Understanding Agriculture-Nutrition Linkages

In recent years, much attention has been given to the connections between agriculture and nutrition in the development sector as a whole. These connections may seem obvious: we get nourishment from the food we eat, and we eat food produced by agriculture. However, the claim that agriculture interventions (e.g. home gardens) can improve nutrition has come under scrutiny, because of the lack of evidence to substantiate it (Masset et al. 2012; Girard et al. 2012). 

At the same time, recent efforts have helped us to better understand these linkages and to begin to close the evidence gaps. Agriculture plays an indispensable role in development, and though it doesn’t automatically improve nutrition, its potential to do so is undeniable. The recent efforts have provided important frameworks for program design and for implementing agriculture interventions that aim to improve the nutrition of vulnerable populations.  These frameworks for “nutrition-sensitive agriculture” interventions help us make sense of complex problems and identify pathways to solutions.

These “new ways” compel us to better understand the problem of malnutrition, to learn about the complexity of improving nutritional outcomes, to understand the role agriculture can play, and to collaborate across disciplines and sectors in order to design and implement interventions that can truly make an impact in improving the nutrition and well-being of the people we serve.

Malnutrition: Why Care?

Every country on earth has a malnutrition problem. In fact, malnutrition in its various forms is the leading cause of poor health in the world! Many populations suffer from multiple malnutrition problems, such as stunting, wasting, overweight, and micronutrient deficiencies (Development Initiatives 2018a). 

Undernutrition alone was found to be the direct cause of 45% of all child deaths in low and middle-income countries—almost half of child deaths (Black et al. 2013). According to the 2018 Global Nutrition Report, 150.8 million children under five are stunted, 50.5 million are wasted, and 38.3 million are overweight (Figure 1). 20 million babies are born with low birth weight each year. One-third of all women of reproductive age are anemic –a debilitating condition caused primarily by micronutrient deficiencies. Moreover, 39% of adults globally are overweight or obese (Development Initiatives 2018a). In 2015, there were 4 million deaths related to overweight and obesity; two-thirds of those were due to cardiovascular disease (GBD 2015 Obesity Collaborators et al. 2017).

Malnutrition in early childhood can irreversibly damage physical and cognitive development, affecting a child’s capacity to learn and succeed in school, increasing a person’s risk of infection and disease, and generally diminishing performance and earning potential throughout the lifetime. This damage represents a great cost in terms of healthcare expenses and lost productivity. Ultimately, it affects an entire country’s development and the well-being of its population (ThousandDays.org 2018).

Understanding Malnutrition

The World Health Organization (WHO) defines malnutrition as: “…deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.” The term malnutrition covers two broad groups of conditions. One is ‘undernutrition’--- which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals). The other is overnutrition, which includes obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes and cancer)” (WHO 2016; Figure 2).

Even though malnutrition can affect anyone, certain groups are more vulnerable. These include young children, pregnant and lactating women, adolescent girls, the elderly, the immuno-compromised (e.g. people with HIV/AIDS), indigenous people, and people living in poverty. People also become vulnerable to malnutrition during or after conflicts, disasters, and famines, or when other problems affect their food and nutrition security (Development Initiatives 2018a).  Malnutrition is especially dangerous for women of reproductive age and for children in their first thousand days of life (i.e. from conception to two years of age), because malnutrition in these situations can have irreversible consequences.

UNICEF’s Conceptual Framework (Figure 3) helps us understand the complexity of malnutrition, including its causes and consequences. Immediate causes have to do not only with nutrient intake, but also with health status [someone who is sick is more vulnerable to malnutrition]. Underlying causes have to do with household food insecurity and with inadequate care practices and an unhealthy environment. Basic causes are broader than the household level; they relate to the sociocultural, economic, and political context, and also to access to services and resources, such as healthcare, education, employment, infrastructure, etc.  In this framework, we can see that the consequences of malnutrition feed back into the underlying and basic causes, resulting in a vicious cycle of malnutrition and poverty (Herforth and Harris 2014; UNICEF 2013)

