How COVID-19 affected food systems,health service delivery and maternal and infant nutrition practices: Implications for moving forward in Kenya

This implementation research study sought to examine the impact of the COVID-19 pandemic on maternal and infant nutrition practices, and related aspects of health and food systems in Nairobi and Uasin Gishu Counties, Kenya. The study triangulated in-depth interviews with 16 pregnant women, 31 lactating women (including COVID-19 positive), 10 facility health workers, 10 community health volunteers, 6 focus group discussions (FGDs) with food vendors, 4 FGDs and 15 stakeholder interviews with government and implementing partners. Trends from Kenyan Health Information System indicators (i.e., exclusive breastfeeding and initiation of breastfeeding, antenatal care) were also examined. During the COVID-19 pandemic, a decline in attendance of antenatal care, and maternity facilities was observed, and corroborated by Kenyan Health Information System data. Lack of clarity among health workers on COVID-19 breastfeeding guidance and fear of COVID-19 infection early in the pandemic were key drivers of early infant formula use, mother–child separation following delivery and delayed initiation of breastfeeding. Most women exclusively breastfed due to Government of Kenya restrictions in movement. Unemployment and job loss was linked to food insecurity and worsened by increased food prices and limited social protection measures. In response, pregnant and lactating women resorted to skipping meals and reducing quantity and variety of foods consumed. Efforts to build forward from COVID-19 in Kenya should include facility and community health education to prevent disruptions in breastfeeding and to support maternal dietary intake, and in the provision of targeted social protection measures alongside other multisectoral interventions (i.e., psychosocial support) for Kenyan pregnant and lactating women.     

Integrating nutrition services into health care systems platforms: Where are we and where do we go from here

Integrating maternal–child nutrition into health care services is a desirable but complex task that requires implementation research studies. This special supplement, entitled “How to Strengthen Nutrition into the Health Platform: Programmatic Evidence and Experience from Low‐ and Middle‐Income Countries” presents a collection of mixed‐methods research and case studies mostly conducted in sub‐Saharan Africa that help us gain a better understanding of the barriers and facilitators for this integration to happen. Collectively, the evidence confirms that integrating nutrition services as part of health care systems and other platforms is feasible, but for that to be successful, there is a need to address strong barriers related to all six key health care systems building blocks identified by the World Health Organization. These include financing, health information systems, health workforce, supplies and technology, governance, and service delivery. Moving forward, it is crucial that more robust implementation science research is conducted within the rough and tumble of real‐world programming to better understand how to best integrate and scale up nutrition services across health care systems and other platforms based on dynamic complex adaptive systems frameworks. This research can help better understand how the key health care systems building blocks need to interlock and communicate with each other to improve the policymakers' ability to integrate and scale up nutrition services in a more timely and cost‐effective way.     

The role of nutrition in integrated early child development in the 21st century: contribution from the Maternal and Child Nutrition journal

Even though it is widely recognized that early childhood development (ECD) is one of the most important predictors of future social capital and national productivity, the recently published ECD Lancet Series reports that about 250 million children under 5 years are at risk of not reaching their developmental potential, mainly as a result of poverty and social injustice. So why is this and what will it take to reverse this situation? The purpose of this special issue is to highlight important contributions from previously published articles in Maternal & Child Nutrition to the field of nutrition and ECD. The collection of papers presented in this special issue collectively indicates that although nutrition‐specific interventions are essential for child development, they are not sufficient by themselves for children to reach their full developmental potential. This is because ECD is influenced by many other factors besides nutrition, including hand washing/sanitation, parenting skills, psychosocial stimulation, and social protection. Future research should focus on mixed‐methods implementation science seeking to understand how best to translate evidence‐based integrated ECD packages into effective intersectoral policies and programs on a large scale. In addition to health and nutrition, these programs need to consider and include responsive parenting (including responsive feeding), learning stimulation, education, and social protection. Future studies should also address if and how childhood obesity affects human physical, socioemotional, and cognitive development.     

