strategies and technologies enabled communities to produce and access greater amounts and
variety of micronutrient-rich foods all year round. Effective nutrition education and improved techniques
in food processing, preservation and preparation increased the consumption of micronutrient-rich foods
among target populations.
Through appropriate strategies and technologies the capacity of resource-poor, HIV-affected commu-nities
to combat micronutrient deficiencies can be strengthened.
Key words: capacity building, strengthened institutional framework, crop and diet diversification, bio-intensive
agricultural methods, participatory approaches, food-based approaches, orphans and vulnerable
children, HIV-affected communities, micronutrient deficiencies
* Contact: Juliet.Aphane@fao.org

Food-based, Low-cost Strategies 93
Introduction
Southern Africa has the highest prevalence
rate of HIV in the world (1). In 2004, the sub-region
accounted for almost a third (29%) of
all new HIV infections and AIDS-related
deaths globally, with national adult HIV
prevalence rates at 37.3% in Botswana, 28.9%
in Lesotho, 21.0% in Malawi, 21.3% in
Namibia, 21.5% in South Africa, 38.8% in
Swaziland and 24.6% in Zimbabwe (1). The
combined effects of widespread food insecu-rity,
malnutrition and HIV/AIDS infections
increase death rates in adult populations,
leaving an unprecedented increased number
of orphans and children in a vulnerable and
compromised situation. A number of chil-dren
become economically and nutritionally
vulnerable even before they are orphaned
because, when illness affects a household,
there is often a breakdown in the family’s
ability to maintain its livelihood (2). The
long-term HIV-related medical care takes a
toll on family resources (3); productivity
(as in food production and paid work)
declines, family income is significantly
reduced, livelihoods are eroded, and family
food and nutrition security are compro-mised.
Consequently, household vulnerabil-ity
is increased and resilience in dealing with
stresses is decreased.
The project ‘Protecting and Improving
Food and Nutrition Security of Orphans and
HIV/AIDS Affected Children in Lesotho and
Malawi’ was developed as a pilot regional
initiative to alleviate the impact of the AIDS
epidemic on affected children and their communities.
The project, funded by the German Federal
Ministry of Food, Agriculture and Consumer
Protection (BMELV) and technically sup-ported
by three United Nations (UN) agen-cies
– the Food and Agriculture Organization
of the United Nations (FAO), the United
Nations Children’s Fund (UNICEF) and the
World Food Programme (WFP), was imple-mented
from November 2004 to May 2008 by
the Governments of Lesotho and Malawi. The
goal of the project was to improve the house-hold
food and nutrition security of orphans
and other vulnerable children and families
affected by HIV in the short and longer term.
The immediate objectives of the project were
to: (i) strengthen the capacity of local, district
and national institutions to plan and under-take
more effective actions to improve food
and nutrition security among orphans and
other children affected by HIV, and to provide
support to their families and communities;
and (ii) demonstrate programming models
and methods for multi- sectoral action in pro-tecting
and improving food security and
nutrition of orphans and HIV-affected chil-dren
and their families.
The two pilot countries were selected on
the basis of having high HIV prevalence,
eroded livelihoods and a high number of
orphans. In Lesotho, Mafeteng was selected
as the pilot district for the project; and in
Malawi, two districts, Mangochi and Mwanza,
were piloted.
In the specific case of the piloted coun-tries,
the combined effects of malnutrition
and AIDS increased death rates among
adult populations. Today, in both coun-tries,
AIDS is the primary cause of the
increasing number of orphans and vulner-able
children (OVC). In Malawi, out of a
population of 12 million people, it was esti-mated
that there were over one million
orphans countrywide, half of them result-ing
from HIV-related deaths (4). UNICEF’s
report on the state of the world’s children
estimated the number of orphans in
Lesotho, with a population of 1.9 million
inhabitants, at 180,000 (4).
Because of higher adult death rates, the
number of OVC increased at a much faster
rate than families and communities could
cope with. In times of economic and social
stresses, children, because of their vulnera-bility,
are usually the first to succumb.
Hence, the focus of the project was above all
on the food and nutrition situation of vul-nerable
children. In both countries, for
regular programmes, the majority of HIV-related
interventions focused on clinical
aspects of the disease and reducing adult
prevalence rates.
Food always ranks high among the hier-archy
of needs for poor people and indeed,
in participatory community needs assess-ment
forums organized by the project,

94 J.M. Aphane et al.
addressing food security issues was listed as
a top priority. The central importance of ade-quate
dietary intakes for an individual’s
overall health and productivity, and espe-cially
for maintaining one’s immune system,
is well established (5,6). However, within the
project’s target communities, food insecurity
and poor nutrition, including micronutrient
deficiencies, were common. This greatly
impaired the ability of both HIV-positive and
HIV-negative individuals and their house-holds
to maintain their health and well-be-ing.
This dire situation was often exacerbated
by poor agronomic conditions and practices
in the target areas.
In Lesotho, Mafeteng, the target district,
lies within the southern lowlands of the coun-try.
Compared with the other agro-ecological
zones, the southern lowlands zone is semi-arid,
prone to drought and has the highest
incidences of chronic food insecurity. During
winter months (May to August), average night
temperatures are below 0°C and normally
vegetable production ceases. An abundance of
wild green leafy vegetables is available during
the rainy season which runs from October to
March. Due to poor soils and the arid condi-tion
of the district, vegetable production is a
challenge. The raising of small livestock is also
precarious as animals have to compete for
water and food with humans. Resource-poor
families depend largely on the staple food –
maize – for survival. Hence an average stunt-ing
rate of more than 40% among children
aged 12–59 months was registered by the
Lesotho Demographic and Health Survey in
2004 (7). In view of the challenging agronomic
conditions in Mafeteng and the socio-economic
circumstances of the target group, two agricul-tural
techniques of bio-intensive vegetable
production, i.e. keyhole gardening and double-dug
method of gardening, were introduced as
part of the effort to meet the demand for
increased micronutrient intakes. For the major-ity
of the project target population, keyhole
gardens, which are raised keyhole-shaped
mounds of earth, were found to be more suit-able
as they require less labour and land size
than double-dug gardens. Through keyhole
gardening, all participating households – the
majority of which had non-productive gardens
before the project – were enabled to produce
more vegetables than they could consume, in
addition to attaining more variety.
Malawi, in general, has far better agro-nomic
potential than Lesotho. The main
sources of micronutrients in the diet were
vegetables and fruits. However, the supply of
horticultural produce was seasonal. During
the rainy season, there was an abundance of a
variety of wild vegetables which targeted
communities relied on for relish and micro-nutrient
intake. Due to waterlogging, not
much vegetable cultivation took place at this
time. Also, as there is only one main growing
season, labour was mainly reserved for culti-vation
of major field crops, primarily maize.
Both cultivated and wild fruit were also avail-able
during this period. While vegetable gar-dening
was not operational in the rainy
season, water scarcity and lack of inputs were
impediments to horticultural production in
the dry season. In this regard, the project
assisted target communities in building two
dams to support horticultural production in
the dry season. Bio-intensive methods of hor-ticulture
were also introduced.
Due to a severe drought which coincided
with the beginning of the project, household
food insecurity in target communities was
high. Food intake was so low that children
could not go to school because of hunger.
Through improved agricultural techniques,
target communities were assisted in staple
food production and crop diversification.
With this intervention, from severe food inse-curity,
households in target communities had
bumper harvests and food consumption was
highly improved.
Methods
To support effective project implementation
to enhance livelihoods of intended beneficiar-ies,
ownership of the intervention and as part
of capacity building, a participatory approach
was used in implementing the project, i.e.
stakeholders were involved in aspects of the
project, from planning to implementation.
For each of the pilot districts, a district
work plan for the project was first elaborated
collaboratively by stakeholders from relevant

sectors of government, non-governmental
organizations (NGOs), voluntary community
groups and the UN in a 4-day workshop. The
workshops defined four specific technical
areas for intervention at community level.
These were food and nutrition security, health,
education, and social welfare. The multi-stakeholder
collaboration contributed in pro-moting
ownership of the initiative; in ensuring
that issues of real concern on the ground were
addressed by the project; and in enhancing
collaboration of all stakeholders in the imple-mentation
of the plan. An implementation
structure was established within the existing
frameworks at national and district levels to
suit the inter-sectoral nature of the project.
Linkages were made between national- and
district-level institutions to facilitate commu-nication
and to exchange information on
project activities. The national level was to
provide policy guidance while obtaining infor-mation
from the field for possible incorpora-tion
in programme and policy development.
Subject selection and coverage
Even though the focus of the project was to
improve the food and nutrition situation and
welfare of HIV-affected children, the target
unit was a community, rather than individual
children or families. Target communities were,
therefore, selected on the basis of high HIV
prevalence and the high number of OVC.
The intervention targeted three districts
in the two pilot countries. In Lesotho,
Mafeteng district had a total of 14,281 orphans
which accounted for 16% of registered
orphans in the country, as observed by the
Lesotho Disaster Management Authority and
WFP in 2003 (8). Project target areas covered
62 villages with a population of 6918
households.
In Malawi, the project was implemented
in two districts that had high HIV prevalence
rates and, consequently, high numbers of
orphans – Mangochi and Mwanza, situated
in the southern part of the country. The
number of orphans in the two districts was
estimated at 26,963 for Mangochi and 19,942
for Mwanza, accounting for about 7.2% of
registered orphans in the country (9). The
project targeted a total of 2886 households in
both districts.
Supporting institutional framework
In both countries, committees comprising
membership from existing institutions were
established at national and district levels to
support project implementation. The general
institutional structure at central and district
levels was similar for both countries. At
national level, the project was guided by a
National Steering Committee, with the
Ministry of Agriculture and Food Security as
chair and the Ministry of Health (Department
of Social Welfare) as co-chair. Other members
included the Ministry of Education and stake-holder
institutions such as the National AIDS
Commission and relevant NGOs. The com-mittee’s
role was to provide overall policy
guidance to the project.
Given that this project was technically
supported by three UN agencies, FAO,
UNICEF and WFP, a tripartite Technical
Working Group (TWG) consisting of FAO as
the lead agency, UNICEF and WFP was
formed to provide technical advice to the
Project Management Team (PMT).
The District Administration had the role
of overseeing, coordinating and monitoring
implementation of activities at this level.
A District Coordinating Committee chaired by
the office the District Administrator performed
this function. The committee comprised
professionals and technicians from relevant
government departments and non-state insti-tutions
that were engaged in development
activities of relevance to the project.
As mentioned earlier, district work plans
were elaborated collaboratively by all stake-holders
at project inception. Participants
included staff from relevant sectors of gov-ernment,
NGOs, relevant volunteer groups
and the UN, in order to develop ownership
of the initiative and to enhance collaboration
of all stakeholders in the implementation of
the plan.
Community intervention activities were
based on the four project focus areas of food

and nutrition security, health, education and
social welfare that were determined by stake-holders
at the planning workshop. Activities
covered in each of the focus areas were as
follows.
1. Food and nutrition security. Depending on
need, target communities were assisted in
producing food at household level to combat
food insecurity and improve dietary diversity
to enhance health and nutritional status. In
particular, improving the micronutrient con-tent
of the diets of target communities was
crucial because of the high HIV prevalence.
Nutrition education was central to activities
in this focus area.
2. Health. Activities in this focus area centred
on assisting target groups with basic primary
health care issues through education and the
provision of basic drugs and first aid sup-plies.
Training of volunteers in home-based
care, primarily to support people living with
HIV, was highly appreciated by target com-munities.
The volunteers in turn provided
home-based care services to the terminally ill
in their communities. Volunteers were also
trained in basic nutrition principles and
hygiene. In collaboration with local service
providers, community education workshops
and campaigns on HIV were conducted.
Sanitation clubs were organized to promote
hygiene messages and establishment of sani-tation
facilities such as pit latrines, rubbish
disposal pits and dish racks.
3. Education. Sensitization workshops on the
importance of education were conducted for
community leaders and community mem-bers.
Subsequently, several strategies to
increase enrolment and retention of children
in school, particularly OVC and girls, were
developed and implemented. These included
training of teachers in psychosocial care to
enhance a conducive learning environment;
conducting workshops for Parent–Teacher
Associations to enhance their abilities in man-aging
the schools; and introducing Mother
Groups who were specifically responsible for
dissuading young girls from early marriages
by encouraging and monitoring them to stay
in school. Out-of-school youth were taken to
vocational training where they learnt income-generating
skills such as plumbing, motor
mechanics, brick-laying, carpentry, sewing
and business management practices. In col-laboration
with the project partner agency,
UNICEF, life skills such as good agricultural
practices, crafts and food preparation were
introduced in schools.
4. Social welfare. With project support, rele-vant
government institutions worked together
to promote, protect and support the rights
and interests of OVC. Seminars to sensitize
local authorities and community members on
children’s rights and responsibilities were
conducted; volunteer groups were assisted to
establish Child Welfare Forums and were
subsequently trained on psychosocial sup-port,
and child protection and participation.
In child care centres, caregivers were trained
in child development issues, nutrition and
other related subjects. With support from rel-evant
government establishments, commu-nity
members were made aware of existing
laws that protect women and children against
abuse, and on their property rights.
Discussions in this chapter focus primarily on
the food- and nutrition-related experiences of
this initiative.
For sustainability and as part of the in-built
exit strategy, the project used local
expertise to provide service and support to
target communities in implementing activi-ties.
Implementing Partner (IP) institutions
with suitable skills and capacities were iden-tified
from state and non-state institutions.
Relevant government ministries assumed
ownership of activities under their sector and
collaborated with the IPs. Through project
support, training workshops to build or fill
capacity gaps for IPs were conducted. The
project engaged IPs from relevant sectors, as
dictated by technical skills required for the
implementation of different project activities.
Community-level pre-intervention studies
Prior to community-level intervention, two
studies, a baseline and a participatory com-munity
needs assessment, were carried out.
The baseline study was used to determine
the state of primary parameters before project
intervention at community level and to collect

basic data for comparison with impact survey
data. Three major components of the study
were as follows:
• Household survey – designed on the basis
of the project work plan, the instrument
included questions on demography,
nutrition, health, education, occupation,
OVC, household assets and family diet,
and collection of anthropometric data for
children 6 to 59 months of age.
• Focus group discussions – these aimed at
investigating major challenges faced by
children and their caretakers, and coping
mechanisms engaged in by families and
community members in this regard.
• Census of service providers – this involved
conducting a census of NGOs, civil soci-ety
organizations, community-based
organizations and volunteer groups
working in the target areas on project-related
interventions.
The participatory community needs assessment
study served to engage ultimate beneficiaries;
learn about their felt needs and capacities; and
involve them in planning community level
activities. To a large extent, existing institu-tional
capacities and gaps in project-related
areas were identified through this study.
Potential IPs were also identified by the study.
Baseline Studies
Lesotho
The baseline study uncovered alarmingly
high prevalence rates of stunting and wasting
in children aged 6–59 months, at 40.7% and
13.1%, respectively. These results were higher
than in the 2002 EPI Cluster Survey which
estimated a prevalence stunting rate of 30.3%
for the district (10). The high baseline rate of
32.1% chronic undernutrition for children in
this age group strongly indicates some
inadequacy in feeding practices for this age
group, as well as poor hygiene practices.
Breastfeeding alone should be nutritionally
adequate for infants up to 6 months of age;
and should be continued and gradually
replaced with supplementary foods constituting
a balanced diet by 24 months of age. With
good infant feeding practices, such a high
rate of chronic undernutrition is unjustifiable
even among food-insecure communities. This
finding indicated the need for nutrition and
health education in this area.
Stunting rates peaked at 46.5% in the
12–23 months age group (see Table 5.1).
Although the rates dropped in the older age
groups up to 48–59 months, the prevalence
was still very high at more than 40%. Boys
and girls were similarly affected. Stunting
rates for orphans and children in foster care
were slightly higher at 44% compared with
those of children living with biological par-ents,
at 40%, although the difference was not
statistically significant.
On household food production, informa-tion
collected by the survey showed that
although many households (72%) had vege-table
gardens, they were largely unproduc-tive,
providing only an estimated 10% of the
amount consumed by the household. A simi-lar
situation applied to fruit trees: most were
old and bore fruit of poor quality. As dietary
diversity is important for good nutritional
status, this information provided direction
for project emphasis at community level.
Malawi
Baseline study anthropometric results showed
that the prevalence of stunting among chil-dren
6–59 months of age was 43.3% in
Mangochi and 40.3% in Mwanza, just slightly
lower than the national average of 48% (11).
In Mangochi, the high stunting rate of 34.1%
for the 6–11 months age group increased
sharply to 41.0% in the 12–23 months age
bracket. The sharp increase could be an indi-cation
of inadequate young child feeding
practices since the rate drops (although
slightly) in the next age bracket. Yet another
hike (to 42.1%) was observed among older
children 48–59 months of age (see Table 5.2).
At this age, children should be able to con-sume
all foods eaten by the rest of the house-hold
members. The high stunting rate could
indicate both inadequate feeding practices
and household food insecurity.

Table 5.1. Prevalence of stunting (low HAZ) among children in Lesotho at baseline, by sex and age.
n
Stunting (%)
Moderate + severe
(HAZ ≤−2) Severe (HAZ ≤−3)
Children aged 6–59 months
Males 266 41.5 12.8
Females 244 39.6 13.4
Male and female children
6–11.9 months 65 31.5 0
12–23.9 months 127 46.5 19.7
24–35.9 months 121 45.3 13.9
36–47.9 months 114 41.3 15.6
48–59.9 months 84 32.1 9.0
HAZ, height-for-age Z score.
Table 5.2. Prevalence of malnutrition among children in Malawi at baseline, by age.
Age group (months)
Mangochi Mwanza
Stunting (%) Underweight (%) Stunting (%) Underweight (%)
6–11.9 34.1 21.0 22.9 13.7
12–23.9 41.0 22.6 27.8 12.5
24–35.9 37.9 23.2 54.1 19.7
36–47.9 30.6 11.4 51.4 16.4
48–59.9 42.1 17.4 47.1 19.6
For project intervention, the above find-ings
from the two districts suggested inter-vention
in the areas of young child feeding
practices, household food security, hygiene
and sanitation. Appropriate activities to
address these challenges were implemented
under the focus areas of health and food and
nutrition as outlined above under ‘Methods’.
The figures in Table 5.3 show that, due to
drought at the time, for most households
(58.2%) staple food stocks would be depleted
six months before the next harvest period of
April to June. The situation was slightly bet-ter
in Mwanza, where 46.0% of households
would be without food stocks six months
before the next harvest period. Although most
households mentioned buying as an option
when food stocks were depleted, since dis-posable
income was scarce in these communi-ties,
this situation implied a period of serious
food and nutrition security challenges ahead,
particularly for resource-poor households in
target communities. On a larger scale, such
findings would justify the declaration of an
emergency. In this situation, the project was
compelled to support target communities
with the production of staple crops although
the anticipated intervention was to assist with
horticultural crops and small livestock for
diet diversification.
Participatory Community Needs
Assessment Studies
As indicated above, participatory community
needs assessment studies were conducted
primarily to ensure that target communities
would be in the forefront in the planning and
implementation of project activities at this
level. The studies provided forums for groups
in target communities to discuss and agree on
their needs and priorities and how the liveli-hoods
of OVC could be enhanced. These
studies revealed views, concerns and desires

Table 5.3. Percentage distribution of availability of staple foods and stock depletion in Malawi at baseline.
Mangochi Mwanza
n % n %
of target communities on matters affecting
OVC livelihoods in general.
The participatory needs assessment proc-ess
entailed consultations with key inform-ants
through interviews; and focus group
discussions with interest groups such as com-munity
volunteer groups, income-generating
groups, agricultural groups, burial associa-tions,
primary caregivers of OVC and the
youth. Community needs were identified in
each discussion group and prioritized in a
‘plenary’ before presenting to a wider com-munity
in an open public forum for further
debate. It was during the open public forum
discussions that Community Action Plans
were outlined for each prioritized community
need. Findings and desires of target commu-nities
in relation to initiatives that would
enhance OVC livelihoods are summarized
below.
Lesotho
Food security
• Access to adequate, good-quality food
was seen as the most central issue because
it affects many other issues such as abil-ity
to learn, resistance to diseases and
creativity. As such, food production, par-ticularly
horticulture, was a top priority.
• Scarcity of water in the district is a major
impediment to increasing agricultural
production. Therefore, low-cost irriga-tion
techniques to enhance production
should be sought.
• The area of Mafeteng has poor soils that
have been ill-managed for decades. It
was felt necessary to introduce agricul-tural
methods that would also enhance
the condition of the soil.
• Assistance in small livestock production
(poultry and piggery) was a strong desire,
as it would improve the quality of meals
and serve as an income-generating activity.
Education
• Education was given the same impor-tance
as food when issues of OVC were
discussed.
• Access to education by all children, from
pre-school to high school, was rated as
very important.
• Although primary school education is free
in Lesotho, a number of OVC could still
not enrol because they could not afford
some of the mandatory requirements such
as registration fees, uniform and books.
Staple food available
Yes 91 22.9 113 29.8
No 306 77.1 266 70.2
When staple food was/will be
depleted
April–June 124 33.7 108 32.2
July–September 214 58.2 154 46.0
October–December 24 6.5 63 18.8
January–March 6 1.6 10 3.0
Source of food in time of scarcity
Buying (Admarc, local market,
vendors)
398 96.6 386 99.5
Begging/gift 12 2.9 0 –
Assisted by relatives 1 0.2 1 0.3
Food for work 1 0.2 1 0.3

• Many children, in particular OVC,
could not afford fees for high school
education.
Vocational training
• Target communities felt that children in
Lesotho were disadvantaged as they did
not have access to vocational training
because such schools are few.
• Due to emotional stress and other fac-tors,
some OVC were not able to attain
good grades for entry into tertiary
institutions and would therefore bene-fit
from vocational training. Thus,
there was a need for an exponential
increase in the number of schools that
can offer life skills for children who
are not able to make it in the academic
stream. Some of the skills mentioned
which would benefit the youth
included farming, carpentry, sewing
and knitting.
Life skills in schools
• As OVC have fewer chances of being
educated beyond free primary educa-tion,
community members concluded
that there was a need to incorporate life
skills into the regular primary school
programme.
Health
• Poor access to health care for OVC was
attributed to lack of disposable income at
the household level and the fact that
health services were not easily accessible
at the village level. While lack of finan-cial
resources impacts OVC households,
they also suffer poor access to health
services.
• Lack of access to psychological therapy
for the population in general and OVC in
particular was noted with concern. OVC
are more likely to need therapy and
counselling due to the trauma of the loss
of loved ones and/or having to deal with
terminally ill parents.
• Basic primary health care services pro-vided
by community volunteers (sup-port
groups) were appreciated.
Community members recommended
that support groups be supplied with
first aid kits and medical kits since there
was a shortage of nurses in their
villages.
Access to social services
• There was variable knowledge on the
rights of children among the different
social groups. In some villages chiefs
and other people in authority were
knowledgeable and articulate about the
subject while in others there was much
ignorance. Therefore, efforts had to be
made to increase knowledge on the
rights of children among all social cate-gories
such as local authorities, teachers,
support group members, the youth and
priests.
• Communities knew little about services
offered by the Department of Social
Welfare of the Ministry of Health and
Social Welfare, such as social grants
(Lesotho Maluti 100/US$13.5 per
month) for the elderly and destitute. In
the few cases where the services offered
by the Department were known, com-munities
complained about the long,
unclear and complicated bureaucracy in
accessing the services. Communities
suggested that members of support
groups be trained so that they could
assist in the rollout of social welfare
services.
• Local authorities (chiefs) have the respon-sibility
and potential to play a crucial
role in the protection of the OVC. The
role of the chief includes acting as guard-ian
for OVC. It was therefore agreed that
chiefs should play a more central role in
ensuring that rights of OVC are protected
and the needs and well-being of OVC are
addressed.
• A village-level register, where births,
deaths and numbers of OVC and other
people with special needs are recorded,
should be developed under the responsi-bility
of the chief.

Malawi
Food security
• Relief food items were top of the list of
priorities as most households had already
run out of maize, the main staple, by the
time of the study (August 2005), well
ahead of the normal lean period
(December–March). The situation was
more critical for OVC primary caregivers
who were mostly aged, unproductive
and dependent on community support
for survival.
• Agricultural inputs – fertilizers and
improved seeds (open pollinated varie-ties)
– were high on the priority list.
There was limited use of low-cost tech-nologies
such as compost manure, agro-forestry,
marker and contour ridges, and
incorporation of crop residues. These
technologies were used by only a few
farmers.
• Communities expressed the need for
training in areas such as low-cost agri-cultural
technologies, crop storage and
food preservation, small livestock hus-bandry
and fruit production. This train-ing
was necessitated by the weak
extension service system – there was
very little extension drive to adequately
promote appropriate technologies.
• Access to small livestock – goats, chick-ens,
guinea fowls, rabbits – was expressed
as a strong desire by target communities.
Because of poverty, there was lack of
diversity in the local diet and the asset
base was depleted.
Health
• Access to health facilities was minimal
for all the communities covered by the
study. Primary health care was con-strained
by lack of resources as it was
almost exclusively a government-driven
programme; access to and utilization of
voluntary counselling and testing serv-ices
was quite low; and nutrition educa-tion
in the health service delivery system
was weak. Target communities requested:
(i) training of Support Groups and Peer
Educators on HIV awareness, nutrition
education and primary health care; and
(ii) provision of boreholes, drugs for
water purification and medication for
home-based care for the chronically ill.
Education and training
• Communities expressed concern about
the continuing decline in enrolment,
attendance and retention of girls and
OVC in primary schools. Poverty and
household-level food insecurity in par-ticular,
and lack of OVC economic
empowerment programmes, were
regarded as the main factors for the
declining trends. In addition, OVC
access to secondary school education
was hampered by their guardians’ ina-bility
to pay school fees which, rela-tively,
were prohibitively high. Target
communities requested assistance with:
(i) school feeding programmes as an
incentive for increasing OVC and girls’
enrolment; (ii) bursary schemes for OVC
and girls selected for secondary school
education; and (iii) life skills training for
youth.
Welfare services
• There was limited information dissemi-nation
on women’s and children’s rights
at community level; the few community
institutions that provided awareness
training were hampered by lack of
resources and access to information, edu-cation
and communication materials;
and communities remained dependent
on radio programmes for accessing infor-mation
on human rights issues, yet only
a few people had functioning radios.
• Community-based child care and home-based
care systems at community level
were underdeveloped and fragile due to
resource constraints, untrained caretak-ers
and committees, and lack of support
and capacity in service delivery.
• There was no organized system for OVC
vocational skills training and no promo-tional
programmes for income-generat-ing
activities for OVC and target

communities. Communities requested
assistance with: (i) women’s and chil-dren’s
rights’ awareness programmes;
(ii) support on home-based care, voca-tional
training for OVC, recreation facili-ties
for OVC and youth; and (iii) training
in psychosocial counselling.
Information from baseline and participatory
community needs assessment studies was
used in planning activities for intervention at
community level.
Project Strategies, Activities
and Outcomes
Intervention strategies at community level
were largely evolved from the specific district
studies carried out in relation to the project
(i.e. the situation analyses, baseline and par-ticipatory
community needs assessment stud-ies)
as well as information provided by the
district planning workshops. Based on this
information, it was clear that among the four
technical project focus areas (food and nutri-tion
security, health, education and social
welfare) identified by stakeholders at the
planning workshops, food and nutrition
security issues were a primary concern that
needed urgent attention. Strategies for inter-vention
in this focus area (as in other project
focus areas) were developed through a par-ticipatory
process, taking into account the tar-get
communities’ socio-economic, health and
nutrition conditions, as well as the agronomic
potential for each country and district. Hence,
community-level activities between the two
countries were similar but not necessarily
identical. For instance, Malawi has a far better
agronomic potential than Lesotho, and there-fore
had more food production activities. As
such, this chapter shares project experiences
by citing examples from one or both countries
as appropriate.
In selecting strategies, it was also consid-ered
that livelihoods were eroded within
project target communities; the high HIV
prevalence had taken a toll on family finan-cial
and human resources; food and nutrition
insecurity, including micronutrient deficien-cies,
were widespread; the general health of
individuals was poor; and for many families,
the asset base was depleted. Further, the
majority were primarily subsistence farm
families whose main food supply and liveli-hood
were from their own production.
Because of their low purchasing power, which
was exasperated by increased and prolonged
expenditure on health care due to high HIV
prevalence, target communities could not
access fortified foods even where these prod-ucts
were available in local markets. Therefore,
low-cost, food-based strategies had to be
sought to combat food and nutrition insecu-rity
including micronutrient deficiencies and
to improve the health and nutritional status
of target communities.
Although food supplementation inter-ventions
play a crucial role in improving
nutritional status in communities where there
are specific and known nutrient deficiencies,
studies to investigate specific nutrient defi-ciencies
in target communities were not car-ried
out, partly due to the short duration of
the project period. In addition, the efficacy
and sustainability of these interventions in
rural, resource-poor communities are some-times
limited. This is primarily a result of sev-eral
factors, including the socio-economic and
logistical challenges often faced by communi-ties
in accessing such services. Sustainability
of supplementation interventions is also a
major concern.
This was seemingly the case in Malawi:
the Government of Malawi maintained a pol-icy
of supplying vitamin A capsules every six
months to all children from 6 months to 5
years old to prevent vitamin A deficiency dis-orders,
which were a serious problem in the
country. Yet, 59% of pre-school children were
found to be vitamin A deficient in a study
carried out in 2003 (12). Further investigation
on the case of the Malawi supplementation
programme would be interesting and inform-ative
for programme planning and/or
redirection.
Ideally, for biological efficacy and sus-tainability,
supplementation programmes
should be implemented in parallel with food-based
interventions that include an emphasis
on nutrition education. In this way, the short
(supplementation) and long (food-based)
term approaches complement each other,

assuring continued micronutrient supply
even when supplementation sponsorship
ceases.
To ensure regular consumption of
diverse, micronutrient-rich diets among tar-get
communities, continued supply of both
plant and animal food sources in all seasons
was obligatory. In this regard, strategies and
techniques such as crop and diet diversifica-tion,
bio-intensive methods of horticultural
production and production of small livestock
as animal food sources were engaged.
Nutrition education and practical demonstra-tions
on improving local diets through con-sumption
of diverse foods from plant and
animal sources were incorporated and car-ried
out throughout the duration of the
project. Strategies engaged in by the project
made a significantly high positive impact on
the lives of target communities through
improved food availability and increased
consumption of highly diverse diets. The
impact cannot always be concisely demon-strated
as, owing to the urgency to save des-perate
communities from impacts of food
insecurity, data were collected using both
quantitative and qualitative methods.
Crop and diet diversification
As the project started in Malawi (November
2004), the country was experiencing a severe
drought. Even though the project originally
aimed at increasing the availability and con-sumption
of micronutrient-rich foods prima-rily
through horticulture and small animal
production, it became apparent there was an
urgent need to also promote the production
of staple foods, particularly maize, the major
staple. The food insecurity situation at this
time was dire. For instance, based on the
results of the baseline study (see Table 5.3), it
was projected that food stocks would be
exhausted 6 months before the next harvest
for most households in Mangochi (58%) and
many in Mwanza (46%).
A weakness in the production system
adhered to by many subsistence farm families
in much of southern Africa is monocropping,
resulting in a scarce food base, particularly in
the range of staple foods. Among households
in target communities in Malawi, maize is the
predominant staple, with barely any substan-tive
alternative to fall back on. While maize
was grown by 98% (almost all) of households
in Mangochi and 90% in Mwanza, the only
other staple – cassava – was cultivated by 8%
of households in Mangochi and 4% in
Mwanza. Sweet potato, which is used largely
as a snack and to complement the staple dur-ing
hunger periods, was grown by few house-holds
– 14% in Mangochi and 2% in
Mwanza.
Hence, when the maize crop fails, famine
ensues in the sub-region. A varied diet is
known to be the key factor in preventing
micronutrient deficiencies and malnutrition
(13). FAO and the International Life Sciences
Institute recommend consumption of varied
foods from animal and plant food sources to
prevent micronutrient deficiencies and mal-nutrition
(13).
In Malawi, to assist beneficiaries improve
their food base and as part of a varied diet,
the project promoted drought-tolerant crops
such as cassava, sweet potato and sorghum.
Legumes such as soy and groundnuts were
also promoted. Communities were trained in
the cultivation and husbandry of these crops.
Cassava and sweet potato planting materials
were distributed to groups within villages for
multiplication and further expansion in
household fields. In addition, small amounts
of soy and groundnuts were distributed
among households in target communities for
cultivation and multiplication. Technical sup-port
through extension services was provided
for cultivation of plants throughout the har-vest
period by an IP institution in Mangochi
and the Ministry of Agriculture in Mwanza.
Communities were very active in the imple-mentation
of these activities, and established
good rapport with service providers.
Staple foods are generally recognized as
good sources of carbohydrates. However,
given the amount and frequency of their con-sumption,
many staple foods, especially
cereal staples, can also serve as good sources
of protein and several micronutrients (14,15)
(see Table 5.4). For example, for an adult
woman, the contribution of 100 g of orange
sweet potato towards her recommended
nutrient intakes is 210% of vitamin A, 33% of

Table 5.4. Nutrient content of some staples per 100 g and their percentage contribution to the Recommended Daily Allowance (RDA).
Micronutrient
Sorghum Sweet potato, orange Maize, white Cassava Cassava leaves
Amount
Contribution
to RDAa (%) Amount
Contribution
to RDA (%) Amount
Contribution
to RDA (%) Amount
Contribution
to RDA (%) Amount
Contribution
to RDA (%)
Vitamin A (mg RE) 7.0 1.0 1467 210 0 0 147 2.0 5197 74.1
Vitamin D (mg) 0 0 0 0 0 0 0 0 0 0
Vitamin E (mg) 1.0 6.7 0 33.3 1.0 6.7 0 0 0 0
Vitamin C (mg) 0 0 25 33.3 0 0 72 96.0 33 44.0
Thiamin (mg) 0.3 27.3 0.1 9.1 0.4 36.4 0.3 27.3 0.1 9.1
Riboflavin (mg) 0.1 9.1 0.1 9.1 0.2 18.2 0.1 9.1 0.2 18.2
Niacin (mg) 2.8 0.6 3.6 1.4 0.9
Vitamin B6 (mg) 0.2 18.2 0.2 18.2 0.3 27.3 0.7 53.9 0.5 38.5
Folate (mg) 14.0 23.0 25.0 36.0 104
Vitamin B12 (mg) 0 0 0 0 0 0 0 0 0 0
Pantothenic acid
0.9 0.7 0.4 0.7 0.3
(mg)
Calcium (mg) 25.0 28.0 6.0 46.0 211
Phosphorus (mg) 222 31.7 55.0 7.9 241 34.4 168 24.0 72.0 10.3
Magnesium (mg) 171 55.2 20.0 9.5 127 41.0 24 7.7 62.0 20.0
Potassium (mg) 131 348 287 583 550
Sodium (mg) 7.0 10.0 35.0 5.0 11.0
Iron (mg) 4.1 22.8 0.5 2.8 3.5 19.4 1.9 10.6 3.1 17.2
Zinc (mg) 1.6 20.0 0.3 3.8 1.8 22.5 0.7 8.8 0.4 5.0
Copper (mg) 211 55.6 0.2 22.2 0.2 22.2 0.1 11.1 0.2 22.2
Manganese (mg) 0.6 0.6 0.5 0.3 0.1
aCalculations for the RDA were based on Whiting and Barabash (15); where there are blank spaces, this reference did not provide the RDA and values from other sources were not
used for consistency.
(Source: Tanzania Food Composition Table (15).)

vitamins E and C, and lesser amounts of other
micronutrients. Consumption of 100 g of
white maize (popular among population
groups that consume maize as a staple) can
contribute significantly towards dietary
requirements for the B complex of vitamins:
36% for thiamin, 18% for riboflavin, 27% for
vitamin B6, as well as zinc at 23%. According
to figures in Table 5.4, sorghum is a good
source of thiamin, phosphorus, magnesium,
iron, zinc and copper. It should be noted that
many adults commonly consume at least 300
g of these foods daily, an amount which can
contribute significantly towards meeting their
recommended nutrient intakes.
Cassava presents an interesting case: the
root is often degraded in comparison to other
staples, mainly because of its low protein con-tent
(14), but cassava leaves compensate for
the difference since the root is often consumed
with the leaves as relish. Per 100 g, the protein
content of maize is 8.1 g, sorghum 11.3 g, rice
6.5 g, cassava 2.6 g and cassava leaves 3.7 g.
Figures in Table 5.4 show cassava as a good
source of vitamin C (even when taking into
account its sensitivity to heat and some loss
during cooking), thiamin, vitamin B6 and
phosphorus. Furthermore, as mentioned
above, where cassava is a staple food, the
leaves are often used as relish for the root.
The nutrient content of cassava leaves per-fectly
complements that of the root as can be
observed from Table 5.4: the contribution to
the recommended daily allowance of the root
versus the leaves is respectively 2% versus
74% for vitamin A, 11% versus 17% for iron
and 96% versus 44% for vitamin C (15). The
project therefore promoted the production
and consumption of cassava as part of a var-ied
diet and not an alternative single staple.
Like sweet potato, the advantage of cassava is
that it can be harvested on demand, thus
avoiding food or nutrient losses during
storage.
Outcome
• Food diversity was greatly enhanced
through crop diversification: (i) an esti-mated
52 t of soy was produced; (ii) 112
ha of cassava were planted by 2886
households with an estimated production
of 1545 t; (iii) 144 ha of sweet potato were
planted with an estimated production of
1748 t; and (iv) 246 ha of groundnuts
were planted with an estimated produc-tion
of 231 t. These figures are remarka-ble
compared with the negligible
amounts of these crops that were pro-duced
by only a small percentage of
households before the project.
• Through nutrition education and train-ing,
communities successfully integrated
soy (which was a new crop to many) into
local regular recipes. Soy flour was mixed
with maize meal in preparing all three
meals, making the staple more nutrient-rich.
In addition, soy flour was also
added when preparing the regularly con-sumed
green leafy vegetables and other
foods used as relishes.
• Increased food consumption, including
of micronutrient-rich foods, was
enhanced in target communities through
crop diversification, increased food base
and nutrition education.
Ensuring continuity of vegetable
supply in all seasons
Experience in Lesotho
Vegetable production was one of the strate-gies
engaged to improve dietary diversity
and increase the micronutrient intake of tar-get
communities. In Lesotho, the baseline sur-vey
showed a clear association between
dietary diversity and nutritional status, where
53% of children living in households on low-diversity
diets were stunted, against 39% of
those whose households consumed moderate
to highly diverse diets. Further, vegetables
and fruit are highly recommended as good
sources of micronutrients and fibre. FAO and
the World Health Organization advocate a
minimum daily intake of 400 g of fruit and
vegetables per adult person for the promo-tion
of good health and prevention of several
micronutrient deficiencies (16). Consumption
of micronutrient-rich foods is recommended
in maintaining and boosting the body’s
immune system. As such, because of high

HIV prevalence rates, improving the micro-nutrient
content of the diets of target commu-nities
was a key objective. HIV weakens the
immune system, increasing susceptibility to
opportunistic diseases and poor health out-comes.
Intake of nutritionally adequate,
micronutrient-rich food is important for unin-fected
people too, to maintain good health
and strengthen their immune systems.
Ensuring the availability of micronutrient-rich
foods on a regular basis was therefore
imperative for project target communities.
In Lesotho, however, as shown by the
baseline survey, vegetable and fruit produc-tion
fell far short of household consumption
needs, accounting only for an estimated 10%.
On average, about 70% of households in tar-get
communities had vegetable gardens and
67% had fruit trees, though these products
were produced in relatively small amounts.
However, since vegetable gardening was in
the culture of target communities, this oppor-tunity
could be exploited by assisting the tar-get
communities to improve and increase
production. The challenge was to introduce
effective low-cost technologies appropriate
for the conditions and capacities of the target
communities.
Year-round supply and consumption of
vegetables could be ensured through bio-intensive
agricultural techniques of vegeta-ble
production and nutrition education,
respectively. In view of the challenging agro-nomic
conditions in Mafeteng, the pilot
district and the socio-economic circum-stances
of the target communities, two meth-ods
of bio- intensive agricultural production
techniques – keyhole gardening and double-dug
methods – were introduced as part of
efforts to improve and increase vegetable
production. For the majority of households
in project target communities, keyhole gar-dens
were found to be more suitable (Fig.
5.1). With keyhole gardening, vegetable pro-duction
could be sustained all year round,
even under extreme hot or cold tempera-tures,
enabling households to access micro-nutrient-
rich foods in all seasons. In addition,
at least five varieties of vegetables at a time
can be produced in a keyhole garden, thus
supporting dietary diversity; the produce
from one keyhole garden is more than enough
to feed a family of eight persons; the struc-ture
of a keyhole garden ensures soil fertility
for 5 to 7 years; keyhole gardens retain mois-ture
and can be maintained with disposable
domestic water; there is no need for chemical
fertilizers or pesticides, making it suitable for
communities where disposable income is
scarce; and once constructed, keyhole gar-dens
require minimal labour and can be eas-ily
maintained by the elderly, children or sick
persons. Keyhole gardens were thus well
suited to HIV-affected communities.
Prior to assisting target communities to
develop keyhole gardens, a core group of
Peer Educators from local villages received
in-depth training on the proper construction
of keyhole gardens. Subsequently, in each vil-lage
within target communities, training ses-sions
and demonstrations on construction
and maintenance of keyhole gardens were
conducted. Thereafter, households within tar-get
communities were assisted to construct
individual gardens, with close supervision by
Peer Educators. For all households, the project
provided inputs such as a variety of seed
spinach, green beans, carrot, lettuce and
onion, and nets to protect plants from hail or
snow. Other inputs like poles, stones and
manure were a responsibility of households
themselves. Households were also at liberty
to plant other vegetables and herbs they
desired using their own seed.
Target communities showed a lot of
enthusiasm and commitment in building the
keyhole gardens. As the initial construction
of keyhole gardens is labour-intensive, com-munity
members worked in groups, until
the construction for all households was com-pleted.
This approach ensured that house-holds
without labour such as those headed
by the elderly or children were assisted to
acquire keyhole gardens. All keyhole gar-dens
in participating communities produced
a variety of lush vegetables as can be seen in
Fig. 5.1. The quality of the produce was so
good that it attracted a local reputable ‘chain’
supermarket, although the quantity
produced was not sufficient to sustain a
sales contract. In terms of sustainability,
the bio-intensive keyhole approach is
promising: nearby communities not targeted
by the project copied the technology and

Fig. 5.1. Keyhole garden in Mafeteng in Lesotho. Through the keyhole bio-intensive method of
gardening that ensures soil fertility, target communities were enabled to produce vegetables in all
seasons. A keyhole garden can produce many varieties of vegetables at a time, is easy to maintain and
needs very little watering.
constructed keyhole gardens without exter-nal
support. Also, some target households
built additional keyhole gardens without
project support. This implies that the tech-nology
can be easily incorporated as a liveli-hood
activity, and that the capacity to do so
exists. Also, during the course of this project,
keyhole gardens survived a drought not
experienced in 30 years, hailstorms, frosts
and a tornado.
Outcome
• Production of vegetables through key-hole
gardening was thus a resounding
success in Mafeteng, the target district in
Lesotho. Indeed, in the area of food secu-rity,
keyhole gardens were a flagship
activity of the project in Lesotho.
• An estimated 5354 out of a total of 6918
(77%) households were assisted in start-ing
or improving vegetable production,
and were also trained in principles of
nutrition and preparation of nutritious
meals using produce from the gardens.
These figures reflect an increase of 7%
(from the initial 70% before project inter-vention)
in households which developed
vegetable gardens with project assist-ance.
This figure is distorted by the
majority of households in the peri-urban
area (who largely had no vegetable gar-dens
before the project) and who did not
participate in vegetable gardening, but
preferred to engage in income-generat-ing
activities with quick returns (such as
brewing) to obtain funds to purchase
food. Nevertheless, in rural target com-munities,
almost all households partici-pated
in this activity.
• Communities that produced only about
10% of their vegetable requirements prior
to project intervention were enabled to
increase their produce by more than 100%.
Experience in Malawi
In Malawi, during the rainy season, there is
an abundance of indigenous wild vegetables

(e.g. amaranthus, mushrooms) that communi-ties
largely relied on as relish to consume with
the staple food, maize. As elaborated earlier,
during this season, cultivation of exotic vege-tables
was very limited due to waterlogging
and unavailable manpower as household
labour is primarily engaged in the production
of field crops. In the dry season, because of
water scarcity, vegetable production was
almost non-existent. Consequently, vegetables
were normally extremely scarce and therefore
limiting in community diets. Interestingly, at
the participatory community needs discussion
forums, vegetable production was the among
priority activities expressed by target groups.
Construction of a dam as a source of water for
vegetable irrigation was proposed as a means
to overcome the water problem. To demon-strate
enthusiasm and determination in this
regard, with little financial and technical (on
engineering) assistance from the project,
beneficiaries manually constructed two dams
(as shown in Fig. 5.2) by trapping water from
a nearby mountain waterflow.
Communal gardens with separate plots
for each household were developed near the
dams. Subsequent to training in horticulture
and to exploit the results of the hard labour in
building the dams, beneficiaries diligently
tended the gardens, with technical assistance
from a local IP. At household level, bio-intensive
methods of vegetable production
were introduced, mainly double-dug garden-ing.
With these two approaches, target com-munities
had access to a variety of vegetables
in the dry and rainy seasons. Marketing of
produce was not incorporated in project
activities as it was not envisaged that, within
the short duration of one phase of an inter-sectoral
project, poor communities could be
transformed from a state of dire food insecu-rity
to one in which they would have excess
food to sell. Nevertheless, households did
manage to get some cash from informal sales.
Some of the excess produce was preserved.
Assistance in fruit production was
another area of need expressed by beneficiar-ies
at the discussion forums staged by the
participatory community needs assessment
study. Commonly grown fruit in Malawi
include mango, pawpaw, orange, tangerine
and banana. A challenge regarding fruit trees
in a majority of target households was that
many were old and yielding both lower qual-ity
and reduced quantity of fruit. Each house-hold
in target communities hence received
Fig. 5.2. Dam constructed by community members in Mangochi district, Malawi, with technical
assistance sourced locally through the project.

three improved fruit seedlings of mango,
pawpaw and guava. Although the newly
supplied fruit trees had not yet started pro-ducing
at project end, consumption and use
of different varieties of fruit were included in
nutrition education sessions.
Outcome
• With technical assistance and some mate-rial
inputs from the project, target com-munities
in Mangochi manually
constructed two seasonal dams to ensure
water availability for vegetable produc-tion
in the dry season (see Fig. 5.2).
• All households in target communities
(n = 2886) were provided with seed,
which included spinach, cabbage, car-rots,
green beans, onion and tomatoes,
and received technical assistance in
developing vegetable gardens. Access to
water from the dams enabled beneficiar-ies
to grow vegetables during the dry
season, ensuring continuity of vegetable
supply in both seasons, as there was an
abundance of wild indigenous vegeta-bles
in the wet season.
• All households in target communities
received nutrition education and practi-cal
demonstrations on enhancing the
nutritional content of local diets using
vegetables, which are traditionally con-sumed
with the staple as a relish.
Beneficiaries testified that because of
new methods of preparing different veg-etable
dishes, consumption increased,
particularly by children and sick
individuals.
Increased availability and consumption
of animal-source foods
In rural settings, animals are kept as an indi-cator
of wealth and are therefore a status
symbol rather than production assets.
However, in resource-poor, food-insecure
communities, livestock is kept as a form of
asset protection and used for food only when
the situation becomes dire, very rarely for
consumption to balance their diets. Data from
the household survey in Malawi showed that
although raising poultry was practised by
many (88% in Mangochi and 67% in Mwanza),
the numbers of chicken owned by each house-hold
were too few to make a meaningful con-tribution
to the diet or asset base. Ownership
of other types of livestock was insignificant.
Overall in Lesotho, 57.3% of households kept
animals of any kind, the median being five
animals (cattle, sheep, goats, horses or don-keys)
per household. As in Malawi, poultry-raising
was popular, but mainly there were
very few numbers per household. To enable
target communities to have access to animal-food
sources, the project promoted small live-stock
husbandry.
Consumption of animal-source foods on
a regular basis is important to provide macro-nutrients
such as protein and micronutrients
such as vitamin A, iron and several minerals.
Micronutrients from animal sources are more
bioavailable than those of plant origin, which
are precursors that need to be converted into
the active form of the vitamin or mineral
before they can be utilized by the body. For
example, carotene, a precursor of vitamin A
found in plants, has to be converted in the
human body into vitamin A before utiliza-tion.
In sick individuals it is possible that this
conversion may not be efficient; hence regu-lar
consumption of animal-food sources is
recommended.
Like backyard gardens, small livestock
projects have been promoted for decades, but
very few are sustainable for long after the
project period. To avoid doing ‘business as
usual’, the project investigated livestock man-agement
approaches and practices that could
be sustained by target communities to ensure
continued supply of animal-source foods.
The following elements were found appropri-ate
and incorporated in the training and man-agement
approach component introduced to
target communities.
1. Procurement of suitable livestock breeds.
Affordability, productivity and efficiency were
taken into account in selecting the breed of
livestock to be introduced. Management
requirements for the selected breed were also
considered, to ensure its suitability for the
capacity and capability of target communities.