Nutrition-specific and Nutrition-sensitive Approaches to Malnutrition

Approaches to address malnutrition can be described as being nutrition-specific or nutrition-sensitive. Nutrition-specific interventions address the immediate causes of malnutrition, and some of the underlying causes (UNICEF 2017). The Lancet 2013 Series on Maternal and Child Nutrition reported that stunting (an indicator of chronic undernutrition) can be reduced by 20% if core nutrition-specific interventions are scaled up to reach 90% of the target population (Bhutta et al. 2013). Examples of core nutrition-specific interventions include micronutrient supplementation for children and for women of reproductive age (e.g. zinc, iron, vitamin A, calcium and folic acid); promotion of exclusive breastfeeding during the first six months of life and of adequate complementary feeding from six months to two years of age; and prevention and treatment of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) in children (Bhutta et al. 2013).

Nutrition-specific interventions are essential, but on their own they are not enough to reduce chronic malnutrition to more “acceptable” levels, much less to achieve a world free of hunger. This is why nutrition-sensitive interventions are also necessary. Nutrition-sensitive interventions address underlying and basic causes of malnutrition by integrating nutrition goals into interventions from other sectors, such as agriculture, education, health and WASH (water, sanitation and hygiene) (UNICEF 2017).

Agriculture to Nutrition Pathways and Principles

Figure 4 depicts the current framework that helps us understand the pathways that link agriculture and nutrition (Herforth and Harris 2014). The pathways are interconnected rather than linear. An understanding of how these interactions function in a particular context would help change agents know how nutrition-sensitive agriculture activities could improve access to food and healthcare, promote adequate caring practices and contribute to an enabling environment. These could eventually improve the nutrition of the entire household, not just mothers and children.

The main pathways from agriculture to nutrition are through:

1. Food production
2. Agricultural income
3. Women's empowerment

Food Production Pathway

Food production may seem an obvious pathway from agriculture to nutrition, because it can directly affect the quantity and kinds of food available for consumption in smallholder households. It can also affect food availability and prices in local markets due to the sale of some farm produce. Farming families do not necessarily aim to produce all the food that would meet their dietary needs, or to consume all the food they produce. While many smallholder farmers do consume a large portion of the food they produce at their farms (Figure 5), they also spend a significant amount of their income to purchase food. If we account for food produced and consumed from the farm, plus food that is purchased, many smallholder farmers are net consumers; sometimes they spend more than half of their household budget on food (Rapsomanikis 2015).

Farming families consider many factors when producing crops or livestock: costs, risks, market prices, productive assets (e.g. land, farm tools), and their own household needs and preferences. When preferred foods are not consistently available, affordable or accessible in markets, the production pathway could be a good option to address both food and nutrition security (Herforth and Harris 2014). 

Here are some examples of interventions that follow the food production pathway:

• Improving the production of a staple crop. This would increase its availability for household consumption, which would in turn increase dietary intake of protein and energy, which could result in improved nutritional outcomes.
• Promoting the cultivation and consumption of micronutrient-rich foods (e.g. from home gardens) among households that depend mainly on staple crops. This could improve the quality and diversity of the family’s diet.
• Substituting a known crop or variety with a similar one that contains more iron or Vitamin A, more protein, or better-quality protein. Examples include orange-fleshed sweet potato, quality protein maize, and beans biofortified with iron.

These interventions could increase food access in farming households, if they are thoughtfully designed and if they successfully meet food production goals. 

Food processing and storage, one of the steps in the food production pathway, can affect—for good or ill—how much food is available, and for how long. It can also affect the health of the family. Post-harvest management can affect food’s shelf-life, nutrient content, and safety.  For example, drying a crop can increase its shelf life. However, if dried improperly, mold can grow on the crop and produce mycotoxins; when consumed, these can have acute and/or chronic effects on people’s health.