Practical approach to nutrition and dietary intervention in pediatric food allergy

Although the need for nutritional and dietary intervention is a common thread in food allergy management, the type of food allergic disorder and the identified food allergen will influence the approach to dietary intervention. A comprehensive nutrition assessment with appropriate intervention is warranted in all children with food allergies to meet nutrient needs and optimize growth. However, dietary elimination in food allergy may also have undesirable consequences. Frequently, an elimination diet is absolutely necessary to prevent potentially life‐threatening food allergic reactions. Allergen elimination can also ease chronic symptoms, such as atopic dermatitis, when a food is proven to trigger symptoms. However, removing a food with proven sensitivity to treat chronic symptoms may increase the risk of an acute reaction upon reintroduction or accidental ingestion after long‐term avoidance, so it is not without risk. Additionally, it is not recommended to avoid foods in an attempt to control chronic symptoms such as AD and EoE when allergy to the specific food has not been demonstrated. Ultimately, allergen elimination goals are to prevent acute and chronic food allergic reactions in the least restrictive, but also the safest environment to supply a balanced diet that promotes health and growth and development in children.     

Integrating nutrition into health systems: What the evidence advocates

There is considerable evidence of positive health and nutrition outcomes resulting from integrating nutrition‐specific interventions into health systems; however, current knowledge on establishing and sustaining effective integration of nutrition into health systems is limited. The objective of this review is to map the existing types of integration platforms and review the evidence on integrated health and nutrition programmes' impacts on specific nutrition outcomes. A literature search was conducted, and integrated nutrition programmes were examined through the lens of the six World Health Organization (WHO) building blocks, including the demand side. Forty‐five studies were included in this review, outlining the integration of nutrition‐specific interventions with various programmes, including integrated community case management and Integrated Management of Childhood Illness, Child Health Days, immunization, early child development, and cash transfers. Limited quantitative data were suggestive of some positive impact on nutrition and non‐nutrition outcomes with no adverse effects on primary programme delivery. Through the lens of the six WHO building blocks, service delivery and health workforce were found to be well‐integrated, but governance, information systems, finance and supplies and technology were less well‐integrated. Integrating nutrition‐specific interventions into health systems may ensure efficient service delivery while having an impact on nutrition outcomes. There is no single successful model of integration; it varies according to the context and demands of the particular setting in which integration occurs. There is a need for more well‐planned programmes considering all the health systems building blocks to ensure compliance and sustainability.     

The “Fill the Nutrient Gap” analysis: An approach to strengthen nutrition situation analysis and decision making towards multisectoral policies and systems change

Improved nutrition situation analysis can increase the understanding of the likely magnitude and main causes of the nutrient gap among a particular target group, for example, children under 2 or pregnant and lactating women, in a particular context. The World Food Programme, with input from University of California Davis, International Food Policy Research Institute, Epicentre, Harvard University, Mahidol University, Save the Children, and UNICEF, has developed a framework for strengthened nutrition situation analysis and decision making called the “Fill the Nutrient Gap” (FNG), which aims to support identification of strategies to increase availability, access, and choice of nutritious foods, to ultimately improve nutrient intake. The FNG engages stakeholders from different sectors throughout the analytical process to provide input and discuss findings to collectively identify and prioritize context‐specific strategies. The FNG analysis contributes to better understanding the nutrition situation because it (a) focuses on the dietary intake side of the malnutrition framework and analyses in‐depth the nutrient intake of different target groups; (b) linear programming is used in combination with review of secondary data to characterize barriers to nutrient intake, in particular to understand the availability, cost and affordability of nutritious diets for households and target groups with higher nutritional needs, and model potential interventions to improve them; (c) it links the nutrition situation analysis to decision making by providing an evidence base for decision makers to inform their strategies; (d) it facilitates multisectoral discussion on barriers to nutrient intake and enables a prioritization of context‐specific strategies (both nutrition specific and sensitive) to improve the nutrition situation across food, health, and social protection systems.     