For example: (i) in both countries, the dual-purpose
chicken (koekoe), which is a cross-breed
between the traditional and hybrid chicken,
was selected. This breed does not require strin-gent
and costly maintenance like the hybrid.
Like the traditional breed, the dual-purpose
chicken requires basic care and management,
yet its egg and meat production capacity is
almost as efficient as that of the hybrid; (ii) In
Malawi, imported male hybrid dairy goats
were cross-bred with local indigenous female
goats to increase their milk-producing charac-teristics.
With continued, controlled breeding,
the progeny will eventually inherit the milk-producing
trait of the hybrids. Participating
households (n = 290) were supplied with two
local female goats and one hybrid male goat.
Not all households received goats immedi-ately,
but the ‘pass-on’ arrangement, whereby
the first recipient passes on the first progeny to
other beneficiaries, was put in place. Poor
households, particularly those that were
headed by women, were given priority as first
recipients of parent stock.
2. Growing animal feed. The project encour-aged
participating households to grow feed
for the animals on a small piece of land and
have it ready before the first stock was deliv-ered
to beneficiaries. This practice is a depar-ture
from the traditional method of feeding
livestock, particularly chickens, on household
leftovers. In food-insecure households, there
are hardly any leftovers. If any, they are typi-cally
too meagre to sustain the animals, result-ing
in the failure of the livestock-raising
venture.
3. Providing animal shelter. Before a household
was supplied with the parent stock (chickens,
goats or guinea fowl), a shelter for the ani-mals/
birds constructed from affordable,
locally available material was prerequisite.
Providing shelter facilitated monitoring of
animals and easy collection of droppings to
use as manure.
4. Ensuring availability of water sources. This
was crucial, so that there was no competition
for water between humans and animals, par-ticularly
in very dry or drought-prone areas.
An additional pre-condition for communities,
therefore, was to ensure there would be ade-quate
water sources for both humans and ani-mals
before embarking on raising livestock.
With improved chicken production and
management, participating households con-sumed
eggs more liberally than they did
when traditional methods of husbandry
(where chickens were much less efficient in
laying) were employed. Households also
consumed more chicken than they did
before. This observation applied to both
countries.
Guinea-fowl raising was introduced in
Malawi. The attempt was not very successful
as the birds tended to be wild, poor brooders
and escape frequently from the premises.
In Lesotho, only a few households were
assisted (as pilot) to raise poultry. Subsequent
to training in raising chickens, beneficiaries
had to grow food for the birds as a prerequi-site
to receiving the parent stock. The same
principle was applied to the piggery under-taking
in Lesotho.
Dairy goats were introduced only in
Malawi. In Lesotho, because of the wool
industry, a zero-grazing regulation between
dairy and Angora goats is in place country-wide.
Therefore, dairy goats were not intro-duced
as part of a small livestock intervention.
In Malawi, goat’s milk was primarily used to
feed children. Households raising goats also
donated some milk to Community-based
Child Care Centres on a regular basis. The
contribution of goat meat to local diets could
not yet be confirmed, as the small livestock
intervention was still in its infancy when the
project ended. In both countries, the livestock
intervention could only be introduced
towards the end of the Phase I of the project.
It should be mentioned though, that this is an
intervention target communities were very
enthusiastic about, as it contributes to food
security, income generation and asset base.
Communities participated conscientiously in
training and in the initial stages of this inter-vention
and continued to be diligent in mas-tering
the management and husbandry of
livestock.
Outcome
• One hundred and fifty-five female-headed
households in Mangochi and 135
in Mwanza benefited from being the first
recipients of two female goats each, and

were to pass on the first progeny to other
intended beneficiaries. Children’s diets
in recipient households were nutrition-ally
enhanced by the goat’s milk.
• Subsequent to training of target commu-nities
in chicken-rearing, 1100 dual-pur-pose
chickens were distributed (600 in
Mangochi and 500 in Mwanza) to the
first recipient households, who would
subsequently pass on the progeny to
other intended recipients. As stipulated,
all participating households (60 in
Mangochi and 50 in Mwanza) had shel-ters
built for the birds and other prereq-uisite
tools recommended for good
management.
• In Lesotho, as this activity was initiated
towards project end, only a small group
of 385 households was included in poul-try
and piggery projects. Primarily, inten-sive
training on poultry-raising of a core
group of trainers (Peer Group Trainers)
from target communities, who would in
turn train community members in the
anticipated Phase II of the project, was
conducted.
• Increased consumption of eggs and
chicken was observed among house-holds
raising chickens.
• By project end, the first litter of piglets
was passed on to the next recipients.
Improved food production and processing
In the two districts of Malawi, communities
were trained in good farming practices and
supported with inputs. For maize produc-tion,
training in agricultural techniques such
as the Sasakawa planting method, box ridges
and constructing marker ridges using the
A-frame method along with contour ridges,
was provided. Inputs of fertilizer and open-pollinated
maize seed were provided to all
2886 households in target communities in
the two districts. This transformed benefici-aries
from a situation where they fell short of
food supplies six months before the next har-vest
season to one in which they realized a
bumper crop, and were able to donate maize
to village grain banks. With project assist-ance,
beneficiary households (see Fig. 5.3)
Fig. 5.3. A woman in one of the targeted communities in Malawi, proud of her bumper harvest.
Improved food production and processing entailed training target communities in improved agricultural
techniques which increased production such that beneficiaries were transformed from a situation where
they fell short of food supplies six months before the next harvest season to one in which they realized a
bumper crop and were able to donate maize to village grain banks.

produced enough maize to feed their fami-lies
(approximately one tonne per house-hold)
until the next harvest season and to
provide sufficient seed for the following sea-son.
Because of the bumper harvest, each
beneficiary household willingly provided a
contribution of one bag (50 kg) maize to
village grain banks. The contributed maize
was used to support Community-based
Child Care Centres as well as the old and the
chronically ill who were unable to plant their
own fields.
As soy (mentioned under crop diversi-fication)
was a new crop to many house-holds
in target communities, training on
processing and preparation of the bean was
conducted. Through nutrition education,
the integration of soy into local dishes was
swift. Soy flour was mixed with maize meal
in preparing all three meals, making the sta-ple
food more nutrient-rich. In addition to
other dishes, soy flour was also added when
preparing the regularly consumed green
leafy vegetables and other foods used as
relishes. Women were very enthusiastic
about the introduction of soy into their
diets. Not only were they thrilled about
incorporating soy into their everyday diets,
they also learnt new recipes like making
cakes from maize and soy flour.
Demonstrations of these new recipes were
staged in field days and other gatherings
when possible.
Outcome
• All 2128 households in target communi-ties
had bumper harvests, realizing
approximately one tonne each. This
experience transformed beneficiaries
from a situation where they fell short of
food six months before the next harvest
to one in which they had extra grain to
give away.
• Over 400 people from target communi-ties
were trained in soybean processing
by extension agents from the Ministry of
Agriculture and staff from Bunda College
of Agriculture. The regularly consumed
maize meal and green leafy vegetables
were often mixed with soy flour, enhanc-ing
the nutrient content of local diets.
Improved food preservation and storage
Through improved food preservation and
storage, target communities could be assisted
to have continued access to a varied diet,
including micronutrient-rich foods, in all sea-sons.
In both countries, during the dry season
or winter months, when wild vegetables and
fruit are not in season, maize is the predomi-nant
food, with token relishes (nutritious and
non-nutritious) as complements. Yet in the
summertime or rainy season when micronu-trient-
rich wild vegetables and fruit are in
abundance, a lot of these foods go to waste
because of inadequate storage facilities and
rudimentary or lack of preservation practices.
In addition, as discussed above, through
project intervention in food production, there
was abundance of micronutrient-rich foods,
in excess of immediate household consump-tion
needs. Through project intervention,
households were trained and assisted in
appropriate methods of food preservation
and storage.
In Malawi, because of the bumper har-vest,
village grain banks were introduced and
made operational. The project facilitated the
establishment of village grain banks in all tar-get
communities in the 17 villages that consti-tuted
the project coverage area. Through
demonstrations, communities were taught
improved methods of grain preservation and
storage. The 50 kg bags of maize that were
donated by each participating household
were stored in the village grain banks.
Individual households also had harvested
maize grain to store. At household level, the
project encouraged beneficiaries to build
improved storage barns using locally availa-ble
material (mainly straw and bamboo) as
shown in Fig. 5.3. The same material was
used to construct village grain banks.
However, although rodents were controlled
to a large extent through these structures, the
grain was still attacked by insects, mainly
weevil.
FAO estimates postharvest losses in
developing countries at 14–16%, with 4–6%
attributable to storage. In this regard, FAO
highly recommends the use of metallic silos
for small and medium farmers to control
losses during storage. Training of trainer

courses have been conducted in several coun-tries
in collaboration with FAO, the ultimate
objective being training of artisans at com-munity
or village level. Through this pro-gramme,
20 artisans from the two target
districts in Malawi were trained in the con-struction
of metallic silos which guarantee
zero storage losses if used properly (17).
However, the cost of these silos was a limit-ing
factor to access by individual households
and village administration. Village authori-ties
were in the process of exploring assist-ance
to obtain a few silos for collaborative
use by the community.
Improved solar dryers to preserve
excess vegetables and fruit were introduced
in both countries. The technique of drying
vegetables and fruit has been used by com-munities
for generations, but the methods
are rudimentary, allowing only a limited
amount of food to be preserved. Much larger
quantities of vegetables and fruit could be
preserved using solar dryers. In training
community members to use solar dryers,
nutrition education sessions as well as cook-ing
demonstrations on how to prepare palat-able
dishes using dried products were
conducted. These training sessions were
very popular among target community
members, particularly women. Subsequent
to training in food preservation and storage
techniques, target communities were able to
preserve the vegetables they produced
through gardening and the wild ones that
come with the summer rains. Increased
availability of horticultural produce in all
seasons resulted in increased consumption
of these products.
During field days, women showcased
dishes prepared from dried products using
traditional and new recipes they acquired
from training sessions. With new/improved
recipes, consumption of vegetables increased,
even among children. Dried fruit was very
popular as a snack.
Outcome
• Village grain banks were established in
all 17 villages in target communities in
anticipation of maize to be donated by
project beneficiaries.
• All households in target communities in
Malawi were assisted to construct
improved grain storage barns using
locally available material, resulting in
reduced postharvest losses through
improved preservation and storage
methods.
• Twenty artisans from target communities
were trained in the construction of metal-lic
silos which, if used properly, can result
in zero storage losses.
• Through solar drying, increased amounts
of vegetables and fruit were available
throughout the seasons and food losses
were decreased.
Conclusion
As illustrated above, this initiative has shown
that it is possible to invigorate resource-poor,
food-insecure communities affected by dis-ease,
including a high prevalence HIV, to
attain dietary diversity and combat micronu-trient
deficiencies through food-based
approaches. In the fight against HIV, nutri-tion
and antiretroviral drugs are equal and
complementary partners; regular intake of a
diverse diet which includes micronutrient-rich
foods is essential for boosting the immune
system and maintaining good health for
infected and uninfected individuals in a
community.
This project achieved its objective of
improving the food and nutrition security of
HIV-affected children and their communities.
Through project intervention in Lesotho, tar-get
communities increased their vegetable
production from an estimated 10% of their
consumption needs to more than 100%, with
increased diversity. In Malawi, communities
whose food stocks were depleted six months
before the next harvest period had bumper
yields, and testified that they had never expe-rienced
such returns. Indeed, the interna-tional
project evaluation team, in its final
report (May 2008) stated (18):
One remarkable aspect of the project is the
enthusiasm it could generate among
beneficiary households and collaborators in
the districts. It showed that a dynamic

development is possible even in communities
hit hard by drought and diseases and that
local support systems can be created and/or
re-invigorated.
The success of this intervention is attributable
to strategies engaged in its implementation
and some of the elements incorporated in the
planning process.
• Strengthened institutional framework. To
support the project implementation strat-egy,
an institutional framework and sys-tem
was established at central and district
levels. However, the project did not cre-ate
new structures, but rather strength-ened
and utilized existing ones. Where
necessary, supporting structures were
introduced within existing institutions.
For example, in Lesotho, an inter-sectoral
District Coordinating Committee to
guide and oversee project activities was
established within the District
Administration structure. When the
National OVC Coordinating Committee
became operational, this committee was
converted to a District Child Protection
Team (DCPT) with linkages to the
National Committee. DCPTs in the rest
of the country were established based on
the experiences of this committee, which
was established for the project. Further,
through the experience of the project, the
structure and function of this team was
strengthened. DCPTs (in both countries)
have linkages to the National OVC
Coordinating Committees and are sup-ported
by the Departments of Social
Welfare in the Ministries of Health and
UNICEF. Through this local support,
some of the successes of the project at
district and community levels should be
sustained.
• Participatory approaches. The project pro-moted
ownership of this initiative by
using participatory approaches through-out
the implementation process. First,
the district work plan was developed by
district stakeholders themselves and thus
project activities were relevant to the sit-uation
on the ground. Further, through
participatory community needs assess-ment
studies, target communities were
engaged and involved in the planning
and implementation of activities that
addressed their felt needs. Thus, service
providers and target communities imple-mented
project activities with vigour.
Although this approach is time-consum-ing,
it is worth the investment due to its
returns on sustainability.
• Capacity building. Through the participa-tory
community needs assessment stud-ies,
institutional capacities and gaps in
skills necessary for project intervention
at district and community levels were
revealed and, to the extent possible,
addressed. Likewise, community capaci-ties
and capabilities were revealed and,
where possible, strengthened. Thus, the
issue of sustainability of project interven-tions
was partly addressed by strength-ening
existing structures to support
communities beyond the project period;
and grassroots initiatives and coping
mechanisms were also strengthened and
improved within the context of capacity
building.
Overall, in both countries, this intervention
was found to have improved the lives of ben-eficiaries
by the impact assessment studies
conducted at project end. In its report, the
International Evaluation Team (18) endorsed
this finding, asserting
… the mission agrees with the statement
made in the beneficiary assessments that
‘there is no doubt that overall the project has
had a significant impact on the lives of
OVC, those who take care of them and other
members of the community’. This statement
is evident at the material level: e.g. in
Lesotho in spite of a severe drought
horticultural activities promoted by the
project, particularly keyhole gardens,
continued to flourish; in Malawi, harvests
were increased and income generated due to
project support.
Furthermore, besides the intended objectives
and outputs, this project contributed towards
achievement of Millennium Development
Goals 1 and 6, which are eradicating poverty
and hunger, and combating HIV/AIDS,
respectively. Most importantly, food and
nutrition security including consumption of

micronutrient-rich foods in HIV-affected
communities was substantially improved. It
should be mentioned that the achievements
of the projects could benefit from further
technical and financial support to strengthen
their sustainability. Respective countries are
advised to incorporate successful strategies
into appropriate regular programmes and
similar interventions.
Acknowledgements
The contents and material used in this chap-ter
are almost entirely based on information
and reports from the project ‘Protecting and
Improving the Food and Nutrition Security of
Orphans and HIV/AIDS Affected Children in
Lesotho and Malawi: Phase I’.
The authors would like to express their
gratitude to the Governments of Lesotho and
Malawi for providing the opportunity to
undertake and support for the project to show
evidence that it is possible to empower
resource-poor communities affected by
drought and disease, including HIV, to evolve
from a situation of dire food insecurity to one
in which they have access to a variety of foods
in excess.
The authors sincerely acknowledge the
extensive and invaluable contribution of the
project’s IPs, collaborators and consultants.
Special thanks for the extensive and excellent
research support provided to the project goes
to the consultants, Dorothy Chilima (posthu-mously),
Pier Martel and Gilbert Mkamanga.
Valuable comments and inputs were
received from Brian Thompson, Leslie
Amoroso and Janice Meerman, colleagues in
the Nutrition Security and Policy Group of
the Nutrition and Consumer Protection
Division of the FAO.
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6 Animal-source Foods as a Food-based
Approach to Address Nutrient
Deficiencies and Functional Outcomes:
a Study among Kenyan Schoolchildren
C.G. Neumann,*1 N.O. Bwibo,2 C.A. Gewa3 and N. Drorbaugh4
1Departments of Community Health Sciences and Pediatrics, Schools of Public Health
and Medicine, University of California, Los Angeles, California, USA;
2Department of Pediatrics, University of Nairobi, Nairobi, Kenya;
3Department of Global and Community Health, George Mason University, Fairfax,
Virginia, USA; 4Public Health Nutrition Consultant, Los Angeles, California, USA
Abstract
The importance of micronutrients in growth, cognitive development and combating infection is becoming
more evident. The main approaches to ameliorating micronutrient deficiencies have been non-food-based
approaches. This chapter describes a randomized, controlled, school feeding study that tested for a causal link
between animal-source food intake and micronutrient nutrition, growth, cognitive and behavioural outcomes.
Twelve rural Kenyan primary schools were randomized to one of four groups. Standard I children received
the local plant-based dish githeri (maize, beans and greens) as a school snack with added meat, milk or fat (the
latter to equalize the energy content). Control children received no feedings but participated in data collection.
Outcome measures at baseline and longitudinally were 24-hour food intake recall, anthropometry, cognitive
function, physical activity and behaviours during school free play. The meat group showed the steepest rate
of increase in Raven’s Progressive Matrices scores and in zone-wide school end-of-term total and arithmetic
test scores. The meat group showed the greatest increase in percentage time in high levels of physical activity,
initiative and leadership behaviours compared with all other groups. For growth, in the milk group only
younger and stunted children showed a greater rate of gain in height. The meat group showed near doubling
of upper mid-arm muscle area and the milk group a smaller increase. Serum vitamin B12 showed significant
improvement. This is the first randomized controlled feeding study to show the effect of meat- versus milk-versus
plant-based snacks on children’s functional outcomes. Food-based approaches, particularly utilizing
animal-source foods, offer potentially sustainable solutions to multiple deficiencies.
Key words: animal-source foods, meat, milk, growth, development, micronutrients, Kenya
Introduction
Macro- and micronutrient deficiencies associ-ated
with poor dietary quantity and quality
are prevalent globally, and especially in
low-income countries. Children and women
of reproductive age are particularly vulnera-ble
(1,2). Limited availability, accessibility
and intake of animal-source foods at the
* Contact: cneumann@ucla.edu

118 C.G. Neumann et al.
household level, along with a lack of knowl-edge
about their value in the diet and role in
health, contribute to poor diet quality, particu-larly
in women and children (3). Insufficient
energy and protein quality are also important
coexisting problems (4). Moreover, the poor
bioavailability of micronutrients, particularly
iron and zinc, in high-fibre and high-phytate
plant-based staple diets and the low content of
some micronutrients, particularly vitamin B12,
in these foods contribute to deficiencies (3).
In recent years, the vital role of micronutri-ents
in particular in promoting physical growth,
cognitive development and combating infec-tion
in children has come to the forefront;
mainly iron, zinc, vitamin A and vitamin B12
(5–9). Deficiencies of these micronutrients have
a large negative societal impact. App roaches to
combating multiple micronutrient deficiencies
are evolving rapidly and have largely involved
the utilization of multiple micronutrient distri-bution.
Vitamin A capsules have a long history
of use for prevention of vitamin A deficiency, as
do iodine tablets and injections for preventing
iodine deficiency. In addition, iron and folic
acid preparations have long been used to pre-vent
iron deficiency and anaemia, particularly
in pregnancy. Multiple micronutrient sprinkles
have been added to servings of food and used
particularly in several African countries (10).
Most recently, administration of zinc has been
recommended for treating prolonged diar-rhoeal
disease and now as prophylactic treat-ment
to prevent the development of pneumonia
(11,12). The above approaches are useful for
the short-term treatment of acute and severe
deficiencies (13).
Food fortification has a considerably
longer and successful history, especially iodi-zation
of salt, fortification of margarine, cook-ing
oils and fats with vitamin A, and
fortification of wheat with iron and occasion-ally
B vitamins (13). Yet, quality control in
developing countries has been problematic.
Often, multiple micronutrient deficiencies are
present rather than single deficiencies, and the
problem arises if multiple tablets are needed.
Possible negative interactions between iron
and zinc have also been reported (14).
The above ‘nutriceutical’ approaches are
also problematic in terms of sustainability, with
reliance on often relatively expensive imported
products, difficulties in reaching remote and iso-lated
rural populations, and the need for record-keeping
to prevent toxicities (as in the case of
vitamin A). Moreover, as macronutrient and
multiple micronutrient deficiencies often coex-ist,
interventions with only one or two micronu-trients
may not alleviate all functional deficits.
Intervention studies utilizing supplements such
as vitamin A, iron and zinc, either singly or in
combination, have had varying results (15).
As for fortified foods, many rural sub-sistence
households deal relatively little with
the cash economy, grow the bulk of their own
food, rely on small transient markets for pur-chases
and may not have access to fortified
products sold mainly in shops in towns,
where prices may be prohibitive. New
advances have been made in biofortification,
such as growing/breeding high-zinc maize
and wheat, high-lysine cereals and vitamin
A-rich yellow rice and sweet potatoes (16).
However, except for yellow rice and perhaps
sweet potato, this technology is still extremely
limited in implementation and far from being
accepted. Increasing the quantity of the usual
diet consumed will not address diet quality
and the need for multiple micronutrients.
Food-based solutions for dealing with
micronutrient deficiencies, although extre mely
challenging, are potentially sustainable, afford-able,
effective and feasible approaches to
addressing macro- and micronutrient malnu-trition.
Food-based approaches are more feasi-ble
and sustainable in rural areas of poor
countries, especially with the use of locally
available and familiar foods and traditional
preparation and preservation methods (3,17).
Meat, fish and fowl of a wide variety and type,
organ meats including offal and a variety of
rodents, snails, molluscs, insects and annelids
offer a good source of multiple micronutrients
(18,19). Meat products are energy-dense and
contain relatively high amounts of iron and
zinc as well as vitamin B12 in bioavailable
(absorbable) form (19). Haem protein in meat
enhances iron and zinc absorption from plant
foods. Dairy products, although lacking in iron
and zinc, are good sources of calcium and vita-mins
A and B12.
Animal-source foods, particularly a broad
assortment of meat and animal products, sup-ply
complete protein and readily bioavailable

Animal-source Foods 119
micronutrients (20). The fat and protein con-tent
of meat increases energy density, which is
particularly relevant for young children, given
their relatively small gastric volume. Milk and
other dairy products, eggs, meat, fish and
poultry provide high-quality, readily digesti-ble
and complete protein containing all essen-tial
amino acids (21). Moreover, meat, fish,
and poultry contain haem iron, which
enhances non-haem iron and zinc absorption
from cereals and legumes when mixed with
those foods (22–24). Although cereals and leg-umes
may contain considerable amounts of
iron, zinc and calcium, these plant foods have
high content of phytate and fibre which form
insoluble compounds, thereby reducing
absorption of iron, zinc and calcium (25).
They require large volumes to satisfy energy
requirements compared with energy-dense
meat-containing feedings.
In general, animal-source foods are inher-ently
richer and contain more absorbable
micronutrients than plant foods, specifically
of iron, zinc, riboflavin, vitamin A, vitamin
B12 and calcium (26). Animal foods can fill
multiple micronutrient gaps at a greater con-centration
and lower volume of intake than
can plant-source foods (19,26). For example,
100 g of beef has zinc content more than twice
that of maize and beans and is up to ten times
as absorbable (27). However, not all animal-source
foods are of equal nutritional benefit.
Meat and milk are not nutritionally equal;
milk cannot be a substitute for meat, although
it has similar vitamin B12 and protein content
and more vitamin A. This is particularly
important in populations where milk con-sumption
is relatively high and meat con-sumption
is particularly low. Red meat (beef,
lamb, pork) and some small fish have consist-ently
higher zinc and iron content than other
meats such as poultry and many larger fish.
Milk, eggs and fish are important sources of
preformed vitamin A, and fish and milk pro-vide
calcium and phosphorus (28). Vitamin
B12 is provided almost exclusively by meat,
fish, poultry and milk, and is not found in
plant foods. Other important nutrients
supplied by meat, fish and poultry include
copper, riboflavin, magnesium, phosphorus,
chromium, lysine and selenium (21). Fish are
a rich source of high-quality protein and
micronutrients such as iron, selenium, vita-min
C, vitamin D and preformed vitamin
A (29–32). Sea fish and other sea animals are
rich in iodine (33,34) and zinc, and small fish,
when consumed whole, are an excellent
source of calcium, vitamin A and iron (31).
The Nutrition Collaborative Research
Support Program (NCRSP) reported signifi-cant
statistical associations between the intake
of animal-source foods and increased rates of
growth and cognitive development, high
levels of physical activity, positive pregnancy
outcome and decreased morbidity in three
parallel longitudinal observational studies in
Egypt, Kenya and Mexico (20,35–37). In the
NCRSP studies, it emerged that those chil-dren
who consumed little or no animal prod-ucts,
particularly meat, performed least well
on cognitive tests measuring verbal compre-hension
and abstract and performance per-ceptual
abilities, as evaluated by Raven’s
Progressive Matrices (RPM) (38). In addition,
those children consuming the fewest animal
products were the least attentive in the class-room,
less active physically and showed the
least amount of leadership behaviour in the
playground during free play (39,40). The
greatest deficits in linear growth were found
in those with little or no animal-source foods
in their diet (41). The evidence from these lon-gitudinal
observational studies strongly sug-gested
a positive link between the intake of
animal-source foods and improved cognitive,
behavioural and physical development after
statistically controlling for an array of covari-ates
(35–37,39,41).
The above findings stimulated the need
for a randomized controlled intervention
feeding study to test for a causal relationship
between intake of animal-source foods and
health, growth and cognitive function. Thus,
a randomized, controlled, school feeding
intervention trial – the first such study – was
designed to answer whether animal-source
foods, specifically meat and milk, reduce micro-nutrient
malnutrition and promote growth,
cognitive function, micronutrient status and
overall health of schoolchildren in rural Kenya;
and is described in this chapter. Specifically,
it was hypothesized that: (i) supplementa-tion
with milk versus meat would demon-strate
different benefits – the milk group

would show a greater rate of growth in stat-ure
than the meat group because of the higher
calcium and phosphorus content in milk; (ii)
the meat group would show the greatest
improvement in cognitive function, school
performance and physical activity; (iii) vita-min
B12, iron, haemoglobin, zinc and ribofla-vin
status would improve most in the meat
group – in the milk group, improvement in
vitamin A status and a moderate improve-ment
in vitamin B12 and riboflavin status
would also be seen compared with the group
receiving a local plant-based dish and the
control group; and (iv) weight gain would
increase in all supplemented groups com-pared
with the control group.
Methods
A randomized, controlled, school feeding
intervention study of two cohorts of primary-school
children in rural Embu District, Kenya,
was designed to test for the presence of a
causal link among their intake of animal-source
food, rate of growth and development,
and micronutrient status. We designed the
school feeding intervention by adding the fol-lowing
foods to the traditional local plant-based
dish (githeri): meat, milk or oil added as
energy, versus a control group with no inter-vention
feeding. As milk and meat are often
thought to be equivalent, it was felt important
to compare a meat and a milk intervention
separately, as these differ in their content of
some important nutrients (particularly iron,
vitamins A and B12, calcium and zinc). Extra
oil was added to the githeri to equalize the
energy content in the three intervention
groups and to determine whether the same
benefits could be gained by merely increasing
energy intake using a common food. Based on
prior findings in Embu, increasing the intake
of the usual diet was not expected to show the
same benefits as increasing animal products
in the diet (36,42). Interventions that increased
energy intake have been shown to improve
developmental gains in some countries (43).
The Embu study site was uniquely suited
to this intervention study as a cadre of over
100 previously trained, very experienced, local
field workers from a previous study were
available and able to administer all of the
assessments. The methodology for data collec-tion
had been used extensively in this locale,
making the acceptance and implementation
much easier than starting anew elsewhere.
Moreover, the community was extremely
cooperative and an excellent rapport had been
established with the research team.
Two sub-locations were selected in Embu
District, which had approximately 2600
households and 18 schools. Twelve schools,
based on their size and accessibility for daily
food delivery, were randomly assigned to
each of the four conditions, with three schools
per condition. The total sample size of
Standard I children for Cohort I was 525, and
Cohort II was 375 children. Cohort II was
enrolled exactly one year after Cohort I
because of a prolonged teacher strike and
severe drought during the early months of
the Cohort I study. Cohort II students were
recruited from the same schools and the same
feeding groups (replicate study) as Cohort I.
Children with obvious mental retarda-tion
or other chronic handicapping conditions
were excluded from data collection, and chil-dren
who switched to schools with a different
assigned feeding were excluded from data
collection, but all were fed with their class-mates
when at school. Those with prolonged
absences (>3 months) were likewise excluded
from data collection, but not from feeding. Six
children refused to eat meat, and eight chil-dren
refused to drink milk. Thirty children
were excluded from analyses. The children,
enumerators and teachers were not blinded
to the meat and milk interventions but were
not aware of the hypotheses.
Ethics
Approval was obtained from the UCLA
Human Subject Protection Committee, the
Ethics Committee of the University of Nairobi
School of Medicine, and the Office of the
President before the study commenced.
Verbal informed consent by parents, assent
by children and community permissions were
also obtained.

Design
The randomized, controlled feeding inter-vention
study was designed with schools
randomized to three feeding groups and a
control group that received no feeding, and
is described in greater detail in previous
publications (44–46). Feeding assignments
were the same for each school and classroom
within each school. Each treatment group
comprised three schools with children aged
6–14 years (median 7.4 years). The study
continued over seven 3-month school terms
(2.25 years). School feedings were provided
only during the days that schools were offi-cially
open and not during school holidays.
Feeding intervention
Children received mid-morning ‘snacks’
every day they attended school. The control
group participated in all measurements but
did not receive an intervention feeding. Each
control family received a milk goat at the end
of data collection, a gift of the parents’ choice.
The snacks for all three intervention groups
were based on githeri, a local plant dish com-posed
of maize, beans and greens. For the
meat group, finely minced beef (Farmer’s
Choice, Nairobi, Kenya) with 10–12% fat was
added to githeri. The milk group was given a
glass (250 ml) of ultra-heat-treated (UHT)
whole cow’s milk in addition to the basic gith-eri.
The plain githeri (energy) group received
githeri with extra oil (Kimbo, Unilever, East
African Industries, Nairobi, Kenya) added to
equalize the energy content of the three
snacks. Fat was used in all three types of feed-ing,
but most was added in the plain githeri
group. Midway in the study the oil was found
to be fortified with retinol (37 mg/g) but was
not initially labelled. Ingredients were
increased by approximately 25% after one
year as children increased in size and drought
continued. Feedings were designed to offer
about 20% of required daily energy intake.
Preparation and nutrient composition of the
snacks have been described in detail previ-ously
(47,48). Snacks furnished ~1060 kJ (~250
kcal) per day (Table 6.1).
Pilot testing and retraining of field staff,
and baseline observations of children, were
carried out from June to August 1998 for
Cohort I, before the start of feeding with the
Table 6.1. Nutrient content of school snacks.
Githeri + meat Githeri + milk Githeri + extra oil
Year 1: Sept–Nov 1998
Serving size 185 g (includes
60 g meat)
100 g + 200 ml milk 185 g + 3 g oil
Energy (kJ) 1028 1063 1032
Energy (kcal) 239 241 240
Protein (g) 19.2 12.7 7.9
Iron (mg), total 2.42 1.52 3.16a
Zinc (mg), total 2.38 1.46 1.35
Vitamin B12 (μg) 0.75 0.96 0.0
Years 2–3: Jan 1999–Mar 2001
Serving size 225 g (includes
85 g meat)
100 g + 250 ml milk 230 g + 3.8 g oil
Energy (kJ) 1346 1346 1346
Energy (kcal) 313 313 313
Protein (g) 21.7 15.2 8.4
Iron (mg), total 2.94 1.57 3.93a
Zinc (mg), total 2.89 1.66 1.68
Vitamin B12 (μg) 0.91 1.16 0.0
aTotal iron presented. The actual percentage absorbed would be ∼5% due to high phytate and fibre in the plant githeri.

feeding intervention initiated at the begin-ning
of September 1998. For Cohort II, base-line
data were obtained from June to August
1999, and feeding commenced in September
1999. During the second school year of the
study, the children from the first year contin-ued
to be supplemented in their Standard II
classrooms and then in Standard III. To ensure
the hygienic and nutritional quality of the
snacks, personal medical examination of all
food handlers was required and obtained
periodically. Proximate analysis of the snack
types was carried out every 3 months to
evaluate macronutrient content and any
necessary adjustments made. Micronutrient
analyses were carried out at Medallion
Laboratories (Minneapolis, Minnesota, USA),
two to three times per year.
Baseline measures
Baseline measures of the variables to be used
as outcomes and covariates were collected
within 2 months before initiation of the school
intervention feeding at the start of the school
term. Analyses of measurements (t tests) were
carried out to detect any statistically signifi-cant
differences among the feeding and con-trol
groups at baseline.
Household census
The household census included the number
and age of household members, deaths, births
and identification of the household head. The
definition of household membership included
people who usually live in the household,
who shared the food and were part of an eco-nomic
unit. The biological parents of the
index child, and the relationships among
those who resided in the household on a reg-ular
basis (not absent over three consecutive
months), were designated.
Socio-economic status
The socio-economic status (SES) score used a
composite of land and house ownership and
land usage for cultivation; income from any
source; expenditures; ownership of house-hold
goods and implements; forms of trans-portation;
type and structure of the house;
latrine; parent’s occupations and their
involvement in leadership and community
positions; ownership of or access to radio,
television and newspapers; type of water
supply; electrification; number and types of
animals owned, cash crops, etc. Different
weightings were assigned to possessions
based on their relative importance and value.
The SES score was validated by community
leaders using their own criteria for ranking
SES in the former NCRSP study. A statistically
significant correlation between the SES scores
was obtained by each method (36).
Parental information
Parental literacy testing, using Ministry of
Education graded material for reading and
writing, was assessed for each parent. The
highest completed grade of schooling of the
parents was recorded. Parental height was
also obtained. Nearly 100% of mothers were
measured and tested, but only about 70% of
the fathers were available for data collection.
Schools
Children’s attendance was assessed for each
term based on teachers’ reports and records.
Also, the daily school feeding logs at each
feeding session were a source of information
on daily school attendance.
Child measures
Physical status
Baseline health histories and physical exami-nations
of each child were carried out by
nurses and physicians. Obviously retarded or
chronically ill children were excluded from
the study. Clinical nutritional status was
assessed, and vision and hearing were evalu-ated.
Spleen enlargement was assessed as an
indicator of malaria status as well as blood
smears. Stool samples were examined for
intestinal ova and parasites using the formal–
ether sedimentation method and Lugol’s
stain (49).

Venous blood samples were obtained at
baseline and at the end of years 1 and 2.
Haemoglobin was analysed using the
Hemocue apparatus (50) and biochemical
analyses of micronutrients were carried out
only for Cohort I. C-reactive protein was
assessed as a marker of infection and inflam-mation
(51). Malaria parasites were detected
by thick and thin blood smears (quantitative
counts of the number of parasites per red and
white blood cells) (49). Also, malaria
Plasmodium falciparum antigen dipsticks were
used to compare results to microscopy and
found nearly 50% more cases of malaria (52).
These analyses are described in detail else-where
(53,54). A random urine sample was
collected to assess iodine status, with analy-ses
carried out at a World Health Organization
(WHO) Iodine Reference laboratory at the
University of Nairobi.
Growth
Measurements of head and arm circumfer-ence,
height, weight, triceps and subscapu-lar
skin folds were obtained longitudinally
every three months using methods des-cribed
by Jelliffe and Jelliffe (55) and WHO
(56). Methods are fully described by
Grillenberger et al. (57). Indices such as arm
fat area, arm muscle area and body mass
index were derived from the above meas-urements
(58,59).
Food intake
Usual daily intake was assessed by semi-quantitative
24-h recall from the mother and
from the child, if present. Data at baseline
from three consecutive visits, spaced 2–3
weeks apart, were averaged to give the
usual 24-h intake of nutrients. Thereafter,
food intake was obtained monthly. The
WorldFood Minilist was used to convert the
data to nutrient intakes (42). The nutrient
database for Embu was based on Embu
foods with 48 ingredients and dishes actu-ally
analysed for nutrients (Medallion
Laboratories) and the remainder estimated
from a variety of appropriate high-quality
data sources (48,60).
Cognitive, behavioural and activity measures
The cognitive tests, and behavioural and
activity assessments, were those extensively
used in the 1984–1987 NCRSP studies in the
same population (36,39). The same highly
trained and experienced field staff performed
the testing and observations reported here.
The measures have been subjected to repeated
scrutiny, and their reliability and validity
have been demonstrated (36,39). The meth-ods,
which included the Verbal Meaning Test
designed in East Africa, Digit Span (61) and
RPM, have been fully described by Whaley
et al. (45). The RPM is a non-verbal test of per-formance,
abstract meaning, perception and
problem-solving (fluid intelligence) (38). For
all cognitive tests, raw scores were used in the
analyses, as standardization is not available
in Kenya and standardization based on chil-dren
in the USA is not appropriate or mean-ingful
(36,39). Cognitive assessments were
carried out once every 3-month term. End-of-term
examination scores were obtained from
the Head Teacher’s office. These examina-tions
were zone-wide and uniform in content
and grade level across the schools in the area.
Total scores and scores in each school subject
were obtained from the schools for each child
for each term. Frequent quality control, valid-ity
and reliability measures, and training
exercises were carried out.
Physical activity and behaviours
These were measured by observation tech-niques
using time sampling to obtain esti-mates
of child activity and social interaction
during unstructured play in the schoolyard
and activity and attentiveness in the class-room.
Timed observations were used: 30 s for
observation and 30 s for recording. A total of
30 min per child per term was required. Strict
criteria to define activity and behaviours were
used (39,40). Levels of high, medium and low
activity were recorded using predetermined
criteria. Behaviours of leadership, initiative,
solitary play, sustained activity and display
of negative or positive emotion were all
strictly defined and recorded once per term.
In the classroom, paying attention to school-work
at hand and to the teacher, talkativeness

and playing were used to evaluate on-task or
off-task behaviours or paying attention in
class (39). As for cognitive testing, frequent
quality control, validity and reliability meas-ures,
and training exercises were carried out.
Statistical methods for the intervention study
Once schools were randomized to one of the
four intervention groups (control, plain gith-eri
(energy), milk or meat), data collection
began with baseline measurements (times
before 0) and then continued as the school
feeding intervention was initiated. Children
were observed from one to 18 times at differ-ent
intervals, depending on the type of
measurement.
The study had a nested or hierarchical
design (62): schools within feeding groups
and children within schools. The primary
goal of data analyses was to compare rates of
change across children and feeding groups.
The software SAS for Windows 8e (SAS
Institute, Cary, North Carolina, USA) was
used with SAS PROC MIXED to compute
estimates and standard errors for two types
of parameter: (i) fixed effects (feeding group,
baseline age, gender, school), including the
mean intercepts and slopes for the four
groups; and (ii) random effects (morbidity,
anthropometry and food intake), including
the intercepts and slopes of the individual
children and school effects (63). Validity of
the models was confirmed using standard
statistical methods.
Results
Baseline findings
Selected baseline characteristics are shown in
Table 6.2. No significant relationships were
seen for any variables by feeding group.
Although not significantly different among
the groups, the mean SES score for the milk
group was somewhat lower than for the meat
group. The average household size was six,
and families tended to be nuclear or extended
but small. Most mothers completed six pri-mary
grade levels. The writing ability of
mothers was at a mean grade level of 4.6, and
for reading, 6.6. For schooling, fathers com-pleted
one grade higher than the mothers,
completing a mean grade of 7, and their read-ing
and writing literacy abilities were consist-ently
a grade higher than those of the mothers,
with a mean grade level of 8.0 for reading and
mean grade level of 6.5 for writing.
Both height and weight were reported as
Z scores (height-for-age, HAZ; weight-for-age,
WAZ) (54). The mean age of the children
at baseline was 7.4 years, range 6–14 years.
Children are permitted to start Standard I
classes at any age, with the poorer children
tending to start as late as 14 years. Stunting
(HAZ £−2) was found in 19.4% of the sample
as a whole, 23.0% percent of the boys and
15.5% of the girls. Severe stunting (HAZ £3)
was found in 4.6% of the children; the younger
the group, the lower the percentage of stunt-ing.
Underweight (WAZ £−2) occurred in
about 30% of boys and 30% of girls. Mild
underweight (−2<WAZ<−1) was seen in
42.1% of boys and 31.1% of girls.
Body composition estimates
Children were generally lean, with mean tri-ceps
and subscapular skin folds below the
5th percentile based on reference data for
African-American children from the National
Health and Nutrition Examination Survey
(64). On average, arm fat area was in the
5th percentile and arm muscle area in the
5th–10th percentile (58). A higher percentage
of older children were underweight compared
with younger children.
Food intake
Foods were converted into nutrients con-sumed
per day. Detailed information on
food intake is presented elsewhere (48). Total
energy intake was within the recommended
range for a child weighing 20 kg (the mean
baseline weight), which is the 20th percentile
of weight-for-age. At the 50th percentile of
weight for this age, the recommended
intake would be 9211 kJ/day (2200 kcal/
day) (56,65). Total protein intake was also in
the normal range, but total animal-source

Table 6.2. Selected baseline characteristics of Cohort I children.
n
Feeding group
Meat Milk
Plain githeri
(energy) Control
Household SESa 494 95 ± 5 83 ± 5 87 ± 6 93 ± 1
Household SESa 494 95 ± 5 83 ± 5 87 ± 6 93 ± 1
Age of child (months)a 484 93.6 ± 2.7 88.5 ± 2.6 87.0 ± 2.7 88.1 ± 2.7
Male children (%) 494 50 53 51 53
Female children (%) 247 50 47 49 47
Anthropometricsa
Height (cm) 116.5 ± 1.3 115.8 ± 1.3 115.7 ± 1.3 115.8 ± 1.3
Weight (kg) 20.1 ± 0.4 19.7 ± 0.4 19.8 ± 0.4 19.8 ± 0.4
WAZ −1.3 ± 0.1 −1.2 ± 0.1 −1.0 ± 0.1 −1.1 ± 0.1
HAZ −1.6 ± 0.2 −1.3 ± 0.2 −1.3 ± 0.2 −1.3 ± 0.2
WHZ −0.4 ± 0.1 −0.4 ± 0.1 −0.2 ± 0.1 −0.3 ± 0.1
AMA 1558.4 ± 26.8 1566.7 ± 25.8 1575.1 ± 27.1 1560.03 ± 27.4
AFA 424.5 ± 21.4 435.7 ± 20.7 440.0 ± 21.8 429.3 ± 21.8
Maternal height (cm) 156.2 ± 0.6 157.0 ± 0.6 156.6 ± 0.6 156.3 ± 0.6
Paternal height (cm) 164.9 ± 1.0 167.9 ± 1.0 165.6 ± 1.1 166.9 ± 1.1
Nutrient intake
Energy (kJ) 7376 7480 7132 7312
Energy (kcal) 1758 1781 1698 1741
Protein (g) 54.7 53.4 53.6 50.7
Vitamin B12 (μg) 0.37 0.39 0.73 0.54
Riboflavin (mg) 1.06 1.02 1.04 1.03
Vitamin A (μg RE) 274 240 359 333
Calcium (mg) 274 269 268 307
Available iron (mg) 1.51 1.39 1.44 1.4
Available zinc (mg) 1.13 1.02 1.09 0.99
Micronutrient status
(% below cut-off)
Cut-offb
Haemoglobin <115 g/l 51.6 46.3 49.6 48.4
Plasma ferritin <15 μg/l 2.4 10.9 1.5 10.7
Serum iron <9.0 μmol/l 63.9 40.0 47.1 56.1
Serum zinc <10.7 μmol/l 61.5 70.1 64.0 66.7
Serum copper <11.0 μmol/l 0 0.8 0.7 0.8
Plasma vitamin B12
severe <125 pmol/l 46.9 30.6 23.0 19.7
moderate 125–221 pmol/l 33.9 41.0 37.1 38.5
Plasma folate <6.8–13.6 nmol/l 0 0.9 0.8 0.8
Plasma retinol
severe <0.35 μmol/l 31.3 23.9 16.7 17.5
moderate 0.35–0.70 μmol/l 67.6 65.0 66.7 75.7
RBC riboflavin <170 μmol/l 14.9 18.4 28.8 33.7
WAZ, weight-for-age Z score; HAZ, height-for-age Z score; WHZ, weight-for-height Z score; AMA, arm muscle area;
AFA, arm fat area; RE, retinol equivalents; RBC, red blood cell.
aValues are means and standard deviations.
bCut-offs for deficient values are provided by Siekmann et al. (54).
protein and protein from meat, fish and
poultry were extremely low. Fat intake was
generally low, 24 g/day or 13% of energy, as
were the intakes of saturated fat and choles-terol.
Both fibre and phytate intakes were
high, 43.8 ± 18.0 g/day and 3361 ± 1402
mg/day (mean±standard deviation),
respectively (42).

Micronutrient intake
Inadequate micronutrient intakes were highly
prevalent, particularly iron, zinc, vitamin B12,
calcium, vitamin A and, to a lesser degree,
riboflavin. Given the low haem iron in the
diet, the bioavailability of both iron and zinc
was low (3,42). For most micronutrients, the
group differences in intake were not signifi-cant.
However, intakes of vitamins A and B12
were significantly lower in the milk and meat
groups compared with the plain githeri
(energy) and control groups. Vitamin A intake
from animal-source foods was low, with total
intake below recommended levels and most
of the vitamin A derived from carotenoid
sources. Low riboflavin intake was found in
almost a quarter of the children. Inadequate
intakes of vitamin B12 were highly prevalent.
Total iron intake was 17.7 ± 6.3 mg/day
(mean±standard deviation). However,
available iron and haem iron, from meat,
fish or poultry, were generally very low or
negligible, with estimated iron availability
of only 9–10% (3,42). A similar picture was
seen for zinc. Although zinc intake was 7–9
mg/day, estimated zinc absorption was only
11–12% (42). Calcium intake was also low,
with daily calcium intake of 261 ± 118 mg
(mean ± standard deviation; about 35% of
the recommended level).
Biochemical micronutrient status
Baseline biochemical micronutrient determi-nations
confirmed the deficiencies predicted
from food intake data referenced above. The
main deficiencies found were of vitamins A
and B12, iron, zinc and riboflavin (54). Vitamin
B12 deficiency was present in 68.2% of the chil-dren,
with 30.5% having severe deficiency
and 37.7% having mild-to-moderate defi-ciency.
The meat group had the highest prev-alence
of severe vitamin B12 deficiency at
baseline compared with the other groups.
Vitamin A deficiency was present in approx-imately
90% of the sample with severe defi-ciency
present in 22% and mild-to-moderate
deficiency found in 65–75% of all groups.
No clinical signs of vitamin A deficiency
were found during the baseline physical
examination.
Low haemoglobin concentrations (<115
g/l) indicative of anaemia were seen in
48.9% of the sample as a whole, and severe
anaemia (<70 g/l) in 9.0%. The latter chil-dren
were treated with ferrous sulfate for
30 days and had a moderate improvement in
anaemia. There are multiple possible aetiolo-gies
for the anaemia. Malaria is endemic in
Embu, iron deficiency is likely based on its
low dietary availability, and vitamin B12 and
vitamin A deficiencies can also cause anae-mia
(66). Hookworm is not common, but a
high percentage of children had amoebiasis,
a source of intestinal blood loss (54).
Results of the intervention
Cognitive function
Results of the intervention on children’s cogni-tive
function have been explained in detail
by Whaley et al. (45). There were significant
group differences on RPM test scores (P = 0.01)
(Fig. 6.1). The meat group showed the steepest
rate of increase in RPM test scores. The milk
group showed the lowest rate of increase in
RPM test scores, significantly below all other
groups. On arithmetic tests, both the plain
githeri (energy) and meat groups performed
significantly better over time than the milk
and control groups (P < 0.02 to 0.03). No sig-nificant
differences were seen in scores on
tests of verbal meaning and digit span. As for
school performance as measured by end-of-
term test scores, the greatest percentage
increase in zone end-of-term total test scores
was observed in the meat group, with the
greatest percentage increase in arithmetic
subtest scores also seen in the meat group, both
statistically significant increases (Fig. 6.2) (45).
Physical activity and behaviours during
free play
Results of the intervention on physical activity
and behaviours have been presented in detail
by Sigman et al. (46). Over time, the highest
percentage of time spent in high levels of
physical activity during free play was seen in
the meat group (Fig. 6.3). The meat group also
showed the greatest decrease in percentage of

21
20
19
18
17
–0.5 0.0 0.5 1.0 1.5 2.0
RPM test score
Relative years in the study
Fig. 6.1. Changes in Raven’s Progressive Matrices (RPM) test scores by relative year in the study (over
a 2-year period) and feeding group ( , control group; , plain githeri (energy) group; , milk group;
, meat group). (Adapted from Neumann, C.G., Murphy, S.P., Gewa, C. Grillenberger, M. and Bwibo,
N.O. (2007) Meat supplementation improves growth, cognitive, and behavioral outcomes in Kenyan
children. Journal of Nutrition 137, 1119–1123 with permission from the American Society for Nutrition.)
Meat Energy Milk Control
25
20
15
10
5
0
–5
–10
Feeding group
Increases in end-of-term test scores
Fig. 6.2. Increases in end-of-term test scores ( , total scores; , arithmetic scores) by feeding group
(Cohort II). (Adapted from Neumann, C.G., Murphy, S.P., Gewa, C. Grillenberger, M. and Bwibo, N.O.
(2007) Meat supplementation improves growth, cognitive, and behavioral outcomes in Kenyan children.
Journal of Nutrition 137, 1119–1123 with permission from the American Society for Nutrition.)

10
8
6
4
Percentage of time spent in
high activity (%)
2
0
–0.19 0.0 0.5
1.0 1.5 1.9
Relative year
Fig. 6.3. Change in high activity over time by feeding group ( , control group; , plain githeri
(energy) group; , milk group; , meat group). (Adapted from Sigman et al. (46), with permission
from the Food and Nutrition Bulletin.)
2.0
1.5
1.0
0
–0.19 0.0 0.5
1.0 1.5 1.9
Relative year
0.5
leadership activity (%)
Fig. 6.4. Change in leadership activity over time by feeding group ( , control group; , plain githeri
(energy) group; , milk group; , meat group). (Adapted from Sigman et a l. (46), with permission
8
7
6
5
4
3
2
1
0
–0.19 0.0 0.5 1.0
Relative year
1.5 1.9
initiating behaviours (%)
Fig. 6.5. Change in initiating behaviour over time by feeding group ( , control group; , plain githeri
(energy) group; , milk group; , meat group). (Adapted from Sigman et al. (46), with permission
time spent in low levels of physical activity.
When compared with all other groups, the
meat group showed the greatest increase in per-centage
of time in leadership activities (Fig. 6.4)
and the greatest increase in percentage of time
in initiative behaviour (Fig. 6.5). Children in
the plain githeri (energy) group were also more
active and displayed more initiative and lead-ership
behaviours than those in the milk and
control groups, although not nearly as much

as for the meat group. The milk group per-formed
the most poorly of the three interven-tion
groups.
Growth
All feeding groups showed a greater rate of
weight gain compared with the control
group. For the milk group, only younger
children (£6 years) and stunted children
(HAZ £ −2) showed a greater rate of gain in
height than the other children in the milk
group. None of the other groups showed any
significant rate of gain in height. The meat
group showed the steepest rate of increase
of mean arm muscle area (indicative of lean
body mass) (Fig. 6.6), and the milk group
showed the next greatest improvement.
A significant positive association was found
between mean arm muscle area and percent-age
of time spent in high levels of physical
activity in the meat group.
Discussion
This chapter describes the first randomized,
controlled, feeding intervention study with
meat supplementation ever carried out. It
shows a causal set of positive relationships
between meat intake and important func-tional
outcomes in children: improved cogni-tive
performance; increased high levels of
physical activity; increased initiative and
leadership behaviours; and increased mean
arm muscle area. Milk supplementation
resulted in improved linear growth in younger
and already stunted children. Compared with
the control group, all supplemented groups
improved overall weight gain, suggesting a
chronic energy deficit and inadequate energy
intake for any catch-up growth.
The improved cognitive performance
and increased physical activity and leader-ship
and initiative behaviours in the meat
group may be linked to the greater intake of
AMA (mm2) Fig. 6.6. Increases in mid-upper-arm muscle area (AMA) by time in study (Cohort I and II) and feeding
0 5 10 15 20 25 30
1750
1650
1550
Time (month)
group group ( , control group; , plain githeri (energy) group; , milk group; , meat group).
(Adapted from Neumann, C.G., Murphy, S.P., Gewa, C. Grillenberger, M. and Bwibo, N.O. (2007)
Meat supplementation improves growth, cognitive, and behavioral outcomes in Kenyan children.
Journal of Nutrition 137, 1119–1123 with permission from the American Society for Nutrition.)

vitamin B12 and more available iron and zinc
as a result of the presence of meat, which
increases iron and zinc absorption from fibre-and
phytate-rich plant staples (3). Meat,
through its intrinsic micronutrient content,
other constituents and high-quality protein,
may facilitate specific mechanisms, such as
speed of information processing, that are
involved in learning tasks such as problem-solving.
This is reflected in the significant
increase in RPM test scores in the meat group.
The milk group performed the poorest on the
RPM testing. A possible explanation is that
milk, with its high casein and calcium con-tent,
impedes iron absorption; and iron is inti-mately
involved with cognitive function (45).
The increase in mean arm muscle area in the
meat group may be because of the intake of
zinc and complete protein, which both pro-mote
protein synthesis (67–69). In summary,
this chapter documents health, cognitive and
functional benefits associated with animal-source
food consumption. These benefits were
seen with the addition of relatively modest
amounts (60 g) of meat.
Recent studies have also documented
the benefits of food-based approaches inte-grating
meat. A recently completed study in
Guatemalan children reported improve-ments
in vitamin B12 status and development
following supplementation with beef or
vitamin B12 (70). A quasi-experimental com-munity-
based dietary intervention in Malawi
involving dietary diversification with an
increase in the utilization of fish reported sig-nificant
improvement in lean body mass of
stunted children after 12 months (22). Other
studies are underway integrating animal-source
food into diets to ameliorate deficien-cies
in both infants and children using a
variety of types of meat.
Challenges for integrating animal-source
foods in food-based approaches
A number of constraints impede the integra-tion
of animal-source food, especially meat,
into diets, particularly in resource-poor set-tings.
At both the household and the commu-nity
level, various approaches for addressing
micronutrient deficiencies and increasing
access to and availability of animal-source
food, particularly meat, are being used.
Various traditional food processing and
preparation methods such as soaking, fer-mentation,
germination/malting, thermal
processing and mechanical processing can be
used to enhance the bioavailability of micro-nutrients
from plant-based diets (71,72) by
reducing the phytate.
Promotion of small-animal husbandry,
particularly by women and children, prima-rily
for household consumption and second-arily
for income generation, is being promoted
by a number of non-governmental organi-zations
(NGOs) as a strategy for improving
nutritional outcomes in populations with
little access to animal-source food. This
approach is being tried in multiple sites in
Ghana though a project initiated by the Global
Livestock Collaborative Research Support
Program, called ‘Enhancing Child Nutrition
through Animal Source Food Management
(ENAM)’ (73). This project has documented
an increased diversity of animal-source food
in the diet when mothers had an income-generation
activity based on animal-source
food, as well as an increase in mothers’
nutrition knowledge and greater diversity of
animal-source foods fed to their children
(74,75). Other studies have shown household
livestock ownership and production to posi-tively
affect production and consumption of
animal-source food, overall dietary intake,
household income and nutritional status
(76,77). At the household level, small animals
can provide a variety of products, including
meat, milk, butter, yoghurt and fat, to meet
nutritional needs. After meeting those needs,
animal-source food can be sold for income
generation. Microcredit can help promote
nutrition improvement with maternal educa-tion
and income generation by providing
small loans to start small businesses. Badly
needed are services from extension agencies
and NGOs targeted at women by women, as
they do the bulk of care for small household
animals (78,79). Gender issues need to be
addressed with regard to intra-household
distribution of animal-source food, as the
most vulnerable household members – young
children, women of reproductive age and