Improving food access alone does not guarantee improved nutrition outcomes. As mentioned above, the pathways are not linear, and their components are interrelated. As illustrated in Figure 6, a nutrition-sensitive program needs to also consider access to healthcare and child care practices, because healthcare influences health status, and caring practices influence nutrition outcomes. Improving nutrition outcomes is the ultimate goal, so all three need to be addressed. Key components of the enabling environment also need to be considered; these include markets; natural resources; health, water, sanitation; and nutrition and health knowledge/practices.

All these pathways might seem overwhelming. You may wonder how this can possibly all be accounted for in your small agriculture program. One single organization does not need to address every aspect in the pathway. Instead, seek to understand the pathway and its interactions within this framework, and then look for ways to collaborate and partner with people who work in other areas of influence. As you complement each other’s work among a target population, your joint efforts can achieve your mutual goals for improved nutrition outcomes.

An example of this is the Home Gardens Program that Maya Health Alliance (MHA) is piloting in Guatemala. Globally, Guatemala has the sixth-highest rate of chronic malnutrition; 47% of children under five are stunted (USAID 2018; Development Initiatives 2018b), and this number rises to 70-80% among the Mayan communities that MHA serves. After implementing nutrition-specific interventions that helped reduce chronic malnutrition by 15-20% in these communities, MHA decided to design and pilot a home gardens program with the goal of improving access to a more diverse diet for better nutrition outcomes. 

In 2018, MHA teamed up with ECHO and other organizations to bring diverse perspectives into the program design phase, including people with backgrounds in nutrition, public health, agriculture, and program management. Having diverse perspectives equipped the team to identify foods already being produced by the households, to understand home garden methods used by the communities, to develop a seasonal calendar, to recognize water needs (e.g. irrigation, household use), to respect women’s use of time (e.g. child care), to create training tools, and to adapt the nutrition education component, among other things. All these important elements required time, mutual learning and adaptation, in order to design an evidence-based home gardens program that would complement the nutrition-specific interventions and reduce the incidence of chronic malnutrition among these communities. If successful, the results of the process and the impact of this pilot program will be shared and scaled up to reach more communities.

Agricultural Income Pathway

The agricultural income pathway aims to increase household income, so that more money is available to meet the nutritional needs of the household—in terms of food purchases, but also of non-food purchases (for example, related to clean water and sanitation facilities) that would improve living conditions and support good nutrition. 

This pathway is appropriate when diverse foods are available and affordable locally, to meet the nutritional needs of the family—women and children in particular. The pathway is best used when inputs, resources and markets work well to meet nutritional needs throughout the year. These conditions may not be optimal, and require collaborations and consideration into program design; for example, using value chain approaches (discussed below). Moreover, many smallholder farmers sell at least part of their farm products for household income (see Figure 5), and many produce cash and/or non-food crops, making the agriculture income pathway necessary for improving nutrition.

As with the food production pathway, be sure to look at the different aspects and interactions within the framework, and design programs carefully. Do not assume that increased income will automatically be spent on nutritious foods and healthcare. Consider using social and behavior change (SBC) approaches to improve knowledge and practices related to nutrition.  The USAID Health Communication Capacity Collaborative (HC3) Website is an excellent toolkit and training resource in this subject (USAID/HC3 2018).

Women's Empowerment Pathway

The women’s empowerment pathway gives the agriculture-to-nutrition framework a gender lens. It describes the impact of women’s spending power; of their responsibilities for childcare and housekeeping; and of the amount of time and energy women spend. When a program aims to increase women’s income from agriculture, the women’s empowerment pathway connects to the agricultural income pathway.

Studies have shown that when women have decision-making power over the household income, they are more likely than men to spend it on food and healthcare, particularly for their children. Women’s ability to control household economic and productive resources (including their own time) positively correlates with improved self-care and child care practices. In general, it correlates with better decisions to invest in the nutrition, healthcare and well-being of children (Smith et al. 2003). This means that an initiative to increase women’s control of agricultural income can enhance the income pathway to nutrition, since money will be spent for things like food and health care, which directly affect children’s nutritional status. Training that helps female and male farmers to gain farm management and business skills could also enhance this pathway (Herforth and Harris 2014).