The policy challenge of coexisting undernutrition and nutrition-related chronic diseases

The original focus on energy and protein needs for combating malnutrition gave way to UNICEF promoted concerns for maternal care and complementary feeding in association with longer-term breast feeding. Nevertheless the World Food Summit's drive to halve malnutrition rates by 2015 was not accelerating the fall in malnutrition prevalences. The UN's Standing Committee on Nutrition's commission highlighted the crucial role of maternal nutrition and low birthweights, the need for a life cycle approach to prevention and the current global effects of maternal/fetal and childhood malnutrition in amplifying the impact of the new epidemic of obesity and chronic diseases. The emphasis on poverty reduction and free market solutions is too crude and national interventions geared to protecting the vulnerable, promoting equity with major community involvement in integrated multifaceted programmes are needed. The same principles apply to overnutrition and specifically to the avoidance of the current pandemic of the metabolic syndrome. An intergenerational amplification of diabesity is now emerging as overweight but poorly fed micronutrient deficient girls enter pregnancy and produce ever more susceptible children. So new strategies are now needed as recognized by economists but not by doctors and nutritionists! Economy, agriculture, food processing and marketing policy changes are crucial in determining patterns of food consumption because the costs of foods and their availability, rather than policies centred on individual responsibility for consumer choice, are the keys to making coherent public health advances.     

School closure,COVID‐19 and lunch programme: Unprecedented undernutrition crisis in low‐middle income countries

The coronavirus disease 2019 pandemic has affected nearly 70% of children and teenagers around the world due to school closure policies. School closure is implemented widely in order to prevent viral transmission and its impact on the broader community, based on preliminary recommendations and evidence from influenza. However, there is debate with regard to the effectiveness of school closures. Growing evidence suggests that a child's SARS‐CoV‐2 infection is often mild or asymptomatic and that children may not be major SARS‐CoV‐2 transmitters; thus, it is questionable if school closures prevent transmission significantly. This question is important as a majority of children in low‐ and middle‐income countries depend on free school meals; unexpected long‐term school closure may adversely impact nutrition and educational outcomes. Food insecurity is expected to be higher during the pandemic. In this viewpoint, we argue for a more thorough exploration of potential adverse impacts of school closures in low‐ and middle‐income countries and recommend actions to ensure that the health and learning needs of vulnerable populations are met in this time of crisis.     

Nutrition Transition and Its Health Outcomes

Advances in agriculture and food systems, consequent increases in food availability, and a shift in dietary consumption patterns with economic development and urbanization of developing societies leads to adverse health outcomes. The structure of the habitual diet is altered and is characterized by increasing consumption of fats, saturated fats largely from animal sources and sugars. Lifestyle changes in an increasingly urbanized environment which occurs concurrently contributes to a reduction in physical activity levels which promotes overweight and obesity. The essence of these changes is captured by the term ‘nutrition transition’ which accompanies the demographic and epidemiologic transition in these countries with economic development. The existing burden of undernutrition in developing countries is thus compounded by the adverse effects of the nutrition transition, notably the increasing prevalence of obesity and non-communicable diseases. This double burden of malnutrition adds to the health and economic burden of developing societies.     

Making the health system work for the delivery of nutrition interventions

Addressing malnutrition requires strategies that are comprehensive and multi‐sectoral. Within a multi‐sectoral approach, the health system is essential to deliver 10 nutrition‐specific interventions, which, if scaled up, could substantially reduce under‐5 deaths in high‐burden countries through improving maternal and child undernutrition. This study identifies the health system components required for the effective delivery of these interventions, highlighting opportunities and challenges for nutrition programmes and policies. We reviewed implementation guidance for each nutrition‐specific intervention, mapping the delivery process for each intervention and determining the health system components required for their delivery. We integrated the components into a single health systems framework for nutrition, illustrating the pathways by which health system components influence household‐level determinants of nutrition and individual‐level health outcomes. Nutrition‐specific interventions are typically delivered in one of four ways: (i) when nutrition interventions are intentionally sought out, (ii) when care is sought for other, unrelated interventions, (iii) at a health facility after active community case finding and referral, and (iv) in the community after active community case finding. A health system enables these processes by providing health services and facilitating care seeking for services, which together require a skilled and motivated health workforce, an effective supply chain, demand for services and access to services. The nutrition community should consider the processes by which nutrition‐specific interventions are delivered and the health system components required for their success. Programmes should encourage the delivery of nutrition interventions at every client–provider interaction and should actively generate demand for services—in general, and for nutrition services specifically.     