HIV-positive individuals – are often denied
animal-source food.
More household and community initia-tives
for food preservation are needed to pre-vent
spoilage and wastage and to ensure a
steady supply of animal-source food, espe-cially
for poor households who cannot afford
to purchase meat, fish and poultry in the cash
economy. Creative preservation techniques
for animal-source food have included blood
biscuits as well as cereals fortified with dried
blood, used in Latin America and in parts
of Africa, resulting in improved iron status
(80–83). A study is underway in Kenya of
HIV-positive women and their children using
a meat-containing biscuit.
A problem with rearing animals for con-sumption,
including fish, is the need for pres-ervation
to prevent spoilage in the absence of
refrigeration. Smoking and solar drying are
common options to produce safe, shelf-stable
products under controlled conditions. The
NutriBusiness project whereby community
women’s groups produce weaning foods has
been successful (84–87). Their groups, on a
trial basis, have solar-dried rabbit and
chicken, producing finger foods such as chips
that can be powdered for inclusion in wean-ing
porridge. Weaning mixes are sold for
income generation, as are non-meat products.
Several African countries have now adopted
this approach. The NutriBusiness project pro-vides
an example of a successful enterprise
by rural Kenyan women to preserve plant
and meat foods. Meat products are now being
added to weaning mixes as a strategy to
improve meat, fish and poultry intake in chil-dren.
Small-scale community development
approaches address not only the problem of
improving children’s health, nutrition and
development, but also interrelated problems
of rural poverty and gender inequity.
At farm and community level, improve-ment
of the nutrient content of soil in which
forage is grown is required, and affordable
fertilizer and more sustainable agricultural
practices through improved extension serv-ices
are badly needed. Appropriate models
for small livestock development utilize zero-grazing.
Aquaculture to produce small fish
for human domestic consumption is gaining
in popularity and needs to be better balanced
with fish production for animal feed. Schools
can also be used to improve nutrition status.
School gardens and small-animal husbandry
projects can increase children’s knowledge
as well as access to animal-source food.
Agricultural extension services (government
and NGOs) need to be extended to women
and schoolchildren who perform much of the
raising of small animals at a household level
by women extension workers. Several NGOs
such as Heifer Project International, Farm
Africa and World Vision already have suc-cessful
programmes to promote raising small
livestock using appropriate technologies and
education on animal husbandry targeting
communities. In the Paravet programme in
Kenya, women veterinarians train local
women to take care of animals through agri-cultural
extension (88,89). Appropriate nutri-tion
education emphasizing the preparation
and value of different foods for dietary
improvement would greatly enhance these
programmes (20).
While food-based solutions are more
complex and interdisciplinary in nature and
require long-term commitments, they are
more likely to address malnutrition at its
source, leading to long-term sustainable
improvements. Food-based approaches, we
believe, can offer more protection and sustain-ability
than single- or multiple-micronutrient
non-food supplements. The addition of mod-est
amounts of meat, fish, poultry and other
animal-source foods to the diet can greatly
improve the health, micronutrient intake,
overall nutrient status and function of rural
populations, particularly of women and chil-dren
(20,44,90,91). Putting ‘meat on the table’
requires a supply of small animals within the
production capabilities of smallholder farm-ers
and families. Extension workers need to
provide technical support and nutrition edu-cation
to women in household animal pro-duction
and in the preparation, preservation
and feeding of such animal-source foods,
particularly meat, to children and young
women.
Nutrition improvement is vital and
should be an integral part of health, educa-tion
and development efforts. A major con-straint
on the development of human capital
and capacities is the loss of human potential,

both physical and mental, due to poor nutri-tion
(92). Food-based approaches in rural
areas are most likely to be sustainable in
improving diet quality and energy density
with animal-source food in contrast to ‘pill-based’
approaches. Improved nutritional sta-tus
is important in building human capital
and is a first and fundamental step to reduc-ing
poverty and promoting social and eco-nomic
development.
Acknowledgements
The study, ‘Role of Animal Source Foods to
Improve Diet Quality and Growth and
Development in Kenyan School Children’,
was supported by the Global Livestock
Collaborative Research Support Program
(GL-CRSP) directed by Montague W.
Demment, whose broad vision encompassed
the inclusion of human nutrition as part of
livestock development, United States Agency
for International Development (Subgrant
No. DAN-1328-G-00-0046-00); the James A.
Coleman African Study Center (UCLA);
and was funded in part by the National
Cattlemen’s Beef Association (PCE-G-98-
00036-00). Dr Marian Sigman, a child devel-opment
expert, directed the cognitive, activity
and behavioural aspects with the assistance
of Dr Shannon Whaley. Dr Robert Weiss
directed statistical analyses. Pia Chaparro
contributed to the background and develop-ment
of this chapter. Biochemical assess-ment
was directed by Dr Lindsay H. Allen.
Dr Suzanne Murphy directed the food intake
analysis. Monika Grillenberger, Erin Reid and
Jonathan Siekmann also conducted fieldwork
and analysis of data. The authors thank the
families and schools of Embu who partici-pated
in the study.
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7 Small-animal Revolving Funds:
an Innovative Programming Model
to Increase Access to and Consumption
of Animal-source Foods by Rural
Households in Malawi
A.C. MacDonald,1 B.J. Main,*2 R.H. Namarika,3 M.E. Yiannakis1 and A.M. Mildon2
1World Vision International Nutrition Centre of Expertise, Mississauga, Ontario,
Canada; 2World Vision Canada, Mississauga, Ontario, Canada; 3World Vision Malawi,
Lilongwe, Malawi
Abstract
Increased intake of animal-source foods is a key means to improve nutritional status in populations with
high levels of nutrient deficiencies. However, there are few examples of programming models that have
successfully improved both access to and consumption of animal products in resource-poor settings. This
chapter presents a case study of a community-based intervention to increase household access to and
consumption of animal-source foods, implemented as part of a comprehensive, 9-year nutrition and health
programme in Malawi.
A community-managed revolving fund scheme was used to distribute small animals to rural house-holds,
accompanied by training on animal husbandry and intensive nutrition education to promote con-sumption
of the animal products. This was integrated into a broader anaemia control strategy, which
included iron supplementation and malaria control. Cross-sectional surveys were used to evaluate pro-gramme
effectiveness, including comparison of beneficiary communities with non-programme areas.
Household rearing of all small animals increased from 43% to 65% in programme areas. Significantly more
households in the programme area both raised and consumed the target animals at the final evaluation.
Anaemia prevalence in pregnant women decreased from 59% to 48% in the programme area, but increased to
68% in the comparison group. In pre-school children, anaemia prevalence decreased similarly in both groups.
The revolving fund scheme successfully increased access to and consumption of small animals in
programme communities. Anaemia prevalence decreased in women, but the specific contribution of the
animals to this cannot be separated from the combined impact of the integrated programme.
Key words: animal-source foods, anaemia, revolving fund
Introduction
The nutritional benefits of animal-source
foods are well documented, as is the lack of
these foods in the diets of many populations
suffering from high levels of nutritional defi-ciencies
(1). However, the identification of
effective strategies to increase access to and
* Contact: Barbara_Main@worldvision.ca

138 A.C. MacDonald et al.
consumption of animal-source foods by vul-nerable
populations has proven challenging.
Many projects which promote livestock-raising
are oriented towards improving
household income rather than nutritional sta-tus,
and therefore fail to promote consump-tion
of the animals or to measure changes in
dietary patterns of beneficiaries (2). There are
few published examples of interventions that
have both successfully increased household
access to animal-source foods and demon-strated
an impact on specific nutritional
deficiencies. Strengthening knowledge and
experience in this area therefore remains a pri-ority
for the international nutrition community.
This chapter presents a case study from
Malawi, where an intervention to increase
households’ raising and consumption of
small animals through a revolving loan dis-tribution
scheme accompanied by intensive
nutrition intervention was implemented as
part of a comprehensive micronutrient and
health programme. Although animal-source
foods have multiple nutritional benefits, a
major emphasis of the overall programme
was on prevention and control of iron defi-ciency,
and therefore anaemia prevalence
was used as the outcome indicator.
Iron deficiency anaemia is the most
common nutritional disorder in the world, dis-proportionately
affecting a significant percent-age
of women and children in developing
countries (3). Often subtle in manifestation,
anaemia exacts a tremendous burden in terms
of lost earnings, premature death and poor
health outcomes. Lack of dietary iron is the
primary causal factor in approximately half of
anaemia cases worldwide (3). The iron sources
with greatest bioavailability (i.e. most readily
absorbed and utilized by the body) are animal
products, which contain haem iron. However,
typical diets in many developing countries
provide very little iron or iron that is poorly
absorbed by the body. Rural families in Malawi,
for example, tend to consume a maize-based
diet that is high in phytate, a strong inhibitor
of iron absorption, and very low in haem iron
and other enhancers of iron absorption.
Anaemia prevalence has been assessed as 73%
in children under 5 years old, with 82% of their
mothers also anaemic (4). An analysis of the
iron intake of pregnant women in rural
Malawian communities found that 89% of die-tary
iron was non-haem, and that the intake of
bioavailable iron was significantly associated
with iron status (5). Interventions to improve
dietary intake of bioavailable iron, particularly
through animal-source foods, are urgently
needed in such settings to combat the high lev-els
of iron deficiency and anaemia. Such inter-ventions
have the added advantage of reaching
the whole population and providing a variety
of nutritional benefits, including high-quality
protein and multiple micronutrients (6).
However, among the limited published
reports of studies aiming to increase iron intake
through animal-source foods, few have effec-tively
paired the dietary interventions with
improved nutritional status. In Vietnam, iron
intake in children increased following an inter-vention
that included home gardens, fishponds
and animal husbandry, but iron status was not
assessed (7). Iron status (serum ferritin) of
schoolgirls in Thailand improved following a
similar multidimensional food-based interven-tion,
but concurrent interventions (iron supple-mentation
and an improved school meal
programme) prevented attribution of the bio-chemical
results directly to household dietary
changes (8). In some cases, food-based inter-ventions
have resulted in improved family
income but no changes in diet quality of target
beneficiaries (9). Other intervention studies
have demonstrated an increase in household
food security and consumption of animal-source
foods by women and children, but did
not measure changes in nutritional status
(10,11). Thus there remains a critical need for
well-designed and evaluated interventions to
increase access to haem iron sources in popula-tions
where anaemia is highly prevalent.
An important lesson from these pre-viously
published reports is that effective
strategies to increase intake of iron-rich
animal-source foods require significant effort
to integrate nutrition education with activi-ties
to increase access to appropriate animal
products (12). Interventions need to be ori-ented
towards household consumption of the
animals raised, as opposed to a primary focus
on income generation through livestock sales
(2). Additionally, the animals must be able to
reproduce frequently enough to provide a
regular source of meat and must be culturally

Small-animal Revolving Funds 139
acceptable and able to thrive in the local envi-ronment.
Incorporating an understanding of
cultural factors affecting preferential food
allocation within the household is also key in
many settings, as these issues may play a role
in limiting the intake of animal-source foods
by children and women (13).
Food-based interventions to address anae-mia
must also be delivered in combination
with essential primary health care measures.
Although iron deficiency is the most common
cause of anaemia, other factors also contribute
to and exacerbate anaemia status (14). These
include infectious diseases, particularly malaria
and hookworm infection; other micronutrient
deficiencies, such as folate, vitamin B12 and
vitamin A; blood losses during menstruation
and childbirth; and inherited conditions such
as sickle cell disease. The aetiology of anaemia
in Malawi includes both iron deficiency, due to
the dietary limitations discussed earlier, and
malaria and parasitic infections. The 2001
Malawi Micronutrient Survey found malaria
prevalence to be extremely high, ranging from
17% in non-pregnant women to 60% in chil-dren
aged 6–36 months (15).
Methods
World Vision, an international non-govern-mental
organization, initiated the MICro-nutrient
And Health (MICAH) programme in
Malawi in 1996, with funding from the
Canadian International Development Agency
and World Vision Canada. The programme
goal was to improve the nutrition and health
status of women and children, specifically
focusing on iron and iodine deficiencies.
MICAH was implemented from 1996 to 2005
in 16 project sites throughout Malawi, cover-ing
14 of the 26 districts in the country, prima-rily
in rural areas.
The raising of small animals was identi-fied
as the focal intervention of MICAH’s
dietary diversification strategy due to the
high bioavailability of key micronutrients
such as iron and zinc in animal-source
foods. A revolving fund scheme was devel-oped
as the implementation strategy for this
intervention.
MICAH’s small-animal revolving fund
scheme (SARF) employed a distribution
method whereby the programme provided
initial animal stock to a number of individu-als
who were selected according to criteria
determined by the community. These indi-viduals
were then required to give the first
offspring from their animals to others in the
community, and so on until full distribution
throughout the community was achieved.
Prior to receiving any animals, the beneficiar-ies
were required to construct a shelter to
house them, according to training provided
by staff from the Ministry of Agriculture’s
Department of Veterinary Services. Where the
community identified beneficiaries (such as
the elderly or adults with chronic illnesses)
who were unable to construct the required
shelter, a committee would be formed to assist
that household. The type of shelter con-structed
varied throughout the country
according to the local environment. The ani-mals
distributed included goats (initially),
rabbits, chickens and guinea fowl. The accom-panying
nutrition education promoted the
consumption of all animal-source foods.
Significant resource investments were
made from the very onset of the programme
to engage the community, so that MICAH’s
SARF was developed as a collaboration
between village health committees; Ministry
of Agriculture, Irrigation and Food Security
(MoA) veterinary extensionists; MICAH staff;
local implementing partners; and community
members. Preliminary capacity-building ini-tiatives
included a five-day training session
led in partnership with MICAH staff and rep-resentatives
from the MoA and the Ministry
of Health (MOH). In addition to education on
the other programme activities, these sessions
focused on animal husbandry techniques.
Trainings were developed by MICAH part-ners
to address regional differences and were
based on the expertise of the local veterinary
extensionist and his/her MoA resources. In
many cases a community ‘expert’, such as a
successful farmer in that locale, was asked to
assist with MICAH training to share their
knowledge and lessons learned. Workshop
participants, comprising four or five men and
women from each village, left the training
sessions to act as trainers of trainers to initiate

promotion and peer education activities
with in their own communities. Building upon
these health promotion initiatives, commu-nity
members were surveyed regarding their
interest in participating in the SARF. Interested
households were then provided with educa-tion
on animal husbandry, including the con-struction
of the animal enclosures.
Initially the programme focused on
goats, by providing an improved variety of
male goats for breeding with traditional
local female goats to produce offspring with
bet ter meat and milk production potential.
However, a mid-term evaluation revealed
that because goats are relatively large and
important animals within the community
setting, they were not being consumed on a
regular basis by households and were not
under the control of the women, who pro-vided
meals for the household. Rather, they
would be used for ceremonial purposes such
as a chief’s wedding, a funeral or major reli-gious
events. At these events, it was usually
the men who would consume the meat and
women would often only receive a small
portion, if any at all. It was thus concluded
that although the goats were valued as an
input by the communities, the intervention
was not directly contributing to an increase
in consumption of animal-source foods by
women and children, the key target groups
of the programme.
Through collaboration and discussion
with the MoA, MOH and MICAH imple-menting
partners, the promotion of rabbits
was identified as a possible means of impro-ving
the quality of dietary intake within the
target area, as an alternative to goats. Rabbits
are small and therefore not as highly valued
as the larger goats. Also, rabbits reproduce
quickly, unlike the one goat kid per year,
and were thus more likely to be used by
women for family meals. The lower per-ceived
value of the rabbits also enabled the
women to have decision-making control
over the use of the rabbits, whereas the goats
were under the control of the male house-hold
head.
Since the consumption of rabbit meat
was new to most project communities, sig-nificant
effort was required in introducing
the concept. Cooking demonstrations and
taste tests involving influential members of
the communities, particularly religious lead-ers,
proved an effective means of overcom-ing
initial hesitation regarding the rabbits.
The staff also assessed each community to
decide on the committee that would take up
the responsibility of the rabbit revolving
funds and identification of initial beneficiar-ies.
In some cases, the initial beneficiary was
the chief’s household, or another influential
member of the community. This was due to
the fact that once these influential people
adopted the new practice of rabbit-rearing,
it would be deemed acceptable by the oth-ers.
In other cases, especially needy families
would be identified as primary beneficiaries
so that the community would be able to see
the difference made in the diet and lives of
people with few resources. In this way, the
programme adapted to the unique charac-teristics
of each community in order to maxi-mize
the acceptance and coverage of the
intervention.
The SARF was managed by local village
health committees, which were responsible
for overseeing and monitoring the interven-tion.
While MICAH suggested that animal
offspring benefit at least three other house-holds,
it was ultimately the responsibility of
the local community to define the payback
plan for their village. A sub-committee was
responsible for gathering village-level statis-tics.
The sub-committee secretary maintained
a master registry of village households,
SARF animals distributed and their related
statistics, including births, deaths, probable
cause of death, vaccination status and dates
of mass vaccinations.1 MICAH staff then
used these data to address any issues that
needed to be resolved; however, beneficiar-ies
were encouraged and empowered to
resolve problems at the community level.
The local veterinary extensionist was also
required to submit reports on small- animal
husbandry activities (including MICAH
SARF) to the MoA.
1 While MICAH recommended that the commu-nity
collect certain information, each SARF sub-committee
established its own registry format with
data collection based on local needs.

Within each village, MICAH also estab-lished
a small-animal revolving drug fund.
SARF training included the identification and
treatment protocols for common animal ill-nesses
that beneficiaries might encounter.
Animal owners were encouraged to purchase
the appropriate medicine from the revolving
drug fund when an animal was ill. This
revolving fund was also administered by
the village health committee, which had a
designated treasurer in charge of finances.
Medicines were sold for a small profit to cover
the cost of transportation (for restocking) and
inflation. Although the initial animals intro-duced
in the community were pre-vaccinated,
it was the responsibility of the local veteri-nary
extensionist and animal owner to follow
up on immunizations for future offspring.
The local veterinary extensionist also organ-ized
periodic mass immunization campaigns
with vaccines provided by the government
via the existing MoA system.
In addition to the small animals, MICAH
Malawi promoted and supported the estab-lishment
of household and communal gar-dens,
in close collaboration with the MoA.
The emphasis was on cultivation of fruits that
enhance iron absorption through vitamin C
(such as citrus fruits) or that are rich in vita-min
A (mango, papaya), and indigenous vari-eties
of dark green leafy vegetables. Solar
driers were introduced as a best practice in
preservation of fruits and vegetables, to pro-vide
a year-round source of micronutrients.
The SARF intervention was also integrated
into MICAH’s overall anaemia prevention
and control strategy, which included the
following activities: iron supplementation
(weekly to women of childbearing age and
children under 5 years old, daily to pregnant
women); fortification of staple foods with
iron, zinc, vitamin A, B vitamins and folate;
malaria prevention and treatment; hookworm
control; latrine construction; and capacity
building and advocacy for improved anaemia
programmes at all government levels.
Programme evaluation
Effectiveness of the MICAH programme in
Malawi was evaluated through cross-sectional
surveys, a baseline in 1996 and final evalua-tion
in 2004. Two-stage cluster sampling was
employed, using proportionality to popula-tion
in the selection of clusters and house-holds.
Key indicators were assessed through
semi-structured interviews with a standard-ized
questionnaire and by collection of
biochemical, clinical and anthropometric data
(16). At the final evaluation in 2004, a sample
of communities outside the programme
areas (hereafter referred to as the non-
MICAH group) was also included as a means
to evaluate the MICAH programme effective-ness
through comparison with similar
communities which received the usual gov-ernment
interventions, but not the additional
anaemia control package delivered by
MICAH.
Mobile laboratories were set up in the
participating communities to collect data on
haemoglobin, malaria and parasite infec-tion.
Haemoglobin was measured onsite
from finger-prick blood samples using a
portable haemoglobinometer (HemoCue
AB, Angelholm, Sweden). Malaria parasites
were also examined onsite by thick blood
smears using Field’s A and B staining tech-nique
(17). A direct microscopy technique
was used for stool examination to look for
ova, cysts and parasites. All laboratory pro-cedures
were conducted by qualified tech-nicians
from selected health facilities in
Malawi.
Data were entered and analysed using
standard statistical packages (e.g. EpiInfo,
SPSS). Significance testing for differences
from baseline to follow-up, and between
MICAH and non-MICAH groups in the final
evaluation, was done by chi-square tests for
categorical variables and t tests for continu-ous
variables. A wealth index (18) was applied
to confirm the similarity of the MICAH and
non-MICAH communities.
The MICAH programme, including the
evaluation design, received ethics clear-ance
from the Ministry of Health in Malawi.
At the community level, the surveys were
conducted after verbal consent from tradi-tional
authorities in the participating
clusters, and from the sampled household
heads and respondents, on behalf of their
children.

Results
The MICAH programme was implemented
in 16 project sites, directly reaching 272,400
people in 45,400 households throughout
Malawi. General characteristics of the target
population are described in Table 7.1. There
were improvements in women’s literacy,
household access to water and sanitation
facilities, and child growth in both MICAH
and non-MICAH areas over the 8-year period
between the baseline and final surveys.
However, the improvements in access to clean
water and prevalence of childhood under-weight
were markedly greater in the MICAH
programme areas.
The findings of the wealth ranking anal-ysis
are not presented here, but there was no
material, nor statistically significant, differ-ence
in median household wealth score by
MICAH versus non-MICAH village.
Ownership and utilization
of small animals
The MICAH SARF intervention provided
40,000 small animals as initial inputs to com-munities.
At the close of the programme,
15,000 offspring had been distributed through
the revolving loan system. The resulting
increase in small-animal ownership in
MICAH households is reflected in the 2004
evaluation data (Table 7.2).
An important element of the SARF inter-vention
was educating the target population
to view their animals as a food source, not
primarily as an income-generating activity.
To this end, an extensive nutrition education
effort accompanied the distribution of ani-mals
and training on their care and breeding.
Table 7.3 presents evaluation data indicating
that household consumption of animal prod-ucts
did increase over the programme lifetime
and in 2004 was significantly greater in
MICAH compared with non-MICAH house-holds
for chicken, goat and rabbit meat.
In the 2004 survey only, 24-hour recall
data were collected to determine food con-sumption
patterns among children aged 6–59
months using a 7-point scale. Approximately
25% of the children (n = 408) reported con-suming
meat the previous day. However, the
questionnaire did not assess either the spe-cific
types of meat or the quantity consumed.
Prevalence of anaemia
The ultimate purpose of the SARF interven-tion,
as one component of the broader inte-grated
strategy of the MICAH programme,
was to reduce anaemia in vulnerable groups
through increased household access to a
Table 7.1. General characteristics of the study population.
Indicator 1996 (n) 2004 MICAH (n) 2004 non-MICAH (n)
Illiteracy among women ≥14 years old (%) 55 (1682) 27a (4322) 31 (2210)
Households with access to a clean water
55 (1269) 81a,b (1932) 73 (981)
source (%)
Households with access to sanitary
facilities (%)
49 (1269) 94a,b (1935) 90 (988)
Stunting in children aged 6–59 months
(% with HAZ < –2)
56 (504) 40a (1387) 39 (651)
Underweight in children aged 6–59 months
(% with WAZ < –2)
29 (504) 13a,b (1387) 23 (651)
Wasting in children aged 6–59 months
(% with WHZ < –2)
8 (504) 2a (1387) 2 (651)
MICAH, MICronutrient And Health (programme); HAZ, height-for-age Z score; WAZ, weight-for-age Z score; WHZ,
weight-for-height Z score.
aStatistically significant difference compared with results for 1996 (P < 0·05).
bStatistically significant difference compared with 2004 non-MICAH group (P < 0·05).

While iron deficiency is the major cause of
anaemia worldwide, it is not the only relevant
cause in Malawi. Table 7.5 presents the preva-lence
of malaria and hookworm, major contrib-utors
to anaemia, in MICAH and non-MICAH
areas. However, it is not possible to determine
the relative contribution of each causative fac-tor
to the high rates of anaemia with the level of
data collected in the MICAH surveys.
The coverage of other essential anaemia
control interventions, implemented in conjunc-tion
with the SARF, is described in Table 7.6.
The comprehensive anaemia control
strategy implemented by MICAH Malawi
prevents determination of the specific con-tribution
of the SARF intervention to the
observed reductions in anaemia. However,
statistical analysis of data collected from
women in 2000 (not presented here) and 2004
found a positive association between several
key interventions and higher mean haemo-globin
levels (19). For both pregnant and
non-pregnant women these included absence
of malaria infection, consumption of iron
supplements and presence of a household
latrine. The presence of small animals at the
household was positively associated with
haemoglobin for non-pregnant women.
On the other hand, further analysis of 2004
data from pre-school children found that nei-ther
consumption of meat in the past 24 h nor
household ownership of livestock was protec-tive
for anaemia. Associations with being non-anaemic
were consuming dairy products in
the past 24 h (odds ratio (OR) = 0.40, 95%
Table 7.2. Household ownership of animals.
Indicator
1996
(n = 1272)
2004 MICAH
(n = 1930)
2004 non-MICAH
(n = 988)
Households with any small animals (goat, chicken,
rabbit, guinea fowl, duck, pigeon) (%)
43 65a,b 50
Households with goats (%) 32 27a 26
Households with chickens (%) 40 59a,b 47
Households with rabbits (%) 1 17a,b 3
Households with guinea fowl (%) <1 8a,b 3
Households with ducks (%) 3 6a 6
Households with pigeons (%) 4 5a 4
MICAH, MICronutrient And Health (programme).
Table 7.3. Household consumption of animal
products.
Product
Households with various small
animals reporting consumption
as main use (%)
1996 2004 MICAH
2004
non-MICAH
Chicken eggs 28 52a 47
Chicken meat 33 58a,b 42
Goat meat 13 26a,b 17
Rabbit meat 0 65b 39
Guinea fowl
0 63 52
meat
aStatistically significant difference compared with results
for 1996 (P < 0·05).
bStatistically significant difference compared with 2004
non-MICAH group (P < 0·05).
highly bioavailable source of iron and other
key micronutrients. The changes in anaemia
observed from baseline to final evaluation are
presented in Table 7.4.
Significant reductions in anaemia preva-lence
were observed in MICAH areas for both
pregnant women and children under 5 years
old, whereas a similar improvement occurred
only in children in the non-MICAH area. No
baseline data were collected for non- pregnant
women of childbearing age, but, in 2004,
women in the MICAH area had a significantly
lower prevalence of anaemia compared with
those in the non-MICAH communities.

Table 7.4. Prevalence of anaemia in vulnerable groups.
Target group 1996 (n) 2004 MICAH (n) 2004 non-MICAH (n)
Children under 5 years old (% with Hb < 11 g/dl) 86 (637) 60a (1337) 63 (729)
Pregnant women (% with Hb < 11 g/dl) 59 (392) 48a,b (203) 68 (85)
Women 15–49 years old (% with Hb<12 g/dl) N/A 39b (1518) 53 (787)
MICAH, MICronutrient And Health (programme); Hb, haemoglobin; N/A, data not available.
Table 7.5. Prevalence of malaria and hookworm.
Malaria in children under 5 years old (%) 33 (648) 13a (1284) 13 (694)
Malaria in pregnant women (%) 24 (392) 7a (199) 6 (82)
Hookworm in school-age children (%) 18 (690) 0a (1019) 0.3 (506)
Table 7.6. Coverage of anaemia control interventions.
Daily iron supplementation to pregnant women (%) 49 (168) 51a,b (465) 46 (238)
Weekly iron supplementation to women aged
15–49 years (%)
confidence interval (CI) 0.19, 0.85); living
within 4 km of a health facility (OR = 0.60,
95% CI 0.45, 0.78); and ownership of cultivated
land (OR = 0.15, 95% CI 0.03, 0.71). De-worming,
after adjustment for confounders, had no or
negative associations with anaemia.2
However, there was an apparent impact
of household small-animal ownership on child
N/A 72b (299) 8 (147)
growth. Normal weight-for-age was positively
associated with belonging to a household pro-ducing
dairy products or eggs for home con-sumption
(OR = 0.72, 95% CI 0.57, 0.92), iron
supplementation (OR = 0.58, 95% CI 0.46, 0.75),
preserving fruit or vegetables (OR = 0.63, 95%
CI 0.43, 0.91) and access to a village health
committee (OR = 0.72, 95% CI 0.52, 1.003).
Improved height-for-age was positively
associated with consumption of two forms of
protein in the previous 24 h (OR = 0.59, 95% CI
Weekly iron supplementation to children under
5 years old (%)
N/A 68b (1061) 6 (577)
Households consuming fortified maize flour (%) N/A 12b 2
Children under 5 years old sleeping under
an insecticide-treated bednet (%)
N/A 87b 75
Pregnant women sleeping under an
insecticide-treated bednet (%)
N/A 78b 60
MICAH, MICronutrient And Health (programme); N/A, data not available.
2 Rose, G., Main, B. and Namarika, R. (2007) Health
and nutrition practices associated with child
growth and anemia in rural Malawi: findings from
an integrated Micronutrient and Health Program.
Unpublished paper.
3 Note: rounding error, upper confidence limit <1.0,
P = 0.049.

0.38, 0.91), proximity to health facility (OR = 0.75,
95% CI 0.60, 0.93) and weekly iron supplemen-tation
(OR = 0.79, 95% CI 0.64, 0.99).4
Discussion
Small-animal ownership and consumption
The SARF intervention of MICAH Malawi
was successfully implemented on a large
scale, and resulted in a significant increase in
both small-animal husbandry and consump-tion
of animal foods at the household level
(Tables 7.2 and 7.3). However, the survey did
not assess the number of animals owned by
individual households, such that a household
with one chicken was weighted the same in
the analysis of animal ownership as a house-hold
with several animals of different species.
This additional detail would have provided a
stronger picture of the differences between
MICAH and non-MICAH areas in terms of
animal husbandry, as well as clarifying the
potential extent of animal food consumption
by the beneficiary households.
It is not surprising that the small animals
promoted by the programme (particularly
rabbits and guinea fowl) were found in a
higher proportion of MICAH households
compared with the non-MICAH group in
2004, which points to the specific contribu-tion
of the programme to increased animal
husbandry at the household level. However,
it is noteworthy that some non-MICAH
households were also raising these animals,
which previously were uncommon in the
rural areas targeted by the programme. This
likely reflects the strong integration of the
MICAH SARF intervention within the MoA,
such that it was adopted as a core MoA strat-egy
and began to reach into non-MICAH
areas through MoA staff and support. In addi-tion,
in 2001, the SARF methodology was
incorporated into several other development
programmes in Malawi. Through advocacy
from the Malawi National Micronutrient
Coordinator (a position within the MOH but
supported by MICAH), MICAH’s success
with small animals was shared with the World
Health Organization (WHO) and Malawi Red
Cross Society, resulting in SARF expansion in
non-MICAH areas. United States Peace Corps
Volunteers also received training in SARF
programming, allowing further expansion
due to the wide coverage of the Peace Corps’
operational areas in Malawi. This replication
of MICAH’s SARF outside the programme
areas likely led to dilution of the impact of
MICAH on small-animal ownership in the
evaluation data, although a significant differ-ence
was still observed between programme
and non-MICAH households. However the
adoption of this intervention by various
development initiatives is a strong indication
of the high degree of acceptability of the SARF
model, as well as its perceived value and
effectiveness as a means to sustainably
improve the dietary quality of rural house-holds
in Malawi.
During the intervention period, a major
drought in Malawi took place in the 2001/02
maize-growing season. In order to cope with
the severe food shortage, households were
forced to sell valuable resources in order to
find food. This included the small animals
distributed as part of the MICAH programme,
which were either sold for money to buy
maize or were consumed. In normal circum-stances,
at least a breeding pair would be
kept, but in such a time of severe food short-age,
hunger and malnutrition, all resources
available were used in order to survive.
Although the MICAH programme did not
collect nutrition data during the drought
period, it is assumed that levels of malnutri-tion
of all types, including anaemia, either
did not improve or deteriorated during this
crisis and that recovery and nutritional reple-tion
afterwards would require a significant
period of time, as well as inputs from external
programmes such as MICAH. In response, the
MICAH programme launched an intensive
animal restocking programme in 2002–2003,
and by the final programme survey in 2004,
72% of households in the programme area
had small animals. This coverage might have
been even higher without the major losses of
the drought period.
4 Note: rounding error, upper confidence unit <1.0,
P = 0.049.

Formal qualitative analysis of the critical
factors for success of the SARF intervention
was not conducted. However, ongoing analy-sis
of monitoring data and reflective discus-sions
between staff, implementing partners
and beneficiaries of the programme resulted
in common agreements. The following key
components of the SARF intervention are
believed to have led to its success in increas-ing
household access to and consumption of
animal-source foods: (i) community manage-ment
of the entire process and ongoing
responsibility for the revolving fund scheme;
(ii) promotion of animals over which women
have primary control; (iii) strong integration
and partnership with relevant government
ministries; (iv) intensive nutrition education
to promote consumption of the small animals;
and (v) locally developed strategies to increase
acceptability and adapt the care and housing
of animals to the environment and available
resources.
Anaemia prevalence
Anaemia prevalence decreased significantly
in pregnant women in MICAH areas com-pared
with non-MICAH, and was signifi-cantly
lower in non-pregnant women in
MICAH areas in 2004. In pre-school children,
a similar dramatic decrease from baseline to
2004 was observed in both MICAH and non-
MICAH areas (Table 7.4). It was beyond the
scope of the programme evaluation to assess
the prevalence of iron deficiency or the rela-tive
contribution of various causes of anaemia
in the study population. Therefore, the fol-lowing
discussion of probable explanations
for the difference in results between women
and pre-school children when comparing
MICAH and non-MICAH communities is
based on reasonable interpretation of availa-ble
data.
The positive results for anaemia in
women in MICAH areas are likely a reflection
of the impact of the integrated, comprehen-sive
anaemia control strategy implemented by
the programme. The small animals were a key
component of this, as a means to improve die-tary
intake of a highly bioavailable source of
iron and other key micronutrients. However,
it is not possible to determine the specific con-tribution
of the SARF intervention to the
improvements in anaemia, as individual con-sumption
data are not available, nor can the
contribution of animal-source foods be sepa-rated
from the role of other essential anaemia
control interventions.
The MICAH programme established a
community-based delivery system for weekly
iron supplementation to women of childbear-ing
age and pre-school children, resulting in
high (over 65%) coverage of these target
groups (Table 7.6). In contrast, less than 10%
of non- pregnant women and pre-school chil-dren
in non-MICAH areas reported taking
regular iron supplements. In addition,
MICAH initiated fortification of maize with
multiple micronutrients (including iron) at
the village level. This intervention was
expanded to include 19 mills in six partner
project sites by the end of the programme.
Coverage of insecticide-treated bednets for
malaria prevention was higher in MICAH
areas, but malaria prevalence declined sig-nificantly
from baseline to similar levels in
both MICAH and non-MICAH areas by 2004
(Table 7.5). This can be attributed to national-level
efforts to address the high prevalence of
malaria, which MICAH also supported in its
operational areas (including distribution of
nearly 97,000 insecticide-treated bednets).
Furthermore, hookworm prevalence in
school-age children was virtually eliminated
in both MICAH and non-MICAH areas by
2004 (Table 7.5), again due to efforts broader
than the MICAH interventions alone.
The anaemia control interventions
unique to the MICAH areas were the small-scale
fortification, routine community-based
iron supplementation and promotion of
small-animal husbandry for household con-sumption
of bioavailable iron. Fortification
was not implemented on a wide enough scale
to be the main contributor to improved anae-mia
levels in women, as only 12% of house-holds
were consuming the fortified maize at
the final evaluation (Table 7.6). Both iron sup-plementation
and small-animal husbandry
reached high (65% or greater) coverage levels,
but it is not possible to determine the exact
contribution of each to the successful reduc-tions
in anaemia prevalence.

It may be that the observed reduction in
anaemia among pre-school children in both
MICAH and non-MICAH areas was prima-rily
a response to improved malaria control
interventions. Mid-term data collected in
2000 (not presented here) indicated that
anaemia prevalence in pre-school children
had been reduced but remained critically
high despite MICAH’s emphasis on iron
interventions for this age group. This led
programme staff to conclude that malaria
prevention played a greater role in anaemia
of young children than previously antici-pated.
Malaria prevention efforts were there-fore
greatly expanded in the remaining years
of the programme, in conjunction with the
national malaria campaign, and, in 2004,
anaemia levels in pre-school children had
further declined in both MICAH and non-
MICAH areas, both of which benefited
from high coverage of malaria control
interventions.
It is noteworthy that, despite iron defi-ciency
being a major cause of anaemia world-wide,
neither the higher coverage of iron
supplementation nor the increased availability
of small animals at the household level appears
to have resulted in greater improvements in
anaemia among children in MICAH areas.
Furthermore, analysis of the available food
consumption data failed to find a protective
effect on anaemia of meat consumption in the
previous 24 h. However, no data were col-lected
on portion size or frequency of meat
intake. It may be that the quantities consumed
were insufficient to impact anaemia preva-lence.
More detailed analysis of intake patterns
would be helpful to strengthen the benefit of
the SARF intervention for the youngest chil-dren,
a group in which anaemia prevalence
remains unacceptably high. At the same time,
it is important to recognize the benefits of con-sumption
of animal foods beyond the poten-tial
for a specific impact on anaemia. It has
been well documented that the high-quality
protein and multiple bioavailable micronutri-ents
contained in animal-source foods have an
important impact on optimal child growth and
cognitive development (20). Therefore, the
lack of an apparent impact on anaemia in
young children does not imply that the SARF
intervention was not effective for this age
group. Indeed, regression analysis of the
MICAH 2004 24-hour recall data indicated a
positive association between household
small-animal ownership and production of
dairy products and eggs and weight-for-age
in young children.
Limitations of the evaluation
The MICAH Malawi programme design fol-lowed
the WHO/United Nations Children’s
Fund recommendation that an integrated
approach to the management of iron defi-ciency
anaemia is needed for maximum
effectiveness (14). The SARF intervention
was therefore one component of a multi-pronged
anaemia control strategy, which
also included iron supplementation to
women and children; fortification of staple
foods with multiple micronutrients; malaria
control; and prevention and treatment of
parasitic infections. This integrated approach
is a strong point of the programme in terms
of its ability to address the multidimensional
aetiology of anaemia, but prevents the deter-mination
of the specific contribution of the
food-based intervention to the observed
reductions in anaemia.
In addition, the effectiveness of the SARF
intervention in terms of improvements in
intake of dietary iron cannot be established,
due to the lack of individual-level consump-tion
data. Dietary intake data are difficult to
collect with accuracy, particularly in large
household surveys. As the purpose of the
MICAH surveys was to measure the overall
effectiveness of the programme, not to con-duct
detailed research on specific interven-tions,
it was beyond the scope of the
evaluation to assess individual food intake
patterns. Thus, while reported consumption
of animals at the household level increased
in MICAH programme areas, intra-household
allocation is unknown. Therefore, no conclu-sions
can be drawn as to the extent key target
groups benefited from the increased availa-bility
of animal-source foods. It is known
that, in some contexts, intra- household dis-tribution
of animal-source foods does not
favour the most nutritionally vulnerable

family members (13). MICAH did address
such issues in the decision to promote rabbits
rather than goats, once it was identified that
goats were not likely to be consumed by the
target beneficiaries. However, further study
on individual consumption patterns and
related underlying issues would str engthen
the case for the SARF’s potential as an anae-mia
control intervention, as well as provid-ing
valuable information to enhance the
intervention design for future replication in
similar settings.
Conclusions
The SARF intervention implemented by
MICAH Malawi resulted in increased access to
animal-source foods for MICAH households.
In addition, household consumption of ani-mal-
source foods in all categories was higher
among MICAH households compared with
those in the non-MICAH areas in the 2004
evaluation. This experience provides a model
for a food-based approach with strong poten-tial
for replication in other similar contexts.
Critical factors leading to the success of the
intervention include community management
and ownership; integration with government
ministries; promotion of animals over which
women have primary control; and develop-ment
of locally adapted methods to promote
acceptability and to care for the animals.
The positive evaluation findings for
reduced anaemia prevalence among women
in MICAH areas are attributed to the combined
effect of multiple anaemia control interven-tions,
particularly those aimed at increasing
iron intake. While it cannot be proven from
the available data, it is likely that the
increased access to animal-source foods con-tributed
to the results observed. MICAH
Malawi’s experience demonstrates that
food-based interventions can be success-fully
implemented at the community level,
and when integrated with other essential
nutrition and health interventions, contrib-ute
to improvements in nutritional status,
including reductions in iron deficiency and
anaemia.
Acknowledgements
The authors express their appreciation to
Melani Fellows for her support in the prepara-tion
of this chapter and to Kendra Siekmans
for reviewing the chapter and providing help-ful
insights. MICAH Malawi was funded by
the Canadian International Development
Agency and World Vision Canada. A.C.M. led
the implementation and evaluation design of
the multi-country MICAH programme. B.J.M.
and A.M.M. provided management and tech-nical
support from World Vision Canada to
MICAH Malawi. R.H.N. and M.E.Y. led the
design and implementation of the SARF inter-vention
in Malawi and supervised the evalua-tion.
B.J.M. conducted additional analysis on
the evaluation data and A.M.M. was the lead
writer of this chapter, with M.E.Y. contributing
the intervention description.
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California, Berkeley, California.

8 Aquaculture’s Role in Improving Food
and Nutrition Security
B. Thompson*1 and R. Subasinghe2
1Nutrition and Consumer Protection Division, Food and Agriculture Organization
of the United Nations, Rome, Italy; 2Fisheries and Aquaculture Resources, Use and
Conservation Division, Food and Agriculture Organization of the United Nations,
Rome, Italy
Abstract
This chapter provides an overview of aquaculture and discusses the significant nutritional value of its
products and its role in rural development. Nearly half of the total global food fish supply comes from
aquaculture, making it not only an important source of nutrition, but also a key sector that can reduce
poverty through improving livelihoods and well-being at global and community levels. Fish is the pri-mary
source of animal protein in developing countries, contributing about 20% of total animal protein
supply. Aquaculture has the potential to improve the diets of even the poor segments of the world’s popu-lation
through increased consumption of protein, fatty acids (n-3), vitamins and minerals (calcium, phos-phorus,
iron, selenium and iodine). The main aquaculture-producing countries are in Asia. Employment
in aquaculture is highest in China, where 13 million people worked in this sector in 2006. Aquaculture is
growing faster than all other animal food-producing sectors with an average rate of 7.0% per annum since
1970. As growth in this sector is expected to continue, aquaculture infrastructure needs to be improved to
ensure the success of this thriving industry. There is a need to strengthen aquaculture planning and poli-cies
that support the small-scale fisheries sector in developing countries as it is often overlooked by gov-ernments
when designing policies and strategies for rural development. Small-scale aquaculture has to be
developed as a responsible and sustainable entrepreneurial activity that is financially viable so as to assure
its efficacy in poverty reduction and nutrition improvement.
Key words: aquaculture, fish, nutrition, food and nutrition security, rural livelihoods
Introduction
This chapter discusses the contribution that
aquaculture makes to the diet at global and
community levels, and its role in poverty
reduction and food and nutrition insecurity,
to provide guidance to planners on how this
sub-sector can play a greater role in fighting
hunger and malnutrition.
Hunger and malnutrition remain among
the most devastating problems facing the
world’s poor. Tragically, a considerable por-tion
of the global population is currently
suffering from one or more forms of nutrient
deficiency. This remains a continuing travesty
of the recognized fundamental human right
to adequate food, and freedom from hunger
and malnutrition, particularly in a world that
* Contact: Brian.Thompson@fao.org

Aquaculture’s Role 151
has both the resources and the knowledge to
end this catastrophe (1).
The challenge is to rapidly accelerate the
pace by which hunger and malnutrition are
eliminated. Aquaculture has an important role
to play in this effort by providing fish and
other marine and freshwater products, which
commonly are rich sources of protein, essen-tial
fatty acids, vitamins and minerals, and by
providing incomes and employment opportu-nities.
This can be especially important for
poor artisanal fisherfolk whose livelihoods
depend on small-scale fisheries activities.
With support for aqua culture the worldwide
availability of good-quality marine and fresh-water
animal products can be increased,
allowing per capita supplies to keep pace with
the increase in demand. To ensure that such
benefits reach those who need it most, the
involvement of the artisanal fisherfolk in this
effort must not be neglected.
Fish can make a unique contribution to
efforts to improve and diversify dietary
intakes and promote nutritional well-being
among most population groups. Fish have a
highly desirable nutrient profile providing an
excellent source of high-quality animal pro-tein
that is easily digestible and of high bio-logical
value. Fatty fish, in particular, are an
extremely rich source of essential fatty acids,
including n-3 polyunsaturated fatty acids
(PUFAs) that are crucial for normal growth
and mental development, especially during
pregnancy and early childhood. Fish are also
rich in vitamins and minerals (especially cal-cium,
phosphorus, iron, selenium and iodine
in marine products). Fish, therefore, can pro-vide
an important source of nutrients particu-larly
for those whose diets are monotonous
and lacking in other animal-source foods.
Increasing the availability of fish in the diet
increases palatability and leads to increased
consumption of a range of foods, thereby
improving overall food and nutrient intakes.
An Overview of Global Aquaculture
The following information and data are from
The State of World Fisheries and Aquaculture
2008 (2), unless otherwise stated. Aquaculture
makes a significant contribution to food and
nutrition security. At the global level, it helps
fill the gap between the rising global demands
for fishery products and the limited increases
in capture fisheries production. Aquaculture
is the fastest growing food-producing sector
in the world. It is estimated that, by 2012, over
50% of global food fish consumption will
originate from aquaculture. Over 92% of this
production comes from the developing world.
Aquaculture’s contribution by weight to
global fish supply increased from 3.9% in
1970 to 36.0% in 2006. It now dominates all
other animal food-producing sectors in terms
of growth, growing at an average rate of 7.0%
per annum since 1970 compared with 1.4%
and 2.8% per annum for capture fisheries and
terrestrial farmed meat production, respec-tively.
In 2006, 51.7 million metric tonnes
(mmt) of aquatic products, not including
aquatic plants valued at US$78.8 billion, was
produced globally, over half in the form of
finfish. When aquatic plants are considered in
the total production of aquatic products,
world aquaculture production is 66.7 mmt,
worth US$85.9 billion. In contrast to terres-trial
farming systems, where the bulk of glo-bal
production is based on a limited number
of animal and plant species, the aquaculture
sector comprises over 200 different species.
This large number of species raised reflects
the diversity of the sector, particularly the
wide variety of candidate species farmed and
different production systems used.
Currently, the majority of aquaculture-producing
countries are in Asia: eight out of
the top ten aquaculture producers in terms
of quantity in 2006 were Asian countries. In
2006, the top ten producing countries in
descending order were China, India,
Vietnam, Thailand, Indonesia, Bangladesh,
Chile, Japan, Norway and Philippines. The
main species groups reared in freshwater
are finfish while high-value crustaceans and
finfish predominate in brackish water, as
molluscs and aquatic plants do in marine
waters. Of these three environments, fresh-water
aquaculture could be considered
as the most important in terms of contribut-ing
to achieving food and nutrition security.
Marine aquaculture, particularly of sea-weeds
and molluscs, also contributes to
food and nutrition security and poverty

152 B. Thompson and R. Subasinghe
alleviation, as most of its products are pro-duced
within small to medium-scale opera-tions.
While brackish-water shrimp culture
is generally aimed at producing a high-value
export commodity, coastal shrimp
culture also plays an important role in rural
livelihoods and food and nutrition security.
Trends in Consumption and Nutritional
Importance of Aquatic Products
Globally, two-thirds of the total food fish sup-ply
is obtained from marine and inland capture
fisheries; the remaining one-third being derived
from aquaculture. The contribution of capture
fisheries to per capita food supply stabilized at
10 to 11 kg during the period 1970–2000. Recent
increases in per capita availability were obtained
from aquaculture production. Globally, aquac-ulture’s
contribution to per capita food availa-bility
grew from 0.7 kg in 1970 to 7.8 kg in
2006 – at an average rate of 7.0% per annum.
In China, aquaculture dominates fish food
supply. Fish farming practices there have deep
traditional roots and aquaculture accounted for
90% of the fish food supply in 2006, compared
with a worldwide average of 24%.
More ‘food fish’ is consumed globally on
a per capita basis than any other type of meat
or animal protein (16.7 kg per capita in 2006).
In terms of animal protein, food fish repre-sented
15.3% of total supply in 2005 (when
total global animal protein supply was
reported as 27.1 kg per capita), followed by
pork (14.7%), beef and veal (13.6%), and poul-try
meat (12.5%). It is interesting to note here
that farmed aquatic meat production in China
currently ranks second to pig meat, per capita
availability of food fish increasing from 4.5 kg
in 1984 to 26.1 kg in 2006 (2,3).
The main factor behind the high demand
for staple food fish (in particular, inexpensive
farmed freshwater fish species feeding low
on the aquatic food chain) within most devel-oping
countries is their greater affordability
to the poorer segments of the community (4).
At present, food fish represents the primary
source of animal protein (contributing about
20% of the total animal protein supply) in
developing countries.
Although levels as high as 753 kJ/day
(180 kcal/day) are reported from countries
such as Japan and Iceland, the average per
capita energy supply from fish is only 84–126
kJ/day (20–30 kcal/day). In the diets of many
countries, fish contributes more than or close
to 50% of total animal protein (e.g. The Gambia,
Ghana, Equatorial Guinea, Indonesia, Sierra
Leone, Togo, Guinea, Bangladesh, Republic
of Congo, Cambodia, Sri Lanka, Philippines).
The International Conference on Sustainable
Contribution of Fisheries to Food Security,
held in Kyoto in 1995, recognized that aquatic
products contribute meaningfully to the
maintenance of good nutrition (5).
As mentioned, fish are important sources
for many nutrients, including protein of very
high quality, retinol (vitamin A), vitamin D,
vitamin E, iodine and selenium. Evidence is
increasing that the consumption of fish
enhances brain development and learning in
children, protects vision and eye health, and
offers protection from cardiovascular disease
and some cancers. The fats and fatty acids in
fish, particularly the long-chain n-3 fatty acids
(n-3 PUFAs), are highly beneficial and diffi-cult
to obtain from other food sources. Of par-ticular
importance are eicosapentaenoic acid
(20:5n-3, EPA) and docosahexaenoic acid
(22:6n-3, DHA). A review of the benefits of
fish consumption for mothers and infants
was published by the Food and Agriculture
Organization of the United Nations (FAO) in
2000 (6). Fish intake during pregnancy is pos-itively
associated with enhanced neurodevel-opment
during infancy including higher
behavioural attention scores, better visual
recognition memory, and improved language
comprehension (7).
The fat content of fish varies from
1.0 g/100 g in lean white fish to 30 g/100 g in
fatty fish. The n-3 PUFAs are lowest in white
fish (0.5 g/100 g in cod), medium in crusta-ceans
(0.7 g/100 g in mussels) and roe
(1.0 g/100 g) and highest in fatty fish
(>5 g/100 g in mackerel). Many factors can
influence the nutrient content of fish, includ-ing
stage of maturity and feed formulation.
The high-quality protein and essential
fatty acids, vitamins and minerals found in
fish and the effects of adding fish to tradi-tional
bland staple diets are important to

stimulate appetite and increase food con-sumption,
thereby maximizing macronutri-ent
utilization and boosting the host immune
system. This is particularly advantageous in
protecting vulnerable populations including
young children and the aged, and for immu-nocompromised
persons such as those living
with HIV/AIDS.
The Role of Aquaculture in Rural
Development
Although aquaculture complements many
other food-production systems, such as inte-grated
agriculture–aquaculture, rice–fish farm-ing
and livestock–fish farming, aquaculture’s
potential for contributing to global food pro-duction
is still not fully realized. The decision
to establish the Sub-Committee on Aquaculture
under the Committee on Fisheries (COFI) dur-ing
2001 reflects the importance that FAO
Members attach to aquaculture as a tool for
national development. Many recent interna-tional
gatherings, including the Conference on
Aquaculture in the Third Millennium (8), and
the Declaration of the World Food Summit: five
years later (9), recognize the role that aquacul-ture
can play in national economic develop-ment,
global food supply and achievement of
food and nutrition security, and declared that
the sector has the potential to continue to con-tribute
even more to people’s livelihoods.
The objective of rural development is to
facilitate a sustainable rural economy and to
secure improvements in the welfare of rural
populations. The opportunities for the integra-tion
of aquaculture into rural development are
characterized by diverse aquatic resources and
a wide range of stakeholders with diverse live-lihoods.
Objectives may further include food
production, income generation, and wild stock
enhancement for recreation (ornamental fish
or sport). The scale may be intensive commer-cial
or subsistence management within devel-oped
and less-developed economies. At the
local/national level, the integration of aqua-culture
into rural development may take place
in growing (e.g. developing economies) or
declining (e.g. remote rural regions in devel-oped
economies) populations. At all levels, this
is occurring within the context of globalization
and increased mobility of goods, services, capi-tal
and ideas, combined with increased trans-fers
of aquatic species and disease transmission.
Investment is generally attracted by stable and
predictable political and institutional environ-ments,
transparent laws, fair competition and
reliable legal systems. Where rural develop-ment
fails to create the policy environment and
skills to exploit global opportunities, aquacul-ture
– like other sub-sectors – may decline.
Aquaculture provides worldwide
employment to millions of people. Total
employment in the aquaculture sector is high-est
in China where, in 2006, almost 13.06 mil-lion
people worked in this sector (10). In
Vietnam, the employment is estimated at over
700,000 people (11), although these figures do
not yet reflect the large number of people
employed in affiliated industries (fish feeds,
equipment, fish processing and marketing).
In the USA, where aquaculture is identified
as a major growth industry for the 21st cen-tury,
around 200,000 people are employed
within the sector (12). In contrast, between
2002 and 2003 in the European Union (EU),
approximately 65,000 people were employed
in aquaculture, i.e. 15.5% of the total employ-ment
in the fishery sector (13).
Studies in various developing countries
(e.g. China and Vietnam) have shown that
80–100% of the aquaculture products from
rural farm households are marketed. This
suggests that aquaculture can be considered
as a cash-generating activity and thus an
important indirect source of food and nutri-tion
security. In many countries the average
market prices of fish are lower than those of
other animal products such as chicken, pork
and red meat. Especially in Asia the low prices
of aquaculture commodities such as carp and
tilapia make fish highly accessible to even the
poorest segments of the population. Poor
people in land-locked countries, such as Nepal
and Lao PDR, largely depend on freshwater
aquaculture for their fish. In Savannakhet
Province, Lao PDR, fish is the main source of
animal protein food in the diet with average
daily per capita consumption estimated at
55 g and reported to be present in 85% of all
meals, confirming the importance of fish for
the poorest communities (14).