When planning for a project that involves women, be sure to consider how much time and energy they will need to spend on agricultural activities, and also consider when the work must be done. In many parts of the world, women participate in agriculture activities, but also bear the main responsibility for child care and household care. Be careful to ensure that your agriculture program does not unduly burden women with overwhelming expectations of time or energy.

For a more in-depth explanation of the agriculture-to-nutrition pathways, please read the “Improving Nutrition through Agriculture Technical Brief Series” produced by the USAID/SPRING Project.

Value Chains for Nutrition: Expanding the Pathways

Another important aspect of agriculture to nutrition is the pathway that farm produce takes from the farm to the consumer, known as a value chain. A value chain is the set of steps, processes and participants that relate to a specific product (or related products), including production, transformation, transportation and sale to the consumer.

Value chains have great potential to contribute to the nutrition of vulnerable populations. For example:

• Those employed within the value chain earn income that can be used to buy food or to pay for health care, improving nutrition and health.
• A value chain can yield new and/or improved nutritious foods and products for vulnerable populations to access and consume.
• Some processes used in a value chain can reduce waste and nutrient loss, or can increase the availability of nutrients (e.g. fortification).
• Nutrition-sensitive activities can be incorporated within the value chain. For example, the value chain can include nutrition education; facilities that allow and promote breastfeeding; and marketing messages to improve the nutrition knowledge and practices of the consumer.

With the inclusion of agribusiness and markets in the agriculture-to-nutrition pathways, some have suggested that the terminology be changed from “nutrition-sensitive” agriculture to “nutrition-smart” agriculture. The latter term might encourage producers and value chain actors to adjust their business strategies, to consider the nutrition and health of vulnerable populations and of society in general, in addition to considering their own profits (Arias and Htenas 2018). Whichever term is used, nutrition-sensitive or nutrition-smart, the value chain pathway includes tools such as market and value chain analysis, and also principles and program design strategies for value chain development. 

You can read more on these concepts from IFPRI’s (International Food Policy Research Institute) brief, “Value Chains for Nutrition” (Hawkes and Ruel 2011). Some great resources for practitioners are MEDA’s (Mennonite Economic Development Associates) toolkits for market research (MEDA 2007a) and value chain program design (MEDA 2007b), available online.

Agriculture-Nutrition Programming Principles

Now that we better understand the agriculture-nutrition pathways and nutrition-smart investments through value chains, we also need to consider the current guiding principles. These are necessary for effective program design and implementation.

1. Incorporate explicit nutrition objectives and indicators into program design. This ensures that improving nutrition is a priority from the beginning.
2. Assess the local context. What challenges and resources already exist in the community?
3. Target the vulnerable and improve equity. Malnutrition hits some groups harder than others.
4. Collaborate and coordinate with other sectors. Malnutrition has many underlying causes.
5. Maintain or improve the natural resources base. Safeguard water resources especially.
6. Empower women. The women’s empowerment pathway explains why this is so important.
7. Facilitate production diversification, and increase production of nutrient-dense crops and small-scale livestock. Diversity contributes to resilience and to better nutrition.
8. Improve processing, storage and preservation. These can help retain nutrients, reduce crop losses, and decrease the time it takes to prepare nutritious meals.
9. Expand markets for nutritious foods and market access for vulnerable groups. This might be done through farmers’ associations and/or creating value-added products.
10. Incorporate nutrition promotion and education. Try to build on local knowledge.

These guiding principles, the result of a multi-year consultative process led by the Food and Agriculture Organization of the United Nations (FAO), can be found in their publication, “Key Recommendations for Improving Nutrition Through Agriculture and Food Systems” (FAO 2015b).

