Attachment_J.2_Background_on_Contributing_Factors_to_Stunting.docx

ATTACHMENT J.2 – BACKGROUND ON CONTRIBUTING FACTORS TO STUNTING

Critical factors contributing to stunting in Zambia include:

Adolescent and maternal nutrition and health, including anemia during pregnancy, influences a child’s growth and development starting from the womb; early pregnancies which occur when a girl’s body is not prepared for childbearing affects fetal growth due to competition for nutrients with the mother’s ongoing growth; inadequate spacing between pregnancies; low dietary diversity and protein consumption among adolescents, pregnant women and children under the age of five years.

According to the Zambia DHS, only 11 percent of children age 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices; 73 percent of children less than six months are exclusively breastfed and the median duration is 4.1 months. According to World Health Organization (WHO), the transition between exclusive breastfeeding and introduction of complementary foods is the time when malnutrition starts in many infants, contributing significantly to the high prevalence of malnutrition in children.

Building on compelling global evidence, age- appropriate early childhood development is an area of mounting attention in Zambia and the 1,000 most critical days period provides a natural entry point for programming. The brain’s neural pathways supporting communication, understanding, social development and emotional wellbeing grow rapidly during a child’s early years. Deficiencies in stimulation, and in the quality of the caring relationship experienced by children in this critical period of life, irreversibly stunt their emotional, social, physical and cognitive development. Evidence from low-resource settings confirms that improved infant stimulation and improved parenting practices have a beneficial effect on children’s long-term mental health and nutritional outcomes.

Inadequate income is also a crucial factor, as it limits the ability of households to access an adequate high-quality diet. In addition to promoting livelihoods, social protection is an important strategy to accelerate progress in improving maternal and child nutrition for poor households. Integrating food security and social protection interventions has a positive impact on family cohesion and stability and household resilience. It is well documented that cash transfer programs directly affect household consumption and food consumption (Adato and Basset, 2009). In all of the African countries and programs reviewed in this study, household consumption increased and the majority of the additional income from the transfer was spent on food. Most households also improved their diet diversity (including Zambia AIR, 2013).

Another important area of focus is dietary patterns; it is critical that children have access to and consume diverse foods with adequate nutrient and micronutrient density, and safe foods. Numerous studies have tested dietary solutions, including increased consumption of nutrient-dense foods and supplements, nutrition education interventions, and infant feeding behavioral-change strategies. A review of 38 of these studies showed that children receiving one of these dietary interventions gained up to 760 g more weight than control children by 12 to 24 months. However, none of these interventions achieved normal growth in isolation. Prevention of overweight and obesity will not be ignored, particularly since stunting may lead to increased risk of overweight and obesity.

In Zambia, lack of adequate availability of nutritious food is also a major concern. This can lead to insufficient energy consumption and dietary patterns that are poor in essential nutrients, putting individuals at risk for both acute and chronic malnutrition. Reducing post harvest losses due to spoilage or contamination, for example, also increases access to diverse, nutritious foods, and can lead to increased economic resilience for vulnerable households.

Smallholder agriculture production practices will also be addressed under SUN. Evidence shows that increased household income does not necessarily lead to improved nutritional status of its most vulnerable members (World Bank 2006, 2007). A preferred pathway for many households to improved nutrition is increasing women’s production of diverse, nutrient-dense foods that are consumed at home. In households that consume at least some of what they produce, an increase in production can directly affect the diet and nutritional status of household members. This pathway is particularly important in contexts where market access is limited and households routinely depend on self-production. Masset et al. (2012) provides evidence for nutritional effects of increased production for home consumption from increasing small-scale production of nutrient-dense foods. Smallholder agriculture must be complemented by other livelihood activities and will be closely monitored to evaluate the realization of expected outcomes by households.

Many smallholder mixed farming systems found in Zambia and much of Africa combine livestock and crops. These livestock systems are important in providing food at the local level in short market chains, and provide multiple non-market benefits such as food for household consumption, cushions to shocks with vulnerable families owning “savings on four legs,” and manure.

Also notable is the evidence that suggests that up to 35 percent of stunting could be associated with aflatoxin and other mycotoxins. Recent public-health research has shown fungal growth and mycotoxin contamination to be a serious, previously under-appreciated threat to nutrition and health in Africa. The hazard is most severe for infants and young children, when visibly damaged food is not discarded, and where previous malnutrition worsens susceptibility (Marasas et al., 2008). Studies from the early 1970s established the association between aflatoxin exposure and growth impairment in animals (Khlangwiset, Shephard and Wu 2011), and two recent studies in West Africa clearly show the relationship between aflatoxin exposure and growth retardation. A longitudinal study then supported this result over time, finding children in the highest quartile of exposure having 1.7 cm less height gain than those in the lowest quartile (Gong et al., 2004).

Water, sanitation, and hygiene are other key interventions to reduce stunting. Sixteen percent of households in Zambia still use a bush or open field for defecation, though this is an improvement since 2007, when one in four households had no toilet facility. Only 28 percent of rural households were observed to have a place for washing hands, of which 17 percent had soap, while 46 percent had no water, soap, or other cleansing agent.(DHS 2013 survey). The Revitalizing Agriculture to Improve Nutrition (RAIN) project in Zambia piloted the integration of agriculture, health and nutrition interventions; however, the final assessment concluded there was no significant reduction of stunting through this integrated approach. While RAIN did have a strong focus on women’s roles and concluded there was a strong linkage between women’s empowerment and children’s nutrition, WASH activities were not included in the initial design. The lack of integration of WASH could explain in part why stunting was not reduced.

Poor water and sanitation lead to both diarrhea and environmental enteropathy (EE), a chronic subclinical disorder of the small intestine that affects its nutrient absorption capacity. For many years, diarrhea has been implicated as a cause of poor growth (Humphrey (2009) showed that while diarrhea does impact growth, the direct effect is relatively small and EE may be the much more significant contributor. EE is a condition that occurs when children live and play in unhygienic environments, resulting in ingestion of fecal bacteria eventually contributing to a reduction in the nutrient absorption capacity of the small intestine that then causes stunting.

According to the GRZ mid term annual joint water sector review of 2014 in Zambia it was observed that 30% of newly drilled boreholes become dysfunctional within 2 years of construction and experience significant down time periods due to the lack of appropriate operation and maintenance services.

Addressing gender dynamics is central to changing nutritional outcomes for adolescents, pregnant women and their children. A large body of evidence across many regions consistently finds that income controlled by women is more frequently used on food, education and health care for the family, particularly for children (UNICEF 2011). Gender dynamics also influence the allocation of food in the household; care-seeking behavior, timing and spacing of pregnancy, male participation in childcare, and time spent caring for and feeding a young child. Increasing women’s access to income and input in decisions about the use of income can, therefore, strengthen the income pathway to nutrition by enabling expenditures on food and health care.

Climate variations pose challenges to Zambia’s ongoing efforts to combat poverty, reduce food insecurity and sustainably manage natural resources. Agriculture, which constitutes nine percent of GDP, predominantly consists of rain fed, subsistence farming and is thus highly sensitive to unpredictable changes in weather patterns. Increasing temperatures and erratic rainfall patterns have altered crop water requirements, significantly impacting yields and have increased the spread and incidence of pests and diseases.

Potential changes in agricultural productivity due to climate variations may exacerbate already high rates of malnutrition and food insecurity without appropriate adaptation.