Economic feasibility studies have shown
that aquaculture is economically feasible
under many different circumstances. Many
types of low-cost, low-risk, simple technolo-gies
have emerged in recent years. Comparative
studies between rice, rice–fish and fish–
farming systems in sub-Saharan Africa dem-onstrated
that farmers investing in aquaculture
increased their household incomes considera-bly
with only minor investments. In Europe,
the USA, China and other Asian countries the
increases in production and the number of
people active in aquaculture over the last dec-ade
have shown that production systems
ranging from extensive to highly intensive can
be economically feasible.
The average annual per capita income of
people employed full-time in the fisheries sec-tor
(including aquaculture) in China was
about US$540 in 1999, which was more than
double that of rural terrestrial farmers. In
South-east Asian countries, such as Cambodia,
Thailand and Indonesia, a similar situation
can be found; farmers engaged in aquaculture
generally generate higher household incomes
than those who are not. In Vietnam, 50% of the
farmers involved in aquaculture consider it as
their main source of income and derive on
average 75% of their household income from
it. Specifically, catfish and shrimp culture
have, in recent years, provided an average
annual household income of over US$1000,
which is significantly more than that gener-ated
by comparable agriculture practices (15).
Initial data from a study in the Mekong
Delta in Vietnam suggest that aquaculture
development can contribute to a decrease in
migration by young women from rural areas
to urban centres by offering local opportuni-ties
to earn a living. The decreased need for
urban migration could prevent women from
being compelled into prostitution, thus fewer
women would be at risk of becoming infected
with HIV/AIDS.
Unlike many other sectors of the economy
worldwide, aquaculture has been resilient to
the global economic crisis. Although precise
figures are lacking, aquaculture’s contribution
to poverty alleviation, food security, employ-ment,
trade and gender opportunities has
increased over the past decade. This is reflected
in the growth in volume and value of produc-tion
and through the expanding presence of
aquaculture products in world markets, in
particular as raw material to the processing
sector and through the availability of aquacul-ture
products. Issues such as ownership by the
beneficiaries, people-centred approaches,
growing species which feed low on the food
chain, targeting all household members, use
of farmer field school type methodologies, as
well as technologies that are developed
according to the local context with network
approaches, have all contributed to this.
Utilizing Aquaculture to Improve Food
and Nutrition Security
The role that fish can play in improving diets
is undisputed, and this can be particularly
important in regard to children’s diets and
child nutrition. A household food and nutri-tion
security survey conducted in Luapula,
Zambia, in 1997–1998 illustrates this point
(16). In the Luapula Valley, fish is often the
most important source of high-quality pro-tein
foods (other sources include milk, eggs
and meat). The data show that children whose
main staple food is cassava and whose diets
regularly include fish, and other high-quality
protein-containing foods, had a significantly
lower prevalence of stunting than those
whose diets did not. When programmes that
improve access to fish are combined with
effective nutrition education to promote the
inclusion of fish in children’s diets, child
nutrition can be markedly improved in a very
cost-effective manner.
Aquaculture can contribute to improved
food and nutrition security through various
channels: local food supplies can be improved
through the increased availability of low-cost
fish; employment opportunities and incomes
can be raised; and consumption of fish can be
increased directly. While increasing the
quantity and variety of fish and other foods
consumed by the poor will reduce undernu-trition,
such dietary improvements are not
automatic benefits of aquaculture develop-ment.
Food consumption and good nutrition
are not determined solely by how much food
is produced or available. Households must

have physical and economic access to an ade-quate
amount and variety of food, and house-hold
heads and caregivers must have the
time, knowledge and motivation to make the
best use of the household’s resources to meet
the food and other basic needs of all mem-bers.
The key to securing the maximum nutri-tional
benefits from aquaculture development
is to ensure that the poor and undernourished
gain greater access to the increased supplies
of fish and that they can enhance their
aquaculture-derived income.
Aquaculture comprises diverse produc-tion
systems of farming plants and animals in
inland and coastal areas, many of which have
relevance for the poor. In the context of the
rural poor, aquaculture often complements
catches from traditional fisheries. The latter
continue to play an important role and, in
many areas, remain adequate to satisfy sub-sistence
needs and provide a valuable source
of income for farmer/fishers. In many cases,
the captured species form the basis for house-hold
food and nutrition security, enabling the
use of livestock or cultured fish as sources of
income. Aquaculture becomes an attractive
and important component of rural livelihoods
in situations where increasing population
pressures, environmental degradation or loss
of access limit catches from wild fisheries (17).
Aquaculture in small-scale integrated
farming systems can provide high-quality
animal protein and other nutrients that can be
especially valuable for nutritionally vulnera-ble
groups. Aquaculture commonly provides
protein at prices generally affordable to the
poorer segments of the community, and it cre-ates
‘own enterprise’ employment, including
jobs for women and children, while providing
income through sale of what can be relatively
high-value products (18). Employment oppor-tunities
are also possible on larger farms, in
seed supply networks, market chains and
manufacture/repair supporting services.
Indirect benefits include increased availabil-ity
of fish in local rural and urban markets
and possible increases in household income
through sales of farm products, which will
become available through increased local con-sumption
of fish. Aquaculture can also benefit
the landless from utilization of common
resources, such as finfish cage culture, culture
of molluscs and seaweeds, and fisheries
enhancement in communal waterbodies (1).
An important, though often overlooked,
benefit which is particularly relevant for inte-grated
agriculture–aquaculture systems is
their contribution to increased farm efficiency
and sustainability. Agricultural by-products,
such as manure from livestock and crop resi-dues,
can serve as fertilizer and feed inputs
for small-scale and commercial aquaculture.
Fish farming in rice fields not only contrib-utes
to integrated pest management (IPM),
but also management of vectors of human
medical importance (17). Furthermore, ponds
become important as on-farm water reser-voirs
for irrigation and livestock in areas
where there are seasonal water shortages (19).
Aquaculture activities may provide supple-mentary
income during lean seasons when
food and nutrition security is low, thus
smoothing the seasonal flows of income
related to annual cropping. Fish can also be a
form of investment of savings that can be
used as collateral for securing loans or sold in
times of hardship to buffer the effects of lean
seasons or loss of income.
Aquaculture producers have, through
various technological interventions (e.g.
improved feed, better performing broodstock,
good health management, genetic improve-ments,
etc.), achieved important productivity
gains and cost reductions. Over time, this has
led to a decrease in prices, despite short-term
intervals of significant price swings. The
prices of fishery products have not increased
as a result of the growing international
demand. Instead, they show a decreasing
trend (20). Prices of some aquaculture prod-ucts
in the EU and the USA have decreased
considerably over the past years. While
salmon and shrimp were considered high-value
commodities for affluent society in the
1980s, they are now much more common fare.
The increase in salmon and shrimp consump-tion
can be considered a result of their lower
prices, as well as of wider availability, diversi-fication
in products, and use of salmon and
shrimp in convenience and ready-to-eat meals.
The price of internationally or locally traded
aquatic products dictates its contribution to
food and nutrition security as it affects pro-duction.
The current trend indicates that these

price fluctuations are in favour of increasing
local production, thus assisting rural liveli-hoods
and food and nutrition security.
Many aquaculture activities, including
marketing, are undertaken by women. This is
particularly the case for small-scale opera-tions.
Aquaculture may therefore provide
supplementary income to women who are
the key managers of household resources that
may be preferentially directed to consump-tion.
Increasing women’s income strengthens
their position in society. Their empowerment
encourages them to become further involved
in decisions in the development process.
Research into the use of genetically mod-ified
aquaculture species is increasing,
although commercial availability of geneti-cally
modified fish is still scarce and the con-tribution
of genetically modified organisms
(GMOs) to food fish production almost nil.
FAO does not discourage the use of GMOs as
food, provided that they pose no risk to the
environment and are safe to eat. The empha-sis
on biotechnology and its contribution to
food and nutrition security, poverty reduc-tion
and income generation is increasing.
Preparedness to address this challenge in a
responsible manner is required. The major
biotechnology sectors involved in aquacul-ture
are similar to those for agricultural sec-tors.
Development of the knowledge required
to optimize safe biotechnological innovation
in aquaculture is of particular significance,
and presents a unique set of challenges,
mainly due to the diversity of species cul-tured
and production systems used.
Biotechnological interventions – such as
achieving higher feed conversion rates,
improving aquatic animal health through
accurate molecular diagnostic tools and vac-cines,
and adapting species to difficult envi-ronmental
circumstances (e.g. tilapia for cold
or saline environments) – assist in increasing
aquaculture’s contribution to global food and
nutrition security. Although such biotechnol-ogies
are yet to be fully utilized in aquacul-ture,
mainly due to the small-scale nature of
the global aquaculture sector, particularly in
the systems producing high-value species
such as salmon and shrimp, many biotech-nologies
are duly utilized. Many genetic
improvements in aquatic species have been
achieved and these are through the employ-ment
of traditional selective-breeding pro-grammes.
It may be noted that most cultured
fish species can be considered much closer to
their wild genetic origins than currently
farmed livestock (21).
Managing Environmental Impacts
of Aquaculture
Malnutrition is more prevalent in resource-poor
areas, and in those with poor infrastruc-ture
and services. A challenge from an
environmental point of view is to identify
technologies suitable for such circumstances.
The selection of those technologies must be
based on a thorough understanding of why
environmentally undesirable land uses are
practised. Policies must induce farmers, espe-cially
poor farmers on marginal lands, to
adopt improved farming methods which are
ecologically sound, socially acceptable and
economically beneficial.
Negative environmental impacts (such
as the destruction of mangrove areas, effluent
discharge, abandonment of farms) which tra-ditionally
were inextricably linked to aqua-culture,
and shrimp culture in particular, are
no longer common. The introduction by many
countries of Good Management Practices and
sectoral codes of practice, often based on the
FAO Code of Conduct for Responsible
Fisheries (CCRF), is a clear sign of changes
within the sub-sector (22). Aquaculture, as
other natural resource users, is sometimes
criticized for paying little attention to the
impact of its activities on biodiversity and the
natural resource base. Cases of escaped
salmon causing sea lice to be transferred to
wild stocks, and the capture of shrimp brood-stock
in the wild, are just some examples from
the recent past. FAO has been actively
working in these fields and improvements (in
planning and regulation) are being made to
avoid negative impacts on the environment
and biodiversity (23). Such efforts towards
minimizing the environmental impacts of
aquaculture and ensuring its sustainable
development within the framework of CCRF
will enhance the sub-sector’s contribution to

food and nutrition security, poverty allevia-tion
and rural development.
Community-centred Approaches
to Strengthen Household Food and
Nutrition Security
Experiences of the last decades have shown that
initiatives to alleviate poverty and achieve food
and nutrition security can seldom be sustained if
planned without the involvement of the
community. Community-centred approaches
encourage self-reliance and self-help and, by
doing so, raise self-esteem. Such approaches aim
at empowering communities to make optimal
use of locally available resources, and to
effectively demand additional resources and
better services to improve their livelihoods.
Building on traditional social networks of sup-port
and mutual assistance, community-centred
approaches mobilize community members in
activities to meet their perceived needs and
development priorities, thus making a signifi-cant
contribution to sustainable development at
local and national levels. Community-centred
approaches help ensure that a range of stake-holders,
including women and marginal groups,
become part of the development process, real
issues and needs are addressed, implementation
and monitoring are improved, and sustainability
enhanced by giving users the leading role in
developing and adapting activities.
Community-centred approaches rely on
participatory planning and appraisal tech-niques.
They have been used widely to
increase the adoption and dissemination of
aquaculture and the guiding principles have
been reviewed by FAO. Household food and
nutrition security and nutrition have shown
to be good entry points for coordinating and
planning local development projects that
feature aquaculture activities and participa-tory
approaches have been adapted to the
local setting. One such example is the experi-ential
learning in Farmer Field Schools (FFSs)
in rice farming, which opened opportunities
for the integration of aquaculture to better
crop management, particularly in relation to
IPM. Farmers spend weekly five to six hours
together, of which two hours are spent in the
field observing the ecosystem. The process is
facilitated by trainers, who themselves have
spent a whole season in the field learning
about the ecosystem and designing curricula
for the FFS. Rice farmers experiment with
physical modifications of the fields to accom-modate
fish, such as digging trenches in dif-ferent
shapes and sizes or small ponds at
different locations. They are innovative in
adapting their production systems to local
market conditions – raising larger fish for sale
or household consumption or smaller fish
if they can sell them to grow-out operations
nearby. Better utilization of resources,
increased income and a healthy crop of rice
and fish reinforce farmers’ acceptance of IPM
and rejection of pesticides. Experience shows
that many groups of farmers decide to con-tinue
the process of information exchange in
self-organized ‘farmer clubs’ long after project
and programme promoted FFSs have ended.
A Framework for Increasing Contribution
of Aquaculture for Food and Nutrition
Security and Poverty Alleviation
The Bangkok Declaration and Strategy (8)
emphasizes the need for the aquaculture sec-tor
to continue development towards its full
potential, making a net contribution to glo-bal
food availability, domestic food and
nutrition security, economic growth, trade
and improved living standards.
Integration of aquaculture into national
development
In order to achieve the full potential of
aqua culture, it should be pursued as an
integral component of community develop-ment,
contributing to sustainable livelihoods,
promoting human development and enhanc-ing
social well-being of poorer sectors.
Aquaculture policies and regulations should
promote practical and economically viable
farming and management practices that
are environmentally sustainable and socially
acceptable. If aquaculture is to attain its
full potential, the sector may require new

approaches in the coming decades. These
approaches will undoubtedly vary in different
regions and countries, and the challenge is to
develop approaches that are realistic and achiev-able
within each social, economic, environmen-tal
and political circumstance. In an era of
globalization and trade liberalization, such
approaches should not only focus on increasing
production, they should also focus on producing
a product that is affordable, acceptable and
accessible to all sectors of society.
Stakeholder participation in decision
making in aquaculture
Aquaculture development initiatives until the
early 1990s aimed largely at the increase of
production to satisfy the rising demand of the
growing world population and compensate
for local declines in capture fisheries produc-tion.
Before the 1990s, aquaculture develop-ment
approaches focused mainly on the
transfer of technologies, research and exten-sion,
ensuring that there would be sufficient
fish seeds/fingerlings through centralized,
state-owned hatcheries. In the 1990s, this
approach, like that in other rural sectors,
changed with a growing awareness on the
part of governments that market liberaliza-tion
was important for the development of the
sector. Since the second half of the last decade
of the 20th century, it was acknowledged that
aquatic resources are extremely important for
the livelihoods of millions of poor people in
developing countries and that the participa-tion
of the poor in decision-making processes
affecting their livelihoods is essential.
Strategic planning, appropriate policies and
good legal and institutional frameworks
The aquaculture development paradigm of
the 1990s resulted in a number of successes
and failures. The main cause of failures, in
particular in Africa, was the focus on subsist-ence
aquaculture accompanying production
increases, without taking into consideration
the other preconditions for development of
the sector such as feed and credit availability
and need to market the produce. Other rea-sons
for failure were: mismanagement,
unclear land and water rights, emphasis on
technologies, disregard for the environment,
and the use of inefficient and centralized gov-ernment
hatchery systems.
Aquaculture successes, however, are also
found in many regions. In Europe and in
North and South America, the boom in the
culture of salmonids in the 1990s has created
employment in areas with few alternative
possibilities with the result of increasing
standards of living of many coastal areas.
Together with the boom in aquaculture, the
affiliated industries (feed, drugs, equipment,
processing and marketing) flourished. In Asia
and Latin America, development of shrimp
culture has provided employment and income
to many coastal populations.
The weakness of government and civil
society institutions in many developing coun-tries
reduces the capacity to support aquacul-ture
development. Influencing institutions to
provide increased and better-quality services
in support of aquaculture development needs
a long-term effort, internal commitment from
the management, well-directed capacity-building
programmes and a network
approach with partner institutions, in order
to become successful.
Aquaculture development can further be
enhanced by applying participatory and trans-parent
policy development processes.
Aquaculture is often neglected by govern-ments
when designing policies and strategies
for rural development. For instance, few
Poverty Reduction Strategy Papers of The
World Bank and Country Strategy Papers of
the EU consider aquaculture as a means to
rural development or achievement of food and
nutrition security and alleviation of poverty.
Aquaculture interventions focused on
poverty alleviation and food and nutrition
security that have proven to be successful are
characterized by, among other factors: owner-ship
by the beneficiaries, use of participatory
approaches, designed as small scale in terms
of investment, demand-led with farmers first,
people-centred approaches, raising species
which feed low on the food chain (e.g. carp,
catfish and tilapia), targeting all household
members, and use of FSS type methodologies as

well as technologies that are developed accord-ing
to the local context with network
approaches. On the other hand, aquaculture
interventions that failed to contribute to the
alleviation of rural poverty and achievement of
food and nutrition security generally made use
of inappropriate subsidies and training allow-ances,
established large centralized hatcheries,
used technology-led interventions, were short
term, with management, extension and plan-ning
approaches that were top-down (24).
Small-scale aquaculture contributes to
the alleviation of poverty and achievement of
food and nutrition security. In addition, com-mercial,
larger-scale aquaculture, as is prac-tised
in many developed and developing
countries with species such as shrimp,
salmon, tilapia, catfish, grouper and carp, can
enhance the production for domestic and
export markets and the generation of employ-ment
(in production, processing and market-ing).
Indirectly, tax revenues from commercial
aquaculture enterprises and foreign exchange
earnings (when exporting) allow govern-ments
to invest in sectors that add to the
achievement of food and nutrition security.
New markets are emerging worldwide.
As high-value species are increasingly
exported (intra- or inter-regionally) and low-value
products are imported (a particular
trend in Asia where, for example, shrimp are
exported and canned pilchards imported),
there is a clear need by aquaculture farmers to
improve the quality and safety of their prod-ucts
in order to gain a wider access to export
markets. However, with the more stringent
requirements of export markets, small-scale
farmers are facing difficulties in producing for
export. As they strive to meet export con-sumer
requirements, they may become
uncompetitive. The lack of competitiveness
could drive them out of the sector. Empowering
small farmers to become competitive in global
trade is becoming urgent and, perhaps, a sig-nificant
corporate social responsibility (25).
Education and capacity building
Raising awareness at all levels of society of
the potential of aquaculture is one of the main
components of any framework for aquacul-ture
development. Education, information
sharing and capacity building are other cross-cutting
themes that are relevant to most
aspects of aquaculture development and
management, particularly for harnessing the
potential for food and nutrition security and
poverty alleviation. Better integration of
aquaculture in rural development is impor-tant
in view of the often limited government
resources for education and extension. In this
respect, a framework for aquaculture devel-opment
should address, at farm level, issues
such as resource use efficiency and the eco-nomic
or livelihood incentives that influence
farm household members when they decide
on cropping patterns and the use of water,
feeds, fertilizer, chemical treatments and
other inputs. Emphasis should also be given
to farmers’ knowledge of the available pro-duction
and pest management options, as
well as on their ability to apply these.
Farmers’ management strategies are not
based solely on economic criteria but also
include minimization of risk, cropping flexi-bility,
traditional and cultural preferences for
species and techniques, available labour and
labour requirements. Extension and capacity
building are crucial for informed decision
making (26). Other important elements of any
framework that increase the contribution of
aquaculture to the achievement of food and
nutrition security are related to legal, finan-cial,
investment, marketing and trade aspects.
The existence of good aquaculture legislation
can provide an important contribution to sus-tainable
aquaculture development. It can
minimize (or avoid) environmental impacts
and can contribute to the development of an
environment in which aquaculture is eco-nomically
viable. Moreover, land, fisheries
and aquaculture legislation can increase the
access of poorer parts of the population to
aquatic resources, which directly contributes
to the achievement of food and nutrition
security.
Access to banking services, credit and
insurance allows aquaculture farmers to
work more effectively, which indirectly will
lead to higher production, growth in income
and employment. Investment in aquacul-ture
is often negatively affected by a weak

institutional framework. Investments in aqua-culture
are generally made for the long term.
Unstable political and administrative envi-ronments
may therefore entail less invest-ment,
including direct foreign investment.
Trade barriers can affect the viability of aqua-culture
activities to a large extent.
Public–private sector partnership
and regional cooperation
Public–private partnerships in aquaculture
and the establishment of aquaculture net-works
have been shown to contribute consid-erably
to the sub-sector’s development.
Although the establishment of such partner-ships
and networks may be a time-consuming,
costly and difficult task, they make it possible
to address constraints and opportunities in a
manner that otherwise would not have been
allowed. Cooperation between government,
non-governmental organizations and civil
society further provides opportunities for rais-ing
awareness, targeting and creating dia-logues
between the various stakeholders on
aquaculture–food and nutrition security link-ages.
Regional cooperation between aquacul-ture
farmers, producers and marketing
associations, research institutes and govern-ments
is essential. In this respect, a good
example in South-east Asia is the Support to
Regional Aquatic Resources Management
(STREAM) programme of the Network of
Aquaculture Centres in Asia-Pacific/FAO/
UK Department for International Development
and Voluntary Services Overseas. This pro-gramme
has proven to be successful in bring-ing
aquaculture to the agenda of national and
regional conferences that deal with rural
development, food and nutrition security and
poverty issues in particular. South–South
cooperation between Asian countries and
those in Africa and Latin America is a useful
tool to disseminate these experiences.
Recommendations
If an effective enabling environment is cre-ated,
cultured fish and other aquatic products
could play a significant role in achieving the
Millennium Development Goals. In this
respect, the following actions are
recommended.
1. Improve the extension and development
approaches used for rural aquaculture,
including:
• A holistic, farming systems-based approach
integrating aquaculture into rural
livelihoods.
• A participatory, needs-based approach
that takes full account of the capacity of
the poor, the resources available to them
and the risks they face.
• Farmer-led extension and research.
• Promotion of sustainable, appropriate
technologies commensurate with the
resources available.
2. Encourage and promote the production
of aquaculture products as a source of
nutrition for human consumption with the
help of targeted nutrition education
programmes.
3. Promote effective rural development
through sound governance and with the
participation of the rural poor for decision
making at all levels. Rural aquaculture
has to be developed as an entrepreneurial
activity that is financially viable, even for
small-scale operations. All aquaculture
developments should specifically address
and minimize any potential adverse impacts
on the poor.
4. Give greater emphasis to advocacy (out-side
the sub-sector) to raise awareness on the
role for aquaculture in rural development,
while empowering and linking stakeholders
to policy decisions.
5. Improve information on small-scale
rural aquaculture, its role in rural liveli-hoods,
and its impact on food and nutri-tion
security and poverty alleviation
programmes.
6. Establish monitoring systems with better
indicators.
7. Increase institutional capacity and the
allocation of resources to ensure the appro-priate
role of aquaculture in alleviating pov-erty
and improving food and nutrition
security.

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9 A Home Gardening Approach
Developed in South Africa to Address
Vitamin A Deficiency
M. Faber*1 and S. Laurie2
1Nutritional Intervention Research Unit, Medical Research Council, Cape Town,
South Africa; 2Agricultural Research Council – Roodeplaat Vegetable and Ornamental
Plant Institute, Pretoria, South Africa
Abstract
Home gardening, focusing on provitamin A-rich vegetables, is a long-term strategy that can contribute to
combating vitamin A and other nutritional deficiencies which are of public health significance in developing
countries. The provitamin A carotenoid content of foods and their potential contribution towards meeting
the vitamin A requirements of the target population are predominant considerations in the selection of crops
to be planted. This chapter describes a home garden approach that integrates gardening activities with
nutrition education, using community-based growth monitoring as entry point. Studies using this approach
in South Africa showed a favourable effect on maternal knowledge of vitamin A nutrition, dietary intake of
provitamin A-rich vegetables, caregiver-reported child morbidity and children’s vitamin A status. Provitamin
A-rich vegetables and fruits contributed significantly towards achieving the recommended dietary intake of
vitamin A and various other micronutrients. Seasonal availability of provitamin A-rich vegetables and fruits
needs to be taken into consideration to ensure year-round availability of provitamin A-rich foods.
The approach is flexible and entry points other than community-based growth monitoring can be
used to promote production and consumption of provitamin A-rich vegetables and fruits. Demonstration
gardens to serve as training centres, community-based nurseries for orange-fleshed sweet potato cuttings
and a seed distribution system are important components of the home garden projects. Various constraints
experienced with vegetable gardens and possible solutions are highlighted. Participation in gardening
projects is self-selective. Non-participating households within the project areas are, however, exposed to
the promotion activities, resulting in a spill-over effect to non-participating households.
Key words: food-based approach, home gardens, vitamin A, provitamin A carotenoids, vegetables and
fruits, South Africa
Introduction
Vitamin A deficiency is prevalent in most
developing countries. Globally 33.3% or 190
million children younger than 5 years are
deficient in vitamin A, with South-east Asia
and Africa having the highest prevalence of
vitamin A deficiency at 49.9% and 44.4%,
respectively (1).
Vitamin A is essential for maintaining
immune function, eye health, vision,
growth and survival in humans (2). Vitamin
* Contact: mieke.faber@mrc.ac.za

164 M. Faber and S. Laurie
A deficiency is the leading cause of pre-ventable
blindness in the world. Children
who are vitamin A-deficient have lower
resistance against common childhood
infections such as respiratory and diar-rhoeal
diseases, measles and malaria (2).
Globally, vitamin A deficiency resulted in
6% of deaths (0.6 million) among children
under 5 years old in 2004 (3). Improving
the vitamin A status of children between 6
months and 5 years reduces the all-cause
mortality by 23% in areas with high vitamin
A deficiency (4).
Nutritionally vulnerable communities
often consume monotonous low-energy,
low-protein diets that are predominantly
based on starchy staples and often include
little or no animal products, limited dietary
fat and few vegetables and fruits. As a result
their diets are low in a number of micronu-trients,
including vitamin A. Dietary modi-fication
strategies that aim to increase the
vitamin A intake include various approaches
to increase: (i) the production, availability
and access to vitamin A-rich foods; (ii) the
consumption of vitamin A-rich foods; and/
or (iii) the bioavailability of vitamin A in
the diet (5).
Dietary sources of vitamin A consist of
either preformed vitamin A (retinol) from
foods of animal origin or provitamin A caro-tenoids
(predominantly b-carotene) from
foods of plant origin that are converted to
retinol by the body. Preformed retinol from
foods of animal origin is the most bioavaila-ble
dietary source of vitamin A, but these
foods are often not within the financial reach
of the poor. Foods of plant origin are more
affordable and can be cultivated at household
level. Local production of provitamin A-rich
vegetables and fruits, including the under-utilized
indigenous wild-growing leafy veg-etables,
can provide households with direct
access to foods rich in provitamin A caroten-oids.
Therefore, home gardening is a funda-mental
strategy to address vitamin A
deficiency in resource-poor communities by
increasing the availability of, access to and
ultimately consumption of foods that are rich
sources of vitamin A. Integration of small-animal
husbandry (such as fish, poultry,
small livestock, milking cows or goats) with
home gardening increases dietary variety
and availability of foods rich in preformed
retinol (6).
Home gardening can be part of a sustain-able
long-term strategy that complements
household food security, nutrition education,
supplementation and food fortification inter-ventions.
It is recognized that the various
interventions to address vitamin A deficiency
should be used in combination because they
each serve a particular target group and none
of them has 100% coverage (6). It is further
recognized that home gardening projects that
aim to produce particularly provitamin A-rich
foods for household consumption will not
eliminate vitamin A deficiency, but can help
to reduce the risk of vitamin A deficiency by
increased consumption of home-grown pro-vitamin
A-rich vegetables (6).
Berti et al. (7) argued that home garden-ing
is inherently an effective intervention
which most people, given access to land and
other agricultural inputs, can adopt. However,
to ensure that gardening activities translate
into improved dietary quality, home garden-ing
projects need to include a strong nutrition
education and behaviour change component
(5). Dietary modification through successful
promotion of behaviours that provide ade-quate
dietary intake, together with ensuring
availability of supply, is likely to be both sus-tainable
and affordable (8).
Furthermore, it is believed that home
gardens are preventive, cost-effective, sus-tainable,
culturally acceptable and have the
potential for income generation (9,10).
Gardening projects empower households to
take ultimate responsibility for the quality of
their diet by growing their own nutrient-rich
foods and making informed consumption
choices. It has further been argued that the
benefits of gardening projects are tangible
and rewarding for the community (11). Home
gardening projects can reach a majority of
rural and many urban/peri-urban house-holds
and all their members, not just a par-ticular
age group, as is the case, for example,
in high-dose vitamin A supplementation pro-grammes.
Generally, communities that have
no or limited access to supplementation and
food fortification programmes benefit the
most from home gardens.

Home Gardening Approach 165
Home Garden Projects to Address
Vitamin A Deficiency in South Africa
The national prevalence of vitamin A defi-ciency
among 1- to 9-year-old South African
children was 64% in 2005 (12). Compared
with a national survey conducted in 1994 (13),
the vitamin A status of South African children
appears to have deteriorated despite the
national vitamin A supplementation pro-gramme
which targets 6- to 59-month-old
children and postpartum mothers within 6–8
weeks of delivery. National vitamin A supple-mentation
coverage rates were found to be
72.8% for children aged 6–11 months and
13.9% for children aged 12–59 months (14).
Children in South Africa generally con-sume
a diet that is low in animal foods, veg-etables
and fruits, resulting in approximately
half of the children consuming less than 50%
of the required amount of vitamin A (15). The
consumption of vegetables and fruits is gen-erally
low in the rest of the South African
population as well. Analysis of household
availability of different foods showed that 196
g of vegetables and fruits were available per
person per day at the household level (16).
This amount is about half of the World Health
Organization’s recommended daily intake of
more than 400 g of vegetables and fruits per
person to protect against cardiovascular dis-ease
and certain cancers (17). Rural and urban
South African women in KwaZulu-Natal and
Western Cape Provinces considered afforda-bility,
and to a lesser extent availability, as
major constraints for the consumption of veg-etables
and fruits (18).
Home gardens can provide households
with direct access to provitamin A-rich vege-tables
that are not readily available or within
their financial reach. In theory, a well-planned
home garden of size approximately 15 m × 10
m can supply a sufficient amount of provita-min
A-rich vegetables to fulfil the vitamin A
requirements among other micronutrients of
a household of six throughout the year (19).
This chapter gives an overview of home
garden projects that were done in South
Africa by the Medical Research Council
(MRC) and Agricultural Research Council
(ARC). The aim of these projects was to
address vitamin A deficiency through
increased production and consumption of
vegetables and fruits all year round, particu-larly
those rich in provitamin A carotenoids.
Integral to these projects is the emphasis on
nutrition and agriculture linkages.
The first project was initiated in 1998 and
formed the foundation for the second project.
The study population for the first project was
composed of residents of Ndunakazi, a rural
village in the Valley of a Thousand Hills in
KwaZulu-Natal Province. Almost 50% of the
children in the area were previously shown to
be vitamin A deficient (20). The population
density of this village was low and approxi-mately
200–300 households with, on average,
eight persons per household were scattered
over a mountainous area of approximately 11
km long and 1 km wide. The gardening activ-ities
were integrated with community-based
growth monitoring and linked to nutrition
education. The project had high input from
the research team and was closely monitored.
Project evaluation showed a positive impact
on maternal knowledge regarding vitamin A
nutrition, dietary vitamin A intake and the
vitamin A status of children aged 2–5 years
(21). The research team gradually withdrew
while putting mechanisms in place to enable
continuation of the gardening activities.
Aspects that were given consideration
included seasonal availability of vegetables
and fruits (determined during 2003–2005)
(22) and a sustainable seed system.
Unpublished results from a survey done in
2007 suggested that the gardening activities
were sustained after withdrawal of the
research team. The latter survey showed that
a substantial number of households obtained
provitamin A-rich vegetables and fruits from
either a home garden or a community/group
garden; and that the vitamin A intake was
higher than at baseline.
In the second project from 2002 to 2005, a
similar approach was used but with less input
from the research team, and with the focus on
community mobilization and technology
transfer. The study population resided in
seven rural villages, approximately 200–700
households per village, in Lusikisiki, situated
in the Pondoland Coastal Plateau in the
Eastern Cape Province.

Crops cultivated in the home gardens
The aim of the aforementioned two projects
was to improve the vitamin A intake of nutri-tionally
at-risk populations. The b-carotene
content of the crop and its potential contribu-tion
towards the vitamin A requirements of
the target population were predominant con-siderations
in the selection of crops to be
planted. Crops inherently rich in provitamin
A carotenoids (particularly b-carotene)
include dark-green leafy vegetables (e.g. spin-ach
and wild-growing leaves), carrot, orange-fleshed
sweet potato, butternut squash,
pumpkin, mango and papaya.
Although the bio-efficacy of provitamin
A carotenoids in plant foods is less than pre-viously
thought (23), it has been shown that
plant provitamin A carotenoids from green/
yellow vegetables can sustain vitamin A sta-tus,
as demonstrated in Chinese children (24).
Consumption of cooked green leafy vegeta-bles
(25–27), sweet potato (26,28,29) and car-rots
(27) was shown to improve vitamin A
status, providing evidence supporting the use
of provitamin A-rich plant foods in food-based
strategies to address vitamin A
deficiency.
Orange-fleshed sweet potato varieties
offer one of the highest sources of naturally
occurring b-carotene, but are currently not
widely grown in Africa (30). A randomized
controlled trial done in South Africa showed
that orange-fleshed sweet potato was accepted
well by primary-school children and
improved their vitamin A status when given
as part of the school meal (29). Between 70%
and 92% of the b-carotene in orange-fleshed
sweet potato is retained during cooking (31).
Of the orange-fleshed varieties available,
some were found naturally, while others have
been developed through conventional breed-ing
(32). Sweet potato varieties have also been
developed through improved biotechnology
(33,34). Sweet potato is adaptable to a broad
range of agro-ecological conditions and is
suitable for low-input agriculture. It is, in
many ways, an ideal crop for gardening
projects, as it grows on low-nitrogen soils, is
more drought-tolerant than conventional
vegetable crops, crowds out weeds and suf-fers
from relatively few pests (35).
The colour of the sweet potato is directly
related to the b-carotene content, and colour
intensity (cream, yellow, yellow-orange,
dark orange) may therefore be used as an
indicator of provitamin A value (36).
Vegetable garden projects in South Africa
use varieties with an orange to dark-orange
colour and are supported by a breeding pro-gramme
for orange-fleshed sweet potato at
the ARC – Roodeplaat Vegetable and
Ornamental Plant Institute. Orange-fleshed
varieties had been used as early as the 1980s
in the ARC programme but were mainly
aimed at the frozen-food industry, and were
characterized by low dry-matter content,
poor storability, and tended to have long
curved shapes (37). In 1996, the renewal of
orange-fleshed sweet potato breeding began
by examining breeding lines used in the
1980s, selecting some with higher dry-matter
content and acceptable shape; and, in addi-tion,
orange-fleshed cultivars originating
from the USA were obtained from the germ-plasm
collection of the International Potato
Center. Vegetable garden projects in South
Africa originally used some of the US varie-ties
(particularly Resisto, W-119 and Excel).
After several years of crossing, evaluation
and selection, three orange-fleshed varieties
(Khano, Serolane and Impilo) were released
from the ARC programme between 2006 and
2008 (38,39). The breeding programme is
developing sweet potato cultivars with high
b-carotene content, good yield, good taste,
drought tolerance and tolerance to major
diseases, and is linked with the HarvestPlus
Sweet Potato Biofortification Program
(40,41).
Orange-fleshed sweet potato is a new
crop in South Africa. Nevertheless, in a
paired preference test, 85% of respondents
preferred the taste of orange-fleshed sweet
potato to the usual white-fleshed sweet
potato, and 53% had a definite liking for the
colour (42).
The use of orange-fleshed sweet potato
to combat vitamin A deficiency is an interna-tional
trend. Orange-fleshed sweet potato is
used to combat vitamin A deficiency in sub-
Saharan African countries, e.g. in Western
Kenya, Mozambique and Uganda (43–45), as
well as South and West Asia (46).

Ndunakazi project
The Ndunakazi home garden project was ini-tiated
in 1998, with the aim of improving the
vitamin A status of children through produc-tion
and consumption of provitamin A-rich
vegetables and fruits.
Community-based growth monitoring
activities were used as a platform for the pro-motion
and implementation of the home gar-den
project. The community-based growth
monitoring project was established in 1995
because of the lack of health facilities within
the area (47). The growth monitoring project
had an estimated coverage of 90% and an
average monthly attendance ratio of 71% for
children aged 5 years and younger (48). The
community-based growth monitoring activi-ties,
therefore, provided a suitable platform
for the promotion and implementation of the
home garden project as a large number of
mothers had access to the nutrition education
and agricultural training activities that were
given during the growth monitoring sessions.
Growth monitoring sessions were hosted
at households which were identified taking
into consideration the geographical location,
accessibility, number of pre-school children in
the vicinity of the household, availability of
space and willingness of the mother within
the household to participate. The households
made their homes available on a voluntary
basis, once a month, to serve as meeting
points. Activities during the monthly sessions
included: (i) growth monitoring of children
aged 5 years and younger; (ii) basic nutrition
education (including aspects of breastfeed-ing,
complementary feeding, hygiene and
sanitation); and (iii) counselling of mothers or
referral to the clinic when growth faltering
occurred in children. The growth monitoring
activities were carried out by nutrition moni-tors
(local people, but not specifically from
within the village, trained for the project),
who were employed by the MRC.
A home garden project was integrated
with the growth monitoring activities during
the last quarter of 1998. Demonstration gardens,
which served as training centres for gardening
activities, were established at each growth
monitoring site. During the monthly growth
monitoring sessions, household production
and daily consumption of provitamin A-rich
vegetables and fruits were promoted through:
(i) education on vitamin A nutrition (simple,
inexpensive education material that was
attractive and acceptable to both the mothers
and the nutrition monitors was used to guide
the nutrition monitors through the lessons);
(ii) cooking of locally produced provitamin
A-rich vegetables; and (iii) demonstrations of
the planting process in a demonstration gar-den.
Many of the mothers were not familiar
with the provitamin A-rich vegetables, so
cooked vegetables on growth monitoring
days were used to: (i) introduce the mothers
and children to these vegetables; (ii) teach the
mothers various ways of preparation; and
(iii) give the mothers the opportunity to
observe their children eat and enjoy it. The
latter served as motivation for the mothers to
plant these vegetables at household level and
to prepare them at home.
The nutrition education component of
the garden project focused on, among other
things, optimal food preparation methods to
maximize the bioavailability of provitamin A
carotenoids. Based on evidence that between
3 g (28) and 5 g (49) of fat per meal is required
to enhance carotenoid absorption, the moth-ers
were encouraged to add the minimum
amount of fat to the meal containing provita-min
A-rich foods.
Destroying the food matrix in which the
carotenoids are incorporated may help to
improve the bioavailability of carotenoids.
During food preparation, mechanical process-ing
of vegetables through, for example, cut-ting,
chopping or grinding disrupts the
sub-cellular membranes in which the caroten-oids
are bound (50). The mothers were there-fore
encouraged to grate carrots, for example.
To retain the nutrients (particularly heat-labile
and water-soluble micronutrients) dur-ing
cooking, the mothers were encouraged to
use little water and not to overcook the vege-tables.
The mothers were further encouraged
to eat yellow fruits (e.g. mangoes, papayas
and yellow peaches) when fully mature.
On the day of growth monitoring, gar-dening
activities were promoted and demon-strated
by a nutrition monitor to all mothers
attending the growth monitoring session.
Crops that were planted in the demonstration

gardens were orange-fleshed sweet potato,
carrot, spinach (Swiss chard) and butternut
squash. KwaZulu-Natal has a tropical climate
and a papaya tree was therefore planted in
each demonstration garden. Pumpkin and
imifino (a collection of various dark-green
leaves that is eaten as a vegetable; the leaves
either grow wild or come from vegetables
such as pumpkins, beetroots and sweet pota-toes)
were already produced locally, but the
quantity grown and eaten was low (51).
Consumption of pumpkin and imifino was
promoted, but these vegetables were not
planted in the demonstration gardens.
Mothers were encouraged to plant provi-tamin
A-rich vegetables and papaya trees at
the household level in addition to any exist-ing
crops. A crop rotation system was recom-mended
for soil improvement and pest
control. Staggered planting, which is small,
regular plantings at intervals during the
planting season, was promoted to lengthen
the period of availability of individual provi-tamin
A-rich vegetables.
Impact of the home garden project on
maternal nutritional knowledge, vitamin A
intake and vitamin A status
The effect of the garden project on maternal
knowledge, dietary intake and vitamin A sta-tus
of 2- to 5-year-old children was evaluated
through two cross-sectional surveys – one at
baseline (February–March 1999) and a follow-up
survey 20 months later (November 2000). A
neighbouring village that had similar commu-nity-
based growth monitoring activities but no
home garden project served as control village.
A significant improvement in maternal
knowledge on vitamin A nutrition was
observed. Within 20 months, most of the
mothers in Ndunakazi could: (i) name at least
three food sources of vitamin A (Ndunakazi
71% versus control village 18%); (ii) relate the
colours yellow/orange and dark green with
vitamin A-rich vegetables (Ndunakazi 82%
versus control village 15%); and (iii) name at
least one symptom related to vitamin A defi-ciency
(Ndunakazi 74% versus control village
27%) (21).
Before implementation of the garden
project, the children consumed a cereal-based
diet, with staple foods being a stiff porridge
made with maize meal, bread and rice.
Legumes, mostly beans, formed an integral
part of the diet. The intake of vitamin A-rich
foods was low, resulting in a median vitamin
A intake of 35% of the required amount (52).
The home gardening project added variety to
the diet and did not replace a major compo-nent
of fruits and vegetables previously con-sumed
(mostly cabbage, banana and orange).
The intake of yellow/orange-fleshed and
dark-green leafy vegetables increased, and as
a result, the intake of vitamin A increased, with
at least 85% of the vitamin A intake being from
provitamin A-rich fruits and vegetables (53).
The prevalence of vitamin A deficiency
(serum retinol <20 mg/dl) decreased from
58% at baseline to 34% in the Ndunakazi
village. Ndunakazi children from households
with project gardens had a significantly
higher mean serum retinol concentration than
(i) the Ndunakazi children without a project
garden at household level and (ii) children
from the control village (21). During the two
weeks prior to the follow-up survey, children
in Ndunakazi suffered less from diarrhoea
than children in the control village (10% ver-sus
22%) (54).
A qualitative assessment using focus
group discussions showed that the commu-nity
gained a sense of empowerment through
a better understanding of what makes their
children healthy (through the nutrition educa-tion),
how to check this (through the growth
monitoring) and skills to produce food to
achieve this (through the training in gardening
activities). The community was positive
towards the home gardens, realizing the health
benefits and relating the project with poverty
alleviation (55). The mothers’ understanding
of the underlying factors of poor growth and
health of their children, which was obtained
through monthly growth monitoring and
nutrition education, contributed towards the
success of the home garden project.
Seasonal dietary intake of provitamin
A-rich vegetables
The dietary surveys that were done in
February and March 1999 and November
2000 showed seasonal variations in the

consumption of yellow and dark-green leafy
vegetables (56). Climatic conditions and sea-sonal
patterns affect the cultivation of provi-tamin
A-rich vegetables and this can
potentially affect dietary vitamin A intake.
Additional data were, therefore, collected on
the seasonal availability of these vegetables
and the impact thereof on dietary vitamin A
intake (22). The proportion of 2- to 5-year-old
children who consumed provitamin A-rich
vegetables and fruits at least once weekly was
determined from February to December in
2003, and during February, May, August and
November in 2004 and 2005. Although the
absolute values differed, results of these sur-veys
showed that butternut squash, pumpkin
and orange-fleshed sweet potato were con-sumed
mostly during the first quarter/half of
the year, while spinach and carrot were con-sumed
mostly during the second half of the
year. The proportion of children who con-sumed
orange-fleshed sweet potato was low,
suggesting that a more intensive promotion
campaign was needed to sustain local pro-duction
and frequent consumption of this
newly introduced crop.
Foods reported during a quantified die-tary
survey in 2005 showed that consumption
of spinach and imifino complemented each
other, with imifino being consumed mostly
during the first and last quarter of the year
and spinach (mostly Swiss chard) during the
third quarter (57). This highlights the impor-tance
of promoting the consumption of both
conventional (spinach) and traditional (imi-fino)
leafy vegetables to ensure year-round
consumption of dark-green leafy vegetables.
Quantified dietary intake for 2- to 5-year-old
children during February, May, August
and November of 2005 showed that the prev-alence
of inadequate dietary vitamin A intake
was approximately 20% or less, with the low-est
prevalence (6%) reported for the November
survey. The provitamin A-rich vegetables and
fruits contributed between 49% and 74% of
total vitamin A intake (22). This suggests that
provitamin A-rich vegetables and fruits can
sustain an adequate vitamin A intake through-out
the year for the majority of the popula-tion.
Promoting and cultivating a variety of
provitamin A-rich vegetables and fruits will
extend the period of and ensure year-round
availability, provide variety and spread the
risk for crop failure. The period of availability
of certain vegetables can be lengthened by
manipulating agricultural practices. Du Plooy
et al. (58) showed, for example, that the avail-ability
of orange-fleshed sweet potato can be
extended to at least nine months of the year in
areas with moderate winter climate by using
various planting and harvesting dates, plant
spacing and soil storage.
Availability of provitamin A-rich
vegetables and fruits
The 2003 survey showed that unavailability
was the main reason for not consuming spe-cific
vegetables during the off-season. This
survey showed that the majority of house-holds
did not have access to butternut squash
for the period April to December, pumpkin
and orange-fleshed sweet potato during the
second half of the year, and carrots and spin-ach
during the first half of the year (22).
To ascertain to what extent the house-holds
had access to provitamin A-rich vegeta-bles
and fruits through the local shops, the
availability of vegetables and fruits in the five
most accessible shops in the village and sur-rounding
areas was recorded during 2004.
Potato, cabbage, onions and tomato were
available most of the time in all five shops.
The provitamin A-rich vegetables pumpkin,
butternut squash and carrot were not availa-ble
in the shops. In terms of fruits, apples and
bananas were available for most of the time,
while the availability of oranges fluctuated.
For provitamin A-rich fruits, mangoes were
never available, some yellow peaches were
available during February to April, and some
papayas were available during December
(22). In areas where provitamin A-rich vege-tables
and fruits are not available in local
shops, the community will not have easy
access to these foods unless they produce
them locally.
Contribution of provitamin A-rich vegetables
and fruits towards dietary intake of nutrients
other than vitamin A
Two surveys in the project area showed that
home gardens focusing on provitamin A-rich

vegetables and fruits can improve the overall
nutritional quality of the diet, and address
multiple nutrient deficiencies simultaneously.
In the first survey, which was done in
February–March 2000 (one year after imple-mentation
of the project), dietary intake was
determined for 2- to 5-year-old children from
households with and without a project gar-den.
Children from households with a project
garden had significantly higher dietary
intakes for riboflavin, vitamin B6 and vitamin
C, and a tendency towards a higher calcium
intake; provitamin A-rich vegetables and
fruits contributed more than 50% of total
intake for calcium and iron, and between 25%
and 50% of total intake for magnesium, ribo-flavin
and vitamin C (53).
Similar findings were observed through
a repeated cross-sectional dietary survey that
was done for 2- to 5-year-old children in
February, May, August and November of
2005, which showed that provitamin A-rich
vegetables and fruits contributed towards
total dietary intake of especially calcium and
iron, and to a lesser extent of magnesium,
riboflavin and vitamin C (22). This is a signifi-cant
additional benefit of the home gardening
project, more so as these nutrients were all
shown to be deficient in the diets of 1- to
9-year-old South African children as deter-mined
in the National Food Consumption
Survey of 1999 (15).
Community-based nursery for orange-fleshed
sweet potato and distribution of seeds
To ensure that the households have access
to orange-fleshed sweet potato planting
material, a community-based sweet potato
nursery in a netted structure, 10 m × 5 m, was
established at one of the households in 2003.
The nursery contains approximately 200
plants in planting bags from which cuttings
are obtained. The plants are replaced with
virus-tested stock plants every two to three
years to keep supply cuttings of good quality.
The number of cuttings that were distributed
from the nursery was 1377 in 2004, 2430 in
2005, 3220 in 2006, 7970 in 2007, 3955 in 2008
and 5750 cuttings in 2009. Considering that
there are approximately 200–300 households
in this village, these numbers are quite
significant. The nursery supplies cuttings not
only to households in the village, but also to
households and schools in nearby villages.
A distribution system for seeds for but-ternut
squash, carrot and spinach is linked to
the community-based orange-fleshed sweet
potato nursery. Seeds are bought in bulk,
repacked and distributed at a price signifi-cantly
lower than in the shops in the village
or nearby towns, where small packages are
sold at expensive prices.
Sustainability of the project
The research team gradually withdrew after
the impact evaluation that was done in
November 2000 (21). The growth monitoring
project, which served as a platform to pro-mote
the gardening activities, was terminated
through a gradual withdrawal process in
2006. Since the implementation of the com-munity-
based growth monitoring project in
1995, the roads and transport system
improved considerably. As a result, the com-munity
now had relatively easy access to the
nearest clinic, and households were encour-aged
to take their children to the clinic for
regular growth monitoring, as this would
also give them regular access to health pro-grammes
such as the vitamin A supplementa-tion
programme.
From March to May 2007, a question-naire
was completed for 100 randomly
selected households that were recruited
through grade 4 to grade 7 scholars of the
local school (unpublished data). The caregiv-ers
of the scholars were interviewed using a
structured questionnaire to determine sources
of vegetables and fruits, household food con-sumption,
knowledge of nutritional benefits
of provitamin A-rich vegetables and fruits,
and gardening practices at household level.
Dietary intake was quantified for the scholars
and caregivers using a 2-day repeated 24-hour
dietary recall. The SAS software package ver-sion
9.1 (SAS Institute Inc., Cary, North
Carolina) was used to convert food intake to
macro- and micronutrients, using the SAFoods
food composition database.
The average age of the caregivers
who were interviewed was 38 ± 10 years
(mean ± standard deviation), and 48% had

some secondary school education (grades
8 to 12).
Eighty per cent of the households col-lected
imifino from the wild. Approximately
one-third of the households obtained provita-min
A-rich vegetables from a community or
group garden. This could be a reflection of
two group gardens planting mostly provita-min
A-rich vegetables that were established
in the area (one in 2004 and the other in 2005).
More than 40% of the households planted
provitamin A-rich vegetables in their own
gardens. Figure 9.1 shows the percentage of
households who obtained provitamin A-rich
vegetables from either a home or a commu-nity/
group garden. Although the main func-tion
of the vegetable gardens was to produce
food for home consumption, 40% of those
households with vegetable gardens (20% of
the total study population) sold some of their
produce.
Crops faced a variety of physical, eco-nomic
and structural challenges. Animals
destroying the crops were seen as the major
physical threat, and this problem can be
attributed to the lack of fencing affecting
nearly two-thirds of households growing
vegetables. Other major problems experi-enced
by more than half of the households
growing vegetables were plant diseases,
insects, lack of money to buy supplies and
shortage of water for irrigation. Lack of seeds
and access to orange-fleshed sweet potato
cuttings was a problem for less than 10% of
the households growing vegetables.
The respondents were knowledgeable on
the nutritional benefits of provitamin A-rich
vegetables and fruits. Ninety-six per cent of
the respondents thought that yellow/orange
vegetables are good for their children. Main
reasons given for this were because it is
healthy (42%), contains vitamin A (13%) and
promotes child growth (10%). A variety of
other reasons were listed (each by <10% of
the caregivers). When asked to name one
symptom related to not eating yellow/orange
vegetables, four symptoms were each named
by at least 10% of the respondents: eye prob-lems
(26%), diarrhoea (22%), sores (15%) and
poor child growth (13%).
Ninety-one per cent of the respondents
were familiar with the term vitamin A: 62%
knew that vitamin A is a nutrient in food; 78%
associated the colours yellow and orange
with provitamin A-rich vegetables; 68%
named three foods that are rich sources of
vitamin A; and 89% could name one symp-tom
related to vitamin A deficiency.
The quantified dietary data showed that
the median (interquartile range; 25th–75th
percentile) vitamin A intake for the caregiv-ers
was 662 (444–886) retinol equivalents
60
50
40
30
20
10
0
Carrot Butternut squash Pumpkin Orange-fleshed
sweet potato
Spinach
Percentage of households (%)
Fig. 9.1. Percentage of households in Ndunakazi obtaining provitamin A-rich vegetables from either a
community/group garden ( ) or a home garden ( ) in 2007.