The FAO also has an in-depth report of the consultative process results, and a checklist and guidance document for program design:

• Synthesis of Guiding Principles on Agriculture Programming for Nutrition (FAO 2013).
• Designing Nutrition-Sensitive Agriculture Investments (FAO 2015a).

Conclusion

Malnutrition is a widespread problem, with irreversible and generational consequences–especially for vulnerable populations like women and young children. Malnutrition’s causes are complex, related to an individual’s diet, but also to her health status and to household conditions that include food (in)security, childcare practices, and the environment. At a more basic level, the causes of malnutrition are even more complex, affected by the education system, kind of infrastructure, and availability of resources.

We need both nutrition-specific and nutrition-sensitive interventions in order to address these complex causes. Nutrition-sensitive agriculture programs can contribute to the solutions, but improving agriculture production does not automatically improve nutrition for farming families. When we understand the agriculture-to-nutrition pathways and principles, we can design and implement programs that are more effective.

No single organization can adequately address malnutrition. We need to learn about the connections and interactions within these pathways, collaborate with other individuals and organizations that work in complementary areas (e.g. nutrition, gender equity, health, agribusiness, etc.), and become bridge builders. Only then will we be able to unleash agriculture’s potential to improve the nutrition and well-being of the most vulnerable.

Training and Other Resources

If you want to dig deeper into agriculture-nutrition linkages, here is a list of free training resources:

• Nutrition-Sensitive Agriculture Training Resource Package, produced by the USAID/SPRING Project. This package includes the themes covered in this article and more, such as developing a seasonal calendar and behavior change concepts (USAID/SPRING Project 2018).
• USAID’s Online Training Course on Nutrition-Sensitive Agricultural Programming. This interactive 3-hour video course has modules on basic nutrition concepts, agriculture-to-nutrition pathways, and nutrition-sensitive programming (USAID n.d.).
• The New Extensionist Learning Kit (NELK) by the Global Forum for Rural Advisory Services (GFRAS) recently added Module 16: Nutrition-Sensitive Extension. The new module includes a manual, workbook, presentation and guide that cover some basics about nutrition and that also refer to topics discussed in this article (GFRAS 2018).
• The USAID “Integrating Gender and Nutrition within Extension and Advisory Services” (INGENAES) Project has an extensive library of documents online. Their training manuals include:
  • Introductory Workshop on Integrating Gender and Nutrition within Agricultural Extension Services: Facilitators Guide (USAID/INGENAES Project 2016b).
  • Integrating Gender-Responsive & Nutrition-Sensitive Approaches When Working with Farmer Groups Engaged in Markets: A Training of Trainers Manual (USAID/INGENAES Project 2016a).

Other helpful online resources include:

• The Key Nutrition Resources collection on ECHOcommunity.org.
• Linking Agriculture and Nutrition, which is a main theme of the USAID/SPRING Project. This article includes many references to USAID/SPRING materials, including their agriculture-to-nutrition pathways framework.
• A Toolkit on Nutrition-Sensitive Agriculture and Food Systems has also been made available by the FAO, which includes the previously mentioned key recommendations and program design documents, as well as a compendium of indicators for nutrition-sensitive agriculture, programmatic options, and guidelines on understanding the causes of malnutrition.

Many online communities of practice are a good source of expertise and information; some also offer occasional opportunities for in-person interactions. For example:

• The Agriculture-Nutrition Community of Practice (Ag2Nut CoP) is an independently run and diverse community. The Ag2Nut Community platform allows members to connect with each other via its online platform, email, and webinars.
• The Agriculture, Nutrition & Health (ANH) Academy is a global research network that helps academics and practitioners connect through their learning and sharing platform.
• Innovative Methods and Metrics for Agriculture and Nutrition Actions (IMMANA) is a research initiative trying to close evidence gaps and to generate new scientific evidence in agriculture-to-nutrition linkages.

References

Arias, D., and A. Htenas. 2018. “It’s Time for ‘Nutrition Smart Agriculture.’” 

