Kaleab Baye presented on diets and stunting in Ethiopia. Stunting rates have declined overall but inequalities persist, with the lowest wealth quintile having the highest rates. Complementary foods in Ethiopia are often low in quantity, diversity, and quality. Improving maternal and child nutrition requires interventions across food systems to increase availability, accessibility, and affordability of nutrient-dense foods as well as improving caregiver feeding practices and maternal health. Comprehensive measures are needed to assess diet quality and reduce consumption of unhealthy foods and risks to food safety.

1. Diets and stunting in Ethiopia
Kaleab Baye (Associate Prof; PhD)
Center for Food Science and Nutrition, Addis Ababa University
Honorary research fellow, Bioversity International
Visiting research fellow, International Food Policy Research Institute
Diets, Affordability and Policy in Ethiopia: From Evidence to Action
Addis Ababa | December 12, 2019

2. Background
Stunting- failure to grow to an expected height for age
Consequences of stunting
- higher risk of mortality,
- poor cognitive performance,
- low productivity and earnings in later life
(Black et al., 2008/2013)
- Higher risk of chronic diseases in later-life
(Uauy et al.,2008)
SOWC, 2019

3. Stunting trends
2000 DHS
2005 DHS
2011 DHS
2016 DHS
0 10 20 30 40 50 60 70 80 90 100
Lowest Second Middle Fourth Highest
Wealth quintile
% of stunted children (< 5 years)
57.7
38.4
0
10
20
30
40
50
60
70
2000 DHS 2005 DHS 2011 DHS 2016 DHS
%ofstuntedchildren
Widening inequality!

4. Timing of stunting in Ethiopia
Golan, J.; Headey, D.; Hirvonen, K.; Hoddinott, J. 2019. Changes in Child Under-Nutrition in Ethiopia, 2000–16. In The Oxford Handbook of the Ethiopian Economy; Oxford
University Press: Oxford, UK, 2019; p. 399

5. Framing “healthy” complementary diets
 Healthy diets are defined in various ways, but they generally need to be
adequate in:
1. Quantity: adequate energy intake for healthy growth
2. Diversity: a variety of food groups providing varying levels and types
of nutrients
3. Quality: contains needed macro-and micro-nutrients without
unhealthy additives, trans-fats, added sugar, etc.
4. Safety: microbial/chemically safe to consume
 What do we know about children’s diet in Ethiopia?
HLPE. 2017. Nutrition and food systems. A report by the High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security, Rome.
PAHO/WHO. 2004. Guiding principles of complementary feeding

6. 1. Quantity
 Energy and nutrient intake is relatively low in rural areas
 Amount of food consumed/meal is low
10-30 % of the theoretical gastric capacity
 % of children (6-23 months) that meet the MMF is 45% (DHS, 2016)
o59% urban
o43% rural
oLowest quintile 38%
oHighest quintile 55%
Abebe, Desse & Baye (2017)-Maternal Child Nutr.
Mengistu, Moges, Samuel & Baye (2017)- Nutrition
EPHI (2013)- Ethiopian National Food consumption survey

7. 2. Dietary diversity (min. 5 out of 8)
 from 4.4 % (2011) to 12.5% (2016)
 MDDS is consistently associated
with stunting
2011 DHS
2016 DHS
0 10 20 30 40 50 60 70 80 90 100
Lowest Second Middle Fourth Highest
Proportion (%) of children meeting the MDD (5 out 8 food groups)
Wealth quintile

8. Legumes
Cereals
Legume-based stews
injera
Food consumption patterns

9. 3. Quality
 Studies on the proportion of unhealthy food in the diets of infants and young
children in Ethiopia are scant (focus remains on undernutrition)
 Growing consumption of sweets and cookies are appearing in the diets of the
rural poor, high sugar intake with tea, etc.
 Ultra-processed (high-sugar/salt) foods were consumed by 14 % of infants
and young children in rural Wollo (FFV, 2017)
 Clearly more data is needed

10. 4. Safety
 Not captured in routine national surveys
 Some estimates of the burden of foodborne
diseases exists from WHO
Ethiopia categorized in the high burden region
 Diarrheal counts can give us an idea of the risks

11.  Missed opportunities in preventing stunting in 2019: LiST model
0
100000
200000
300000
400000
500000
600000
Casesofstuntingavertedwithscale-upto90%
Baye, K (in press) Prioritizing the scale-up of evidence-based nutrition and health interventions to accelerate stunting reduction in Ethiopia. Nutrients .