(RE) and for the scholars 561 (406–797) RE.
This is substantially higher than the vitamin
A intake reported for children and caregivers
in the area before implementation of the
home garden project; a median vitamin A
intake of 150 (56–579) RE for 2- to 5-year-old
children and 177 (97–644) RE for caregivers
was reported (52).
In summary, the results of the 2007 sur-vey
showed that the caregivers were knowl-edgeable
on the nutritional benefits of
provitamin A-rich vegetables and fruits; a
substantial number of households obtained
provitamin A-rich vegetables and fruits from
either a home or community/group garden;
and vitamin A intake was higher than at base-line.
These results suggest that that the gar-dening
activities in the area were sustained
after withdrawal of the research team.
Lusikisiki project
The Ndunakazi project had high input from
the research team and was closely monitored.
The question, though, was whether this
approach could be implemented on a wider
scale and with less input from the research
team. The Lusikisiki project was implemented
in 2002, with the aim of promoting local pro-duction
and frequent consumption of provi-tamin
A-rich vegetables and fruits. The focus
of the project was on technology transfer,
mobilization of the local community and
involvement of the local governmental
Departments of Health and Agriculture. This
enabled reduced input from the research
team. Agricultural extension officers served
as agricultural advisors for the project and
acted as links between the researchers and
community members involved in the project.
Two community members per village
were identified and trained as project health
volunteers. Implementation was based on the
‘training of trainers’ principle and, during the
second year of the project, each group of vol-unteers
trained two more groups in each vil-lage.
The project health volunteers were
responsible for cultivating and promoting
provitamin A-rich vegetables with the sup-port
of the agricultural extension officers,
providing nutrition education, and for growth
monitoring for 1- to 5-year-old children with
the support of the Department of Health.
The project built on existing structures
and activities, namely: (i) decision making
and problem solving were linked with exist-ing
monthly farmer forum meetings; (ii)
growth monitoring was added mostly to
crèche activities; and (iii) the demonstration
plots were established mostly in existing gar-dens.
Since the existing gardens were already
fenced, there were no additional costs to fence
the demonstration gardens.
At four of the seven sites, growth moni-toring
was added to crèche activities. Crèches
are convenient sites, as access to children
attending the crèche is readily available.
However, using a crèche as the site for growth
monitoring has its limitations. The caregivers
of the children were often not present during
the growth monitoring sessions, making it
difficult for the project health volunteer to
give feedback to the caregiver on the child’s
growth (which is an integral part of growth
monitoring). Also, caregivers who did not
attend the growth monitoring sessions held
at a crèche could not benefit from the nutri-tion
education and promotion given during
the growth monitoring sessions.
The monthly growth monitoring sessions
and annual/biannual farmers’ days were used
to: (i) create awareness on the importance of
vitamin A and health; and (ii) promote project
activities in the area (e.g. distributing pam-phlets
on vitamin A-rich vegetables, making
cooked and processed products of orange-fleshed
sweet potato available for tasting).
In each of the seven villages, orange-fleshed
sweet potato field nurseries were
established in order to ensure a continuous
supply of cuttings. Selection criteria for sites
for demonstration plots and community-based
field nurseries included fencing, water
available for irrigation and willingness to
engage in the process. Training in gardening
activities was done at both the demonstration
plots and the field nurseries.
Homesteads at the demonstration gar-dens
and nursery sites were used to demon-strate
the preparation and processing of
orange-fleshed sweet potato, with emphasis
on sweet potato bread, soup, chutney, juice,
sweet potato leaves as green vegetables and a

sweet potato curry dish. This introduced a
variety of preparation methods, which could
potentially lead to a more frequent use of the
orange-fleshed sweet potato. Using a variety
of products also could create a greater demand
for the orange-fleshed sweet potato, which
could potentially enhance the sustainability
of local production. Bottled products such as
chutney are a way to lengthen the period of
availability of orange-fleshed sweet potato
for consumption. When using orange-fleshed
sweet potato in baking bread, part of the
wheat flour is substituted with boiled orange-fleshed
sweet potato. It is, however, impor-tant
that the dark-orange varieties are used to
ensure that the baked bread provides ade-quate
amounts of vitamin A (59). Processed
products using orange-fleshed sweet potato
should also be economically viable (59). With
the high prevalence of overweight and obes-ity
in South Africa (56% of adult females are
either overweight or obese) (60), it is impor-tant
that prepared dishes and processed prod-ucts
are low in fat, sugar and salt.
In 2005, three years after initiation of the
project, participating and non-participating
households were compared in terms of child
morbidity, nutritional knowledge, dietary
intake and gardening practices. Table 9.1
shows that the project activities had a favour-able
effect on the caregivers’ knowledge of
vitamin A nutrition, morbidity of 1- to 5-year-old
children as reported by the caregivers, con-sumption
of provitamin A-rich vegetables and
growing of provitamin A-rich vegetables (61).
These observations suggest that the project
contributed significantly towards nutritional
outcomes. However, a significant limitation of
the project was the lack of quantitative base-line
data. Thus, the study cannot provide con-clusive
evidence that the observed differences
between participating and non-participating
households were because of the project per se.
Community-based growth monitoring as
platform to promote provitamin A-rich
vegetables and fruits
In the two projects described above commu-nity-
based growth monitoring activities,
Table 9.1. Summary of results comparing project households with control households in the Lusikisiki
food-based project three years after implementation. (Adapted from Laurie and Faber (61).)
Caregiver’s knowledge
of vitamin A nutrition
Morbidity for 1- to
5-year-old children
Vegetable consumption
for 1- to 5-year-old
children
Obtained provitamin
A-rich vegetables from
own garden
Thought yellow
vegetables/fruits are
good for children: 73%
versus 45%
Vomiting: 6% versus
13%
Butternut squash: 32%
versus 22%
Butternut squash: 38%
versus 24%
Familiar with the term
‘vitamin A’: 89%
versus 63%
Experienced fever: 30%
versus 42%
Carrot: 31% versus
31%
Carrot: 28% versus
18%
Knew that vitamin A is a
nutrient in food: 83%
versus 53%
Sores on the skin: 6%
versus 19%
Pumpkin: 67% versus
67%
Pumpkin: 70% versus
61%
Named three foods rich
in vitamin A: 56%
versus 27%
Continuous runny nose:
20% versus 33%
Orange-fleshed sweet
potato: 24% versus
15%
Orange-fleshed sweet
potato: 24% versus
10%
Diarrhoea: 2%
versus 7%
Poor appetite: 7%
versus 14%
Spinach: 73% versus
63%
Spinach: 41% versus
28%
Results are given for the project versus control households.

which extended and complemented the
growth monitoring activities of the
Department of Health, provided the platform
to promote the production and consumption
of provitamin A-rich vegetables and fruits.
For sustainability, methods of integrating gar-dening
activities with existing community-based
growth monitoring activities,
particularly those activities falling under the
Department of Health, should be investi-gated.
For instance, in the Eastern Cape
Province, the local Department of Health
implemented community-based growth
monitoring in 2005 and, by 2008, there were
148 growth monitoring sites in the province.
Growth monitoring is done by community
health workers who are attached to a clinic,
and each growth monitoring site has a vege-table
garden at the clinic (62).
In the Lusikisiki project, where the
growth monitoring was done by project
health volunteers who were not remunerated,
various concerns regarding the sustainability
of the growth monitoring activities were
highlighted. These concerns included a lack
of a continuous and adequate supply of pro-vitamin
A-rich vegetables to cook for the chil-dren
attending the growth monitoring
sessions; a lack of financial resources needed
to maintain food preparation activities dur-ing
the growth monitoring sessions (e.g.
cooking oil, sugar, paraffin, firewood); broken
scales and flat batteries and lack of resources
to fix/replace them; and poor interpretation
of the growth curve by the project health vol-unteers
(61). Funding from local government
departments or external agencies is needed to
sustain the activities at the community-based
growth monitoring sites and for the provision
of sustainable stipends for the project health
volunteers. Besides the need for adequate
funds to sustain community-based growth
monitoring, the growth monitoring process
(weighing procedure, plotting the weight and
appropriate counselling) and using appropri-ate
weighing scales were identified by the
Department of Health in the Eastern Cape
Province as areas within community-based
growth monitoring that need to be strength-ened
(62).
The Ndunakazi and Lusikisiki projects
showed that community-based growth
monitoring is a suitable platform for promot-ing
the production and consumption of pro-vitamin
A-rich vegetables and fruits, but there
are constraints as described above. To
strengthen the food-based approach described
in this chapter, it is important that first the
constraints of community-based growth
monitoring be addressed, and second that the
feasibility of other platforms to promote pro-vitamin
A-rich vegetables and fruits be
investigated.
As part of their technology transfer and
capacity development activities, the ARC
explored various other entry points to be used
as a platform to promote the production and
consumption of provitamin A-rich vegetables
and fruits. They collaborated with other role
players and used existing infrastructure to
implement the food-based approach. Entry
points that were explored included school
gardens, clinic gardens, crèche gardens, com-munity
gardens and institutional programmes
such as sustainable land-use programmes or
agricultural assistance programmes (63).
School gardens were used as the entry
point in one of the provinces as part of
‘Sustainable Food Production in Schools’,
which is a sub-programme of the National
School Feeding Programme of the Department
of Education. Teachers from 200 schools
received training in the food-based approach
and demonstration plots were established in
existing school gardens. The community was
introduced to the cultivation of provitamin
A-rich vegetables, particularly the orange-fleshed
sweet potato, during large-scale open
days. In some cases, the orange-fleshed sweet
potato was introduced in clinic gardens that
were used as a platform for training as well as
the distribution of cuttings of orange-fleshed
sweet potato to people visiting the clinics.
The ‘Mdantsane for Vitamin A Program’
is an example of a local project that integrated
the promotion of provitamin A-rich vegeta-bles,
particularly the orange-fleshed sweet
potato, with the vitamin A supplementation
programme. Evaluation of the integrated
project showed an increase in the number of
children who received vitamin A supplemen-tation,
as well as an increase in the cultivation
and consumption of orange-fleshed sweet
potato (64).

Spill-over effect
Participation in gardening projects is volun-tary
and self-selecting, and not all house-holds
will opt to grow their own vegetables.
Non-gardening households can, however,
potentially benefit from community-based
gardening projects because of the increased
awareness that is created by the visibility of
the demonstration and home gardens, as
well as the nutrition education and promo-tion
that is done during, for example, growth
monitoring sessions or farmers’ days.
An evaluation one year after implemen-tation
of the Ndunakazi project showed an
increased vitamin A intake for both partici-pating
and non-participating households
(53). Although some mothers opted not to
have a project garden, many of them realized
the nutritional benefits of these vegetables
and negotiated with other community mem-bers
to obtain some of these vegetables. The
non-participating households also showed an
increased consumption of imifino and pump-kin,
two vegetables that were promoted but
not planted in the project gardens because
they were already grown locally. The increased
vitamin A intake in non-participating house-holds
was, however, not sufficient to improve
the vitamin A status of the children (21).
A spill-over effect was also observed in
the Lusikisiki project. Approximately half of
the non-participating caregivers received
nutritional information from the project
health volunteers, who were local people
from within the villages. Nutritional informa-tion
was provided not only during the
monthly growth monitoring sessions, but
also at local events such as annual farmers’
days (61).
Problems experienced with the vegetable
gardens and possible ways to solve them
Problems experienced with vegetable gar-dens
and possible ways to handle them are
shown in Figs 9.2 and 9.3. Figure 9.2 contains
data for food-based projects done at
Ndunakazi (as determined during the 2007
survey), Lusikisiki (61) and Giyani (unpub-lished
data). Giyani is situated in a dry sub-tropical
region in Mopani District in Limpopo
Province, and data were collected in five rural
villages from 153 households growing vege-tables
in either a home or communal garden.
Shortage of water was a problem for at
least 50% of the vegetable gardens in all three
of the projects. Water is a critical element of
productivity as South Africa is classified as a
water-stressed country (65). Households
often do not have easy access to water for irri-gation.
In Lusikisiki, for example, nearly two-thirds
of the households with vegetable
gardens depended on water from the river for
irrigation (61). The time and labour needed to
collect irrigation water from the river places
an additional burden on the gardening activi-ties.
Gardening projects should, therefore,
include aspects of water-saving and water-harvesting
techniques (66,67).
A lack of fencing, resulting in animals
destroying the vegetables, was also a major
problem (although to a lesser extent in
Giyani). Proper fencing is expensive and most
households in resource-poor rural communi-ties
do not have the financial means to fence
their vegetable gardens. The formation of
small garden groups (approximately ten per-sons
per group) could potentially help to alle-viate
the problem with fencing. In Ndunakazi,
for example, two groups were formed on
their own initiative and they were assisted by
the research organization to obtain sponsor-ship
for fencing of the two gardens. Natural
fencing is another strategy that can be used to
prevent animals destroying the vegetables. It
has been recommended that food-based
approaches to address vitamin A deficiency
include not only local production of provita-min
A-rich plant foods, but also local produc-tion
of animal foods that are rich in vitamin A
such as poultry, small livestock, milking cows
or goats (6). The practicality in terms of the
animals destroying the vegetable gardens
should be taken into consideration when
implementing food-based projects.
Including aspects of integrated pest man-agement
can address some of the problems
experienced with plant diseases and insects.
Compost-making and buying agricultural
supplies in bulk and then redistributing
within the community can help to overcome

0 10 20 30 40 50 60 70 80
Percentage (%)
Fig. 9.2. Constraints experienced in home garden projects at Ndunakazi ( ), Lusikisiki ( ) and Giyani ( )
in South Africa.
Possible constraints
Shortage of water
Lack of fencing
Insects
Lack of funds for supplies
Plant diseases
Lack of seeds
Lack of fertilizer
Lack of pesticides
Lack of garden tools
Lack of sweet potato cuttings
Lack of irrigation equipment
Water for
irrigation
Lack of knowledge
Fencing
Agricultural
supplies
Plant pests &
diseases
Seeds and
cuttings
Water
harvesting
Group gardens
and sponsors
Natural fencing
Soil fertility
Buy in bulk
Integrated
pest
management
Community-based
nursery
Buy seed in bulk
Make own seeds
Compost-making
Possible solutions
Constraint
Fig. 9.3. Possible solutions for handling constraints in home garden projects.

the lack of funds to buy agricultural supplies.
It is further important to address soil fertility
to ensure that households growing their own
vegetables obtain reasonable yields. A situa-tion
assessment in Lusikisiki showed low soil
fertility (61), which often is a constraint in
rural crop production (68).
In 2007, lack of seeds and access to
orange-fleshed sweet potato cuttings were
not seen as a major problem (<10% of the
households with a home garden) in
Ndunakazi, which probably could be ascribed
to the community-based nursery and seed
distribution system that was put into place in
2003. Easy access to a regular supply of qual-ity
seed, seedlings and e.g. virus-free, orange-fleshed
sweet potato cuttings at an affordable
price is critical for the success and long-term
sustainability of gardening activities. A study
in South Africa showed that most of the capi-tal
cost of home gardening is spent on buying
seeds (69). Strategies to ensure an affordable
supply of seeds include using crops that can
be vegetatively propagated (e.g. sweet
potato), buying seeds in bulk which are then
repacked and sold at the community level,
and own seed production (e.g. butternut
squash and papaya).
Conclusions
Integral to the approach described in this
chapter is the integration of nutrition and agri-culture.
Nutritionists from the MRC and agri-culturists
from the ARC have been working
together since 1998 to develop a food-based
approach contributing towards the elimina-tion
of vitamin A deficiency. This is in line
with the view that food-based interventions
should have a well-designed agricultural
component as well as a well-designed nutri-tional
component, and that these two compo-nents
should be mutually reinforcing (70).
The critical components of the approach
are illustrated in Fig. 9.4. The approach is
flexible and allows for different entry points
to be used as platforms for the education
and promotion activities. The food-based
approach as described by Faber et al. (19)
acknowledges the underlying causes of
childhood malnutrition (71) and topics other
than vitamin A nutrition are covered in the
nutrition education component, such as
breastfeeding, immunization, vitamin A sup-plementation,
hygiene and sanitation (19).
Increasing the access to micronutrient-rich
foods through, for example, home pro-duction
is one of the ways in which agriculture
can contribute to improved nutrition (72). The
main aim of the gardening activities in the
projects described in this chapter was to pro-duce
adequate amounts of provitamin A-rich
foods for household consumption. Income
generation was a secondary aim, and only in
cases where there was a surplus of vegetables.
Potential criticism towards an approach
focusing on provitamin A-rich crops is that
people need a range of nutrients, not only
vitamin A. Production of provitamin A crops
was shown to improve the intake not only of
vitamin A, but also of some other micronutri-ents
(53). The provitamin A-rich vegetables
and fruits were shown to contribute signifi-cantly
towards dietary intake of nutrients such
as calcium, iron, magnesium, riboflavin and
vitamin C (22), nutrients which were all found
to be deficient in the diet of South African chil-dren
(15). Because production of provitamin
A-rich crops was promoted in addition to
existing crops already being planted, the vari-ety
of vegetables consumed increased. In
Ndunakazi, for example, vegetables con-sumed
prior to the project were mainly toma-toes,
cabbage, pumpkin and imifino. The
gardening project added butternut squash,
carrot, spinach and orange-fleshed sweet
potato. Increasing the intake of vegetables and
fruits in general will not only improve micro-nutrient
status, but could also reduce many
non-communicable diseases (73). An addi-tional
benefit of specifically provitamin A-rich
foods is that food carotenoids are credited
with other beneficial effects on health, inde-pendent
of their vitamin A activity, such as the
reduction of the risk of degenerative diseases
like certain types of cancer, cardiovascular dis-ease,
cataract and macular degeneration (74).
Integrating the food-based approach
with existing health, agricultural and devel-opment
programmes will enhance sustaina-bility
and cost-effectiveness and will provide
scope for national implementation.

Food-based approach
Demonstration
garden
Training centre
for gardening
activities
References
Additional topics
Breastfeeding
Growth monitoring
Vitamin A supplementation
Hygiene and sanitation
Immunization
Agriculture
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Production of
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Nutrition
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10 AVRDC – The World Vegetable
Center’s* Approach to Alleviate
Malnutrition
M.L. Chadha,1 L.M. Engle,1 J. d’A. Hughes,**1 D.R. Ledesma1 and K.M. Weinberger2
1AVRDC – The World Vegetable Center, Shanhua, Tainan, Taiwan; 2Center for
International Forestry Research, Bogor, Indonesia
Abstract
AVRDC conducts research and development activities to increase access to and improve consumption of
diverse and nutrient-rich vegetables, particularly in areas where malnutrition is prevalent. AVRDC aims
to improve human nutrition through increasing vegetable productivity, availability and consumption;
improving the nutrient content and phytochemical density of vegetables; enhancing the bioavailability of
nutrients from vegetables; and improving the health and economic status of the poor in developing coun-tries.
Activities to increase vegetable productivity, availability and consumption include the genetic
improvement of vegetables (biotic and abiotic resistance and tolerance), development of production sys-tems
to increase year-round availability of vegetables, good crop management practices to improve yield
and reduce chemical inputs, development of postharvest technologies to reduce losses, and the promotion
of vegetable consumption through information technology, school and home gardening, nutrition educa-tion
and designing nutrition seed kits for home gardens. Activities to improve the nutrient content and
phytochemical density of vegetables include collection and evaluation of vegetable genetic resources,
identification and promotion of underutilized indigenous vegetables high in nutrients and bioactive com-pounds,
and selection and/or breeding to increase content of nutrients and bioactive compounds. To
enhance the bioavailability of nutrients, optimum food preparation methods and recipes are developed
and promoted. Finally, the impact of vegetable consumption on health and economic development, as well
as the health benefits of consuming vegetables high in bioactive compounds, is discussed.
Key words: vegetables, indigenous vegetables, micronutrients, bioavailability, breeding, germplasm,
school and home gardens, nutrition seed kits, phytochemicals
Introduction
Hunger is the most severe result of poverty,
causing undernourishment from low energy
intake and nutritional deficiencies. Appro-ximately
one billion people suffering from
hunger live in the developing world (1). While
the main reason for undernourishment among
the poor is the lack of capacity to obtain
adequate, nutritious food, malnourishment
can also exist in poor populations with ade-quate
(in terms of quantity but not quality)
* AVRDC – The World Vegetable Center was formerly known as the Asian Vegetable Research and Development
Center (AVRDC). Since 2007, AVRDC expanded its regional mandate worldwide to become AVRDC – The
World Vegetable Center, abbreviated as AVRDC throughout the chapter.
** Contact: jackie.hughes@worldveg.org

184 M.L. Chadha et al.
food supply. Where there is a sufficient quan-tity
of food, but not always sufficient quality,
the diet can be deficient in one or more micro-nutrients.
The number of people with micro-nutrient
deficiencies is estimated to exceed
two billion.
Vegetables in the diet are essential to
combat malnutrition in the developing world.
Vegetables are rich in essential micronutrients
such as vitamins and minerals, carotenes,
folates and thiamin, as well as dietary fibre.
Although vegetable production is increasing
globally, it is still far too low in many devel-oping
countries. In 2003, when global veg-etable
production was 135 kg per capita,
production in the least developed countries
was only 73 kg per capita. Not only is per
capita production of vegetables unevenly dis-tributed,
but per capita consumption is also
uneven. Total vegetable production is highest
in the People’s Republic of China (313 kg per
capita) while, in contrast, production in
developing countries of Asia is only 80 kg
per capita (2). This uneven production and
consumption highlights the urgent need to
increase both vegetable production and the
availability of affordable vegetables for
consumption in the developing world.
Furthermore, it is essential for nutrition that
these vegetables have high nutrient bioavail-ability.
By increasing vegetable production,
consumption and nutrient bioavailability,
vulnerable populations will be better nour-ished
and therefore more able to tackle the
many other issues associated with poverty.
The mission of AVRDC is ‘to alleviate
poverty and malnutrition in the developing
world through the increased production and
consumption of nutritious and health-promoting
vegetables’. The Center’s activi-ties
are grouped under five research and
development themes. Theme 1 addresses
germplasm conservation, evaluation and
gene discovery; Theme 2 comprises genetic
enhancement and varietal development of
vegetables; Theme 3 consists of seed and safe
vegetable production systems; Theme 4 cov-ers
postharvest management and market
opportunities; and Theme 5 includes nutri-tion
security, diet diversification and human
health. This chapter presents the approaches
and activities undertaken at AVRDC to
improve human nutrition through research
and development activities on the production
and consumption of safe vegetables.
Increasing Vegetable Productivity,
Availability and Consumption
AVRDC’s major research and development
activities focus on the needs of the poor in
developing countries, increasing vegetable
productivity and availability while also pro-moting
increased consumption.
Adapting improved varieties to tropical
environments
Vegetable production in the tropics is highly
seasonal and severely constrained by low
yields and poor quality due to high tempera-tures,
excessive or insufficient moisture, pests
and diseases and poor postharvest handling.
The development of tropically adapted, high-yielding
vegetable varieties is critical and will
result in increased productivity. The first step
taken in the late 1970s by AVRDC was to adapt
vegetables to tropical conditions by develop-ing
heat-tolerant lines of tomato (Solanum lyco-persicum),
Chinese cabbage (Brassica rapa var.
pekinensis) and sweet pepper (Capsicum annuum)
through genetic improvement (3). Increased
tolerance to heat enables vegetable production
during hot summer seasons, thus ensuring a
good harvest even during ‘vegetable-lean’
months and particularly in areas closer to mar-kets
which are often in hot, humid lowlands.
AVRDC is well known for the heat-tolerant
vegetable lines it has developed. By
1978, heat-tolerant tomato lines that set abun-dant
fruits at maximum/minimum tempera-tures
of 30°C/22°C had been identified (4).
AVRDC’s improved lines are now routinely
tested at temperatures normally unfavoura-ble
to fruit set, i.e. maximum/minimum
temperatures of 33.6°C/25.4°C, mean relative
humidity of 79% and total rainfall of 96 mm.
In this adverse tomato production environ-ment,
inbred lines that yield exceptionally
well have been identified (5), thus increasing
the range of environments where tomatoes

AVRDC 185
can be grown. Tomatoes, when consumed in
large quantities, can provide significant
amounts of provitamin A, vitamin C as well
as lycopene. The most recently identified
heat-tolerant vegetable lines are four heat-tolerant
and early-maturing broccoli (Brassica
oleracea) lines. The highest yielding is
BR117SF1203, which yields above 10 t/ha in
the hot, wet summer season in Taiwan (6).
Broccoli is of particular interest because of its
flavour, the possible potential it provides for
protecting against cancer and its other nutri-tional
qualities. Sweet pepper, which is high
in provitamin A and vitamins C and E, could
contribute significantly to improved nutri-tion.
However, sweet pepper production in
the tropics and subtropics is limited because
of the narrow seasonal production windows
primarily due to the lack of heat-tolerant cul-tivars.
To develop a ‘tropical’ sweet pepper,
AVRDC uses chilli pepper as a source of genes
for heat tolerance and disease resistance (3).
At least 35 heat-tolerant Chinese cabbage
lines have been developed. Most of these lines
have been distributed to partners in national
agricultural research systems (NARS) where
they have been either tested directly or incor-porated
into national vegetable breeding
programmes.
Tropical environments are also subject to
heavy disease burden and insect pest pres-sures.
The next step taken by the AVRDC was
therefore to combine heat tolerance with
multiple resistance to pests and diseases.
AVRDC’s current tomato lines combine heat
tolerance and resistance to bacterial wilt
(Ralstonia solanacearum) and geminiviruses.
The combination of resistance to both these
diseases has enabled farmers in southern
India to double their tomato yields from
19 t/ha to 37 t/ha in on-farm trials (7).
Geminivirus resistance also allows farmers
to reduce pesticide applications for the con-trol
of whiteflies (Bemisia tabaci), the insect
vector that transmits geminiviruses.
Additionally, geminivirus resistance permits
tomato production to be extended into peri-ods
when the vectors and virus are prevalent.
Most of AVRDC’s new tomato lines are also
resistant to late blight (Phytophthora infestans),
root-knot nematode (Meloidogyne incognita)
and Tomato mosaic virus (TMV), in addition to
heat tolerance and resistance to bacterial wilt
and geminiviruses.
Increased stable yields of chilli pepper
(C. annuum) have been achieved through
increased resistance to anthracnose
(Colletotrichum spp.), bacterial wilt
(R. solanacearum), Phytoph thora blight (P.
infestans) and a complex of viruses including
Cucumber mosaic virus (CMV), Chilli veinal
mottle virus (ChiVMV), and tobamoviruses (3).
Introgression from wild or related species
has been used extensively to incorporate resist-ance
to pests and diseases in tomato and chilli
pepper, aided by molecular marker-assisted
selection. The short growth duration or early
maturing lines developed by AVRDC has also
facilitated the integration of these crops into
various cropping systems. AVRDC’s improved
mungbean (Vigna radiata) lines combine high
yields and early maturity with resistance to
both Mungbean yellow mosaic virus (MYMV)
and powdery mildew (Erysiphe polygoni). With
these traits, mungbean easily fits into the
wheat-based cropping systems in South Asia
and in cereal fallows in the Indo-Gangetic
Plains (6). About two million hectares in South
and South-east Asia are planted annually with
AVRDC’s mungbean lines, or varieties derived
from its improved mungbean germplasm (3).
After an initial focus on adaptation to
tropical environments and ensuring high
and consistent yields, AVRDC’s focus shifted
to include improvement of nutrition quality
and postharvest characteristics. As malnu-trition
remains a key concern, AVRDC
includes evaluation for nutritional factors as
a core part of its crop improvement activi-ties.
For example, while new tomato lines
are routinely evaluated for b-carotene and
vitamin C, the additional focus on posthar-vest
characteristics has meant that the new
improved lines also have firm fruits, longer
shelf-life and better postharvest handling
characteristics.
The success of the vegetable breeding
programmes at AVRDC is largely due to the
wide array of genetic material in its genebank
which is available for use by vegetable breed-ers
worldwide. The genebank currently holds
more than 55,000 accessions of vegetable
germplasm which are sources of many of
the traits used in the vegetable breeding

programmes not only of AVRDC, but also
those of NARS and the private sector.
In addition to tomato, sweet and chilli
pepper, crucifers and legumes, AVRDC also
has cucurbit and bulb allium improvement
programmes. Improved lines and selections
are freely available, accompanied by the
appropriate Material Transfer Agreement, to
public and private institutions. AVRDC has a
strong tradition of working with NARS and
has contributed to the release of 325 varieties
in 53 countries. The Center also collaborates
with the private seed sector, particularly in
Asia and increasingly in sub-Saharan Africa.
Production systems and good crop
management practices to increase year-round
vegetable availability, with increased yields
but reduced use of chemical inputs
Through the development of tropically
adapted lines of tomato, chilli and sweet pep-per,
and Chinese cabbage, AVRDC has sub-stantially
widened the production window
for vegetables in the tropics and semi-tropics.
Where genetic improvement is not the only
answer, vegetable production issues are
addressed through other means, such as bet-ter
crop management practices or integrated
pest management.
The yield of vegetables grown under the
hot, wet conditions of the lowland tropics can
be increased through better crop manage-ment
practices. AVRDC develops and adapts
technologies to meet the challenges of vegeta-ble
production under harsh conditions such
as the lack of irrigation water, drought, flood-ing,
pest and disease pressures, poor soil
quality, etc. These crop management strate-gies
include grafting (to increase tolerance to
flooding and associated diseases), improved
fertilizer application methods (to ensure the
appropriate amounts of nutrients are availa-ble,
appropriately placed and at the right
time), practices such as mulching and the use
of shelters and raised beds (to conserve soil
moisture, prevent soil degradation especially
during heavy rains and flooding, and to
enhance soil fertility), and the use of efficient
and appropriate irrigation systems that
deliver water directly to plant roots (thus
avoiding wastage and also reducing the prev-alence
of some diseases associated with flood
irrigation).
AVRDC has developed grafting tech-niques
that can mitigate the effect of excessive
soil moisture and other soil stress conditions,
as well as confer resistance to bacterial wilt.
For example, extension of tomato production
in the hot, wet summers in the lowland trop-ics
has been facilitated by the use of rain shel-ters
and the use of grafted tomatoes (tomato
scions are grafted on to flood and/or bacterial-wilt-
resistant tomato or aubergine (Solanum
melongena) rootstocks).
The benefits of mulching on tomato have
been demonstrated in Taiwan (8) using rice
straw to protect the soil. This reduces both
weed growth and conserves soil moisture. In
India, Pandita and Singh (9) demonstrated
the significant improvement due to mulching
with polythene sheets on the growth of sev-eral
vegetables such as okra, aubergine and a
range of cucurbits. The benefits of mulching
are therefore clearly demonstrated, but the
most appropriate mulching material must be
determined to suit specific needs and
environments.
Vegetables, especially tomato, often incur
substantial yield losses due to heavy rain dur-ing
the hot, wet seasons. Plastic rain shelters
prevent impact damage due to heavy rain on
seedlings and particularly on flowers and
young fruit. They also reduce waterlogging.
This protection results in higher marketable
yields (10). The improved drainage due to the
use of raised beds can also minimize the effect
of flooding on tomato yields (8).
The yield and quality of vegetable pro-duce
depend also on the efficiency of the
water management around the plants.
Inadequate, or too much water, results in
plants succumbing easily to pathogen infec-tion
and nutritional disorders. With a micro-drip
irrigation system, such as that developed
by International Development Enterprises
(IDE), water losses due to runoff or unneces-sary
deep infiltration are minimized. This
cheap and simple irrigation system has been
tested extensively and AVRDC now works
closely with IDE and promotes this irriga-tion
technology. Experiments have shown

AVRDC 187
that the water-use efficiency of chilli pepper
and other vegetables was significantly
higher in drip irrigation compared with
furrow irrigation (11).
Postharvest technologies to
reduce produce losses
Vegetables are usually highly perishable and
require careful handling. Additionally, their
production is highly seasonal, often leading
to over-supply, a consequent collapse of
prices and then a scarcity of vegetables.
Providing storage and processing technol-ogy
options are measures that can expand
the vegetable market, increase year-round
availability and reduce excessive price
fluctuations.
AVRDC conducts research on vegetable
postharvest technologies to help small-scale
producers overcome the constraints caused
by the limited shelf-life of most vegetables, to
better understand approaches and obstacles
to enhanced market opportunities, and to
contribute to policy-enabling environments.
An analysis of the quantity and value of
losses along the vegetable supply chain in
Vietnam, Cambodia and Laos PDR identified
the major reasons for these losses among the
major vegetable crops in the region. This
knowledge made it possible for preventive
measures to be instituted to help reduce post-harvest
losses. For selected vegetables, about
17% of harvested crop was lost due to post-harvest
problems, with farmers, among all
actors in the supply chain, bearing the brunt
of those losses. The middlemen and retailers
were found to have more power over market
prices (12) and less risk than the farmers, who
generally had less information or knowledge
and therefore lower capacity to deal with the
postharvest issues.
The degree of perishability and suscepti-bility
to postharvest stresses differ, depend-ing
on the prevailing environmental
conditions. Although postharvest losses var-ied
between the three countries, and between
the different kinds of crops and the seasons
under which the crops were grown, on aver-age,
it appeared that the vegetable industry in
the three countries shares similar levels of
postharvest losses. In all the countries, most
of the supply-chain players complained that
they incur huge losses with vegetables which
are harvested at the mature-green stage, like
tomatoes, due to shrinkage once the fruits
have ripened, unlike chilli pepper which is
harvested at fully ripe stage, or yard-long
beans and cucumber which are harvested at
the young stage and which incur fewer post-harvest
losses.
The loss of potential revenues associated
with postharvest losses in vegetable crops is
expected to impact the whole supply chain
negatively, with the farmers prone to be
exposed to the highest risk. In 2005, the total
combined worth of vegetable production of
the three countries amounted to US$2612 mil-lion.
If postharvest losses and/or wastage are
at the 17% level described above, this trans-lates
to about US$461 million loss of potential
income. Losses are expected to increase when
qualitative and nutritional reductions are fac-tored
into the estimation.
A number of causes of postharvest losses
have been identified that could be resolved
by both technological and non-technological
interventions. For example, previous works
on timing and methods of harvesting are still
applicable to overcome current problems,
while other technologies can be adapted to
resolve specific problems. Some technologies
depend on specific factors, such as type of
crop, environmental conditions, etc., to be
effective. The effectiveness of a technology in
the country where it is intended to be used
must be validated before it is recommended.
In Cambodia, Laos PDR and Vietnam,
the farmers were aware of most of the exist-ing
postharvest problems and their solutions,
and were able to exercise necessary precau-tions
to avoid or minimize postharvest losses.
For example, harvesting damage no longer
seemed to be a major cause of postharvest
losses. Disease problems were identified to be
a significant cause of postharvest loss, but the
farmers were unclear on which measures to
apply to minimize the losses. This highlights
the urgent need to give priority to research on
disease control measures. Disease control
measures that combine an integrated disease
management approach with host plant resist-ance
or tolerance (particularly against

dormant infections such as anthracnose in
tomato and chilli pepper) may be the answer
to the problem.
Promoting vegetable consumption through
school and home gardening and nutrition
education
AVRDC promotes school gardens, home gar-dens
and nutrition education as part of its
activities to promote the production and con-sumption
of indigenous vegetables, and has
been particularly successful in Bangladesh,
seven South-east Asian countries and sub-
Saharan Africa.
Home gardens
The main purpose of the home garden as a
vegetable production system is to enhance
the availability and consumption of micronu-trients,
as well as to increase incomes and
food security in areas where there is an insuf-ficient
or unreliable supply of food. The home
garden system was adopted by approximately
10,000 resource-poor households in Africa in
2001–2005 and the feedback on these home
gardening interventions indicates that home
gardeners in sub-Saharan Africa can harvest
170–250 kg of nutritious vegetables annually
from an average-sized home garden, provid-ing
an excellent alternative for food and nutri-tion
security and income generation (13).
Several short training programmes in home
garden vegetable production, cropping pat-terns,
utilization and the use of Healthy Diet
Gardening Kits have been conducted in
Kenya, Malawi, Mozambique, Rwanda,
southern Sudan, Tanzania, Uganda and
Zambia.
School gardens
Indigenous vegetables can play a major role
in the diversification of diets, leading to a
more balanced source of micronutrients.
However, despite the recognized importance
of indigenous vegetables in supplementing
nutritional needs, they are underutilized. In a
school garden project that promoted indige-nous
vegetables in the province of Laguna,
the Philippines, children and their families
were monitored to assess changes in knowl-edge,
consumption and health between 2004
and 2006 as a result of participating in the
school garden project. All selected children in
three sites (two intervention schools and one
control school) participated in surveys on
knowledge on indigenous vegetables and
their blood haemoglobin values were meas-ured.
Their household representative was
interviewed for a 24-hour food recall.
Schoolchildren who participated in the school
garden project had a greater knowledge of
indigenous vegetables and there was an
increase in their overall vegetable consump-tion.
The children in the intervention sites
had higher blood haemoglobin levels after
participating in the school garden project
than children who did not. Households in the
intervention sites were found to consume sig-nificantly
greater quantities of vegetables
compared with households in the control site.
While there was no identifiable effect on the
consumption of the indigenous vegetables
that were promoted in the school gardens,
there was a significant and positive effect on
the overall vegetable consumption of house-holds
living in the intervention sites (14).
While the impact on parent knowledge
was less, positive significant changes associ-ated
with participation of children in the
school garden project were still found. For
overall vegetable consumption, a signifi-cantly
positive difference was found between
control and intervention groups. Seasonal
influences may have overlaid the impact of
the project intervention, as may have the
overall economic situation of households in
the study area.
Training of women
In Tanzania, over 1000 women farmers were
trained on vegetable production and utiliza-tion.
Regular courses, held at least monthly,
on good agricultural practices for vegetable
crops, marketing and different recipes for
cooking the vegetables were conducted at the
Center’s Regional Center for Africa (13).
Data from training of women in
Cambodia, Lao PDR, the Philippines and
Indonesia demonstrate the important role

AVRDC 189
that women have in vegetable production. In
Cambodia, 94% of women members of house-holds
grew the vegetables for family con-sumption.
The participants could name 42
types of indigenous vegetables that they nor-mally
eat. The most commonly consumed
indigenous vegetables are ivy gourd (Coccinia
grandis), kangkong (Ipomoea aquatica), squash
(Cucurbita moschata), amaranth (Amaranthus
spp.), aubergine (Solanum spp.) and Malabar
spinach (Basella alba). Jute (Corchorus spp.),
which was known to Cambodia’s neighbour-ing
countries, was not familiar to the
Cambodian women participants (15), con-firming
the understanding that the consump-tion
of indigenous vegetables is often
influenced by the cultural background as well
as geographical location.
During training, the women participants
learned better food preparation methods to
enhance the availability of nutrients. In Lao
PDR, women were taught how to prepare
vegetables to increase the availability and
absorption of vitamin A. Dr Bounthom
Phengdy of the National Nutrition Program
under the Ministry of Public Health claims
that 59% of the mortality of Lao children
under 5 years old is associated with malnutri-tion.
Additionally, 30% of Lao women of
childbearing age and 46% of children under
5 years of age suffer from anaemia. About
46% of the Lao population in general is defi-cient
in vitamin A. Lao women usually cook
leafy indigenous vegetables by boiling in
water, but this does not maximize the availa-bility
of vitamin A as leafy vegetables should
be cooked with oil to ensure that the vitamin
A is readily available when consumed in the
form of cooked vegetables.
Assessment of the in-country training for
women showed that the participants gained
new knowledge about indigenous vegetables
and their dietary importance and potential.
The participants learned the importance of
the different indigenous vegetables not only
as a source of food, but as a source of vitamins
and essential minerals. The participants
appreciated the need for proper treatment of
vegetables during cooking in order to pre-serve
the vitamins and minerals and to ensure
their availability in the cooked foods (15). The
women learned about home gardening and
growing indigenous vegetables in their home
gardens, as well as how to preserve seeds for
future planting.
Training on development of recipes
using nutrient-rich mungbean to enhance
protein, iron bioavailability and to diversify
cereal-based diets was conducted for the
women farmer groups in Rajasthan, Bihar
and Punjab. Nutritional studies in southern
India showed that providing schoolchildren
with an inexpensive mungbean/vegetable
dish for lunch significantly improved the lev-els
of iron in their blood (16). The effect of
supplementation on haemoglobin levels,
serum iron, serum ferritin and serum total
iron-binding capacity were all significant.
The effect on the change in haemoglobin level
was highest for children who received a daily
supplementation with b-carotene-enhanced
mungbean preparation. For this group, the
haemoglobin level after intervention was 0.8
g/dl higher than for the control group, indi-cating
an average increase of about 10% in
this group (Table 10.1).
Food scientists from Indian universities
and AVRDC have developed recipes to
enhance the bioavailability of iron using
affordable vegetables; these high-iron mung-bean
recipes have been published and widely
distributed in the region (17,18).
Development of indigenous vegetable
and nutrition seed kits
Since a lack of seeds has been identified as
one of the main reasons for the underutiliza-tion
of indigenous vegetables, AVRDC’s pro-motional
activities include the development
and distribution of Indigenous Vegetable
Seed Kits in South-east Asia and Healthy Diet
Gardening Kits in sub-Saharan Africa.
AVRDC has developed the Healthy Diet
Gardening Kit for home gardens to promote
micronutrient-rich indigenous vegetable
crops such as Amaranth spp., African auber-gine,
nightshade, Ethiopian kale, jute mallow,
spider plant, vegetable cowpea, okra, pump-kin,
moringa and high-b-carotene and cherry
tomatoes as well as other protein-rich crops
like vegetable soybean and mungbean.
The seed kits, each containing seeds of 14
nutrient-rich vegetable crops, have been

Table 10.1. Effects of supplementation on biochemical indicators. (Adapted from Vijayalakshmi et al. (16).)
Hb (g/l) Serum iron (μg/l) Serum ferritin (μg/l) TIBC (μg/dl)
Coeff. t value Coeff. t value Coeff. t value Coeff. t value
Constant 0.37 1.49 23.91 0.37 –1.23 –0.39 136.43 0.83
Initial Hb level
(g/dl)
–0.01 –1.77 0.17 0.28 0.06 1.94 –0.84 –0.55
Initial BMI 0.00 0.04 –2.24 –0.59 –0.07 –0.37 –11.89 –1.25
Member of TR
(yes = 1)
0.34 15.59 19.29 7.01 0.62 4.67 –31.38 –4.51
distributed to about 10,000 poor households
in Kenya, Malawi, Mozambique, Rwanda,
southern Sudan, Tanzania, Uganda and
Zambia since 2001. The feedback indicates
that many African farmers have adopted
the Healthy Diet Gardening Kit system
which has helped them to produce vegeta-bles
for home consumption, thus pro vid-ing
the households with many essential
micronutrients (13).
Under the Seed Village Program and
through demonstrations, about 500 summer
mungbean seed kits (for one acre each) have
been distributed to farmers in Punjab,
Rajasthan and Bihar since 2005. This is an
important step to improve the bioavailability
of iron and protein in these areas of India. To
ensure further improvements in food and
nutrition security in South Asia and Africa,
Healthy Diet Gardening Kits must continue
to be promoted and popularized to contrib-ute
significantly to ameliorating micronutri-ent
malnutrition.
AVRDC’s seed kits are useful and pop-ular
after natural disasters. After any natu-ral
disaster, vegetables usually become
unavailable to the survivors both as a result
of destruction of the crops in the field and
due to poor infrastructure after the disaster
which prevents transportation and market-ing
of any vegetables that are available.
Emergency food relief attempts are often
focused on providing basic staple foods to
prevent hunger. The tsunami of 26 December
2004 was one of the deadliest natural disas-ters
of recent times in South and South-east
Asia. AVRDC responded to the tsunami by
distributing 50,000 vegetable seed kits to
the survivors in Sri Lanka and Indonesia.
This response was based on AVRDC’s posi-tive
responses to distributing kangkong and
other vegetable seeds to families affected by
severe floods in Bangladesh in 1998 (19).
The kits distributed to the tsunami victims
included vegetable varieties which quickly
produced both nutritious and marketable
vegetables (e.g. water convolvulus, peppers
and pak-choi), fertilizers and hoe heads.
The effort was expected to increase the
availability of vegetables in a very short
period to provide the much-needed addi-tion
of micronutrients to the basic staples
provided by emergency food relief. Many
recipients of the vegetable seed kits were
able to generate income by selling the
surplus produce.
Member of IR1
(yes = 1)
0.77 33.07 24.84 7.83 2.02 13.26 –56.44 –7.05
Member of IR2
(yes = 1)
0.79 35.92 27.22 6.81 2.06 10.72 –68.62 –6.80
Sex (girls = 1) –0.07 –4.32 –5.86 –2.74 –0.28 –2.75 –1.17 –0.22
Age –0.02 –1.03 –0.41 –0.09 0.10 0.45 –1.66 –0.14
R2 0.91 0.87 0.94 0.85
F value 305.12 23.75 52.81 18.98
n 225 23 23 23
Hb, haemoglobin; TIBC, total iron-binding capacity; TR, received a traditional preparation of mungbeans with low iron
bioavailability; IR1, received a preparation of mungbeans and cabbage or tomato for a high iron bioavailability based on
ascorbic acid; IR2, received a preparation of mungbeans and carrot for a high iron bioavailability based on b-carotene.

AVRDC 191
The Center’s indigenous vegetable activ-ities
have also attracted disaster relief interest
in the Philippines, where indigenous vegeta-ble
seed kits were provided to 50 families of
displaced gold panners in Pangasinan
Province and families affected by landslides
in Quezon Province.
Improving Nutrient and Phytochemical
Density
Collection and evaluation of vegetable
genetic resources including indigenous
vegetables
AVRDC has long recognized the potential of
indigenous vegetables, as well as the diversi-fication
of the agricultural environment to
contribute to the alleviation of poverty and
for improving nutrition. Indigenous vegeta-bles
are part of the AVRDC’s list of priority
germplasm for collection, evaluation and
utilization. Over 55,000 accessions of seed,
leafy and fruit vegetable germplasm have
been assembled, of which about 12,000 acces-sions
belong to more than 200 species of
indigenous vegetables originating from
Africa and the South and South-east Asian
countries. The collection is housed in the
genebank at AVRDC Headquarters and also
in its Regional Center for Africa. It is being
characterized and evaluated for the potential
of the accessions to improve nutrition and
contribute to farm productivity. In the case
of exotic vegetables, promising accessions
are evaluated for incorporation of traits
through the respective breeding activities.
Indigenous vegetables and promising lines
are evaluated further for agronomic and
nutritional qualities and pest and disease
resistance.
Identification and promotion of underutilized
indigenous vegetables high in nutrients and
bioactive compounds
The large collection of vegetable germplasm
in AVRDC’s genebank provides an opportu-nity
to identify nutrient-rich germplasm.
Initially, some of the indigenous vegetable
species were evaluated for antioxidant activ-ity,
oxalate (anti-nutritional factor), vitamins
A, C and E, and the minerals calcium and iron
(20). Chinese cedar (Toona sinensis) was iden-tified
as a highly nutritious vegetable with a
high (18.6 mg/100 g) b-carotene content, and
high levels of iron (8.65 mg/100 g) and
vitamin E (29.3 mg/100 g). The b-carotene
content of Chinese mahogany was twice that
found in jute (9.46 mg/100 g) and Jew’s
mallow (Corchorus olitorius; 19.6 mg /100 g).
Jute was also shown to be a good source of
vitamin C (500 mg/100 g fresh weight), as
were Jew’s mallow (480–610 mg/100 g fresh
weight) and baobab tree (Adansonia digitata;
350 mg/100 g fresh weight). Different species
of vegetables indigenous to Asia show a wide
range of antioxidant activity. There was more
than a 1000-fold difference in antioxidant val-ues
among 125 edible plant species. Species
high in antioxidant activity include Chinese
cedar, Damocles tree (Oroxylum indicum), rue
(Ruta graveolens), cassod tree (Cassia seamea),
sickle senna (Cassia tora) and sweet potato
(Ipomoea batatas) leaf. Different accessions
within the species also show a wide range of
antioxidant activity, thus confirming the need
to select and promote species, and lines within
the species, that have higher nutritional
values including high antioxidant activity for
improving diets.
In Tanzania, indigenous vegetables form
a substantial proportion of the diets of most
of the low- to middle-income group because
indigenous vegetables are inexpensive and
easily accessible. However, many indigenous
vegetables are still gathered from the wild
and only a few have been domesticated or
described. Micronutrient dietary deficiencies
that lead to nutritional disorders are still com-mon
in Tanzania. It is therefore important to
identify indigenous vegetables and food
preparations that have great potential with
regard to such micronutrients. A study was
undertaken to investigate the micronutrient
content of commonly consumed indigenous
vegetables in several localities in Tanzania.
This was to identify those that are rich in
micronutrients known to be commonly defi-cient
in the diets of many local people. These
deficient micronutrients included minerals

(iron and zinc) and b-carotene (a common
precursor of vitamin A). Commonly utilized
indigenous vegetables from three rural dis-tricts
of Kongwa, Muheza and Arumeru in
Tanzania were analysed for iron, zinc and
b-carotene content. African spider plant
(Cleome gynandra), bitter lettuce (Lactuca
virosa) and amaranth have a high iron content
(of up to 49.95 mg per 100 g edible portion),
while pumpkin (C. moschata) leaves, puncture
vine (Tribulus terrestris), cassava (Manihot
esculenta) leaves, amaranth and cape myrtle
(Myrsine africana) have a high zinc content
(up to 1.63 mg per 100 g edible portion). The
highest content of b-carotene was found in
African spider flower, puncture vine and cas-sava
leaves (up to 16.13 mg per 100 g edible
portion). However, while the analysed sam-ples
contained high levels of the nutrients,
there were large variations within the species.
These variations may be caused by genetic or
environmental factors or by genotype and
environment interactions, and there is need
for careful and detailed analyses and selec-tion
of appropriate lines for promotion as
sources of micronutrients.
Breeding to increase content of nutrients
and bioactive compounds
Nutrient contents of vegetables vary greatly.
Tomato, pepper, onion (Allium spp.), cabbage
(Brassica spp.) and cucumber (Cucumis sati-vus)
are the more commonly consumed veg-etables
in the world; even modest
improvements in their micronutrient densi-ties
would benefit human health. Vegetable
breeding can increase the nutrient content
and concentration of bioactive compounds in
vegetables, thus developing lines which will
be of greater benefit for alleviating micronu-trient
malnutrition (20).
High-b-carotene tomato
Tomato can be an important source of provi-tamin
A if consumed in sufficient quantities.
An increase in the b-carotene content of the
tomato fruit by genetic enhancement could
contribute significantly to better nutrition.
Using a single gene called Beta that originated
from wild tomato, AVRDC has developed
high-b-carotene cherry and fresh market
tomato lines. The b-carotene content of the
orange-fruited high-b-carotene tomatoes
ranges from 3.81 to 6.55 mg/100 g fresh
weight compared with 0.60–0.90 mg/100 g
for the common, red-fruited tomato. Heat tol-erance
and multiple disease resistance have
been bred into the high-b-carotene lines for
tropical adaptation, and this high-b-carotene
tomato is being actively promoted for home
and school gardens.
High-antioxidant solanaceous crops
Tomato and pepper are both important
sources of antioxidants, including caroten-oids,
vitamin C and phenolics. AVRDC has
designed breeding strategies to increase the
concentrations of antioxidants in these crops.
The highest levels of lycopene, vitamin C and
phenolics, as well as the greatest solids con-tent,
were found in the small-fruited wild rel-ative
of tomato, Solanum pimpinellifolium (21).
Interspecific crosses are being made with S.
pimpinellifolium to introgress alleles that
improve lycopene and vitamin C content in
cultivated tomato. Antioxidant activity in
tomato is highly correlated with the total phe-nolics
content and AVRDC’s breeding pro-gramme
is investigating strategies to increase
the total phenolics content of the fruit. Within
the pepper species, significant genetic varia-tion
has been identified for capsanthin, zeax-anthin,
lutein, b-cryptoxanthin, b-carotene,
ascorbic acid, total phenolics and a-tocophe-rol.
The highest levels of provitamin A carote-noids
were found in the brown-fruited lines.
Among the red-fruited peppers, several
entries of the Ancho types from Mexico ranked
among the highest for all carotenoids, vitamin
C, a-tocopherol and total phenolics (21).
Genetic studies are in progress at the Center
to understand the inheritance of specific pep-per
antioxidants and facilitate the develop-ment
of high-antioxidant solanaceous crops.
Within the 150 edible plants from 127 species
evaluated for antioxidant activities, it is clear
that the distribution of antioxidant activity is
highly skewed. Based on data from AVRDC,
most of the species containing high levels of
antioxidants are Asian perennial and locally

AVRDC 193
utilized vegetables, which are also rich in total
phenolic compounds, suggesting great poten-tial
to increase antioxidant consumption by
including Asian native or underutilized veg-etables
in the diet (22). Several plant species
including Chinese cedar, moringa (Moringa
oleifera), sweet potato and amaranth were
among the most promising species for promo-tion
to ameliorate micronutrient malnutrition
due to their ease of production, high antioxi-dant
levels, high micronutrient and phyto-chemical
contents, marketing attributes,
processing properties and palatability.
Enhancing the Bioavailability
of Nutrients
Absorption of plant-based non-haem iron,
although variable (2–15%), is lower than that
of haem iron from meat (~25%) and such
absorption is more subject to factors like those
affecting interactions with enhancers and
inhibitors. Populations in developing coun-tries
with limited resources consume more
plant-based food than the usually more
expensive animal-source foods. Although
total iron intake from vegetables and other
plant-based sources may meet dietary recom-mendations,
iron deficiency may still be prev-alent
due to the low bioavailability of
plant-based iron. Vegetables in which the
level of iron bioavailability is relatively high
include tomato and pepper, and efforts are
continuing to further improve the bioavaila-bility
of iron in plant-based diets.
Better food preparation can enhance
iron bioavailability in iron-deficient popula-tions.
AVRDC groups vegetables into three
categories which reflect the iron bioavailabil-ity
before and after cooking (23): (i) those
which have a low iron bioavailability when
raw, but higher after cooking, such as crucif-erous
vegetables and amaranth; (ii) those
with low iron bioavailability both before and
after cooking, such as mungbean and kang-kong;
and (iii) those with high iron bioavail-ability
before and after cooking, such as
tomato, pepper and ginger. However, the
prolonged storage of cooked vegetables
reduces the bioavailability of iron.
Cooking can double or even increase
tenfold the iron bioavailability of some vegeta-bles.
The bioavailability-enhancing effect of
cooking can be achieved with different heat-ing
processes including boiling, stir-frying
and hot-air drying. The iron bioavailability-enhancing
effect of cooking is independent
of the vegetable vitamin C content. In the
case of cabbage, the cooking effect is due to
the reduction of iron–polyphenol interac-tions
which commonly occur during plant
cell destruction. The nature of the enhancing
factors in these vegetables is similar to the
effect of ethylenediaminetetraacetic acid
(EDTA) which stabilizes iron when it is
released from cells.
The effect of cooking in enhancing iron
bioavailability can be extended to vegetables
with low iron bioavailability and to legumes,
by adding vegetables with high iron bioavail-ability,
such as tomato and moringa, during
cooking (24). High-iron mungbean recipes
were designed accordingly for South and
North India (17,18). Dishes were selected and
modified based on the availability and prices
of ingredients in local markets. In a one-year
trial with schoolchildren (16), in collaboration
with the Avinashilingam Institute for Home
Science and Higher Education for Women in
southern India, mungbean supplementation
improved health parameters (clinical signs,
body weight index, haemoglobin level and
productivity). Haemoglobin levels increased
by 0.8 g/dl for children eating recipes designed
for higher iron bioavailability while those eat-ing
traditional mungbean recipes still had an
increase of 0.3 g/dl in haemoglobin levels.
Promoting dishes and recipes with a higher
iron bioavailability based on mungbean
appears to be a viable strategy to enhance
body iron stores in regions where diets are
predominantly vegetarian and the inclusion
of animal products into diets is not feasible.
Opportunities to promote the modification of
existing preparation practices, i.e. through
nutrition education and local media, can be
used to reach a large number of households.
However, while there was an improvement
in haemoglobin levels through these recipes,
and it is clear that a food-based approach
with a cost-effective plant-based diet can
improve iron deficiency, complementary

dietary strategies including the consumption
of animal-source foods are needed to resolve
severe anaemia. Complementary approaches
required are iron supplementation for people
with severe anaemia, home fortification for
population groups at high risk of anaemia
(pregnant women, children aged 6–23 months),
and food-based approaches including fortifi-cation
of staples and condiments for the pre-vention
of anaemia at population level.
The productivity of households engaged
in agricultural labour in India, measured by
wages and income, is affected by insufficient
iron intake. Wages would on average be 5.0–
17.3% higher if households achieved recom-mended
iron intake levels (25). Enhancing
micronutrient intake can contribute signifi-cantly
to the overall economic growth and
development of any region – as clearly illus-trated
in India.
Assessment of Health
and Economic Benefits
Evaluation of agricultural research often
neglects consumption and nutrition aspects,
yet agricultural research can address micro-nutrient
malnutrition by improving both the
quantity and quality of food intake. AVRDC
has reviewed the conceptual linkages between
agriculture and nutrition to estimate the
strength of the relationship between iron
intake and productivity outcomes, and to
estimate the nutritional benefit of improved
mungbean varieties in terms of net present
value.
AVRDC has developed a methodology
for assessing the nutritional impact of mung-bean,
and summarized for evidence impact
on the steps from mungbean research to con-sumption
(26). A food consumption study
among female piece-rate workers in Pakistan
to analyse the impact of iron consumption on
productivity, measured in wages, showed
that anaemia among women was widespread.
Approximately two-thirds of women suffered
from mild or severe anaemia (Hb <12 g/dl).
The elasticity of bioavailable iron on produc-tivity
measured in wages was 0.056, and the
marginal effect was 9.17 Pakistani rupees per
additional milligram of bioavailable iron con-sumed.
In this study, iron intake was meas-ured
as intake of bioavailable iron, based on
the method proposed by Bhargarva et al. (27).
This is estimated based on total iron intake
and haem iron is assumed to constitute 40%
of iron from meat, fish and poultry. An
enhancing factor is then calculated based on
the intake of ascorbic acid and corrected for
phytate intake. Using the model results, the
estimated impact of mungbean research on
nutrition, in terms of productivity effects, was
found to be substantial, ranging from US$7.6
to 10.1 million cumulative present value (in
1995 US$ at 5% discount rate).
Agriculture plays an important role in
the reduction of malnutrition. Agricultural
research has greatly contributed to the reduc-tion
of hunger and starvation by providing
millions of hungry people with access to low-cost
starchy staple foods. As the challenge
shifts to the reduction of micronutrient defi-ciencies,
more efforts must be directed toward
crops high in micronutrients, such as pulses
and vegetables.
The ‘nutrition transition’ which occurs
with development has reached developing
countries and is contributing to a fast change
in food habits. Indigenous or traditional veg-etables
are declining in importance in the
diet, particularly in wealthier, urban areas.
Weinberger and Swai (28) showed that the
share of indigenous vegetable consumption
to total vegetable consumption is much higher
among poor households (approximately one-third)
than among the wealthiest households
(approximately one-fifth). The variety in con-sumption
of indigenous vegetables decreases
as households become wealthier, while, at the
same time, the variety in consumption of
exotic vegetables increases. By valuing col-lected
indigenous vegetables produced in
local gardens at market prices, Weinberger
and Swai (28) found that, in the poorest group
of households in the surveyed areas in
Tanzania, approximately 8% of all food value
consumed comprises indigenous vegetables,
the average share for all households being
only 4.8%.
Poor households, in particular, rely on
the consumption of indigenous vegetables to
help provide their daily requirements of

AVRDC 195
micronutrients, especially vitamin A and iron.
In poor households, approximately a quarter
of all vitamin A requirements and 11% of iron
requirements are provided by indigenous
vegetables. Thus, while indigenous vegeta-bles
are not a panacea for the complete elimi-nation
of micronutrient deficiencies, they do
have an important role to play in raising lev-els
of micronutrient consumption in low-income
societies.
Not only are indigenous vegetables an
important subsistence crop for poor consum-ers,
they can also provide good opportunities
for commercialization if properly exploited.
A study from Tanzania found that approxi-mately
40% of all produce consumed by
wealthy households is acquired through the
market (28). For instance, traditional African
aubergine has now acquired commercial sta-tus
in Arusha and is sold in supermarkets and
also transported to markets as far away as
Dar-es-Salaam. Indigenous vegetables can
usually be harvested over a longer period of
time than exotic types. Under good manage-ment,
African aubergine and amaranth selec-tions
can be harvested year-round and can be
useful to compensate for price fluctuations.
Input requirements for indigenous vegetables
are also comparatively low relative to the pro-duction
of exotic vegetables; for example,
pesticides are rarely used in the production of
indigenous vegetables but they are necessary
to produce exotic vegetables. In order to tap
the potential of indigenous vegetables for the
benefit of small-scale, resource-poor farmers,
it is essential that future research specifically
incorporates the needs of these farmers
(28,29). This particularly relates to the selec-tion
of improved lines with traits that are
important for small-scale farmers. Indigenous
vegetables enjoy the advantage of being pro-duced
with relatively low levels of inputs and
thus with low capital risk; it is unlikely that
farmers will change this production pattern
in the short term. Thus, selecting indigenous
vegetable lines that require an intensive input
regime will generally be less attractive to
farmers. More emphasis is needed on seed
production, to make high-quality seed of
indigenous vegetables available to small-scale,
resource-poor farmers. Private seed
companies usually have little interest in
indigenous vegetables because domestic mar-kets
for such vegetables are perceived to be
small. However, in partnership with both the
public and private sectors, AVRDC is tackling
this major constraint for the wider production
of high-quality seed of indigenous vegeta-bles,
particularly in sub-Saharan Africa.
Clearly, traditional or indigenous vegeta-bles
are very important in resource-poor com-munities;
thus preserving biodiversity and
indigenous knowledge on production and
consumption, while improving lines and cul-tivation
practices, will contribute to the well-being
of poor farmers by enabling them to
participate in markets as well as contributing
to the health of their households through
increased consumption and thereby alleviat-ing
micronutrient malnutrition.
Conclusions
AVRDC develops vegetable lines and other
technologies that lead to increases in vegeta-ble
production and consumption in develop-ing
countries. Vegetables are the most
affordable source of micronutrients and
health-promoting phytochemicals. Changing
consumption practices is only one of several
components of a food-based approach to
combat micronutrient malnutrition; this can
be advanced using nutritional education and
mass communication technologies. Other
components of such a strategy include a focus
on improved production technologies for
vegetables, as diversity in vegetable con-sumption
increases when production of veg-etables
increases (30–32). Billions of people
are still undernourished and could benefit
from increased vegetable production and
consumption. Greater attention and empha-sis
should be given to horticulture as an
engine of economic growth and as a means to
better diets and nutrition to bring greater and
lasting benefits to the poor.
Terminology
• Allele: one member of a pair or series of
different forms of a gene.