Bhutta, Z.A., J.K. Das, A. Rizvi, M.F. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, R.E. Black, and the Maternal and Child Nutrition Study Group Lancet Nutrition Interventions Review Group. 2013. “Evidence-Based Interventions for Improvement of Maternal and Child Nutrition: What Can Be Done and at What Cost?” Lancet 382: 452–77.

Black, R.E., C.G. Victora, S.P. Walker, Z.A. Bhutta, P. Christian, M. de Onis, M. Ezzati, et al. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” Lancet 382: 427–51.

Development Initiatives. 2018a. 2018 Global Nutrition Report. Bristol, UK: Development Initiatives.

———. 2018b. “Guatemala Country Nutrition Profile - 2018 Global Nutrition Report.”

FAO. 2013. “Synthesis of Guiding Principles on Agriculture Programming for Nutrition.”

———. 2015a. “Designing Nutrition-Sensitive Agriculture Investments - Checklist and Guidance for Programme Formulation.” Food and Agriculture Organization of the United Nations (FAO).

———. 2015b. “Key Recommendations for Improving Nutrition through Agriculture and Food Systems.”

GBD 2015 Obesity Collaborators. 2017. “Health Effects of Overweight and Obesity in 195 Countries over 25 Years.” The New England Journal of Medicine 377: 13–27.

GFRAS. 2018. “GFRAS - NELK Plus Module on Nutrition-Sensitive Extension.” 2018.

Girard, A.W., J.L. Self, C. McAuliffe, and O. Olude. 2012. “The Effects of Household Food Production Strategies on the Health and Nutrition Outcomes of Women and Young Children: A Systematic Review.” Paediatric and Perinatal Epidemiology 26 (July): 205–22.

Hawkes, C., and M.T. Ruel. 2011. “Value Chains for Nutrition.” Washington, D.C.: International Food Policy Research Institute (IFPRI).

Herforth, A., and J. Harris. 2014. “Linking Agriculture and Nutrition: Understanding and Applying Primary Pathways and Principles.”

Masset, E., L. Haddad, A. Cornelius, and J. Isaza-Castro. 2012. “Effectiveness of Agricultural Interventions That Aim to Improve Nutritional Status of Children: Systematic Review.” BMJ 344: d8222.

MEDA. 2007a. Market Research for Value Chain Initiatives - Information to Action: A Toolkit Series for Market Development Practitioners. Mennonite Economic Development Associates (MEDA).

———. 2007b. Program Design for Value Chain Initiatives - Information to Action: A Toolkit Series for Market Development Practitioners. Mennonite Economic Development Associates.

Rapsomanikis, George. 2015. The Economic Lives of Smallholder Farmers. Food and Agriculture Organization of the United Nations (FAO).

Smith, L.C., U. Ramakrishnan, A. Ndiaye, L. Haddad, and R. Martorell. 2003. “The Importance of Women’s Status for Child Nutrition in Developing Countries.”

ThousandDays.org. 2018. “Why 1,000 Days.” 2018.

UNICEF. 2013. Improving Child Nutrition: The achievable imperative for global progress.

———. 2017. “Multi-Sectoral Approaches to Nutrition.”

USAID/HC3. 2018. “Designing a Social and Behavior Change Communication Strategy.”

USAID/INGENAES Project. 2016a. Integrating Gender-Responsive & Nutrition-Sensitive Approaches When Working with Farmer Groups Engaged in Markets: A Training of Trainers Manual.

———. 2016b. Introductory Workshop on Integrating Gender and Nutrition within Agricultural Extension Services: Facilitator’s Guide.

USAID/SPRING Project. 2018. “Nutrition-Sensitive Agriculture Training Resource Package.” Training Package.

USAID. n.d. “Online Training Course on Nutrition-Sensitive Agricultural Programming.” Accessed January 10, 2019.

———. 2018. “Guatemala: Nutrition Profile.”

WHO. 2016. “What Is Malnutrition?“