Children, avian influenza H5N1 and preparing for the next pandemic

The emergence of avian influenza A/H5N1 viruses has driven pandemic preparations to become government priorities across Europe. To date these viruses have remained poorly adapted to humans and the risk of a pandemic based on H5N1 is unquantifiable. However, the risk of a future pandemic is 100%. Preparations are essential and without these many avoidable deaths will occur. Children will be affected at least as much as adults and may play an important role in amplifying transmission. Pharmacological and public health interventions focused on children will save lives through suggested community measures such as pre-emptive closures of schools, and need to be considered carefully, balancing benefits against negative consequences. Child health services will be hugely stressed by any pandemic but also have the potential to save many lives. The challenge will be to deliver core services in the face of major staff illnesses. Detailed local business continuity planning will be essential.     

Integrating nutrition outcomes into agriculture development for impact at scale: Highlights from the Canadian International Food Security Research Fund

The Canadian International Food Security Research Fund programme supported research and scaling up of nutrition‐ and gender‐sensitive agriculture innovations from 2009 to 2018. Women and girls were identified as agents of change and were targeted as the main programme beneficiaries. Projects were implemented in 25 countries through multistakeholder partnerships among universities, research institutions, public and private sectors, and civil society groups, reaching over 78 million people, mainly women and children. Approaches specific to nutrition included growing more nutritious crops, improving dietary diversity, value added processing, food fortification, and nutrition education. Scale‐up for impact was achieved through a number of pathways that started with evidence through rigorous research, followed by a combination of elements such as understanding local and regional contexts to identify specific bottlenecks and opportunities for the deployment and adoption of successful innovations, selecting politically effective or influential partners to lead the scaling up process, and investing in long‐term local capacity and leadership building. Overall, the knowledge generated in the programme indicate that well‐designed nutrition‐sensitive agriculture and food‐based interventions can have meaningful impacts on pathways that will lead to better health and well‐being of women and children through improving household and individual access to nutrient‐rich foods. Longer intervention times are needed to demonstrate changes in health indicators such as reduced stunting. This overview paper summarises the programme and showcases examples from studies that demonstrate the impact pathway for nutrition interventions that encompass efficacy and effectiveness studies, value‐added processing, cost effectiveness of interventions, and bringing a proven intervention to scale.     

Children, avian influenza H5N1 and preparing for the next pandemic.

The emergence of avian influenza A/H5N1 viruses has driven pandemic preparations to become government priorities across Europe. To date these viruses have remained poorly adapted to humans and the risk of a pandemic based on H5N1 is unquantifiable. However, the risk of a future pandemic is 100%. Preparations are essential and without these many avoidable deaths will occur. Children will be affected at least as much as adults and may play an important role in amplifying transmission. Pharmacological and public health interventions focused on children will save lives through suggested community measures such as pre-emptive closures of schools, and need to be considered carefully, balancing benefits against negative consequences. Child health services will be hugely stressed by any pandemic but also have the potential to save many lives. The challenge will be to deliver core services in the face of major staff illnesses. Detailed local business continuity planning will be essential.     