• Furrow irrigation: irrigation method in
which water travels through the field by
means of small channels between each
group of rows.
• Germplasm: genetic resources for an
organism. For plants, the germplasm
may be stored as a seed collection in a
genebank or, for trees, in a nursery.
• Grafting: a method of asexual plant prop-agation
where the tissues of one plant are
encouraged to fuse with those of another.
• Indigenous vegetables: vegetable crop spe-cies
that are native to a particular envi-ronment,
or introduced historically to a
region from other geographical areas,
and are regarded as underutilized crops.
• Introgression: the movement of a gene
from one species into the gene pool of
another by backcrossing an interspecific
hybrid with one of its parents.
• Micro-drip irrigation: a water-saving irri-gation
technology which enables slow
and regular application of water directly
to the roots of the plants through a net-work
of economically designed plastic
pipes and low-discharge emitters.
• Molecular marker-assisted selection: a
breeding process whereby a DNA/RNA
variation-based marker is used for indi-rect
selection of a genetic determinant or
determinants of a trait of interest.
• Mulching: putting a protective cover
over the soil, primarily to modify the
effects of the local climate by conserving
soil moisture and moderating soil
temperature.
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11 Introducing Vegetables into the
India Mid-day Meal (MDM) Programme:
the Potential for Dietary Change
E. Muehlhoff,*1 R. Ramana,2 H. Gopalan2 and P. Ramachandran2
1Nutrition Education and Consumer Awareness Group, Nutrition and Consumer
Protection Division, Food and Agriculture Organization of the United Nations,
Rome, Italy; 2Nutrition Foundation of India, New Delhi, India
Abstract
Adequate nutrition is crucial during childhood and a diet rich in micronutrients is vital for good physical
growth and mental development and prevention of infectious diseases. Fruits and vegetables are a vital part
of a balanced diet and a good source of vitamins and minerals, including vitamin A. Schools are increas-ingly
recognized as important settings for promoting healthy nutrition and eating practices in children.
This chapter reviews recent research from Africa and Asia on the effectiveness of food-based interven-tions
to combat vitamin A deficiency. A few recent studies suggest that schools in developing countries can
effectively channel nutrition support to a critical target group of children, using dietary solutions to
improve vitamin A status. An outstanding question remains how such potentially life-giving dietary
changes can most effectively be promoted and maintained on a larger scale.
To respond to this question, this chapter also reviews current literature on school-based fruit and
vegetable initiatives in developed and developing countries. Using country-based data, it then outlines the
process and results of a pilot intervention carried out in urban Indian schools in the Municipal Corporation
of Delhi to promote increased vegetable consumption through the Mid-day Meal (MDM) programme and
create awareness among teachers and children on the health benefits of vegetables. Despite limitations in
the intervention design, many lessons can be learnt from this pilot intervention. It shows that the introduc-tion
of vegetables into MDM is feasible and sustainable, provided that adequate funds are allocated. If
used effectively, the MDM can become a major tool for improving vegetable consumption among school-aged
children in urban and rural India.
Key words: India, schoolchildren, Mid-day Meal, vegetables, vitamin A, nutrition education
Adequate nutrition is crucial during childhood
and a diet rich in micronutrients is vital for
good physical growth and mental develop-ment
and prevention of infectious diseases.
There is some evidence to suggest that a good-quality
diet, with plenty of vegetables and
fruits, during childhood and adolescence may
also protect against chronic diseases such as
heart disease and some cancers in later life
(1,2). The need to increase vegetable and
fruit consumption by children is currently
receiving much attention owing to their known
Introduction
* Contact: Ellen.Muehlhoff@fao.org

Introducing Vegetables into the India Mid-day Meal 199
beneficial effects on health (3). Schools are one
favoured location for these interventions.
This chapter first reviews the current lit-erature
on school-based fruit and vegetable
initiatives and then outlines the process and
results of a pilot intervention carried out in a
small number of urban Indian schools in the
Municipal Corporation of Delhi (MCD) to
promote increased vegetable consumption
through the Mid-day Meal (MDM) programme
and to create awareness among teachers and
children on the health benefits of vegetables.
The Role of Vegetables and Fruit
in Nutrition and Health
It is well accepted that vegetables and fruit are
a vital part of a balanced diet. They are good
sources of a range of vitamins, minerals, phy-tochemicals
and dietary fibre and they play an
important role in preventing and controlling
micronutrient deficiencies, including deficien-cies
in vitamins A, B (folate), C and E.
Vegetables and fruit, owing to their high natu-ral
vitamin C content, can help alleviate iron
deficiency by boosting the absorption of
non-haem iron from plant-source foods (4).
Yellow/orange fruits and vegetables (e.g.
carrot, pumpkin, papaya and ripe mango) and
dark-green leafy vegetables, including indige-nous
vegetables, are rich in provitamin A caro-tenoids,
which the human body can convert
into the active form of vitamin A provided
there is adequate fat in the diet. While it is
understood now that the bioavailability of
provitamin A carotenoids in plant foods is sig-nificantly
lower than indicated several decades
ago (i.e. it requires not six but 12 molecules of
b-carotene in the diet to make one molecule of
vitamin A) (5), evidence from around the
world shows that provitamin A-rich vegeta-bles
and fruit can make a valuable contribu-tion
to vitamin A intakes and improve the
vitamin A status of children in communities
where animal-source foods and/or fortified
foods are infrequently consumed or beyond
the reach of poor people. Recent worldwide
hikes in food prices are putting animal-source
foods even further beyond the means of eco-nomically
disadvantaged households (6). It is
also likely that the diet consumed early in life,
in particular high consumption of fruits and
vegetables, can influence the risk of stroke and
coronary heart disease in later life and reduce
the prevalence of obesity, high cholesterol and
high blood pressure as well as the risk of can-cer
(1,2). Thus, the World Health Organization
(WHO) and the Food and Agriculture
Organization of the United Nations (FAO) rec-ommend
a minimum of 400 g of fruits and
vegetables per day (7), while the World Cancer
Research Fund says that this amount should
be raised to 600 g (8).
Average intakes of fruit and vegetables
throughout the world are however still much
below the recommended population intake
goal, while in developing countries the
situation is critical. A recent study using data
from the WHO 2002–2003 World Health
Survey (200,000 people from 52 developing
countries) (9) indicates that 78% of respond-ents
from mainly low- and middle-income
countries consumed less than the recom-mended
daily minimum (400 g) – too few to
maintain health and prevent disease – with
the poorest populations showing the lowest
consumption.
Effectiveness of Food-based Approaches
in Addressing Vitamin A Deficiency
In view of the critical role of vitamin A in pro-tecting
health, the effectiveness of food-based
approaches in improving vitamin A status is
of particular interest. Recent research from
South Africa and Mozambique demonstrates
that horticultural interventions such as home
and community gardens, backed up by nutri-tion
education, can successfully increase the
dietary intake of vitamin A-rich plant foods
and result in a significant reduction in the
prevalence of vitamin A deficiency in pre-school
children (10,11). Research from South
Africa and the Philippines indicates that the
provision of b-carotene-rich plant foods can
increase the vitamin A status of school-aged
children. A randomized controlled trial imple-mented
in South Africa showed that orange-fleshed
sweet potato was accepted well by
primary-school children and improved their

200 E. Muehlhoff et al.
vitamin A status when given as part of the
school meal (12). In the Philippines, the con-sumption
of carotene-rich yellow and green
leafy vegetables improved the vitamin A sta-tus
of school-aged children, with only a
small amount of dietary fat (i.e. 2.4 g/meal ×
3 meals/day; total of 21 g/day1) needed for
optimal utilization of plant provitamin A
carotenoids (13). The community-based
studies underline the importance of diversi-fying
food availability and improving access
through horticultural interventions in con-texts
in which food insecurity is a major
constraint to increased consumption. The
results from the South African and
Philippines studies confirm that schools in
developing countries can effectively channel
nutrition support to a critical target group of
children. An outstanding question is there-fore
how such potentially life-giving dietary
changes can most effectively be promoted
and maintained.
Schools as Entry Points for Dietary
Diversification and Behaviour Change
Schools are increasingly recognized as impor-tant
settings for promoting healthy eating
practices in children (14–17). The first reason
is the urgent need to improve the quality of
school-aged children’s diets. Undernutrition
and micronutrient deficiencies continue to
impede child growth and development when
children reach school, reduce children’s
capacity and motivation to learn, and lead
them to drop out of school early (18,19).
Children are current and future consumers
and need dietary guidance to create lifelong
healthy eating habits. A second reason is the
high potential for effective intervention in
real-life settings. Nutrition education, the
promotion of healthy diets in school, abun-dant
(often free) fruits and vegetables in
school meals, parental involvement and prac-tical
food and nutrition-related activities in
the school environment, such as food garden-ing
or food preparation, can demonstrably
increase young people’s knowledge and
improve their dietary habits and nutrition
status; in particular, they can encourage
them to eat more fruit and vegetables
(11,12,20–22).
Multi-component approaches are partic-ularly
effective (3,23). For example, reviews
of school fruit and vegetable schemes in
developed countries (3,23) suggest that fruit
and vegetable promotion schemes are likely
to result in significantly increased intakes
among children if programmes are associated
with a mix of components including: promo-tion
in the canteen and around school through
school meal modification; practical learning
by preparation skills and tasting (as opposed
to traditional lectures); special training of
teachers and peer leaders; active participation
of school food personnel; involvement of par-ents
at school and at home; and a sufficiently
long period of implementation and follow-up
(at least 12 months) (3). The influence of
hands-on food gardening, together with
nutrition education, on consumption of fruits
and vegetables is particularly interesting in
that the research findings support intuition
rather than logic. Growing food and prepar-ing
it oneself does not necessarily increase its
nutritional value and there is no logical rea-son
why this should make children like and
value it more; the persuasive factors appear
to be deeper: psychological investment,
familiarity and ownership (21).
A third point is sustainability (20). As
eating habits are learned early and childhood
diet is a significant determinant of consump-tion
patterns in adulthood, school-based
interventions, reinforced by nutrition educa-tion,
can also create long-term dietary behav-iour
change by increasing opportunities for
children to access fruit and vegetables and
making them aware of the significance of fruit
and vegetable intake at an early age, provided
that programme implementation is continued
for several years (3,22).
1 Self-selected snacks contributed additional dietary
fat which were not eaten during meals, so that the
total fat intake for the study group with low fat
intake was 21 g/day, providing 12% of total dietary
energy intake. The study concluded that it is pos-sible
to improve the total-body vitamin A pool size
and restore low liver vitamin A concentrations to
normal concentrations by eating sufficient amounts
of carotene-rich yellow and green leafy vegetables
and minimal amounts of dietary fat.

The FAO Curriculum Concept
and Learning Approach
There are compelling reasons for developing
effective strategies to reach school-aged chil-dren
through their daily diet. The concept of
nutrition education adopted by FAO reflects
these considerations. It is embodied in the
publication Nutrition Education in Primary
Schools: A Planning Guide for Curriculum
Development (17), which extends to nutrition
education the WHO concept of the health-promoting
school (24). This assumes that
health and diet are above all a way of life, cen-tred
on the child and learnt in all the contexts
of a child’s life. To be effective, nutrition edu-cation
should be part of a ‘whole school’
approach that involves not only the classroom,
but also the whole school environment as
well as the family and community (25). An
action-oriented, rather than an exclusively
knowledge-based, food and nutrition curricu-lum
can be linked to the school environment,
which can offer ample scope for making healthy
dietary choices through the provision of healthy
school meals and tuck shops offering a variety
of food choices; clean water and sanitation; and
for learning practical skills, such as growing,
harvesting, processing and preparing micronu-trient-
rich food. Families and communities can
provide help in preparing and serving school
lunches and running school gardens, and
(together with the school) can be regarded as
part of the learning community. Fresh vegeta-bles
and fruits are also procured from local agri-cultural
producers and food suppliers, thus
offering opportunities for local farmers and
suppliers to benefit from increased incomes by
creating effective demand.
Interventions aimed at enhancing school-children’s
dietary status take many forms and
operate at many levels. In respect of fruit and
vegetable consumption, for example, differ-ent
programmes have variously aimed at,
monitored and evaluated the following objec-tives
or outcomes:
1. Vegetables and fruit are abundant, varied
and available at school through the year.
2. School meals are balanced and incorporate
a range of micronutrient-rich vegetables and
fruit in appropriate quantities.
3. Children, families, teachers and school food
service providers understand the nutritional
value of vegetables and fruit and their role in
the diet.
4. Children, families, teachers and school
food service providers value and express
more preferences for vegetables and fruit
(preferences go beyond knowledge and
understanding).
5. Vegetables and fruit are regularly con-sumed
at school in appropriate quantities and
variety as part of diet (practices are not the
same as values and preferences).
6. School vegetables and fruit snacks are
available and are increasingly chosen by
children.
7. Home diet improves, incorporating more
vegetables and fresh fruit.
8. Children’s micronutrient status improves
measurably during the programme.
9. New dietary habits at school, home and in
snacking are maintained.
10. Improved micronutrient status is
maintained.
From a research point of view, actions 1 to 5
are stages on the path to outcomes 6 to 10.
Nevertheless, they cannot be neglected: they
present challenges which must be tackled in
order to prepare the ground for substantive
research which will demonstrate the potential
feasibility of such initiatives to policy and
decision makers for expansion and broad-scale
implementation.
Nutrition in India
Currently there is little research from devel-oping
countries that assesses the feasibility
and effectiveness of real-world school-based
vegetable and fruit promotion. Thus it is all
the more valuable to have a study of the
MDM programme from India, where vegeta-ble
consumption among all segments of the
population is very low.
During the last two decades there has
been rapid economic growth in India; how-ever,
this has not resulted in a commensu-rate
decline in undernutrition or of
micronutrient deficiencies. Despite steady
economic growth of an average of 6% in the

past 15 years, the percentage of children
under 3 years of age who are underweight
fell by only 6 percentage points between
1993 and 2006, from 52% to 46% (26).
Micronutrient deficiencies, particularly of
iron, folate and vitamin A, continue to be
widespread among rural and poor urban
populations. Lack of dietary diversity is
partly due to poor access to vegetables and
fruits and other micronutrient-rich foods at
affordable cost throughout the year, and
partly to lack of knowledge and awareness
about the nutritional value of horticultural
crops, as well as repeated infections, and is a
major factor in the high prevalence of micro-nutrient
deficiencies (27). Concurrently there
appears to be a slow but progressive increase
in overweight and obesity, possibly resulting
from a steep reduction in energy expendi-ture
due to increasing mechanization of
transport, occupational and household work
and some increase in the consumption of
energy-dense foods (27). As these foods are
often low in vitamins and minerals, even
overnourished persons may suffer from
anaemia and micronutrient deficiencies.
Indian diets
Indian diets are predominantly cereal-based
with rice and/or wheat as the main staple
food(s), complemented by pulses, vegetables,
some milk and other dairy products.
Production of milk and other dairy products
has risen significantly in the last two decades
(27,28) and per capita annual milk availability
doubled between 1980 and 2005. Despite this
increase in overall availability, intakes of milk
and dairy consumption have remained low
among the poor, especially in rural areas (29).
Consumption of meat and meat products that
are rich in iron, zinc and vitamin A (mainly
liver) has also remained very low: at an esti-mated
5.2 kg per capita in 2005, it constitutes
one of the lowest average per capita con-sumption
levels worldwide compared with
59.5 kg per capita in China. The reasons for
this are partially cultural as well as economic
and therefore consumption of animal-source
foods is likely to grow only slowly.
India is ranked as one of the world’s big-gest
producers of horticultural produce,
growing nearly 11% of the world’s vegetables
and 15% of all fruit (29). Despite steadily
growing availability nationally (Table 11.1),
actual consumption of vegetables and fruit,
the main sources of vitamin A in populations
that depend largely on plant-based diets, is
very low among both adults and children
(30,31) (see Tables 11.2 and 11.3).
There is evidence that the entire family’s
diet, including pre-school children’s, school-children’s
and women’s diets, are low in veg-etables
and fruit in both rural and urban
populations (30–32). Data from the National
Consumer Expenditure surveys carried out
by the National Sample Survey Organization
further confirm that consumption expendi-ture
on vegetables and fruits is low, with the
exception of urban areas and among affluent
consumers, where fruit consumption expend-iture
is higher (33).
In addition to economic factors and
physical access to vegetables and fruit through
markets, poor awareness about what consti-tutes
a healthy diet is an important factor
determining dietary patterns (34), suggesting
that the Indian population is not aware of the
health benefits of eating adequate amounts of
vegetables and fruit.
To address micronutrient deficiencies, the
Indian Government has adopted a multi-pronged
strategy, which includes dietary diver-sification
through improved access to vegetables
and fruits at affordable prices, micronutrient
supplementation for vulnerable groups like
pregnant women and pre-school children, and
food fortification such as the addition of iron
and iodine to common salt. In addition, dietary
diversification is to be accompanied by effective
nutrition information and education to promote
improved dietary practices and nutritional
intakes, especially for young children (35).
Table 11.1. Per capita availability (g/day) of fruits
and vegetables. (Data from FAOSTAT – Food
Balance Sheets: 1990–2003 (28).)
1990 2000 2003
Fruits 76 95 101
Vegetables 145 178 186

Table 11.2. Average intake of foodstuffs (g/day per consumption unit). (Data from India Nutrition Profile
(INP), 1998 (31).)
Area Cereals
Pulses
&
legumes GLV
Roots &
tubers
Other
veg. Fruits
Condiments
& spices
Flesh
foods
Milk &
milk
products
Fats
&
oils Sugar
RDA 460 40 40 50 60 150 20 30
Delhi C 366.0 66.6 17.5 125.0 63.9 49.3 12.6 16.7 169 24.1 25.9
R 484.3 86.6 6.1 163.2 7.3 55.3 11.2 0.9 115 43.9 17.6
U 361.4 65.9 18.0 123.5 66.1 49.0 12.6 17.3 171 23.3 26.2
INP R 488 33 32 108 70 15 143 14
U 420 55 23 120 75 37 126 14 2
GLV, green leafy vegetables; RDA, Recommended Daily Allowance; C = combined; R = rural; U = urban.
Table 11.3. Dietary intakes (g/day) by age and sex. (Data from India Nutrition Profile (INP), 1998 (31).)
Age group/
sex Cereals Pulses GLV
Roots
&
tubers
Other
veg. Fruits
Condiments
&
spices
Flesh
foods
Milk
& milk
products
Fats
& oils Sugar
1–3 years
Boys 182.9 14.5 17.2 41.4 29.0 10.1 4.5 20.6 97.4 6.5 12.7
Girls 185.2 14.5 19.0 40.0 29.3 10.6 4.3 24.1 92.5 6.2 12.0
RDA 120 30 50 50 50 100 500 20 25
4–6 years
Boys 265.2 20.2 21.9 62.3 40.7 13.8 6.2 20.5 93.8 9.2 13.2
Girls 269.7 20.1 24.3 59.7 40.0 11.8 6.4 23.0 85.9 8.5 13.6
RDA 210 45 50 100 50 100 500 25 30
7–9 years
Boys 327.9 23.9 22.6 72.4 50.6 12.9 7.3 22.4 92.9 10.0 14.7
Girls 321.4 24.2 28.2 69.3 49.7 11.8 7.1 23.0 90.5 9.8 14.1
RDA 270 60 100 100 100 100 500 25 30
10–12 years
Boys 384.9 28.8 28.8 84.3 57.1 15.6 8.8 20.9 96.7 11.0 15.9
RDA 330 60 100 100 100 100 500 25 35
Girls 373.8 26.7 27.3 80.3 53.8 15.4 8.9 22.2 94.2 11.0 15.4
RDA 270 60 100 100 100 100 500 25 30
13–15 years
Boys 453.2 32.6 33.4 93.6 67.0 16.4 10.1 27.0 108 13.0 17.4
RDA 420 60 100 100 100 100 500 25 35
Girls 437.6 32 38 88.2 60.8 15.5 9.5 33.9 100 14.0 16.5
RDA 300 60 100 100 100 100 500 25 30
16–17 years
Boys 530.1 38.0 45.4 98.0 78.9 19.1 11.2 46.9 113 14.0 18.3
RDA 420 60 100 100 100 100 500 25 35
Girls 484.7 34.8 43.0 84.2 66.3 19.2 12.4 49.1 125 14.0 19.6
RDA 300 60 100 100 100 100 500 25 30
≥18 years
Boys 543.2 40.9 41.0 112 81.4 20.1 12.7 36.4 119 17.0 19.0
RDA 420 60 100 100 100 100 500 25 35
Girls 467.9 37.3 36.6 101 72.2 18.8 11.7 33.5 113 26.0 18.4
RDA 270 60 100 100 100 100 500 25 30
GLV, green leafy vegetables; RDA, Recommended Daily Allowance.

The Mid-day Meal Programme
Schoolchildren are seen as a priority target
group for government programmes aiming
at improved nutrition. As early as 1974,
Dr Gopalan emphasized that ‘the school
could be a valuable second front in our
attempts to bring about nutrition and health
upliftment of our population’ (36). Concerned
about the continued high proportion of ‘out
of school’ children in the country, in 1995 the
Government launched the programme of
‘Nutrition Support to Primary Education’,
popularly referred to as the MDM. The pro-gramme
aimed to increase enrolment,
improve school attendance and retention,
inculcate good food habits in children, pro-mote
social integration and improve chil-dren’s
nutritional status. The success of this
scheme is illustrated not only by the tremen-dous
increase in school participation and
completion rates in most of the Indian states
(37), but also by recent evidence from rural
Madhya Pradesh which suggests that the
mid-day meal, which provides 100 g of rice/
wheat, 20 g of pulses and 50 g of vegetables,
has a substantial effect on reducing hunger in
school by helping to close the gap between
actual intakes of energy, protein and iron of
school-aged children and recommended daily
allowances (RDA) by 30%, 100% and 10%,
respectively (38).
Initially, the Government provided 3 kg
of wheat or rice, to be distributed free of
charge to children in government primary
schools from grades 1 to 5 (pupils aged 6–14
years) who achieved over 80% attendance in
the previous month (39). In 2001, the MDM
became a legal entitlement with the Supreme
Court ruling that all primary-school children
in India in grades 1 to 5 have the right to
receive a cooked mid-day meal containing
1255 kJ (300 kcal) of energy and 12 g of pro-tein
per day for 200 days, in all government,
local body and government-aided primary
schools (40). This landmark directive con-verted
the MDM into a legal entitlement, the
violation of which can be taken up in a court
of law. The Supreme Court also directed that
States and Union Territories (UT) ensure
adequate community participation and sug-gested
that community-based organizations,
people’s representatives, non-governmental
organizations and parents be involved in
monitoring and supervision to promote
accountability and ensure that needy chil-dren
can derive optimal benefit from the
programme. The direction and further fol-low-
up by the Supreme Court have been a
major instrument in universalizing the
scheme although wide variations continue
to exist in the regularity, quantity, content
and quality of the meal supplied (35,37).
The right kind of food
While appreciating the directives from the
Supreme Court, which have made it possi-ble
for over 120 million children to benefit
from the MDM, nutritionists have been con-cerned
that the right to food has not been
translated into the ‘right to the right kind of
food’; that is, a balanced, healthy meal
throughout the school year. Given high
levels of micronutrient malnutrition among
children and low intake of vegetables
among low-income populations in India,
the Department of Primary Education
revised the MDM guidelines to include, in
addition to 100 g of cereal and 20 g of pulses,
50 g of non-tuber vegetables per child per
day starting in the academic year 2006/07
(37). Central Government sanctioned addi-tional
funds to the states to cover the cost of
vegetables.
Logistical problems
Despite additional funding, many states have
been slow in implementing the new guide-lines
owing to logistical problems and the
unforeseen rise in food prices which has
eroded states’ purchasing capacity. For exam-ple,
food service providers in urban MCD
had concerns that the cost of vegetables could
fluctuate seasonally, thus jeopardizing the
continuity of adequate supplies. Fresh vege-tables
are perishable and have to be pur-chased
daily or every second day to ensure a
continuing supply of fresh produce. Some
challenges suggest the importance of shared

nutritional knowledge, understanding and
attitudes. Some state governments have
decided to provide eggs or dairy products
twice a week as eggs and milk are considered
more nutritious (41). There was also concern
that children do not like eating yellow and
green vegetables and may therefore reject the
food. These are in part issues related to
nutrition education, suggesting that the
educational potential of MDM must not be
neglected.
Major implementation questions in the
introduction of vegetables in MDM were:
(i) Can the supply side be made to work?
(ii) Will children accept vegetables in meals?
(iii) Will they eat them? (iv) Will all con-cerned
(i.e. food suppliers, school meal serv-ice
providers, teachers, parents and children)
learn to value vegetables and perceive their
importance?
The pilot intervention
The pilot intervention was carried out in
three government primary schools in MCD
to test the feasibility and effectiveness of
promoting vegetables in primary schools,
using the MDM as an entry point. The inter-vention
study was undertaken by the
Nutrition Foundation of India (NFI), New
Delhi, with funds from Solution Exchange, an
electronic forum for the food and nutrition
security community in India, supported by
FAO.
The objective of the intervention was
twofold: (i) to accelerate the process of intro-duction
of vegetables into MDM by interact-ing
with the MDM programme officers, the
vegetable suppliers and food service provid-ers;
and (ii) to orient primary-school teachers
on how to use MDM as a focal point for nutri-tion
education to children on the importance
of a balanced meal with vegetables and on
how low- and middle-income families can
include vegetables into their daily meals at
affordable cost. The Education Department of
MCD permitted NFI to carry out the pilot
intervention through collaboration with local
food service providers. The pilot intervention
was carried out in Central Zone of New Delhi
from 2006 to 2007 for 6 months.
Introduction of vegetables
in the mid-day meal
The first step was to identify a large-scale veg-etable
supplier. Mother Dairy, a cooperative
vegetable supplier, was willing to supply sea-sonal
vegetables and green leafy vegetables at
the cost of Rs. 10/kg throughout the year to
identified food service providers as part of
their corporate social responsibility. Since the
quantity of vegetables supplied was large
(about 250 kg/day) the cooperative was will-ing
to ensure regular daily delivery of good-quality
mixed vegetables (onions, tomatoes,
potatoes, greens and seasonal vegetables) to
the food service provider’s kitchen. They
underwrote the small subsidy when the cost of
the vegetables soared and undertook periodic
monitoring of the quality of vegetables sup-plied.
ISKCON Food Relief Foundation, one of
the not-for-profit private food suppliers pro-viding
MDM to 50,000 schoolchildren per day
in MDC, agreed to introduce vegetables in the
MDM without any additional funds for the
duration of the pilot project (42).
Recipe testing
The next step was to demonstrate how to
introduce vegetables into the recipes. The
food service providers were providing six tra-ditional
rice or wheat and pulse or lentil-based
recipes cyclically in MDM. Each of
these was modified to include 50 g of seasonal
vegetables such as spinach, carrots, yellow
pumpkin, cauliflower or cabbage. Earlier NFI
studies had shown that children disliked
green leafy vegetables and yellow pumpkin
and removed pieces of these from their food.
To prevent this, these were cooked, mashed
and blended into the gravy. Children and
teachers from the three test schools enjoyed
eating these dishes and did not find any dif-ference
in taste. Children liked eating toma-toes,
potatoes, cauliflower, cabbage and peas;
these were introduced as large well-defined
pieces in colourful rice dishes.
By using different recipes with both visi-ble
and invisible vegetables, it was possible to
provide 50 g of vegetables in MDM per child
every day. After initial testing, which showed

that children accepted the recipes, production
of vegetable dishes was scaled up to all 50,000
schoolchildren covered by ISKCON in MCD
schools. Sensory evaluation showed that these
dishes were tasty and children accepted and
relished the MDM with vegetables. ISKCON
continued supplying vegetable dishes through-out
the project period, indicating that the intro-duction
of low-cost nutritious vegetables in
MDM is feasible and sustainable provided that
adequate funds are available.
Nutrition education
Three schools were purposively selected for
the implementation of nutrition education
activities, using MDM as a focal point, involv-ing
36 teachers and 249 children in grade 4.
The schools were located in well-constructed
buildings with good toilets and safe drinking
water to ensure that health and hygiene mes-sages
were supported by a health-promoting
school environment which would encourage
children to practise appropriate behavioural
modifications. The children in these schools
are not from the poorest of the poor and they
are provided with school uniforms, books
and school bags free of cost every year. In
some schools children sat on the floor but the
floor was swept clean. The schools also had
good classrooms with audio-visual facilities
to enable more compelling health and nutri-tion
education. Teachers were graduates with
educational training. The teachers were given
a one-hour orientation on nutrition education
with 20 minutes on how to communicate
nutrition messages effectively, using MDM as
a focal point. They were given information on
how to prepare a balanced meal and to ensure
health, hygiene and food safety, the afforda-bility
of a balanced diet and the different
types of foods to eat regularly to prevent and
combat nutritional deficiencies.
Development and implementation of learning
materials for nutrition education
As the first step to providing nutrition educa-tion
to children, appropriate nutrition and
health education materials were developed
and tested for children aged 5 to 11 years.
Major nutrition education messages included:
(i) what a balanced meal is (or ‘the nature of a
balanced meal’) and its health and nutritional
benefits; (ii) main nutritional problems among
children, including undernutrition, anaemia,
iodine-deficiency disorders and vitamin A
deficiency; (iii) food items which prevent
nutritional deficiencies; (iv) importance of a
variety of vegetables in the diet and how to
incorporate them in meals; and (v) nutritional
and health benefits of good eating habits in
children. Complementary health and hygiene
messages emphasized the importance of
washing hands, bringing a clean plate or
lunch box from home for taking the MDM;
eating without spilling food; and never
throwing away leftover food in the school
premises.
In order to make these classes interesting
and entertaining, a variety of attractive depic-tions
of fruits and vegetables were developed
and used to initiate discussions on the impor-tance
of vegetables (Fig. 11.1). The educa-tional
material included some wall charts but
was mainly play-based, including puppet
shows, snakes-and-ladders games and jigsaw
puzzles. Children were given intensive nutri-tion
education for the period of 1 week. The
children enjoyed learning nutrition and health
messages through attractive visual materials.
A pre- and post-intervention knowledge test
was administered before classes were begun
and within a week of completing the 6 days of
nutrition education.
Impact of orientation training
on teacher’s nutrition knowledge:
results after 1 week
All teachers completed a questionnaire with
20 questions before and after the orientation
training relating to topics reviewed during
the training. All questions carried equal
marks. A paired t test was used to assess
improvements in knowledge.
Even prior to the orientation training the
knowledge levels in teachers were quite high.
There was significant improvement in terms of
both mean scores and the range of scores when

tested 1 week after the training. The correla-tion
between the pre- and post- intervention
scores was low and not significant, perhaps
because the initial knowledge levels were high
(Fig. 11.2). These data suggest that the teachers
had the necessary knowledge to undertake
nutrition education of schoolchildren even
before the orientation training.
Impact of nutrition education
on schoolchildren’s knowledge
Two hundred and forty-nine children study-ing
in class 4 were given nutrition education
using MDM as the focal point for 35 min per
day for 6 days; of these, 149 children were
taught by the researcher while the teachers
watched and 100 children were taught by the
teachers who had received orientation train-ing
while the researcher watched. In addition
the researcher had informal interactions with
children during the mid-day meal. A pre- and
post-intervention knowledge test consisting
of ten questions on food sources of nutrients,
functions of nutrients, balanced diet and
hygiene was administered before classes were
begun and within 1 week after completion of
the 6-day nutrition education. All questions
carried equal marks. Improvement in knowl-edge
was tested using a paired t test.
Pre-intervention test scores were low,
indicating that the knowledge level in these
children was low. As the teachers’ knowl-edge
level was quite good, this implies that
perhaps adequate focused attention was
not being given to nutrition education.
Comparison of the pre- and post-intervention
test scores showed that there was improve-ment
in knowledge soon after nutrition edu-cation
was given to children. Children’s
increase in knowledge was greater when the
researcher taught children but there was also
substantial gain in knowledge when teachers
taught. There was a good correlation between
pre- and post-intervention knowledge scores
in children (Figs 11.3 and 11.4). These data
Fig. 11.1. Fruit and vegetable motorcycle.

20
17
14
11
12
10
8
6
4
2
10
8
6
4
2
suggest that if adequate time is allocated and
efforts are made to undertake focused nutri-tion
education, classroom teaching can have a
key role in improving children’s nutrition
knowledge. However, how long these mes-sages
are retained is an important question,
as is the effect that this knowledge has on
action and behaviour.
8
5 7 9 11 13 15
Pre-intervention nutrition knowledge score
Post-intervention nutrition
knowledge score
Fig. 11.2. Correlation between pre- and post-intervention nutrition knowledge scores of teachers
(correlation = 0.0743, not significant).
0
0 2
knowledge score
4 6 8
Fig. 11.3. Correlation between pre- and post-intervention nutrition knowledge scores of children
taught by researcher (correlation = 0.4267, P < 0.05).
0
0 1 2 3 4 5
knowledge score
Fig. 11.4. Correlation between pre- and post-intervention nutrition knowledge scores of children
taught by teachers (correlation = 0.3642, P < 0.05).

Results after 6–12 months
Data on follow-up of the teachers and chil-dren
after 6 months showed that teachers had
lost some of the knowledge they had acquired
soon after the orientation training. For the
children, repeat testing showed that although
their scores were higher than before they had
the nutrition education, their scores had
declined over time. This decline in knowl-edge
may be due to the fact that teachers did
not have the time to reiterate the nutrition
education messages even once during the
intervening period, as they were not part of
the curriculum. Also, children did not have
any lessons or material in their textbooks in
one place which they could read or show to
their parents at home. It is therefore hardly
surprising that they had forgotten many
things they were taught during the intensive
1-week nutrition education.
Parents’ response
In this project active contacts with parents
were limited and not specifically planned as
part of the study. Available evidence indicates
that to a large extent the parents (especially
mothers) viewed MDM as a useful pro-gramme,
which gave them a respite from pre-paring
lunch early in the morning for their
children. They were satisfied with the hot
cooked meals being provided because chil-dren
enjoyed eating them. There was insuffi-cient
interaction with them to assess whether
their children talked about the introduction
of vegetables in MDM and their nutritional
benefits and whether they were sensitized
regarding the introduction of vegetables in
home food.
Limitations of the intervention study
The intervention had several limitations.
Although vegetables in MDM were provided
for 6 months during the 2006/07 school year,
intensive nutrition education was provided
for 1 week only, which is too short to enable
sustained knowledge gains. The intervention
was non-randomized and thus the scope of
study was limited to the specific reference
population. There was no control group to
determine differences in knowledge between
children who received and did not receive
nutrition education. Moreover, the interven-tion
was not set up to show a link between a
short-term increase in knowledge and a
change in eating behaviour or preferences
resulting from the nutrition education. The
second objective implied that some spin-off
on family food practices was anticipated, but
this outcome was not assessed. Also there
was no assessment to determine whether the
vegetable-enriched MDM resulted in an over-all
net increase in children’s dietary intakes of
vegetables by using pre/post assessment
methodologies such as 24-hour children’s
food diaries or food-frequency questionnaires
through interviews with children and par-ents,
which could subsequently be used,
based on food composition data, to calculate
the nutrients obtained from a typical school
meal. Despite these limitations, the interven-tion
study contributes valuable logistical
experience, explores some essential interven-tion
components needed to lay the ground for
further research and highlights some of the
strategies required.
Discussion
Implications for future interventions
and research design
To address these limitations, what is needed
in future studies of this kind? Reviews of
effectiveness trials suggest that nutrition edu-cation,
for both teachers and students, requires
a great deal more time: six lessons are wholly
inadequate to embed knowledge or change
attitudes and practices (3,23). Nutrition edu-cation
initiatives should be carried out over at
least 12 months (3). The learning community
should be broadened with the aim of raising
awareness of healthy eating in the school
community at large and creating more inter-action
with the home, since research suggests
that involvement of the wider community

enhances impact (43). Such outcomes should
be assessed as rigorously as knowledge gain.
For the children’s nutrition education, learn-ing
must be recycled and built on over time.
Coherent and focused lesson sequences in
course books, grouped around nutrition top-ics,
would help teachers to undertake nutri-tion
and health education systematically,
enable students to revise and make it possible
to carry nutrition messages out of school.
Finally, knowledge transmission should not
be the sole educational aim for teachers, stu-dents,
families or the community. Lesson
objectives should be oriented towards changes
in practice and discourse at home and in the
community. This could involve some reas-sessment
of classroom methodology and
teacher education, and closer practical links
between MDM and lessons.
The study was a useful beginning and it
is appropriate to look beyond it. Policy mak-ers
need to become aware of the importance
of such interventions, and be persuaded to
consider integrating nutrition into the school
curriculum and the teacher education cur-riculum,
supporting this with nutrition-friendly
school policies. The approach to
food supply adopted by the study is also a
good pattern for further initiatives, suggest-ing
potential long-term benefits to the econ-omy.
Increasing the availability and intakes
of vegetables and fruit among a new genera-tion
of consumers will generate demand for
fresh local produce and stimulate agricul-tural
markets (44,45). Creating an enabling
policy environment for small-scale produc-ers
may be particularly important in a rap-idly
changing economic environment like
India, where there are risks of cooperative
suppliers and small farmers being pushed
out of the market by large retail companies
that can offer better conditions to farmers
who produce at scale.
In terms of research design, pre- and
post-intervention assessment should be part
of the project plan, and assessment should
not be limited to knowledge gain. There is a
need to identify what constitutes meaningful
change in knowledge, attitudes and practices
and the effectiveness of specific components
of interventions (23). Measuring dietary
intakes among children is acknowledged to
be a challenge (22), even greater in countries
where research expertise is limited and lack
of financial resources poses major con-straints.
Knai et al. (3) convincingly argue
that countries need support in the design,
conduct and evaluation of robust inter-ventions
and research. This is therefore an
appropriate and timely opportunity to
appeal to the international research commu-nity
to develop reliable, valid and inexpen-sive
assessment tools to measure knowledge,
behaviour modifications and changes in the
quality of children’s diet. Finally, barriers to
effectiveness must be assessed and taken
into consideration to maximize the success
of future interventions.
Conclusions
The intervention study shows that the intro-duction
of vegetables into MDM is feasible
and sustainable, provided that adequate
funds are allocated and there is thoughtful
planning. If used effectively, the MDM can
become a major tool for improving vegetable
consumption among school-aged children in
urban and rural India.
Despite the limitations in the interven-tion
design, many lessons can be learnt from
the pilot intervention. Children accept and
appreciate vegetable-based dishes. However,
prior testing for acceptability and palatability
is a key factor. The pilot study clearly brings
out the need to take account of affective fac-tors
(e.g. dislike of green vegetables) in MDM
planning. Cost was kept down by linking the
food service provider and a large cooperative
vegetable supplier. The Delhi supply chain,
using large centralized kitchens, may be
appropriate for urban areas; alternative solu-tions
are needed for rural areas. Local self-help
efforts in different parts of India show
that school farms and low-cost community
greenhouses can supply vegetables to schools
for incorporation into mid-day meals (46,
unpublished results2).
2 Bamji, M.S., Murty, P.V.V.S and Vardhan Rao, M.V.
(2008) Promotion of vegetables through the Mid-day
Meal program in rural schools. Unpublished data.

Children’s nutrition knowledge can be
improved by teaching and maintained if ade-quate
time is allocated and materials are suffi-ciently
focused. It remains to ensure that the
transition from knowledge to behaviour is
given the same amount of educational attention
as pure knowledge, and that the MDM is fully
exploited educationally as an object lesson for
the children, the school and the community. It is
to be hoped that as the MDM programme devel-ops,
it will provide the opportunity for many
more coordinated experiments and research
projects, which will build on each other.
Acknowledgements
The Nutrition Foundation of India wishes to
acknowledge with thanks the financial sup-port
and encouragement provided by Solution
Exchange and the food and nutrition commu-nity
in India for carrying out this action
research. Thanks are also due to MCD offi-cials,
ISKCON Food Relief Foundation,
Mother Dairy, the teachers and the children in
the MCD schools for their cooperation and
support during the implementation of the
action research.
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12 Developing Micronutrient-rich
Snacks for Pre-conception and Antenatal
Health: the Mumbai Maternal Nutrition
Project (MMNP)
D. Shivashankaran,1 S. Gurumurthy,1 S.H. Kehoe,*2 P.S. Chheda,1 B.M. Margetts,2
P. Muley-Lotankar,1 A. Agarwal,1 N. Brown,2 S.A. Sahariah,1 V. Taskar,3
C.H.D. Fall2 and R.D. Potdar1
1Mumbai Maternal Nutrition Study, Centre for the Study of Social Change,
Roy Campus, Bandra East, Mumbai, India; 2University of Southampton,
Southampton, UK; 3Streehitkarini, Lokmanyanagar Compound, Mumbai, India
Abstract
Observational and trial data suggest that poor maternal micronutrient status as a result of poor dietary
quality before and during pregnancy impairs fetal growth and development. This chapter describes the
development of palatable food supplements produced from locally available vegetarian foods that improve
the quality of the diet of young Indian women living in Mumbai slums.
A vehicle in the form of a cooked snack food that could be distributed daily was developed to provide the
women with supplementary green leafy vegetables (GLVs), fruit and milk. The target nutrient content of the
snack was defined based on intake data from the study population and the UK Estimated Average Requirement
(EAR). The snack was analysed to measure these target nutrient levels and palatability was assessed.
Several approaches were used to deliver the amount of GLVs, fruit and milk that were considered
sufficient to have an impact on the women’s nutritional status. A vehicle was developed that contained
these micronutrient-rich foods and was palatable and acceptable to the women. Some of the target micro-nutrient
levels were achieved using combinations of fresh GLVs, dried fruits and milk powder. Mean
micronutrient levels of the final product (per serving) were: b-carotene 123 retinol equivalents; folate 68 mg;
riboflavin 0.14 mg; iron 4.9 mg; calcium 195 mg; vitamin B12 0.24 mg. These values are between 12% and
43% of the UK EAR. To date, target vitamin C levels have not been achieved.
It is possible to develop palatable, culturally acceptable and safe micronutrient-rich food supplements
using a low-tech approach and locally available fresh and dehydrated ingredients.
Key words: micronutrient, food supplement, green leafy vegetables, fruit, milk, India
Suboptimal maternal micronutrient status
during the periconceptional period, and dur-ing
pregnancy itself, adversely affects fetal
growth and the development of all body
tissues, impairing the subsequent health of
the baby, child and adult (1). Birth weight is a
crude measure of fetal development, but nev-ertheless
it has been shown to be associated
Introduction
* Contact: sk@mrc.soton.ac.uk

Developing Micronutrient-rich Snacks 215
with long-term health outcomes including
cardiovascular disease and diabetes (2).
According to data from the third Indian
National Family Health Survey (NFHS3) (3),
in 2005 almost 22% of neonates in India
weighed less than 2.5 kg. A more recent esti-mate
published in 2009 by the United Nations
Children’s Fund (UNICEF) is 28% (4). It has
been documented that babies born small are
more likely to be stunted in childhood (5–7),
which in females is a risk factor for low birth
weight in the next generation and for both
males and females is associated with lower
adult income (8). Estimates of the prevalence of
stunting in India range from 38% for children
under 5 years of age (UNICEF) (4) to 45% for
children under 3 years (NFHS3) (3). Stunting,
wasting and underweight for age at 3 years
are all more prevalent among children of
lower socio-economic status (3).
The Mumbai Maternal Nutrition Project
(MMNP) is a randomized controlled trial
investigating the effect of providing women
with a micronutrient-rich food for consump-tion
before and throughout pregnancy on
infant outcomes, including size and weight at
birth, infant mortality, childhood growth,
cognitive development and cardiovascular
risk. The trial participants are married women
of childbearing age who are intending to
become pregnant and are living in a slum
community in the city of Mumbai, India. The
trial was launched in January 2006 and is due
to run until 2011. It was approved by the
research ethics committee of the Nair Hospital,
Mumbai, and is on the International Standard
Randomi zed Controlled Trial Register (ISRCTN
62811278).
The MMNP was inspired by the Pune
Maternal Nutrition Study (PMNS) which
was carried out between 1994 and 1996. The
PMNS was an observational study in a rural
Indian population in which women were
interviewed about their dietary habits twice
during pregnancy using a food-frequency
questionnaire (FFQ) developed specifically
for the population. The women were then fol-lowed
up at pregnancy and detailed anthro-pometry
of the baby was carried out within
72 h of birth. The results showed that mothers
(n 633) with higher self-reported intakes at
28 weeks’ gestation of green leafy vegetables
(GLVs), fruits and milk delivered fewer low-birth-
weight babies (9).
The MMNP was subsequently designed
to investigate whether this relationship was
causal, i.e. whether consumption of these
foods by the mother before and during preg-nancy
positively affected the development of
the fetus. The intervention is based on locally
available foods, rather than synthetic nutri-ents.
This approach requires that the women
consume the foods on a regular basis prior to
and during pregnancy. It is intended that the
intervention is an addition or supplement to
the women’s daily intake rather than a
replacement for any of the foods she would
habitually eat. It was therefore decided that
the supplement would take the form of a
snack food similar to those available locally
from street-side stalls and be made available
to women at a time of day when they would
not usually be eating a meal. Once enrolled in
the study, the women are asked to visit a dis-tribution
centre within walking distance of
where they live six days per week in order to
receive the supplement. The woman’s attend-ance
at the centre and consumption of the
supplement are recorded by health workers
on each visit. Pregnancies are identified by
recording the women’s last menstrual period
date. Women who become pregnant are asked
to continue to eat the supplement until
delivery.
The trial has an intervention and a con-trol
arm. The control supplement contains
vegetable ingredients of relatively low micro-nutrient
content that were not associated with
birth outcomes in the PMNS. Blinding is not
possible in this study but in order to mask the
true nature of the intervention the women are
randomized to one of four groups. On a given
day, four different snacks are sent to the field,
two varieties of intervention and two varie-ties
of control.
This chapter describes the stages of
development of the intervention supplement
and the degree to which the following require-ments
have been achieved:
1. Produced from locally available foods.
2. Acceptable to vegetarians.
3. Contains target levels of several ‘marker’
micronutrients.