12. Interventions to improve complementary foods
 Most interventions are led by the MoH, but also supported by other sector
ministries (e.g. MoAG)
 Consists of nutrition education, cooking demonstrations, promotion of home-
gardens…
 Largely focuses on improving knowledge of caregivers about how to feed a child
 Little focus on improving maternal diet and health status
 Focus is often on what the child should eat, and little on how to

13. What can be done to improve diets more effectively?

14. Maternal nutrition/health
A WDDS of >4 food groups during pregnancy was shown to be associated with lower
risk of maternal anemia, LBW, and PTB.
Zerfu, Umeta & Baye (2016). Am J Clin Nutr.
Dairy, fruits, and DGL vegetables are associated with lower risk of adverse pregnancy
outcomes
Zerfu, Pinto & Baye (2018). Nutr & Diabetes
Low breastmilk vitamin A conc. is prevalent in rural Ethiopia
Abebe, Haki, Schweigert, Henkel & Baye (2018). Eur J Clin Nutr
Maternal dietary diversity is associated with child dietary diversity
Nguyen et al (2013) J. Nutr
Also note that food preference starts in utero
Important role can be played by the FBDG that is being prepared

15. Poor caregiver-child feeding interactions are associated with:
- Sub-optimal food/energy intake
- Stunting
Culturally adapted responsive feeding messages improve food intake
(Kassay, Mouquet & Baye- manuscript under preparation)
Abebe, Desse & Baye (2017). Appetite
Baye, Tariku & Mouquet (2017). Maternal Child Nutr.
Caregiver feeding style
Only few HEWs are knowledgeable about what responsive feeding means
Implications: increased attention to how the child is fed in BCC materials
Abebe, Desse & Baye (2016). Food & Nutr Bull.

16. Maternal depression
 In PSNP households in Wollo, maternal post-partum depression
(EPDS≥13) was prevalent (22.8 %) and was significantly associated
with:
o inappropriate complementary feeding
o stunting (P <0.05)
Anato, Baye, Stoecker (in press) Matern Child Nutr

17. Source: GLoPAN food systems framework

18. Drivers of food choice
0
10
20
30
40
50
60
All
Cereals/roots &
tubers
Eggs
Legumes
Vegetable
Fruit
Dairy products
Meat, fish and
poultry Affordability
Accessibility
Health
Availability
Taste
Food safety
Convenience to prepare
Tizazu, Hirvonen & Baye (manuscript under preparation)
FFV baseline survey, caregivers of children 6-18 months (N= 524)

19. Affordability
The share of income needed to meet the
recommended intake of fruits and vegetables,
by income quintile
Hirvonen, Wolle & Minten (2018)
2011 DHS
2016 DHS
0 10 20 30 40 50 60 70 80 90 100
Lowest Second Middle Fourth Highest

20. Penetration of processed (unhealthy) foods
02468
1012
0 100 200 300 400
travel time to nearest city (minutes)
Tesfaye, Haleluya (2019): “Market availability of processed foods in the highlands of Ethiopia”, mimeo. IFPRI-ESSP
Feed the future (FTF 2018) and the Productive Safety net Program (PSNP 2019) surveys

21. Food supply (quantity and diversity)
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
Y2011 Y2012 Y2013 Y2014 Y2015
Energy (kcal)
Baye, Hirvonen, Dereje & Remans. 2019 Energy and nutrient production in Ethiopia, 2011-2015: Implications
to supporting healthy diets and food systems. Plos One 14 (3), e0213182
Grains, roots and tubers
Legumes and nuts
Dairy products
Poultry, fish, meat
Eggs
Vitamin A rich fruits and vegetables
Other fruits and vegetables
Other foods
2015
2011
0.44
0.46
0.48
0.5
0.52
0.54
0.56
2011 2012 2013 2014 2015
Shannonindex
Diversity of food produced
National

22. Key messages
 Improving quality of children’s diet is a top priority- not just for meeting
nutrientsa triple-duty action
 Improving diets should not be a long-term goal- urgently needed!
 Improving diet quality is possible, but interventions across the food systems
are needed to make nutrient-dense foods available, accessible, and
affordable
 Narrowing inequalities (e.g. through nutrition-sensitive social protections)
 More comprehensive diet quality measures are needed and clearly data on
“unhealthy” food consumption and safety of CFs are needed

23. Thank you!