216 D. Shivashankaran et al.
4. Possible to prepare daily in large quanti-ties
by local staff in a ‘low-tech’ kitchen.
5. Palatable enough to be eaten daily over
a period of months.
6. Microbiologically safe (not containing sal-monella,
Escherichia coli, coliforms or unac-ceptable
levels of mould).
7. Nutritionally safe (not exceeding UK safe
upper limits for any nutrient) (10).
The project started with a two-year pilot
study (2004–2005) in the Shetanchowki area
of Mumbai, based in the Streehitakarini
Health Centre. The main trial started in 2006
in Bandra, based at the Centre for the Study
of Social Change, and as of April 2010 has
recruited approximately 5000 women.
Methods
It was decided that the supplement would
take the form of a snack food similar to those
available locally from street-side stalls and be
made available to women at a time of day
when they would not usually be eating a
meal. Nutrient content, acceptability, safety,
cost and availability of ingredients, man-power
and cooking facilities have been con-sidered
when developing the snacks. There
have been four chronological stages of snack
development: pilot study; main trial 1; main
trial 2; and main trial 3.
Target nutrient content
The starting point for setting the target
nutrient content of the snacks was informa-tion
from the PMNS which collected data
on women’s habitual food intake using a
111-item FFQ (9). We estimated average
intakes of ‘marker’ nutrients: b-carotene,
riboflavin, folate and vitamin C. The amount
of nutrient that would increase daily intakes
of the ‘marker’ nutrients above the 75th
centile of intakes of the women in the PMNS
was then calculated (Table 12.1). Because it
was anticipated that MMNP participants
would be more likely to attend on alternate
days (i.e. three days per week) rather than
six days per week, the target nutrient con-tent
was set at double the amount that
would move intake to the 75th centile of the
PMNS. This amount was found to be
approximately equal to one-third of the UK
Estimated Average Requirement (EAR) for
riboflavin and folate (11).
At each stage of the trial, samples of the
snacks were tested for nutrient content.
Homogenized and frozen snacks were flown
to the UK on dry ice and analysed at a
commercial laboratory (Eclipse Scientific
Group, Cambridge). Reversed-phased high-performance
liquid chromatography was
used to test for riboflavin, b-carotene and
vitamin C; vitamin B12 content was analysed
using surface plasmon resonance inhibition
assay; folic acid was analysed by bioassay
Table 12.1. Amount of nutrients consumed by women in the PMNS and the target nutrient content of the
MMNP supplement.
b-Carotene (RE) Riboflavin (mg) Folate (mg) Vitamin C (mg)
Women’s median daily intake during
pilot study
600a 0.65 126 21
75th centile of intake in PMNS 654a 0.82 164 23
Target nutrient content of snack 108a 0.34 76 4
UK EAR (11) 500a 1.2 250 25
Safe Upper Limit (where
1166b – – –
applicable) (10)
PMNS, Pune Maternal Nutrition Study; MMNP, Mumbai Maternal Nutrition Project; RE, retinol equivalents;
EAR, Estimated Average Requirement.
aFigures relate to all sources of retinol.
bFigures relate to b-carotene only.

(Lactobacillus rhamnosus); and all minerals
were analysed by inductively coupled plas-ma-
atomic emission spectrometry.
Formulation
We initially considered supplying the food in
the form of a milk drink, a piece of raw fruit
and an ordinary cooked GLV preparation.
However, this was not feasible in the context of
the trial, for a number of reasons. First, the
daily purchase of all these fresh ingredients
was too costly in terms of staff time. Second, it
was not possible to deliver these foods in a pal-atable
state, or to maintain microbiological
safety, during their distribution throughout the
large slum area. Third, it would have been dif-ficult
to record the women’s intake, in a simple
way, with the foods in this form. Finally, it was
clearly impossible to make the intervention
and control supplements appear similar using
this approach. We therefore decided to com-bine
the three ingredients and to make them
into cooked snacks, similar to street snacks,
like samosas, widely available in Mumbai.
During the pilot study phase, it was not
possible to purchase and prepare sufficient
quantities of fresh ingredients for the snacks
due to manpower constraints. Initial formula-tions
therefore contained dehydrated, pow-dered
GLVs, fruit and milk. A Mumbai-based
commercial company supplied vegetable and
fruit powders prepared using a novel tech-nique
of room-temperature drying. These
powders have superior smell and flavour
compared with heat-dried powders and nutri-ent
retention is maximized. The use of pow-ders
allowed the inclusion of greater quantities
of the GLV, fruit and milk in the limited vol-ume
available. They were combined with
other ‘binding’ or ‘covering’ ingredients such
as chickpea flour or semolina and seasoned
with local spices to give a product which
resembled a food like a samosa or patty.
Product development
The recipes for the snacks were initially
developed by the project nutritionists,
experimenting on a small scale at home in
their kitchens. Preparation of the snacks was
then scaled up with the installation of a large
project kitchen, staffed by 19 men and women
and equipped with a range of basic kitchen
facilities (including a large gas stove, oven,
chilled storeroom and stainless steel prepara-tion
surfaces). Development of new recipes
(to avoid monotony for the women) and the
introduction of more palatable formulations
have been an ongoing process throughout the
pilot study and the main trial.
Choice of specific green leafy vegetable
The choice of GLV to be added to the supple-ments
was initially based on the availability
of the dehydrated powders and the opinions
of project staff as to acceptability. In early
2007, the dehydrated powders of ten different
GLVs (radish leaf, red amaranth, fenugreek,
green amaranth, coriander, colocasia, drum-stick
leaf, onion stalk, shepu, spinach and
curry leaf) were analysed by a UKAS accred-ited
laboratory (Eclipse Scientific Group) for
micronutrient content. The powders were
also analysed for polyphenol (Global
Analytical Services, Heidelberg, Germany)
and oxalate content (Lincoln University,
Canterbury, New Zealand) (12). Polyphenols
and oxalates are considered ‘anti-nutrients’
because they inhibit absorption of minerals,
specifically iron and calcium, respectively
(13,14). The dehydrated powders were
crudely ranked according to nutrient and
‘anti-nutrient’ content; those with the lowest
overall score being the most nutritious and
containing the least anti-nutrient.
Stages of development
As the study progressed a series of major
changes was made to the snacks (Table 12.2).
These were mainly to improve the nutrient
quality and palatability, the latter having an
impact on participant compliance. First, the
amount of GLV powder added to the snacks
was reduced; this was to make the snack more
palatable (large amounts of dried GLV made

Table 12.2. Ingredients, mean nutrient composition and mean percentage contribution to nutrient
requirements of the supplements at each stage of the trial.
Pilot study Main trial 1 Main trial 2 Main trial 3
Dry GLV, fruit
it taste bitter) (Table 12.2, main trial 1). Next,
50% of the GLV powder was substituted with
fresh GLVs (Table 12.2, main trial 2). There
were, however, other reasons for some of the
changes; a problem with rat infestation on the
premises of the commercial dehydrated pow-der
suppliers forced a complete change to the
use of fresh rather than dried GLVs and dried
fruit rather than dried fruit powder. The final
and current formulation being used in the
trial is shown in Table 12.2 (main trial 3).
Assessment of the acceptability
and safety of snacks
New snack recipes were tested for palatabil-ity
by project staff and small panels of local
powder
Reduced GLV
powder
GLV powder +
fresh GLV Fresh GLV
Jan 2003 to Jun
2005
Jan 2006 to Oct
2006
Oct 2006
to Jun 2007
Jun 2007
to present
Ingredient
Dry GLV powder (g) 10 7.5 3.8 0
Milk powder (g) 8 16 12 12
Fruit powder (g) 4 4 4 0
Fresh GLV (g) 0 0 29 30
Dried fruit (g) 0 0 0 4
Micronutrient content per
supplement
b-Carotene (RE) 282 114 200 123
Riboflavin (mg) 0.58 0.20 0.21 0.14
Folate (μg) 135 26.0 50.8 67.5
Vitamin C (mg) 1.6 <1 0.5 1.5
Vitamin B12 (μg) 0.61 0.64 0.58 0.24
Calcium (mg) 298 210 275 195
Iron (mg) 5.46 6.85 5.90 4.90
Macronutrient content per
supplement
Energy (kJ) 795 741 703 611
Energy (kcal)a 190 177 168 146
Protein (g)a 7.0 7.3 6.9 6.4
% of target (% of EARb)
b-Carotene 261 (56) 105 (23) 185 (40) 114 (25)
Riboflavin 170 (48) 59 (17) 62 (18) 41 (12)
Folate 177 (54) 34 (10) 67 (20) 89 (27)
Vitamin C 40 (6) <1 (<1) 13 (2) 38 (6)
Vitamin B12 (48)c (51)c (46)c (6)c
Calcium (48)c (34)c (44)c (31)c
Iron (48)c (60)c (52)c (43)c
Compliance (% of participants
consuming whole rather
than half supplement)
Not measured 64 72 89
GLV, green leafy vegetable.
aMacronutrient content calculated using Indian Food Tables (16).
bUK Estimated Average Requirement during pregnancy (11).
cNo target was set for these nutrients.

women before being distributed to the field.
In addition to this anecdotal approach, accept-ability
was assessed more objectively using
data recorded daily by health workers on the
consumption of the snacks. The proportions
of women attending the distribution centre
and consuming the whole snack (recorded as
‘1’), at least half but not the whole snack
(recorded as ‘0.5’) or less than half (recorded
as ‘0’) were calculated and used to assess the
acceptability of each recipe (Table 12.2,
compliance). Microbiological testing for the
presence of coliforms in snacks was per-formed
during the pilot study at a Mumbai
food safety laboratory. All snacks are pre-pared
and cooked fresh every day and lefto-vers
discarded.
Cost
The costs of the ingredients, staff wages, cook-ing
fuel and packaging were used to calculate
the unit cost of the snacks. This was compared
with the cost of the UNICEF multiple micro-nutrient
tablet (15).
Food intake
We assessed the baseline food intake of the
women using a 213-item FFQ which was
administered by trained interviewers to
women at enrolment. The reference period
was the most recent week. The questionnaire
covered the vast majority of foods that the
women were likely to eat and provided
detailed information on the amount of fruit,
vegetables and milk products consumed. The
increase in intake of these foods as a result of
consumption of the snack was then calculated
with reference to the baseline median intake.
Results
Nutrient content/acceptability
Table 12.2 shows the average nutrient content
of the snacks broken down by trial stage. The
first version of the snack (Table 12.2, pilot
study) was rich in micronutrients with the
exception of vitamin C. However, the dry
GLV powder made the snacks dense and dif-ficult
to eat, and some women ceased to com-ply
with daily consumption. Reducing the
GLV powder and increasing the milk powder
content (Table 12.2, main trial 1) improved
compliance but led to an unacceptable drop
in certain nutrients, particularly folate. The
best overall combination of palatability, com-pliance,
nutrient content and appearance has
been achieved by complete substitution of the
GLV powder with fresh GLVs (Table 12.2,
main trial 3). The target of raising the daily
intake to that of the 75th centile of the PMNS
women is met for the majority of the ‘marker’
nutrients. A significant proportion of the UK
EAR is also met for several nutrients. None
of the snacks has achieved target vitamin C
levels and vitamin B12 levels were low.
Choice of green leafy vegetable
The results of the GLV analysis are shown in
Table 12.3. The GLVs with the lowest overall
score were the most favourable. If the results
are interpreted including all of the nutrients in
Table 12.3, curry leaves and spinach have the
lowest content of bioavailable nutrients and rad-ish
leaves and red amaranth have the highest.
Since the results of these analyses were
available in mid-2007, the choice of GLV
added to the supplements has been based on
these results where availability and cost have
allowed. The acceptability according to the
project team has also been taken into account.
For example, despite having a favourable
nutrient profile, fenugreek was removed from
the snacks as the women did not like the bit-ter
taste of this GLV.
Safety
All microbiological tests for coliforms were
negative in the pilot study. These were not
repeated during the main trial. None of the
snacks exceeded the safe upper limit for
b-carotene content.

Table 12.3. Nutrient and anti-nutrient composition of GLV dehydrated powders and ranking according to nutrient content.
GLV
Nutrient
scorea
Anti-nutrient
content
Anti-nutrient
scoreb
Overall
score
Overall
rankc
Nutrient content per 100 g Soluble
oxalate
(% of total
oxalate)
Polyphenol
Vitamin
B12 (μg)
Vitamin
B2 (mg)
RE
(μg)
Vitamin
C (mg)
Folate
(μg)
Ca (g) Fe (mg) Mg (g) Zn (mg) (mg/kg)
Radish leaf 2.61 57.40 0.90 5.92 2.40 1.52 7250 51.1 800 38 0.00 10.90 2 40 1
Red amaranth 2.79 212.00 1.66 4.60 1.40 0.80 6200 35.6 1300 38 43.90 16.50 10 48 2
Fenugreek 1.33 129.00 0.34 2.50 1.10 2.02 3820 186.0 770 56 0.00 15.50 3 59 3
Green
2.71 97.00 2.16 4.00 0.93 0.33 7900 10.6 890 51 46.50 15.90 10 61 4
amaranth
Coriander 1.10 108.00 0.39 4.40 2.90 1.09 6100 58.0 730 60 0.00 25.90 5 65 5
Colocasia 2.12 46.50 0.52 3.10 <0.2 1.55 8320 15.9 680 58 25.20 10.30 7 65 6
Drumstick 3.02 58.90 0.64 1.90 1.10 1.29 2480 167.0 540 63 0.00 17.80 4 67 7
Onion stalk 1.68 95.30 0.40 1.70 3.70 0.79 3180 51.0 550 69 0.00 9.04 1 70 8
Shepu 1.63 102.00 0.49 3.10 1.20 0.34 2920 105.0 770 64 0.00 26.20 6 70 9
Spinach 1.07 87.00 1.17 5.10 1.00 1.43 5280 13.3 440 70 94.60 8.51 9 79 10
Curry leaves 2.80 43.10 0.60 2.90 1.60 0.30 1460 45.5 150 78 0.00 41.00 7 85 11
GLV, green leafy vegetable; RE, retinol equivalents.
aNutrient score = sum of the ranks for each nutrient. Lower score represents GLV with a greater nutrient content.
bAnti-nutrient score = sum of the ranks for each anti-nutrient. Lower score represents a GLV with a lower anti-nutrient content.
cOverall rank: 1 is most favourable nutrient and anti-nutrient profile.

Cost
The average unit production cost of snacks
made using dehydrated leaves (main trial 1)
was 13 Indian rupees (approximately
US$0.33). This cost was reduced to 5 rupees
(US$0.13) for the snacks made with fresh
GLVs. These prices are comparable to the cost
of similar ‘street’ snack foods that women
consume in this part of India. The unit cost is
higher than that of the UNICEF multiple
micronutrient tablet, which is approximately
US$0.02 per daily dose (15).
Food intake
The baseline frequency of intake of GLVs and
fruit in this population was found to be very
low: median (interquartile range, IQR) of 1.1
(0.57–1.29) and 0.3 (0.15–0.6) servings/day,
respectively. Milk was frequently consumed,
the median (IQR) frequency being 2.1 (2–3),
but in approximately 80% of cases the serv-ing
was that added to tea and therefore a
relatively small quantity (approximately
30 ml/serving).
In this population, one serving (and one
FFQ portion size) is approximately 30 g.
Consumption of the snack increased median
intake of fruit and GLV by approximately 34
g/day (or 113%). Cow’s milk is approximately
88% moisture (16), so 12 g of milk powder is
equivalent to approximately 100 ml of milk.
The median frequency of milk intake was two
portions of 30 ml/day. Consumption of the
snack therefore increases daily median milk
intake by approximately 167%.
Discussion
We have demonstrated that it is possible in
the context of an urban community in India to
develop palatable micronutrient-rich snacks
that young pre-pregnant and pregnant women
will eat on a daily basis. This has been achieved
using a variety of locally available foods and
employing local staff. The potential advan-tages
of a food-based supplement made using
low-tech methods from local ingredients over
synthetic nutrients, such as implemented in
the MMNP, are important and should be
emphasized. It is likely that such an approach
will be more acceptable and sustainable in
the long term as a means of improving health
and nutrient status. It also provides social
enterprise opportunities within the commu-nity
(including for agriculturalists and
kitchen staff), thus benefiting local people
financially.
While the nutrient content of such foods
is unlikely to exceed that of pharmaceutical
interventions, it was possible to achieve tar-get
micronutrient levels for some of the nutri-ents
using locally available ‘food’ ingredients
without the addition of any synthetic micro-nutrients.
A synthetic micronutrient prepara-tion
requires selection of particular nutrients,
and it is not always known which nutrients
should be included. It is likely that there are
nutrients (e.g. essential fatty acids) and phy-tochemicals
(bioactive non-nutrient plant
compounds, e.g. flavonoids) in such foods
that are important in disease prevention
(17,18) and are not present in pharmaceutical
interventions. No data are available on the
bioavailability of the nutrients present in the
snacks or changes to the health or nutrient
status of the women. It will be important to
examine the longer-term effects of daily sup-plementation
on the micronutrient status of
people in this community. The baseline GLV
and fruit intake of the women was found to
be very low and while the snacks may not be
providing the full recommended daily intake
of fruit and vegetables, the increase as a result
of consuming the snacks is substantial. The
aim of the supplementation programme is to
positively shift the distribution of nutrient
intake to ensure that all women are achieving
a nutrient intake that is associated with better
health outcomes for their children. The aim is
not to change the distribution of intake such
that all women are receiving the reference
nutrient intake (equivalent to two standard
deviations above the average requirement).
We believe that this public health approach is
likely to be more acceptable to the women
and more sustainable for their community.
The unit cost of the snack in the MMNP
was substantially more expensive than that of
a micronutrient tablet. However, as pointed

out by Gopalan (19), in countries such as
India where micronutrient deficiencies exist
as a result of a poor dietary quality, increasing
the consumption of micronutrient-rich foods
in a manner which is sustainable to the com-munity
is likely to be more effective than giv-ing
out tablets that are manufactured in
high-income countries. The commercial via-bility
or marketability of the snack has not
been tested at this stage. The average cost of a
similar type of street food snack in this com-munity
would, however, be at least as much
or slightly more than the cost of producing
our snack, so we are confident of the viability
of scaling up the project if the trial shows that
there is a positive effect on birth outcomes.
In our experience, this method of sup-plement
development takes a substantial
amount of time. The length of time is depend-ent
on a number of factors. Each recipe
requires experimentation in the kitchen by
project staff with a prescribed set of ingredi-ents.
The next stage is for taste panels to
approve the snack. They must then be ana-lysed
for nutrient content. For the current
study, it was not possible to find a suitable
laboratory in India for nutrient analysis to be
carried out. This necessitated transportation
of samples to the UK, adding to the develop-ment
time. Finally the ‘acceptability’ of the
snacks to the women participating in the
study had to be assessed to ensure that they
would consume them on a regular basis.
Perishability of the snacks is a potential
problem that could limit the adoption of this
approach on a large scale. The snacks in the
trial are cooked and eaten on the same day.
Another is lack of availability of some of the
‘active’ ingredients at certain times of the
year (e.g. during the monsoon months, fewer
GLVs are available, and those that can be
obtained tend to be the less nutritious ones).
We believe that the problems of poor availa-bility
or contamination should not be insur-mountable,
and have plans to re-introduce
some dried leaf into the intervention supple-ments.
Dried GLV and fruit powders offer
one method of long-term storage of micro-nutrient-
rich foods that could be viable at
community level in India. Future plans
include the development of a supplement
with a longer shelf-life. This will enable the
kitchen staff to plan for holidays, festivals
and times when ingredients are in short
supply.
To date, we do not know the effects of
supplementation on any of the outcomes in
the trial, which include maternal nutrient sta-tus,
birth weight and infant body composi-tion.
It is expected that the trial will be
completed in 2011, and that data will be avail-able
from 1600 pregnancies.
References
1. Barker, D. (1998) Mothers, Babies and Health in Later Life. Churchill Livingstone, Edinburgh, UK.
2. Veena, S.R., Geetha, S., Leary, S.D., Saperia, J., Fisher, D.J., Kumaran, K., Coakley, P., Stein, C.E. and
Fall, C.H. (2007) Relationships of maternal and paternal birthweights to features of the metabolic syndrome
in adult offspring: an inter-generational study in South India. Diabetologia 50, 43–54.
3. International Institute for Population Sciences and Macro International (2007) National Family Health
Survey (NFHS-3) 2005–06 Volume 1. IIPS, Mumbai, India.
4. United Nations Children’s Fund (2008) The State of the World’s Children 2009. UNICEF, New York,
New York.
5. Adair, L.S. and Guilkey, D.K. (1997) Age-specific determinants of stunting in Filipino children. Journal of
Nutrition 127, 314–320.
6. El Taguri, A., Betilmal, I., Mahmud, S.M., Monem Ahmed, A., Goulet, O., Galan, P. and Hercberg, S. (2008)
Risk factors for stunting among under-fives in Libya. Public Health Nutrition 12, 1141–1149.
7. Mamiro, P.S., Kolsteren, P., Roberfroid, D., Tatala, S., Opsomer, A.S. and Van Camp, J.H. (2005) Feeding
practices and factors contributing to wasting, stunting, and iron-deficiency anaemia among 3–23 month-old
children in Kilosa district, rural Tanzania. Journal of Health, Population, and Nutrition 23, 222–230.
8. Victora, C.G., Adair, L., Fall, C., Hallal, P.C., Martorell, R., Richter, L., Sachdev, H.S.; Maternal and Child
Undernutrition Study Group (2007) Maternal and child undernutrition: consequences for adult health and
human capital. Lancet 371, 340–357.

9. Rao, S., Yajnik, C.S., Kanade, A., Fall, C.H., Margetts, B.M., Jackson, A.A., Shier, R., Joshi, S., Rege, S.,
Lubree, H. and Desai, B. (2001) Intake of micronutrient-rich foods in rural Indian mothers is associated
with the size of their babies at birth: Pune Maternal Nutrition Study. Journal of Nutrition 131,
1217–1224.
10. Expert Group on Vitamins and Minerals (2003) Safe Upper Limits for Vitamins and Minerals. Food
Standards Agency, London.
11. Department of Health (1991) Dietary Reference Values of Food Energy and Nutrients for the United
Kingdom. Report on Health and Social Subjects No. 41. The Stationery Office, London.
12. Radek, M. and Savage, G.P. (2008) Oxalates in some Indian green leafy vegetables. International Journal
of Food Sciences and Nutrition 59, 246–260.
13. Lopez, A. and Martos, C. (2004) Iron availability: an updated review. International Journal of Food
Sciences and Nutrition 55, 597–606.
14. Heaney, R.P., Weaver, C.M. and Recker, R. (1988) Calcium absorbability from spinach. American Journal
of Clinical Nutrition 47, 707–709.
15. United Nations Children’s Fund (2008) UNICEF Supply Catalog, 4–2-2008. UNICEF Supply Division,
Copenhagen.
16. Gopalan, C., Sastri, R. and Balasubramanian, S.C. (19889) Nutritive Value of Indian Foods. National
Institute of Nutrition, Hyderabad, India.
17. Liu, R.H. (2003) Health benefits of fruit and vegetables are from additive and synergistic combinations of
phytochemicals. American Journal of Clinical Nutrition 78, 517S–520S.
18. Lila, M.A. and Raskin, I. (2005) Health related interactions of phytochemicals. Journal of Food Science
70, R20–R27.
19. Gopalan, C. (2002) Multiple micronutrient supplementation in pregnancy. Nutrition Reviews 60, S2–S6.

13 Approaches and Lessons Learned
for Promoting Dietary Improvement in
Pohnpei, Micronesia
L. Englberger,*1 A. Lorens,2 M. Pretrick,3 B. Raynor,4 J. Currie,5 A. Corsi,6 L. Kaufer,7
R.I. Naik,8 R. Spegal9 and H.V. Kuhnlein7
1Island Food Community of Pohnpei, Kolonia, Pohnpei, Federated States of Micronesia;
2Pohnpei Agriculture of the Offi ce of Economic Affairs, Kolonia, Pohnpei, Federated
States of Micronesia; 3Environmental and Community Health Section, Department
of Health and Social Affairs, Palikir, Pohnpei, Federated States of Micronesia; 4The
Nature Conservancy–Micronesia Program, Kolonia, Pohnpei, Federated States of
Micronesia; 5College of Micronesia–FSM, Pohnpei, Federated States of Micronesia;
6Global Health Consultant, Ithaca, New York, USA; 7Centre for Indigenous Peoples’
Nutrition and Environment, Macdonald Campus of McGill University, Ste. Anne de
Bellevue, Quebec, Canada; 8Rollins School of Public Health, Emory University, Atlanta,
Georgia, USA; 9Micronesia Human Resource Development Center, Kolonia, Pohnpei,
Federated States of Micronesia
Abstract
The island state of Pohnpei, Micronesia, has experienced much change in diet and lifestyle since the 1970s.
Serious problems of micronutrient deficiencies and non-communicable disease such as diabetes, heart
disease and cancer have emerged, following the neglect of traditional local foods and the shift to rice and
imported processed foods. An awareness campaign on the benefits of local food, especially carotenoid-rich
bananas for nutrition, is the subject of this chapter. A community, inter-agency, participatory programme
was implemented focused on raising awareness on island food production and consumption. Messages
were shared on horticulture, cooking, food processing and conservation through mass media, posters,
print materials, photography, national postal stamps, workshops, displays, youth clubs, farmers’ fairs,
competitions, e-mail and slogans: ‘Go Yellow’ and ‘Let’s Go Local’. Research was undertaken in food
analysis, genebank collections and community case studies as part of a global health project.
As yellow-fleshed carotenoid-rich foods (banana, taro, pandanus and breadfruit varieties) were iden-tified
and promoted, banana and taro consumption increased as did the number of the varieties consumed.
Carotenoid-rich banana varieties not previously marketed such as Karat, Utin Iap and Daiwang became
popular. Foods ready for consumption using local banana and taro varieties appeared in the markets
where these had not been sold previously. The awareness campaign stimulated great interest in Pohnpei
and throughout the region with invitations to present at international meetings and ‘Go Local’ workshops
outside Pohnpei. It was proclaimed as an awareness success and consideration should be given to apply-ing
this approach to other Pacific Islands.
Key words: local food, provitamin A carotenoid, food composition, inter-agency, participatory, community
* Contact: nutrition@mail.fm

Promoting Dietary Improvement 225
Introduction
The Federated States of Micronesia (FSM),
comprising the four states of Pohnpei, Chuuk,
Yap and Kosrae (1), is located just north of the
equator and has a population of about 107,000.
Its 607 islands are spread over a million
square miles of the western Pacific Ocean (2).
Pacific nations share many of the same tradi-tional
staple foods: starchy fruits (breadfruit,
banana) and root crops (taro, cassava and
yam), which are commonly termed ‘local
food’, and are eaten with coconut, fish and
some fruits and vegetables in the traditional
diet (3–5). Large amounts of local foods may
be eaten, from 1 kg up to 3 or 4 kg daily (6).1
In addition to sharing similar foods, Pacific
Islanders share many strongly held beliefs and
values: the ‘Pacific Way,’ a community spirit
born of similarity of life and living values
where the extended family and communalism
are fundamental (3,4,7). It is essential to under-stand
such beliefs and values before planning a
food-based approach for behavioural change
and dietary improvement.
This chapter focuses on work on Pohnpei
Island (population about 34,500), seat of the
national government (8,9). Pohnpei State has
one main island, which is a high volcanic
island, and five outlying low atolls. Pohnpei
was successively colonized by Spain,
Germany and Japan during the period from
1885 to 1945, when these islands became a
part of the United Nations Trust Territory of
the Pacific Islands under United States’
administration. In 1986, FSM became inde-pendent
but continued a close relationship
with the USA through a Compact of Free
Association, which has provided immense
sums of money to the country and greatly
affected local food use and production (9,10).
Although the Compact is to continue to the
year 2023 (9,10), the economic outlook for
FSM is described as ‘fragile’ (9,10) and 29.5%
of Pohnpeians live under the basic needs’
poverty line (10).
Pohnpei Island, with its verdant tropical
foliage, warm temperatures and year-round
heavy rainfall (about 250–500 cm annually in
populated areas), is rich in agricultural
resources. The primary economic activity on
Pohnpei, as throughout FSM, is subsistence
farming and fishing (9).
Micronutrient deficiency and other
health and nutrition issues
Previously vitamin A deficiency (VAD)
appeared to be non-existent in FSM and
Pohnpei (11,12) as a public health problem.
Evident cases of night blindness and VAD
were identified in Chuuk in the late 1980s
(13,14) on the basis of conjunctival impression
cytology and serum retinol. In a randomized
population-based survey in Pohnpei in 1994,
51% of the pre-school children (24–47 months
of age) had VAD, as defined by serum retinol
<20 g/dl, and 33% of Pohnpei children
were anaemic, defined as haemoglobin <11.5
g/dl (15,16).
Micronutrient deficiencies, as well as
serious problems of non-communicable dis-eases
(diabetes, heart disease, and cancer),
appear to be the result of massive dietary and
lifestyle changes which gathered momentum
in the 1970s (11,17,18). Lifestyle changes in
Pohnpei refer to the increasing shift from
activities related to traditional methods of
food crop production, food gathering and
fishing, walking and canoe paddling, and
manual household activities related to tradi-tional
food preparation and other activities
such as clothes washing, towards the adop-tion
of modern lifestyles such as salaried
office work, shopping for foods and use of
motorized vehicles and mechanized house-hold
equipment, such as washing machines.
Whereas immediately after World War II
there was almost a complete absence of obes-ity
and diabetes in Pohnpei (12), approxi-mately
one-third of Pohnpei adult women
are now overweight in every age group
(19,20) and 32.8% of Pohnpei adults now have
diabetes (21).
In 2007, a report based on World Health
Organization (WHO) data showed that of 194
1 A kilogram of local food can easily be proportioned
throughout the day, two cups (each about 250 g) at
midday and two cups in the evening.

226 L. Englberger et al.
nations, FSM was listed second in the world
for problems of overweight and obesity. Based
on body mass index (BMI)2 greater than
25 kg/m2, about 91% of the nation was over-weight,
closely following Nauru, another
Micronesian nation. Of the ten nations listed
as being the most overweight, eight were
from the Pacific Islands region (22).
The overweight problem in the Pacific
may partly be due to a genetic predisposition
towards overweight3 as well as a cultural
preference towards being heavy (23). Data
indicate that, in recent years, there has been a
clear increase in weight among Pohnpeians
(21). However, there are difficulties in using
BMI as a health risk indicator, as BMI does
not distinguish between weight associated
with muscle and weight associated with fat
(18,24). Nevertheless, problems of non-com-municable
diseases (e.g. diabetes, cancer and
heart disease) have clearly increased (25).
The traditional food system
Pohnpei has a striking diversity of plants and
food crops, including over 130 breadfruit, 170
yam and 50 banana varieties (26–29). In addi-tion,
there are over 40 giant swamp taro4 and
20 pandanus fruit5 varieties, numerous varie-ties
of cassava, sweet potato, coconut and
2 BMI is an indicator calculated as weight in kilo-grams
divided by the square of height in metres.
3 This may also be expressed as a metabolic efficiency
for saving caloric energy (Thrifty Gene Theory),
referring to the concept that a ‘thrifty’ metabolism
developed among hunter-gatherers facing periods
of famine and which enabled them to survive by a
greater ability to store excess fat.
4 Giant swamp taro (Cyrtosperma merkusii) is dis-tinctive
from common taro (Colocasia esculenta)
and other taro types in that it is a large plant, grow-ing
to over 6 m high, with huge arrow-shaped
leaves pointing upwards; the corm, which is the
edible part of the plant, often weighs 1–5 kg, and
larger ones more than 25 kg.
5 Pandanus (Pandanus tectorius) is a fruit that is par-ticularly
important on atoll countries in the Pacific.
The individual pieces making up this multiple fruit
may be sucked and chewed for the sweet pulp, or
the fruit may be cooked and the pulp extracted for
making a number of traditional recipes.
many fruits and vegetables. Pohnpei has a
wealth of seafood, with over a thousand kinds
of edible fish (30). Despite the shift towards
imported foods, a dietary study in 2004
showed that many people still largely depend
on these locally grown food crops and sea-food
(31).
There is much concern about the loss of
traditional knowledge due to many factors,
including changing lifestyles and changing
values (27,32). The shift in the diet is part of
the change in lifestyle. Imported processed
foods are convenient, easily available, afford-able,
and are well liked for their taste and the
prestige associated with consuming pur-chased
foods. Other reasons for the shift to
imported foods include changes in family
structure and shift to the cash economy (11).
The US food aid and school lunch pro-grammes
initiated in the 1960s and 1970s,
including US Department of Agriculture
(USDA) surplus commodities, have been crit-icized
as a major reason for the rapid changes
in the diet (11,19,33–36). Some food-related
programmes have been criticized for spread-ing
US-oriented and culturally inappropriate
messages, often promoting US-type foods
and food guides, undermining efforts to pro-mote
local foods (35).
Programmes were carried out to attempt
to counter the shift towards imported foods,
including the regional Family Food Production
and Nutrition (FFPN) Programme6 (37) and
efforts associated with the World Food Day,
supported by the Food and Agricultural
Organization of the United Nations (FAO)
and the United Nations Children’s Fund
(UNICEF), but the effect of these programmes
was small in comparison with other forces
affecting Pohnpei.
In 1998, a programme for providing vita-min
A supplements to Pohnpei children from
1 to 12 years of age was initiated by the FSM
Government with assistance from UNICEF
Pacific (38). Animal-based foods advised else-where
for their rich vitamin A content, such
as milk, egg and liver (39–41), are not com-mon
foods of the traditional diet and not easy
6 The FFPN programme was started in FSM in 1988,
focusing on promotion of local food, gardening
and breastfeeding.

and few had been analysed for any nutrient.
Through key informant interviews, Karat, an
Fe’i banana with deep yellow-orange flesh,
was described as the traditional infant food of
Pohnpei (Fig. 13.1).
Karat was rare and not commonly avail-able
in 1997, despite reports that it was once a
commonly consumed banana.7 A sample of
ripe Karat was obtained and arrangements
made for sending off-island to a laboratory
for carotenoid analysis. The results showed
that ripe Karat is a very good source of
b-carotene (47). A sample of an unidentified
Yap giant swamp taro variety was also
7 Karat is more difficult to grow than other banana
varieties and is somewhat sensitive to sunlight,
growing better in shady rainy areas rather than in
open sunny areas. Also young suckers are vulner-able
to roaming pigs. For these reasons, along with
lack of awareness about the health benefits from
consuming Karat, farmers started turning to the cul-tivation
of newly introduced banana varieties that
were easier to grow.
or cheap to obtain. Yellow- and orange-fleshed
fruits such as ripe mango and papaya,
and vegetables including carrots and green
leafy vegetables, contain provitamin A carote-noids
– b-carotene being the most important –
which are converted in the body to vitamin A
(41). However, a literature review and key
informants clearly revealed that green leafy
vegetables are not well liked and were not
commonly eaten in the past in Pohnpei
(11,35,37). Mango and papaya were intro-duced
to the island after 1826 (29,42) and still
are not major foods, and carrots do not grow
in the hot Pohnpei climate. Thus, these foods
could not have been among those that pro-tected
people against VAD in the past.
The foods on which Pohnpeians rely
most are banana, breadfruit and giant swamp
taro (3,11,28,31). Data available in 1998 pro-vided
no indication that there may be varietal
differences in carotenoid content among these
foods or that some varieties may be caroten-oid-
rich (43–46). None of the local Pohnpei
varieties had been analysed for carotenoids
Fig. 13.1. Karat is a traditional banana variety of Pohnpei, known as an infant food. It has a striking deep
yellow/orange flesh. This photograph presents a postal stamp series focused on Karat banana, produced
in 2005 as a collaborative project by the Federated States of Micronesia Philatelic Bureau and Island Food
Community of Pohnpei. (Photograph by Lois Englberger.)

8 These fans were provided by Sight and Life,
a humanitarian initiative of DSM Nutritional
Products, based in Switzerland. The fans were
developed for assessing the colour of egg yolk, but
also were found useful for assessing banana flesh
coloration.
9 The analyses were conducted at laboratories in
Suva, Fiji; Basel, Switzerland; Honolulu, Hawaii,
USA; San Francisco, California, USA; Madison,
Wisconsin, USA; and Adelaide, Australia.
analysed for carotenoid content and found to
be carotenoid-rich. These findings led to
research interest in Pohnpei about the nutri-tional
potential of local foods, which led to
the study of Karat and systematic study of
other Pohnpei foods and varieties (48).
Thus, the purposes of the project described
in this chapter were to: (i) assess the composi-tion
of local foods and varieties, with a focus
on carotenoid content; and (ii) promote the
production, availability and consumption of
local foods and varieties that are rich in carote-noids,
using a range of methods (education/
communication, horticulture, appropriate
technology, conservation, food processing),
thereby improving health and well-being to
alleviate micronutrient deficiency and other
nutrition-related diseases.
Methods
The project period lasted 10 years, from
December 1997 to December 2007. The inter-agency
project team included members of spe-cific
research teams as well as other individuals
who assisted in the project implementation,
including from agriculture, education and
health agencies, non-governmental organiza-tions
(NGOs), the business sector and commu-nities.
The lead and second author of this
chapter were involved throughout the project.
An ethnographic multiple-methodology
approach, including literature review, key
informant interviews, informal focus group
discussions, photography and participant
observation, was used to document the tradi-tional
food system (49–51).
In order to achieve behavioural change
and increase production and consumption of
local foods, educational and communicative
methods (including mass media as well as
inter-personal methods) were used. These
methods focused on inter-agency commu-nity-
based collaboration and advocacy work,
participatory activities and social marketing
approaches found successful elsewhere (52).
The formation of an NGO, the Island Food
Community of Pohnpei (IFCP), to assist with
coordination of activities for this project was
a major step.
Food collection and analysis
Previous papers describe the work in collect-ing
and preparing the samples of food for
analysis, sample transport and the analytical
methods (53–60).
As carotenoids are characterized by
yellow and orange flesh colouration, efforts
were made to identify those foods and
varieties with yellow or orange flesh.
Ethnographic studies were used to learn
about local foods, which varieties of the
staple foods have yellow flesh, and which
are more acceptable for production and
consumption that might make them suita-ble
for promotion.
As some varieties were rare and diffi-cult
to obtain and variety lists incomplete,
with inadequate flesh colour descriptions,
much time was spent constructing lists of
varieties and describing the varieties prior
to collecting and preparing the samples.
A systematic approach was followed for
photographing the foods, in order to present
the flesh colour and other characteristics.
The DSM Yolk Color fan,8 with its 15 seg-ments
of increasing yellow and orange col-ouration,
was used to provide a standard
assessment of flesh colour (61).
As there are no analytical laboratories in
Pohnpei or FSM, samples were collected,
prepared, frozen and stored in home freez-ers,
and transported to the laboratories. This
presented great challenges due to the need
for keeping the samples frozen throughout
the transport process of indirect flights, long
transit periods and quarantine requirements.
State-of-the-art analytical methods, includ-ing
high-performance liquid chromato-graphy
for carotenoids, were used for the
analyses.9

Dietary and health assessments
Although no population-based dietary sur-vey
was conducted in Pohnpei in this period,
several dietary assessments were conducted,
providing information on dietary intake.
Three assessments were carried out using
modified versions of a 7-day food-frequency
questionnaire, which had previously been
developed for FSM (31,62,63). One of these
was carried out in municipalities throughout
Pohnpei and two focused on one community
as part of its involvement as a case study in a
global health project (see following section).
In addition, a quantitative assessment of the
diet in the case study community was carried
out in 2005, and repeated in 2007 for evaluat-ing
the impact of the campaign for consum-ing
local foods. These assessments were
structured to provide information on the reli-ance
on imported versus local foods.
IFCP carried out health assessments in
the case study community, both at the begin-ning
of the project and at its end. A WHO-supported
STEPS10 survey conducted in 2002
provided a wealth of information on levels of
overweight and chronic diseases.
Results
Identifying and promoting local sources
rich in micronutrients
The assessment of local foods with potential
for alleviating VAD began in 1997. Many
Pohnpei banana varieties were analysed and
in 1998 the banana variety Karat was found
to be a rich source of provitamin A caroten-oids.
A campaign promoting Karat was car-ried
out in 1999 involving workshops, radio
and newspaper releases, and the distribution
of planting materials (64,65). This generated
much interest, as indicated by interviews
and market changes (66). Although Karat
had not been previously sold, it started
appearing in the markets in early 2000, about
a year after the campaign started, reflecting
10 STEPS is a WHO research process tool for non-communicable
disease risk factor surveillance.
the amount of time needed for a banana
plant to bear fruit. In 2006, the volume of
Karat marketed was almost 500 kg in a two-month
period (66).
Establishment of the Island Food
Community of Pohnpei
Concern about the trend towards imported
foods and increasing health problems led to
the formation of an inter-agency NGO, the
IFCP, to address the nutrition dilemma
(67,68). Participants at a foundation meeting
held on 16 October 2003, World Food Day,
indicated strong support for the formation of
this NGO. World Food Day is celebrated each
year on 16 October, the day on which the
FAO was founded in 1945. It is an event care-fully
followed in FSM, as well as many coun-tries
throughout the Pacific Islands. The
meeting was established to focus on local
food research and promotion, and to serve as
a unifying body among the various organiza-tions
working in these areas (i.e. on activities
and initiatives to promote micronutrient-rich
local foods).
The IFCP vision is to live on a productive,
environmentally sound island where a diver-sity
of local island food is produced and con-sumed,
providing food security, sustainable
development, economic benefits, self- reliance,
improved health, cultural preservation and
human dignity. The nine Board Members of
IFCP were selected to represent a wide range
of backgrounds, including health, nutrition,
agriculture, education, cultural/historic pres-ervation,
local business, gender balance and
community representation. Membership is
open to all who would like to help promote
island foods and there is an active e-mail dis-cussion
group.
Strategic planning
A strategic planning session was held by IFCP
members in April 2004 to plan how
the production and consumption of local foods
might best be increased (69). A SWOT (strengths,
weaknesses, opportunities and threats) analysis

showed some of the difficulties that are faced
in promoting local foods: imported foods are
convenient and well liked; few resources are
available for project implementation; there
are negative attitudes about growing foods
and agriculture; many people have a lack of
awareness about the values of local foods and
lack of understanding about the relationship
between diet and health. On the other hand,
Pohnpei has tasty local foods, compelling
research findings of their rich nutrient con-tent,
great agricultural resources, committed
people who would like to promote local food,
and the beginnings of community interest.
One participant commented: ‘There is a
big difference these days in our promotion of
local food, and that is because it is based on
information of analyses of our own foods’.
This participant pointed out that these data
are essential in promoting local food and that
information based on actual Pohnpei varie-ties
is more convincing than general informa-tion
from food composition tables or
information from other parts of the Pacific.
In order to best promote local foods,
research includes different areas: food analy-sis,
dietary/health assessments, and docu-mentation
of Pohnpei’s food varieties and
primary characteristics. Follow-up planning
sessions in 2006 and 2007 advised a continu-ation
of the focus on these four activity areas
(70). This strategic planning process pro-vided
an important framework to the overall
local food promotion and research work in
Pohnpei.
Micronutrient content of
Micronesian local foods
Of Pohnpei foods alone, 21 banana, 24 giant
swamp taro, seven breadfruit and 11 panda-nus
varieties were assessed for carotenoids11
(Table 13.1).
11 This included b-carotene, a-carotene and
b-cryptoxanthin (provitamin A carotenoids) and
lutein, zeaxanthin and lycopene, which are
carotenoids that add to total carotenoid and anti-oxidant
activity.
In addition, six banana, 21 giant swamp
taro, seven breadfruit and 22 pandanus
varieties from other Micronesian states and
countries (including the Marshall Islands,
Kiribati and Palau) were analysed for
carotenoid content. These assessments have
provided further understanding of the
nutritional value of Micronesian foods
(53–60,71–73). The analyses included differ-ent
varieties, different methods of prepara-tion
(raw versus boiled, baked, steamed or
dried) and maturity (half-ripe versus fully
ripe). Sixty-four banana, 83 giant swamp
taro, 28 breadfruit and 51 pandanus sam-ples
were analysed for carotenoid content.
From the analysis, many varieties were
identified as carotenoid-rich, including 15
Pohnpei banana varieties, one breadfruit
variety (the seeded variety Mei Kole) (55,58)
and most of the giant swamp taro and
pandanus varieties.
Karat, and to a lesser extent Utin Iap, an
Fe’i banana with upright bunches, cause the
urine to turn bright yellow after they are con-sumed.
Riboflavin (vitamin B2) is rapidly
excreted in the urine and is known to have
this effect. Thus, Karat and other bananas were
assessed for riboflavin content. Karat was
found to contain rich concentrations of ribo-flavin.
Utin Iap had medium levels and other
Pohnpei bananas contained concentrations
similar to those in common bananas12 (57).
Pohnpei foods, focusing mainly on
banana and giant swamp taro, were analysed
for eight essential vitamins (vitamin A, ribo-flavin,
thiamin, niacin, vitamin B6, folate,
vitamin C13 and a-tocopherol) and 16 essen-tial
minerals, including zinc, iron and cal-cium.
In total, 21 vitamin analyses and 137
mineral analyses were conducted. In the case
of vitamin A, which is found in animal prod-ucts
only, the analyses were of three types of
12 Common banana refers to Cavendish, which is
the variety most widely marketed throughout the
world.
13 Vitamin C is very labile and there is great difficulty
in getting samples from Micronesian to the distant
laboratories without destruction of the vitamin C
content of the samples. Thus, meaningful work
on assessing Pohnpei foods for vitamin C content
could not be done.

Table 13.1. Summary of Pohnpei foods analysed from 1997 to 2007 by substance analysed.
Foods/cultivars analyseda,b Maturity, processing Substance analysedc.d Reference
Banana
Akadahn ripe, raw, steamed A, D, F 54, 55
Akadahn Weitahta ripe, raw B, G, H 57
Daiwang ripe, raw, boiled A, D, F, K 54, 55
Dukerehda ripe, boiled A, B, C, D, E, F 57
Iemwahn ripe, boiled A, D, F 57
Inahsio ripe, raw A, D, F, J 53, 54
Ihpali ripe, boiled A, D, F 54, 55
Karat ripe, raw, steamed A, C, D, F, G, H, I, J, K 47, 53, 54, 55, 57
Karat en Iap ripe, boiled A, B, C, D, E, F 57
Kudud/Utin Rais ripe, boiled A, F 57
Kundina ripe, boiled A, C, D, E, F 57
Mangat ripe, raw A, J 53
Mangat en Seipahn ripe, boiled A, D, F 57
Peleu ripe, boiled A, C, D, E, F 57
Preisihl ripe, boiled A 57
Utin Kerenis ripe, raw A 55
Utin Ruk ripe, raw, boiled A, D, F, J 53, 54, 55
Utin Iap ripe, raw, baked A, D, F, G, H 54, 55, 57
Utin Menihle ripe, raw, boiled B, G, H 57
Utiak ripe, boiled A, D, F 57
Utimwas ripe, boiled A, D, F 57
Utin Pihsi ripe, boiled A, D, F 57
Breadfruit
Mei Kole ripe, raw, boiled, with/
without skin
A, D, F 54, 55
Meiniwe ripe, boiled A, D, F 54
Meisaip ripe, raw A, D, F 54, 55
Meitoal mature and ripe, raw
and boiled
A, D, F 54, 55
Mei Kalik ripe, boiled A, D, F 54, 55
Mei Uhpw ripe, boiled A, D, F 54, 55
Mahr product fermented (mahr)
dough, raw
A 55
Paku kura product sun-dried baked paste A, C, D, F 58
Giant swamp taro
Anetchimo raw and boiled A, D, F 54, 59
Fanal raw and boiled A, D, F, K 54, 55
Jikohki boiled A, C, D, E, F 59
Lahsekir boiled A, C, D, F, K, L 59
Mwahngin Eir boiled A, C, D, F 59
Mwahng Kisilap boiled A, C, D, F 59
Mwahng Medel raw and boiled A, D, F, K 54, 55
Mwahngin Meir boiled A, C, D, F, K, L 59
Mwahngin Palau boiled A, C, D, F, K, L 59
Mwahng Pwiliet boiled A, C, D, F, K, L 59
Mwahng Tekatek
boiled A, C, D, F, K, L 59
Weitahta
Mwahngin Wel boiled A, C, D, F, K, L 59
Mwashei raw and boiled A, D, F, K 54, 55
Nihn Jaimon boiled A, C, D, E, F 59
Nihn Jehm boiled A, C, D, E, F 59
Continued

Foods/cultivars analyseda,b Maturity, processing Substance analysedc.d Reference
Nihn Peres boiled A, C, D, E, F 59
Pahmot boiled A, C, D, F 59
Ponon raw and boiled A, D, F 54
Simihden raw and boiled A, D, F, K 54
Six-moon raw and boiled A, D, F 54
Six-moon red boiled A, C, D, E, F 59
Six-moon white boiled A, C, D, E, F 59
Wahrau boiled A, C, D, E, F 59
Wiklale boiled A, C, D, E, F 59
Pandanus
Unspecified cultivar ripe, raw A, D, F, J 53, 54
Juaipwehpw ripe, raw A, C, D, E, F 71
Luarmwe ripe, raw A, C, D, E, F 71
Binu-Dolongahai ripe, raw A, C, D, E, F 71
Nehnkedak ripe, raw A, C, D, E, F 71
Kipar en Majal ripe, raw A, C, D, E, F 71
Mwajak ripe, raw A, C, D, E, F 71
Jorum ripe, raw A, C, D, E, F 71
Mehkilkil ripe, raw A, C, D, E, F 71
Doapwoadin ripe, raw A, C, D, E, F 71
Binu-Dalinga ripe, raw A, C, D, E, F 71
Enkehlen ripe, raw A, C, D, E, F 71
Fruits
False durian partially ripe, boiled A, D, F 54, 55
Noni fruit partially ripe, raw A, J 53
Garlic pear ripe, raw A, C, D, E, F 71
Greens
Chaya raw A, J 53
Bird’s nest fern – tehnlik boiled A, D, F 54
Pele raw A, J 53
Seafood
Fish liver, yellow-fin tuna boiled M, N 48
Fish liver, skipjack tuna boiled M, N 48
Fish liver, parrot fish boiled M, N 48
Fish egg, skipjack tuna boiled M 48
Fish heart, skipjack tuna boiled M 48
aNames of the local cultivars are presented. Scientific names are: banana = Musa spp.; breadfruit = Artocarpus altilis,
Artocarpus mariannensis; giant swamp taro = Cyrtosperma merkusii; pandanus = Pandanus tectorius; noni = Morinda
citrifolia; false durian = Pangium edule; garlic pear = Crataeva speciosa; chaya = Cnidoscolus chayamansa; pele =
Hibiscus manihot; bird’s nest fern = Asplenium nidus; yellow-fin tuna = Thunus albacores; skipjack tuna = Katsuwonus
pelamis; parrot fish = Scarus nuchipunctatus.
bSome cultivars are known in other parts of the Federated States of Micronesia by further names: Utin Menihle = Usr
Kulasr, Inahsio = Usr Apat Poel, Utin Ruk = Usr Apat Fusus. Some giant swamp taro cultivars (Anetchimo, Fanal,
Mwashei, Ponon) were brought recently from Chuuk to Pohnpei and retained their Chuukese names.
cSubstance analysed: A = b- and a-carotene; B = b-carotene; C = b-cryptoxanthin; D = lutein, zeaxanthin;
E= lycopene; F = water; G = riboflavin; H = folate; I = thiamin, niacin, pyridoxines, ascorbic acid, a-tocopherol;
J = kilojoules, protein, fat, carbohydrate, fibre, calcium, phosphorus, iron, sodium, potassium, magnesium,
manganese, zinc, copper, ascorbic acid, b- and a-carotene; K = iron, zinc, calcium, magnesium, phosphorus,
manganese, copper, sodium, potassium; L = aluminium, boron, cadmium, cobalt, molybdenum, nickel, sulfur;
M = retinol; N = mercury.
db- and a-Carotene, b- and a-cryptoxanthin are provitamin A carotenoids, whereas lutein, zeaxanthin and
lycopene are carotenoids with no vitamin A activity. Common names for the vitamins are: retinol = vitamin A,
thiamin = vitamin B1, riboflavin = vitamin B2, pyridoxines = vitamin B6, ascorbic acid = vitamin C, a-tocopherol =
vitamin E.

fish liver and one type of fish egg and fish
heart, for which there was no previous infor-mation
available. Liver from all three fish
species were rich sources of vitamin A, but
showed great differences in concentrations.
The giant swamp taro varieties were rich in
essential minerals, in particular iron, calcium
and zinc.
The ‘Yellow Varieties Message’
A basic concept relayed throughout IFCP’s
awareness programme has been the ‘Yellow
Varieties Message’ or ‘Go Yellow’. Photographs
show light-fleshed varieties pictured alongside
deep yellow-fleshed varieties, along with their
b-carotene content and health benefits listed.
This visual way of communicating scientific
food composition data is a simple but effective
way of showing that the deep yellow- or
orange-fleshed banana varieties have greater
levels of carotenoids and health benefits.
Community people showed interest in these
initial photographs, as shown by observation,
key informant interviews and other qualita-tive
assessment methods. People spent time at
the post office and local markets studying the
posters displayed there and groups started
asking for training on the posters.
Posters, booklets, T-shirts and banners
were developed to present the ‘Go Yellow’
message, focusing first on bananas (74,75),
but later covering giant swamp taro, bread-fruit
and pandanus (76,77). Posters pointed
out that, although white (or light)-fleshed
varieties contain less carotenoids than yellow-or
orange-fleshed ones, all these local foods
still contain some carotenoids (43).
This message caught the attention of
many people, as shown by the results of struc-tured
questionnaires evaluating the posters
(62,63). When this message is shared, the
group usually shows a noticeable ‘waking
up’ and many start making comments, as
they realize the value of their own foods
which have been so greatly neglected. When
the opportunity permits, information is
shared about other rich micronutrient content
and health benefits of fresh local food, such as
vitamin C and fibre.
Behavioural change relating to banana
marketing
Another IFCP activity focused on raising the
low status of certain banana varieties. This
includes Daiwang, which has been known as
the banana for ‘feeding the pigs’. This attitude
was said to have developed because Pohnpei
farmers look down on crops that are easy to
grow, and this banana is considered as the
easiest of any to grow, hardly requiring weed-ing
or other care. Not a single market in
Pohnpei was selling Daiwang in 2003. Yet
Daiwang is sweet and tasty and is often con-sidered
as the best variety for making the tra-ditional
Pohnpei baked recipe, pihlolo (77).
Daiwang is rich in b-carotene and is one of the
varieties highlighted in the Pohnpei Bananas
poster and other IFCP promotional materials.
As Pohnpeians learned about the health ben-efits
of Daiwang, attitudes started changing.
The Governor of Pohnpei at this time gave
full support to promoting this variety and
posed for a photograph as he ate the banana.
This was included in an article for the local
newspaper (78).
A banana market study in 2006 showed
that over an eight-week period, Daiwang
was sold by four out of 14 markets (79).
Approximately 170 kg of Daiwang banana
were purchased, compared with none mar-keted
previously. This indicates a great shift
in attitudes about this variety. There was an
even greater change in market behaviour
relating to Karat. In 1999, Karat was not sold in
the market, whereas in the 2006 banana mar-ket
study, eight of 14 markets sold Karat. The
markets reported that they had purchased a
total of 450 kg of Karat for marketing and that
they could not always meet the demand for
this banana, which is valued as an infant food.
Utin Iap, another traditional banana variety
with an even higher carotenoid content than
Karat, is also now regularly marketed.
Carotenoid-rich foods
for alleviating chronic disease
Studies have indicated that consumption of
carotenoid-rich foods may help to prevent

cancer, diabetes and heart disease (80–83).
A Pacific Island study has shown that eating
local foods can help to maintain and even
lose weight (84). Public health officers in
Pohnpei reported that people are concerned
about these chronic diseases, asking about
what to eat to avoid contracting them, due
to the urgency of the ‘obesity epidemic’ in
Pohnpei and FSM (85). They do not ask
about what to eat to avoid micronutrient
deficiency. Thus, the promotion of caroten-oid-
rich food for its potential health benefits
for alleviating chronic disease was inte-grated
into the ‘Yellow Varieties Message’
along with the health benefits of carotenoid-rich
foods for alleviating VAD and other
micronutrient deficiency disorders. This
approach has the potential of attracting more
attention to the local food campaign than
focusing only on the prevention of micronu-trient
deficiency.
‘CHEEF’ benefits of local food
Those promoting local food were encouraged
to remind the public of the many benefits of
local foods in addition to health, and to use an
acronym ‘CHEEF’ for helping to remember
these benefits: ‘C’ for Culture, ‘H’ for Health, ‘E’
for Economics and savings, ‘E’ for Environment
and ‘F’ for Food security.
Food security and ensuring local food
availability are critical for survival on islands
in the event of global economy and ship trans-port
disturbances. Local foods are fresh, with
greater assurance that nutrients have not been
lost, and local island food has been shown to
be health-promoting, rich in micronutrients
and fibre. Savings can be made by consuming
food crops that are already available, such as
breadfruit, and income could be earned by
selling home-grown food crops and small-scale
processed local food. Imported food
involves transport, either by sea or air, which
adds emissions to the environment and con-tributes
to global warming, a serious risk for
small islands. Conservation and use of local
food preserves traditional customs and
culture and helps ensure that traditional
knowledge is not lost.
Therefore, by teaching about ‘CHEEF’,
the ‘Go Yellow (Varieties) Message’ was
broadened to more effectively present the
wide-ranging values of local food. People
often related to one of these other benefits, in
particular culture, more than to health. The
use of the ‘CHEEF’ acronym has been taken
up, translated into the local language and
used by community, government and even
youth leaders, evidence that this way of
describing the benefits of local food is
effective.
A further expansion of the ‘Yellow
Varieties Message’ has been about ‘happiness’
and the mood-enhancing properties of the
banana. Early in the programme, it was
noticed that many people, particularly youths,
are not interested in talking about health. On
the other hand, ‘happiness’ appears to be of
universal interest. The question ‘Do you want
to be happy?’ was asked in order to catch
attention, and then information shared
(including handouts) on the rich tryptophan
content in banana and how this is converted
in the body to the mood-enhancing substance
of serotonin, which gives a happy feeling
(86,87). A competition was held to spread the
message, capturing the interest of many
Pohnpeians. Key informants reported that
they were eating more bananas because of
this message and also that they were telling
their friends about it and passing on the mes-sage,
due to their interest in it. In addition to
booklets and posters, the ‘Yellow Varieties
Message’ was communicated through a range
of other materials: newsletters, calendars,
pens, T-shirts, postcards and car bumper
stickers (88–92), as well as PowerPoint pres-entations
conducted in communities.
Farmers’ fairs and an agriculture approach
for promoting health and biodiversity
A unique way of bringing the ‘Yellow Varieties
Message’ to farmers in Pohnpei has been
through the Farmers’ Fair/World Food Day
event in Kolonia, Pohnpei, the first held in
2004 with the theme ‘Grow and Eat Yellow
Varieties for Health and Wealth’ (93)
(Fig. 13.2). From 500 to 1000 people attended

Fig. 13.2. The Pohnpei Farmers’ Fair is an event celebrated as part of the annual World Food Day
celebration. (Photograph by Luciano Mathias.)
each year, with over 100 crops exhibited.
Seventeen varieties of bananas were exhibited
each year.
This event is based on collaboration
between Pohnpei Agriculture of the Office of
Economic Affairs, College of Micronesia–FSM
Cooperative Extension Services (CES), IFCP
and other agencies, along with the participa-tion
of farmers and communities. Greater
monetary prizes were awarded for yellow-and
orange-fleshed bananas, in comparison
to other varieties, in order to focus on their
important health benefits. Healthy cooking
competitions and essay and art competitions
in schools contributed much interest to this
event. Since 2004, the Farmers’ Fair/World
Food Day celebrations (94–96) and municipal
fairs have been annual events. In addition to
the health awareness focus, another aim has
been to promote rare varieties and island bio-diversity.
During the fairs some of the rarest
Pohnpei bananas were exhibited.
The proclamation of Karat as the State
Banana of Pohnpei has been a powerful
method for increasing awareness of the value
of this banana (97). Copies of this proclama-tion
were framed and widely distributed
throughout Pohnpei for hanging in offices
and public places, and mention of Karat as the
State Banana was included in press releases
and local food promotion activities. As shown
in the 2006 banana market study, there were
almost 500 kg of Karat sold in an eight-week
period, whereas Karat was not sold at all in
the markets in 1999, showing the impact of
this campaign (79).
The ‘Let’s Go Local’ message
A slogan that has caught wide attention and
interest in Pohnpei, and throughout the
Pacific, and seems to have a uniting effect, is
‘Let’s Go Local’ (98,99). This term was first
coined in Pohnpei in the 1980s, catching
widespread attention. In 2006, IFCP members
suggested using the term on a colourful bill-board
to promote local food. Two signs were
placed in Kolonia, the main town of Pohnpei
(Fig. 13.3) and a third was placed in Mand
community, as part of the project on
Traditional Food for Health (see later section
on this). The design included a symbolic
drawing of a father teaching his son to plant
local food, with a mother, as supporting
figure, along with eye-catching drawings of

Fig. 13.3. The ‘Go Local’ billboard presented a colourful design with local foods and aimed at increasing
production and consumption of local foods. (Photograph by Lois Englberger, billboard design by Wehns
Billen.)
selected local foods, including pandanus,
Karat, breadfruit and others.
The ‘Let’s Go Local’ slogan was incorpo-rated
in the theme song written for the ‘Going
Yellow’ video (see next section), and was
broadcast on local radio, becoming popular
among youth. The ‘Let’s Go Local’ slogan
was also placed on IFCP’s promotional
T-shirt.
In August 2006, a group of 15 high school
students formed the ‘Let’s Go Local Club’ as a
result of the interest developed through a class
taught by IFCP staff on local foods and health.
The students decided to carry out community
services by distributing the Pohnpei Bananas
posters and teaching about the value of local
foods. Later, the students recruited others,
reaching around 30 core members, including
students from two high schools. Activities
included performances at World Food Day
2006, at a US Embassy Pot Luck Dinner for
promoting local food, and at the 2007 Pohnpei
Cultural Day events. In 2007, the members
taught a programme to elementary school
students at two schools in Kolonia, again
sharing the ‘Yellow Varieties Message’ and
values of local foods (100). This is a new pro-gramme
and there are few data to demonstrate
that high school students are now eating more
local food. However, students are voicing their
interest in local foods and have asked for fresh
ripe bananas and other local foods to be pro-vided
in the school lunch.
Catching attention through film
Karat and the ‘Yellow Varieties Message’ and
‘Let’s Go Local’ slogans have become known
throughout Pohnpei and the Pacific through
the video entitled ‘Going Yellow’ (101)
(Fig. 13.4).
This locally produced 18-minute video
was filmed by Micronesian Seminar14 along
14 Micronesian Seminar (www.micsem.org) is a
research and development organization based in
Pohnpei, but serves the entire Micronesian region.

Fig. 13.4. ‘Going Yellow’ was another campaign slogan referring to the yellow-fleshed varieties of local
food and their health benefits. The Island Food Community of Pohnpei’s local food DVD was given this
name and referred to how the family in the DVD drama shifted to eating yellow-fleshed foods.
(Photograph from Micronesian Seminar.)
with collaboration with IFCP on the script
with financial support from Sight and Life.
The story opens with the dramatic television
news story on the problem of VAD in
Micronesia, leading to a humorous drama,
involving a family used to eating rice, ramen,
turkey tail15 and other imported foods, and
how a visit from a stranger named Bubba
helps the family to see how valuable and
important their local foods are. The actors
and actresses include Pohnpei youth, such as
a young woman who plays the role of a
beauty queen, proclaiming Karat and taro as
her beauty secrets. The film was shown on
local television, up to five times daily when it
was first completed in October 2005. Due to
its popularity, it has continued to be shown
on television up to the time of writing this
chapter. The film is also available at local
video shops, where it can be rented out for
US$1 (102). One Pohnpei video shop owner,
15 Turkey tail, an imported food, is literally the tail
of turkey. It is a popular food in Pohnpei and
considered delicious.
who made ten copies of the video, said in
December 2007: ‘Young and old people like it.
We still are renting it out up to this time’.
Although there are no data to show that this
film directly caused an increase in local food
consumption, key informants maintain that
the film was a contributing factor to the grow-ing
interest in the Pohnpei local food promo-tion
programme and greater availability of
prepared foods ready for consumption. For
example, one business and community leader
said, ‘I can see an impact from your pro-gramme’.
He started sending e-mail com-ments
to the IFCP Go Local Email network
and invited IFCP to give the guest speaker
presentation at one of their large community
celebrations.
The ‘yellow varieties’ and ‘go local’
theme was further strengthened by a short
film of four ‘Let’s Go Local Club’ members, as
they explain the Pohnpei Bananas posters,
yellow-fleshed and carotenoid-rich bananas,
and the ‘CHEEF’ benefits of local foods. The
actors wear their ‘Let’s Go Local’ theme
T-shirts and encourage people to ‘go local’ for
the importance of honouring their forefathers

and ensuring the future of the generations to
come. The 5-minute film was shown over 50
times on the local television programme and
many people saw it. The high school students
were greatly encouraged by the public
showing.
Regional and international organizations
have come to Pohnpei to film documentaries
on Pohnpei’s local food promotion. In
December 2006, the film production unit of
the Secretariat of the Pacific Community
(SPC), Pacific Way, based in Suva, Fiji, filmed
IFCP activities (103) and included these
in their Australian government-supported
Pacific-wide documentary focusing on plant
genetic resources and health. The title of their
film, ‘Let’s Go Local: Looking after Plant
Diversity and our Health’ shows how popu-lar
Pohnpei’s ‘Let’s Go Local’ slogan has
become. This film attracted great interest as it
was distributed at the first Pacific Food
Summit, held on 21–23 April 2010 at Port Vila,
Vanuatu.
Sight and Life filmed a documentary in
Pohnpei in 2006 to present how they have
assisted in the Pohnpei work on alleviating
micronutrient deficiency. They highlighted
the fact that Pohnpei faces the ‘double burden
of malnutrition’, problems of micronutrient
deficiency along with chronic disease (104).
The College of Micronesia–FSM produced
films of the Farmers’ Fairs/World Food Day
events and other short IFCP-coordinated
events, which have been broadcast on local
television, generating interest in local foods.
Getting the message out!
Since 2003, over 115 IFCP articles have
appeared in the local newspaper, usually
accompanied by photographs and recipes
(105). To widen distribution, articles are cop-ied
and provided free to local Pohnpei busi-nesses
and other agencies.
An e-mail exchange for sharing island
food information started in early 2006 for
IFCP members (106). Membership spread to
local food promoters throughout FSM,
Kiribati, Marshall Islands, Palau, other parts
of the Pacific and beyond, and by 2007
included over 500 members. Many people
contribute items and much interest is
expressed. Participants have explained that
they use the information as classroom mate-rial,
share it with colleagues or broadcast it on
local radio, indicating that the messages are
used multiple times. IFCP news items were
shared on other e-mail list servers, including
the Plant Genetic Resources (PGR) News
(about 500 members) and the Pacific Regional
Medical Distribution List (over 190
members).
Another way that IFCP communicates its
messages is via local government radio. Since
August 2006, 80 items (in English) were sent
to the V6AH radio announcer, who translated
them into Pohnpeian and then broadcast
three times daily in Pohnpeian and English
(107). Sometimes the messages were repeated
and transmitted over a period of two or three
days. The announcer is enthusiastic: ‘My lis-teners
like this information on local foods and
now ask for more’.
The IFCP website (www.islandfood.org),
established in June 2005, provides further
information on a range of topics, including
scientific papers and the newspaper articles
from the Kaselehlie Press Health and Nutrition
column. The increasing number of ‘hits’ indi-cates
that interest is growing. We know that
staff of the Governor’s Office and students
from the College of Micronesia–FSM have
started to use this source of information, and
the site provides information to those in far-away
places (108).
Micronesian bananas featured on
national postal stamps
One of the most innovative promotions of
Pohnpei local foods is through collaboration
with the FSM Philatelic Bureau and the devel-opment
of two national postal stamp series
highlighting Micronesian bananas (Figs 13.1
and 13.5). The first focused on Karat banana
and was a Commemorative Series coming out
for World Food Day 2005 (109), including dif-ferent
stamps in four denominations (Fig. 13.1).
The First Day of Issue Ceremony for this stamp
series was celebrated with great pomp and

Fig. 13.5. A series of Federated States of Micronesia postal stamps was produced, which promoted
yellow-fleshed banana varieties. (Photograph by Lois Englberger.)
signing of programmes (which are stamp col-lector
items). A second series in 2007 (Fig. 13.5),
with denominations ranging from 22 cents to
$4.60, focused on eight micronutrient-rich
Micronesian bananas that grow in Pohnpei (110).
Displays, presentations, workshops and
other types of promotion of local food
Displays of local foods were a powerful tool
for promoting local food. Plates of rare micro-nutrient-
rich bananas were displayed and
shared at conferences, workshops and public
events. During an Asian Tsunami relief fund-raising
event conducted by the Red Cross,
several plates of Karat were auctioned for
over US$30 per plate, simultaneously prompt-ing
lots of laughs and raising awareness (111).
IFCP provided fresh drinking coconuts and
local bananas at community ‘fun walks/runs’
in order to counter the trend to offer soft
drinks and sweet cookies at these events. The
FSM National Olympic Committee (NOC)
facilitates most of these runs, and now regu-larly
provides the opportunity for IFCP to
talk to participants about the health and other
benefits of local foods. The FSM NOC now
actively promotes water and healthy drinks
and snacks at all events, even mentioning this
change in one of their newspaper articles.
IFCP has a policy of providing only local
foods at their workshops and meetings (no
rice, sweets or soft drinks) and encourages
other organizations to do the same.
Many displays and presentations relat-ing
to the rich micronutrient content of local
foods, as well as occasional cooking lessons,
were implemented during other local events
such as Pohnpei Cultural Day, International
Women’s Day, Earth Day and Dental Day
(104–106,112,113). Involvement in a pro-gramme
supported by the United Nations
Development Project to assess national agro-biodiversity
capacity provided another
opportunity to highlight FSM micronutrient-rich
foods (114).
A ‘Banana Bingo’ game developed by
IFCP (115) became popular among children
from elementary up to high school levels.
The game includes cards presenting photo-graphs
of different Pohnpei banana varieties

(showing bunches) and is played by calling
out the Pohnpei banana variety names and
marking the cards until a winner is found.
A variation of the game is to ask the winner to
correctly name the flesh colour of the banana
varieties marked, providing even greater
potential for teaching the ‘Yellow Varieties
Message’.
Involvement in overseas conferences
offered the opportunity to present findings of
the research on micronutrient-rich foods of
Micronesia, to make arrangements for further
analyses of Micronesian foods, and to show
the Micronesian community about the inter-national
interest in their foods and local food
promotion work (47,58,116–119). Invitations
to present at six international meetings and
24 ‘Go Local’ workshops beyond Pohnpei
were honoured in 2007–2008 alone. The
events are not linked with direct data show-ing
a change in dietary intake, but they are
linked with a demonstrated increase of inter-est
in local foods. Qualitative data showed an
increase in discussions on local food linked to
these activities, and some community people
even started requesting that newspaper arti-cles
be written on certain local food topics of
interest. Such discussion of local foods is a
critical part of the process leading towards
greater local food intake.
Traditional Food for Health Project
in a global health study
In January 2005, representing the Oceania
region, the IFCP joined (as the twelfth case
study) in a global health project, conducted in
collaboration with the Centre of Indigenous
Peoples’ Nutrition and Environment (CINE),
based at McGill University in Canada (62).
The project was composed of two phases.
Phase 1 documented the traditional food sys-tem
of a selected rural community with a
population of about 500 for a 4-month period.
Baseline information on diet, health and other
information relevant to local food production,
marketing and consumption, including an
agroforestry study (120,121), was included.
Phase 2 was a two-year intervention in that
same community to promote those local foods
selected in the first phase of the project and
employing the approach selected as most
likely to being successful.
With assistance from the Pohnpei
Department of Health, Mand Community in
the municipality of Madolenihmw was selected
as the target community and a Research
Agreement was signed between CINE, IFCP
and Mand Community. Interviewers, fluent in
the local language and familiar with local cus-toms,
were trained on research methods and
procedures, including data confidentiality. The
team, working side by side with IFCP, included
community members and representatives of
three Pohnpei State Departments (Health,
Education, Land and Natural Resources),
Pohnpei Agriculture of the Office of Economic
Affairs, the College of Micronesia–FSM CES
and Peace Corps Micronesia.
This community project was a truly
rewarding experience. Many people of Mand
were sceptical at first, indicating that they did
not want to be ‘guinea pigs’ in a research
project, but after they learned about the aims
of the project, i.e. to learn about the foods that
they have and how to use them for better
health and living, they gave full support.
Workshops and ongoing follow-ups were car-ried
out, focusing on health awareness, recipe
development, energy-efficient charcoal ovens
(which provide convenience, cost-saving and
environmental benefits) and training on con-tainer
gardening.
An evaluation in 2007 at the close of the
project showed that significant impact had
been achieved (63). Results showed an
increase in the frequency of consumption of
banana and taro and an increase in the number
of banana varieties consumed. Local foods
were more frequently served and consumed
at community events, and overall awareness
and behaviour towards local food changed
positively. Data on Pohnpei food nutrient
content and photographs were organized and
put online at the CINE website (122). Further
evaluation data are under preparation.
Conservation of rare varieties
A genebank (field collection) of rare varie-ties
of Pohnpei food crops was started in

2003 at the Pohnlangas Pilot Farm as a col-laborative
project of Pohnpei Agriculture
and IFCP (123). As assessed in November
2007, this collection included 32 banana, 13
breadfruit, 14 pandanus and 69 giant swamp
taro accessions. The purpose of the genebank
project is for collection, awareness, research,
planting material propagation and evalua-tion
of these rare varieties, many of which
are micronutrient-rich.
Another important IFCP effort in con-serving
bananas was to contract a banana
taxonomy and agronomy consultant to pro-vide
international classifications of the
Pohnpei varieties and other advice on banana
development (124). The work of this consult-ant
is closely linked to improving dietary pat-terns.
The information gained has increased
understanding of Pohnpei bananas, their pest
and disease status. This, in turn, has expanded
the potential to increase the production and
the variety of marketable, longer shelf-life,
banana products.
An ongoing effort is the Youth to Youth
Project, a collaboration with the Conserva-tion
Society of Pohnpei, which provides
educational sessions to grade 6 schoolchil-dren,
raising awareness about the importance
of conserving Pohnpei’s unique banana varie-ties,
many of which are rare (125) (Fig. 13.6).
IFCP became involved in this activity in 2003,
and since first joining has carried out these
lessons in five elementary schools. In addition
to learning about the ‘Yellow Varieties
Message’ and other characteristics of the dif-ferent
varieties, practical lessons are given,
involving the students in planting bananas
and preparing interesting new banana recipes.
Development of small-scale food processing
In the past, large amounts of breadfruit were
preserved by pit fermentation. Drying foods,
such as breadfruit and fish, was a common
practice, particularly on the atoll islands.
However, along with the shift to imported
foods, there has been a neglect of traditional
food processing and few modern food preser-vation
methods have been adapted to tradi-tional
foods.
Fig. 13.6. Schoolchildren learn about Pohnpei bananas through use of the ‘Pohnpei Banana: Carotenoid-rich
Varieties’ poster. (Photograph by Lois Englberger.)

There appears to be great potential in
producing micronutrient-rich, value-added
products from local Pohnpei crops and mak-ing
better use of the local food resources.
Workshops involving overseas consultants
were held from 2004 to 2007, raising aware-ness
about local food products that can be
prepared by using simple methods of food
processing, including dried bananas, banana
and fruit nectars, and banana and taro flour
(126–129). Additional training on making
these products and further development of
food processing capacities in Pohnpei are
planned in collaboration with the College of
Micronesia–FSM CES. This effort will increase
production of these products and an overall
increase in local food use. Three different
designs of solar dryers and one design of a
charcoal dryer (for night-time or rainy period
use) were developed and built. Plans are in
place for further assessment and develop-ment
of these dryers.
Overseas students’ collaboration
and local internships
A great boost to island food initiatives in
Pohnpei has been provided through research
collaboration with students from prestigious
overseas universities, including Emory
University, University of Hawaii and McGill
University. Since 2004, five students have col-laborated
with IFCP in carrying out research
projects as a part of their graduate or under-graduate
degree programmes (31,63,78,121).
Their topics included assessments of Pohnpei
nutritional practices and beliefs, agroforestry
relating to changing dietary patterns, banana
marketing, small-scale processing of local
foods and evaluation of the Mand commu-nity
project as a part of a global health study.
These projects have provided valuable data,
such as the volume of banana marketed and
documentation of the types and volume of
processed local foods. These data can play a
significant role in the programme for promot-ing
local foods, as well as establishing net-works
for further potential collaboration in
research and programme development. For
example, the work on documenting the local
food products marketed locally provides the
first such data collected and gives baseline
figures for further evaluation of the impact of
the local food campaign.
In addition, Pohnpei students at high
school and college levels have served as
interns with IFCP, providing a boost for island
food initiatives. From 2006 to 2007, six stu-dents
have worked with IFCP through col-laboration
with the Pohnpei State Department
of Education and the College of Micronesia–
FSM internship programmes. They have
assisted in research projects, organizing and
distributing island food promotion materials
and helping in awareness events, such as the
island food display at the FSM President’s
Inauguration Ceremony in August 2007.
These students report that, as a result of their
internships, they and many of their family
members are consuming local foods as a
larger proportion of their meals.
International interest in Pohnpei’s
micronutrient-rich foods
International interest has provided a further
boost in the local food revival in Pohnpei.
The findings of rich micronutrient content of
Karat and other Pohnpei bananas were pre-sented
at the First International Congress
on Banana in 2004 held in Penang, Malaysia
(130). Articles by Bioversity International
(previously International Plant Genetic
Resources Institute) (131) and New Scientist
(132) led to press releases in newspapers and
magazines throughout the world. Catchy
titles and striking photographs of Karat and
its flesh colour were presented, along with
information on Karat’s rich b-carotene con-tent
and potential health benefits (133–137).
Karat was highlighted as one of the ‘shin-ing
stars in the traditional food galaxy’ (138)
and was included in an FAO-supported
global poster of indigenous foods offering
particular nutritional potential (139), as well
as in the newly produced Pacific Indigenous
Food Poster, where not only Karat, but also
many other yellow- and orange-fleshed
banana varieties are highlighted, along with
other major Pacific Island foods (140).

16 A 50-pound bag of Calrose rice costs US$17.95
(US$0.34 per pound (450 g) with no inedible parts).
This is therefore cheaper than yam, breadfruit and
banana at US$1.25, US$0.50 and US$0.30–0.50
per pound, which includes inedible parts.
The Eden Project, in Cornwall, England,
featured Karat and other Pohnpei bananas as
part of their permanent banana exhibit, along
with fruit from only one other banana-producing
country, Uganda. The Eden Project
(www.edenproject.com) is described as a
‘green theme park’ with living biomes, con-firmed
by the 2004 Guinness Book of Records as
the biggest conservatory in the world, and has
up to 8000 visitors daily. Its Friends magazine
featured a prominent article on Karat bananas
and Karat stamps (141). A voice recording of a
Pohnpeian telling about the importance of
bananas to Pohnpeians is part of the exhibit
(142). Pohnpeians were truly moved about
their involvement in this project (143).
Karat and a Pohnpeian man eating Karat
were featured in the travelling exhibition ‘No
End to the Banana’, produced by Bioversity
International’s banana group (87). The exhi-bition
has been shown at the Central Library
of Leuven in Belgium, the Royal Botanic
Garden of Edinburgh in Scotland, the Eden
Project in England and the National Botanic
Gardens in Ireland. At the time of writing
this chapter the exhibition was touring the
USA, where it has been displayed in the
lobby of the World Bank and the USDA
National Library in Washington, DC and a
number of other locations (87).
The Pohnpei Bananas: Carotenoid-rich
Varieties booklet has gained wide interest.
Copies are sold in Pohnpei by local businesses
and are provided free-of-charge for group
teaching. The booklet is now available at
many libraries worldwide.
An FAO press release highlighted the
importance of the nutrient-rich Micronesian
giant swamp taro varieties findings (144).
Other international publications presented
articles on the unique Micronesian foods
(145–148) and breastfeeding promotion work
in Pohnpei (149).
Discussion: Impact, Challenges
and Lessons Learned
Pohnpei faces serious difficulties and chal-lenges
in maintaining its rich heritage of a
diversity of crops and food varieties, both
within Pohnpei and overseas. Many of the
present generation have become used to eat-ing
imported foods and have developed new
habits and tastes. Schools generally have
small stores either on the school grounds or
nearby, selling primarily imported snack
foods and soft drinks, or such foods as instant
noodles (which are eaten raw), fried dough-nuts
and biscuits. Parents and relatives often
have permissive attitudes relating to eating
habits, and allow children to eat too many
sweets and fizzy drinks between meals. Most
restaurants in Kolonia serve only rice or other
imported starch foods and do not offer local
staple food as an option.
Local food is expensive, with prices as
high as US$1.25 per pound (450 g) for yam.
Families who do not have land in Pohnpei
generally feel they cannot afford to buy local
food, as the corresponding cost of rice is much
lower.16 Relatively few resources are allocated
to the promotion of Pohnpei agriculture and
local foods, despite agreement that health
and nutrition are critical issues. There is a
challenge in identifying the many varieties of
staple crops, in particular giant swamp taro.
There are challenges to collecting samples for
analysis from remote areas and then trans-porting
samples to distant laboratories.
Further challenges exist in developing exper-tise
in small-scale processing and expanding
such processing of local foods to increase
their availability.
There are other obstacles to the promo-tion
of local foods in Pohnpei. Overall educa-tion
levels are low and there is a poor
understanding of the relationship between
diet and health. Another problem is that many
overseas people and advisors have a poor
understanding of the Pohnpei staple foods,
often considering them ‘just starch’.
The Pacific Island Food Composition Tables,
which are the basis of food composition data
for the region, were revised in 2004 (150), but
unfortunately the findings on the rich micro-nutrient
content of Micronesian banana, giant

swamp taro, breadfruit and pandanus varie-ties
were not mentioned. The popular South
Pacific Foods Leaflets (151) were revised in
2006 (152) to include the updated information
about micronutrient content of these foods,
but still these leaflets have not been made
widely available or translated into the local
vernacular.
Despite the challenges, IFCP members
are encouraged as they hear about more peo-ple
noting the values of local food, some lead-ers
even declaring how they stopped eating
rice (153). Pohnpei’s involvement in the
CINE-led global project to promote tradi-tional
foods for health has provided great
hope, as Pohnpeians learn that the problem of
neglected local foods is a worldwide prob-lem.
New ideas have been shared about how
to promote local food more effectively and
how to gain strength from colleagues sharing
the same concerns and interests (154,155).
Social marketing has been described as
the application of marketing principles to the
design and management of social pro-grammes.
It is a systematic approach to solv-ing
problems, in this case public health
nutrition problems related to the adoption of
health-promoting behaviours (156). Social
marketing has been essential in implement-ing
this project, following examples elsewhere
that use multi-sectoral, participatory and
community approaches (52,157).
Lessons learned include the following:
• Assess nutritional content of food varieties.
There are great differences in the nutrient
content of different varieties. It is impor-tant
to promote those that give the great-est
health benefits, along with agronomic
potential, good taste and acceptability.
Careful documentation is important for
assessing varieties for all these factors.
• Begin with foods that are already culturally
important. Past experience has shown that
it is very difficult to promote foods that
are less well liked or unimportant, such as
green leaves. The target audience is more
likely to make behaviour changes related
to foods that are well known and liked.
• Provide a scientific basis for promoting local
foods. Pohnpeians were greatly impressed
by scientific information gathered on
their own local food. The case study
evaluation showed that data from nutri-ent
analyses on Pohnpei foods and varie-ties
provided a more compelling
argument than information on foods
from other places. The scientific evidence
also confirms the wisdom of the forefa-thers
in Pohnpei regarding the use of the
traditional food varieties.
• Promote yellow-fleshed carotenoid-rich foods
for multiple health benefits. Many people
are less familiar with micronutrient defi-ciency
disorders than they are with can-cer,
heart disease and diabetes. The same
carotenoid-rich foods can be promoted
for both alleviating micronutrient defi-ciency
disorders and helping to prevent
chronic diseases such as cancer, heart
disease and diabetes. Key informant
interview data showed that using colour
as a way of communicating concepts of
food composition is an effective way to
share health messages and has been
essential to the success of this campaign.
• Include all age levels and groups. The lead-ers,
including traditional, governmental
and church, business sector, and women
and youth are important groups to tar-get.
Adults often have very fixed food
habits but youth are still forming their
habits.
• Share information utilizing a mix of media
and other methods. Mass media including
radio, television and video/DVD should
all be used to reach a wider audience.
Face-to-face communications are needed,
through workshops, schools and infor-mal
gatherings. Print materials, in par-ticular
posters, newspaper articles,
newsletters and brochures, can put out
important messages. The evaluation of
the case study indicated that the bill-board
and posters were among the mate-rials
most widely known about, although
further evaluation is needed for assess-ing
the understanding of these materials.
• Go inter-agency! Acknowledge and
engage partners and participants. Many
agencies working together can achieve
more and resources can be more effec-tively
used. Acknowledging partners
and participants develops good working

relationships, creating interest for further
inter-agency events.
• Work with communities to help them under-stand
their diets and health problems.
Working at the community level helps to
develop programmes that are relevant to
the local needs. Communities also need
to understand their diets and health
problems. The evaluation of the case
study in Mand showed that awareness
and exposure to the intervention were
high and that interest in increasing local
food consumption and improving life-styles
changed positively.
• Create and promote friendly competitive
events. Experience in Pohnpei and in
other Pacific Islands has shown that com-petitions
(i.e. food crops or recipes) are
popular and are an excellent way to cre-ate
local food interest.
• Use colour, use humour and make it fun!
Colourful illustrated posters and hand-outs
create more interest than black and
white materials. Use humour, such as
that in the youth dramas and skits.
• Keep the messages short, interesting and cor-rect,
and keep them coming! People are
busy. Frequent, short, interesting mes-sages
are more likely to have a positive
impact than occasional long messages.
• Write up your work and share it widely.
Scientific findings published in peer-reviewed
journals command respect and
create interest internationally, as well as
providing greater credibility for funding
opportunities. Short items written up for
radio or e-mail news can share messages
widely.
• Meet the needs expressed by communities,
such as requests for planting materials of rare
varieties and other crops and training on
small-scale processing of local food products.
Families need planting materials of rare
varieties if they are to grow more of these.
Making local foods more convenient and
available is important, in order to face the
changing lifestyles. On-farm and institu-tionalized
collections and small-scale
food processing development are exam-ples
of the work to address these needs.
• Share locally about the international interest
in Micronesian foods. Showing that people
in far-away places and prestigious organ-izations
highly value Pohnpei foods cre-ates
much local interest.
• Practise what you preach! At home and
work (and at workshops), grow and eat
local! Despite the convenience, availabil-ity
and low cost of imported foods, it is
important to make the effort to use local
foods in the home and work environ-ment
(as in workshops and meetings).
Key informant interview data showed
that the use of local foods at public events
is a strong statement in itself.
A final lesson learned is that there are three
important steps in the social marketing food-based
approach: (i) the various social market-ing
techniques create awareness; (ii) awareness
creates demand for local foods; and (iii)
increased demand increases local food pro-duction
and use.
The IFCP used an approach to under-stand
market factors for improving tradi-tional
food use for alleviating micronutrient
deficiencies and problems of chronic disease.
The banana market study showed that Karat
and Daiwang banana are now regularly sold
at local markets, whereas they were not sold
at all prior to the campaign. Interviews were
conducted with market purveyors to under-stand
the quantities of prepared local foods
packaged and marketed for consumption in
2007. While these foods were not commonly
sold previously, during the month of July
2007, a total of 3554 kg of prepared local foods
were recorded as marketed and, of these,
banana products comprised about half the
weight (158). The local foods also included
cooked breadfruit, taro, yam and cassava
products.
The Pohnpei case study carried out in
Mand community showed that there was a
significant increase in the frequency of banana
and taro consumption and the number of
banana varieties consumed, as well as an
increased awareness and interest in local
food. Many workshops in Pohnpei now
choose to ‘go local’, serving coconut juice in
place of coffee or soft drinks and local food
and fish in place of imported rice and meat.
Many restaurants serve local food, whereas
they did not previously, and reports indicate

that the ‘Go Local’ campaign contributed to
this. Several Pohnpei leaders, including a
former Lieutenant-Governor, shifted to local
food and made public statements about this.
However, it is noted that other factors (exer-cise,
stress levels, environment and other life-style
practices) also affect the disease burden,
and it takes time to see an actual impact on
the disease burden.
It is slow but it is happening! One of
IFCP’s slogans, ‘Let’s Go Local’ was enthusi-astically
endorsed by participants from the
SPC member countries at the 2007 regional
Pacific Agriculture Plant Genetic Resources
meeting. It also appears to be a theme that is
being taken up globally. For example, in 2007
TIME Magazine had on its cover page a mes-sage
including ‘Eat local’ (159) and Slow Food
is becoming a topic of discussion.
Consideration should be given to extend-ing
the IFCP approach to other Pacific Island
countries and possibly elsewhere where
conditions are similar. So, remember ‘go yel-low!’
and ‘let’s go local!’
Acknowledgements
Warm thanks are extended to all those people
and many local and overseas agencies
involved in this project. We also warmly
thank those reviewing this chapter, including
Dr Rally Jim, Dr Eliaser Johnson and Yumiko
Paul, Pohnpei State Department of Health;
Jackson Phillip, College of Micronesia–FSM;
Douglas Nelber, Pohnpei State Lands and
Resources; Jane Elymore, FSM Department of
Health and Social Affairs; Dr Mary Taylor,
Secretariat of the Pacific Community; Amy
Levendusky, formerly with Peace Corps
Micronesia/IFCP; and Fran Hezel,
Micronesian Seminar. Thanks are also given
to Luciano Mathias for his photography and
media assistance.
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14 A Food Systems Approach
to Increase Dietary Zinc Intake in
Bangladesh based on an Analysis of Diet,
Rice Production and Processing*
A.B. Mayer,**1 M.C. Latham,2 J.M. Duxbury,3 N. Hassan4 and E.A. Frongillo5
1Centre for Epidemiology and Biostatistics, Faculty of Medicine and Health,
University of Leeds, Leeds, UK; 2Division of Nutritional Sciences,
Cornell University, Ithaca, New York, USA; 3Department of Crop and Soil Sciences,
Cornell University, Ithaca, New York, USA; 4Institute of Nutrition and Food Science,
University of Dhaka, Bangladesh; 5Department of Health Promotion, Education,
and Behavior, University of South Carolina, Columbia, South Carolina, USA
Abstract
The potential to increase the zinc content of rice in communities has been under-exploited. An understand-ing
of the zinc content of rice in communities may be used to plan programmes by identifying and plug-ging
the ‘nutrient leaks’ in the food system from soil to plate. This chapter describes a study that aimed to
measure the zinc content of rice at different stages from production to consumption in communities and
determine the potential for intervention based on the magnitude of differences observed. A second objec-tive
was to demonstrate the potential impact of these interventions on zinc intake of children.
The study took the form of a cross-sectional observational study of the usual practice of growing,
processing and cooking rice, with measurements of the zinc content of rice using inductively coupled
plasma–atomic emission spectroscopy. Dietary assessments were undertaken on children in rice-producing
communities in four districts of Bangladesh.
Comparison of the four villages suggested the potential for improvement of 11% if the soil zinc is
increased from below to above the critical level (0.8 ppm DTPA-available), of 15% with adjustments to
milling, of 16% with changes in cooking and up to 38% with a change in locally available rice varieties.
If all these changes were implemented, the zinc content of low-zinc rice would potentially double and
children’s total dietary zinc would increase by 64%.
Local information on the variability in the zinc content of rice may be used to improve zinc nutrition.
This would be most effective as part of an integrated, community-based nutrition strategy that addresses
constraints and opportunities to improve multiple nutrient malnutrition.
Key words: Oryza sativa, zinc, soil, food processing, diet surveys, food-based approach, food system,
Bangladesh
* We acknowledge the financial support of United States Agency for International Development, Soil
Management Collaborative Support Programme.
** Contact: abm17@cornell.edu

Increase of Dietary Zinc Intake in Bangladesh 255
Introduction
Possible approaches to improving zinc nutri-tion
have been summarized (1,2). These
emphasize supplementation, fortification, die-tary
diversification, agricultural strategies to
increase total zinc and/or absorbable zinc
content in staple foods, and household food
processing methods to increase absorbable
zinc. Improving the zinc content of rice may
be achieved through selection of particular
varieties (3,4), by applying zinc fertilizer (5–9),
by other types of agricultural interventions
(10–13) or by changes in processing (14,15).
While such approaches offer great poten-tial
for change in nutrient intake, in general the
constraints of communities cannot be over-come
and their desires met in ‘mass treatment’
programmes that aim to reach the whole pop-ulation,
for example through the introduction
of a new variety of rice. The variability in the
nutrient content of rice at the village level is
not usually considered in the analysis of the
problem or in the formulation of solutions. The
approach described in this chapter is based on
village-, household- and field-level variability
in the nutrient content of the staple food that
reflects achievable magnitudes of change that
may be implemented in and by communities.
The approach is designed to optimize the
nutrient content of rice by ‘plugging the nutri-ent
leaks’ in the food system at the local level.
This needs a detailed analysis of foods from soil
to plate. After assessing the potential for
improvement at each step, the next stage is to
work with the communities, farmers, mill own-ers
and other stakeholders to introduce changes
that would ‘plug the leaks’ of nutrients in the
system. The strategy is therefore designed to
build on the variability that is found among
and between communities by incorporating
technology and best practice where possible
and practical. The results presented in this
chapter are for the analysis of zinc in rice in
Bangladesh and are the first analytical stage for
such a programme. The next stage would be to
build improvements with the community.
The objectives were therefore to measure
the zinc content of rice at different stages from
production to consumption and determine
the potential for intervention based on the
magnitude of differences observed. In partic-ular,
the following possible changes have
been examined:
1. Increasing soil zinc content (the portion
that is available for plant growth).
2. Reducing the amount of zinc lost in milling.
3. Reducing the amount of zinc lost in
cooking.
4. Choosing rice varieties that have high zinc
content (after milling).
Another objective was to demonstrate the
potential impact of these interventions by
including a dietary survey in the study design.
Simulations of the impact of the above changes
on overall dietary zinc could then be under-taken.
The actual dietary zinc intake in the dif-ferent
villages could then also be compared
using household-level rice composition data.
Methods
The study was a cross-sectional observational
study of the usual practice of growing,
processing and cooking rice, with dietary
assessments carried out on children in the
rice-producing communities (16). Figure 14.1
Soil
Zn
Zn in
raw rice
Zn in
processed
rice
Soil
factors
Rice variety
Milling
Cooking
Zn in
whole
diet
Bioavailable
Zn
Zn
status
Dietary
intake
Fig. 14.1. Schematic depiction of the passage of zinc from soil to humans.

256 A.B. Mayer et al.
shows a schematic plan for the research. Four
villages in different districts were selected for
the study to obtain a range of soil types from
the 14 villages that formed part of the National
Nutrition Survey of Bangladesh, organized
through the University of Dhaka (17). A ran-dom
sample of 40 households was chosen
from the census list in each village. Each
household had at least one child aged 2 to 10
years and agreed to participate in the study.
Ethical approval was obtained from the
Cornell University Committee on Human
Subjects and from the University of Dhaka.
Fieldwork was carried out in May and
October–November 2000 before the start of
Ramadan, the Muslim month of fasting.
Agricultural production and zinc content
of unpolished (paddy) rice
Soil and rice samples were collected from the
boro (irrigated) and aman (monsoon) seasons
from four survey villages and surrounding
areas. During the harvest, farmers were inter-viewed
in their fields and identified the vari-ety
of rice. Rice was harvested from a 1 m2 plot
from each field, then mixed, dried, winnowed
and weighed. A sample of approximately 50 g
was retained for chemical analysis. Soil inside
the 1 m2 harvest area was sampled using a soil
auger to a depth of 15 cm. Ten samples were
taken, mixed, then air-dried and a sample
saved for analysis. The soil samples were ana-lysed
for available zinc content and pH. The
rice zinc content could then be determined
for samples grown in ‘high-zinc soil’ or ‘low-zinc
soil’ based on critical levels of 0.8 ppm
diethylenetriaminepentaacetic acid (DTPA)-
available soil zinc for rice production (18).
Changes in zinc after milling
To measure the impact of milling on the zinc
content of rice, 50 g samples were collected
before and after milling from the study house-holds
and local mills in matched pairs of the
same variety of rice and the same household.
Unmilled rice was de-husked prior to analysis.
Each time the rice was mixed well before taking
the sample. The analysis is restricted to samples
from two villages where there was a local mill
and hence sufficient samples for analysis.
Changes in zinc after cooking
Samples of polished rice before and after cook-ing
matched by household and variety were
collected from the sample households during
the first visit in May. The samples collected at
this time were predominantly from the previ-ous
aman harvest. For this analysis the aim was
for 20 samples from the survey households in
each village. Some samples were spoiled and
could not be analysed; therefore the final sam-ple
size was 73 from four villages. The person
responsible for cooking in each household was
asked about the source of water, whether any
water remained after cooking rice and, if so,
what was done with the water.
Varietal differences in zinc content
of polished rice
A sample of polished rice was collected from
each household at the time of the dietary
survey and the rice compositional analysis
used to individualize zinc intake from rice for
each household. The respondent was asked to
identify the variety of each sample of rice.
Using these samples it was possible to
evaluate village-level differences in the zinc
content of rice varieties.
Dietary intake of zinc related
to the zinc content of rice
In each household, the person responsible for
cooking meals was interviewed during our
second visit in October–November 2000. The
24-hour recall questionnaire format was pro-vided
by the International Food Policy
Research Institute and previously field-tested.
Trained enumerators conducted the inter-views
in Bangla. The respondent recalled all
the raw ingredients of each dish (including
rice) that were used to prepare the meals the

previous day and the proportion of each
cooked dish allocated to each household
member. Adjustments were made for changes
in weight of foods from cooking (19).
Household measures were used for the recall,
and then converted to gram equivalents. The
dietary intake was then calculated for each
household member in the household at the
time of the survey.
A nutrient composition database for
foods other than rice was supplied by the
International Centre for Diarrhoeal Disease
Research, Bangladesh, and included zinc and
energy content for Bangladeshi foods (20).
The daily zinc intake was calculated using the
individual rice zinc composition data from
each household and zinc intake from all other
foods using food composition tables. The
energy intake was calculated using the food
composition tables. Daily intakes of food
items for each family member (including the
2- to 10-year-old child) were calculated using
the ingredients of each dish and household
distribution. The zinc density of the diet was
calculated using the energy intake and
expressed as mg Zn/1000 kJ.
The Estimated Average Requirement
(EAR) for zinc as suggested by the Interna-tional
Zinc Nutrition Consultative Group was
used to assess the adequacy of the diet (1). This
recommendation represents a mean require-ment,
or the dietary intake level at which 50%
of individuals would meet their physiological
requirement. The level for unrefined, cereal-based
diets was used based on a phytate-to-zinc
molar ratio of 27.7 (2 mg Zn/day for
1–3 years; 4 mg Zn/day for 4–8 years; 7 mg
Zn/day for 9–13 years). The individual dietary
intakes of the children were compared against
the EAR within each age group.
Laboratory analysis
Analyses for soil and rice were carried out in
the Soil and Crop Sciences Department at
Cornell University, Ithaca, New York, USA.
Rice samples
Total mineral content (including zinc) was
determined using an open acid digest. The
method of open digestion of samples follows
that described by Havlin and Soltanpour (21).
To obtain a representative sample for analy-sis,
approximately 25 g of each grain sample
was dried and ground in a Wiley mill fitted
with a stainless steel screen. The Wiley mill
has been shown not to contaminate oat grain
with zinc (22). A subsample of 0.5 g of the
ground grain was digested with 1 ml of con-centrated
trace-element-grade nitric acid,
69–70% concentration, at 100°C and an extra
1 ml of nitric acid was added three times
approximately every 2 h and taken to dry-ness.
The heat was increased to 115°C and
nitric acid added another two times. One mil-lilitre
of 30% hydrogen peroxide was then
added. The solution was transferred to clean
plastic containers and 25 ml of 5% nitric acid
added. In each batch of 100 samples, a blank
and a National Bureau of Standards (NBS)
rice standard were included. Duplicates were
run for every 20 samples. The digested rice
solution was analysed using inductively cou-pled
plasma–atomic emission spectroscopy
(ICP-AES) (Spectro Ciros CCD instrument;
details). The zinc content of grain was
expressed as mg/100 g dry weight, a unit that
is used in food composition tables. The coef-ficient
of variation was 4.0%. Recovery of the
minerals from the standards was 101.2 ± 1.1%.
The samples were also analysed for phospho-rus
content as an indicator of phytate (16).
Soil samples
The pH of the soil samples was determined in
water using a pH meter (Accumet model 620;
Fisher, details) standardized to pH 7 and pH 4.
Soil available zinc was determined using
DTPA extraction at pH 7.3. Twenty millilitres
of DTPA were added to 10 g of air-dried soil
at pH 7.3. The mixture was shaken at 120
cycles/min and 8 cm/stroke for 2 h exactly.
The extract was filtered through a no. 42
Whitman’s filter into clean (acid-washed)
plastic containers. To preserve the samples,
three drops of concentrated nitric acid were
added to each plastic bottle and samples were
stored in the refrigerator until analysed. ICP-AES
was used to determine the zinc content
of the extract. The results were adjusted for
moisture content, which was calculated by

258 A.B. Mayer et al.
drying a sample of soil for 2 days at 105°C
and subtracting this from the moist weight.
Duplicate samples were run to assess the
coefficient of variation, which was found to
be 11.1% for zinc. Recovery was 99.8% using
NBS standard. This extraction method is com-monly
used for zinc, but will not necessarily
reflect the field soil conditions because zinc
availability changes under flooded condi-tions.
For this reason the samples collected
during the monsoon (aman) season will not be
as representative of soil available zinc as the
samples collected when the soil was drier,
during the collection of boro samples.
Statistical analysis
Data are presented as mean ± standard devia-tion.
Data were analysed using SPSS version
10.0 (SPSS Inc., Chicago, Illinois, USA) for the
majority of analyses. SAS version 6.12 (SAS
Institute Inc., Cary, North Carolina, USA) was
also used for calculation of daily nutrient
intakes. Student’s t test was used for the dif-ferences
in the means. General linear models
were used for analysis of association of multi-ple
predictors and an outcome variable.
Results
Table 14.1 provides a summary of the rice sam-ples
collected for each stage of the research, the
number of varieties collected and the match-ing
system for samples. The sample size of
children from four villages for the dietary
assessment is also given.
Agricultural production and zinc content
of unpolished (paddy) rice
The unpolished rice grown in the aman sea-son
had higher zinc content (2.08 ± 0.33
mg/100 g) than rice grown in the boro season
Table 14.1. Summary of research steps and samples collected. (Adapted from Mayer et al. (16).)
Research step Samples Location
Season
growna
Month
collected
(2000)
Number
of samples
Number
of rice
varieties
1. Agricultural
production and
Zn content of
unpolished rice
Unpolished rice and
soil samples
matched by variety
and sample plot
4 survey
villages
plus
26 extra
villages
boro May 67 rice
67 soil
14
aman Nov 72 rice
72 soil
25
2. Changes in Zn
after milling
Unpolished rice and
polished rice
matched by variety
and household
2 survey
villages
with mills
aman Nov 33 rice 13
3. Changes in Zn
after cooking
Polished rice and
cooked rice
matched by variety
and household
4 survey
villages
aman
(stored)
May 73 rice 15
4. Village
differences
in Zn content
of rice
Polished rice, one
sample per
household in each
village
4 survey
villages
aman
(stored)
boro
(stored)
May
Nov
89 rice
152 rice
16
24
5. Dietary intake
of Zn related
to zinc content
of rice
24-hour recall
of dietary intake
of children aged
2–10 years
4 survey
villages
– Nov 156 house-holds,
277
children
–
aThe boro is the winter season for rice and rice is grown under irrigation. The aman is a monsoon season for rice
(mostly rainfed). The other rice season is aus which is an early monsoon season.

(1.86 ± 0.34) (P < 0.001). Yield was 441 ± 149
g/m2 on average in the boro season and 220 ±
107 g/m2 in the aman season. The grain zinc
was subject to the typical ‘dilution effect’ of
increasing yield; the samples from plots with
higher yield had lower grain zinc across both
seasons (r = –0.29, P < 0.001). The dilution
effect, and possibly genetic differences among
varieties, most likely contributed to the differ-ence
in grain zinc between the two seasons.
The relationship between rice zinc and
soil zinc, yield and pH has been described
previously (16). Briefly, the zinc content
increased with soil zinc, but on a logarithmic
scale in the boro season, thus requiring rela-tively
large increases in soil zinc to improve
grain zinc. More acidic soils had higher grain
zinc in the boro season. A tenfold increase in
soil zinc would be needed for an increase of
0.23 mg/100 g in grain zinc, i.e.
Grain zinc (mg/100 g) = 3.68–0.31 (pH)
+ 0.23 (log10 soil zinc).
In the aman season, rice zinc was related to
neither soil pH (P = 0.114) nor soil available
zinc (P = 0.665).
By way of illustration, comparing rice
grown in soil greater or less than the critical
zinc level (0.8 ppm) revealed significant
improvements in grain zinc in the boro sea-son
but not in the aman season (Table 14.2).
A difference of 11% for unpolished rice zinc
on average could be expected in the boro
season if the rice was grown in soil with
more than the critical level of soil available
zinc. This difference represents an increase
in soil zinc from 0.36 ppm to 2.80 ppm.
However, this difference would decrease
after milling (see below). The varieties grown
were different in the two seasons and differ-ent
regions. Thus it was not possible to fully
separate the effects of genetics and environ-ment
in the analysis. The assumption is,
therefore, that the higher zinc in the rice
from higher-zinc soils was caused by the soil
or other environmental factors associated
with soil zinc and not confounded by other
factors, such as the choice of variety.
Changes in zinc after milling
More zinc was lost after milling in Batabaria
(39%) compared with Simulia (24%; P < 0.001)
(Table 14.3). We could hypothesize that 15%
more zinc could be retained on average if the
milling vigour was adjusted to the vigour

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