Addressing barriers to maternal nutrition in low‐ and middle‐income countries: A review of the evidence and programme implications

Adequate maternal nutrition during the “first 1,000 days” window is critical from conception through the first 6 months of life to improve nutritional status and reduce the risk of poor birth outcomes, such as low birthweight and preterm birth. Unfortunately, many programmes have targeted implementation and monitoring of nutrition interventions to infants and young children, rather than to women during pregnancy or post‐partum. A literature review was conducted to identify barriers to food choice and consumption during pregnancy and lactation and to examine how low‐ and middle‐income countries have addressed maternal nutrition in programmes. A literature review of peer‐reviewed and grey literature was conducted, and titles and abstracts reviewed by authors. Twenty‐three studies were included in this review. Barriers to adequate nutrition during pregnancy included cultural beliefs related to knowledge of quantity of food to eat during pregnancy, amount of weight to gain during pregnancy, and “eating down” during pregnancy for fear of delivering a large baby. Foods considered inappropriate for consumption during pregnancy or lactation contributed to food restriction. Drivers of food choice were influenced by food aversions, economic constraints, and household food availability. Counselling on maternal diet and weight gain during pregnancy was seldom carried out. Programming to support healthy maternal diet and gestational weight gain during pregnancy is scant. Tailored, culturally resonant nutrition education and counselling on diet during pregnancy and lactation and weight gain during pregnancy, as well as monitoring of progress in maternal nutrition, are areas of needed attention.     

Household food insecurity and child health

Food insecurity, the lack of consistent access to sufficient quality and quantity of food, affects an estimated 800 million people around the world. Although household food insecurity is generally associated with poor child nutrition and health in the USA, we know less about household food insecurity and child health in developing countries. Particularly lacking is research assessing how associations between household food insecurity and children's health outcomes may differ by child age and among children beyond age 5 years in low‐income settings. We use data from a population‐based sample of households with children ages 3–11 years (N = 431) in León, Nicaragua to consider how household food insecurity is associated with three measures of child health: illness, anaemia and low height‐for‐age. Our results provide new evidence that even mild household food insecurity is detrimental to children's health; and that child age conditions the associations between household food insecurity and child health. We find that food insecurity is especially harmful to health during early childhood, but continues to have significant associations with health into middle childhood (up to ages 7–8 years). We discuss the potential implications of these results for future child health research and policies in low‐income countries. © 2016 John Wiley & Sons Ltd     

Food Allergy in childhood: phenotypes,prevention and treatment

The prevalence of food allergy in childhood increased in the last decades, especially in Westernized countries where this phenomenon has been indicated as a second wave of the allergic epidemic. In parallel, scientific interest also increased with the effort to explain the reasons of this sudden rise and to identify potential protective and risk factors. A great attention has been focused on early exposures to allergenic foods, as well as on other nutritional factors or supplements that may influence the immune system in a positive direction. Both interventions on maternal diet before birth or during breastfeeding and then directly on infant nutrition have been investigated. Furthermore, the natural history of food allergy also seems to be changing over time; IgE‐mediated cow's milk allergy and egg allergy seem to be more frequently a persistent rather than a transient disease in childhood, as described in the last years. Food avoidance and the emergency drugs in case of an adverse event, such as epinephrine self‐injector, are currently the first‐line treatment in patients with food allergies, with a resulting impairment in the quality of life and social behaviour. During the last decade, oral immunotherapy emerged as an optional treatment with remarkable results, offering a novel perspective in the treatment for and management of food allergy.     

Marketing of commercial milk formula during COVID-19 in Indonesia

Baby food marketing poses a substantial barrier to breastfeeding, which adversely affects mothers' and children's health. Over the last decade, the baby food industry has utilised various marketing tactics in Indonesia, including direct marketing to mothers and promoting products in public spaces and within the healthcare system. This study examined the marketing of commercial milk formula (CMF) and other breast-milk substitute products during the COVID-19 pandemic in Indonesia. Using a local, community-based reporting platform, information on publicly reported violations of the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions (the Code) was collected. It was found that a total of 889 reported cases of unethical marketing of such products were recorded primarily through social media from May 20 through December 31, 2021. Our results suggest that the COVID-19 pandemic has provided more opportunities for the baby food industry in Indonesia to attempt to circumvent the Code aggressively through online marketing strategies. These aggressive marketing activities include online advertisements, maternal child health and nutrition webinars, Instagram sessions with experts, and heavy engagement of health professionals and social media influencers. Moreover, product donations and assistance with COVID-19 vaccination services were commonly used to create a positive image of the baby food industry in violation of the Code. Therefore, there is an urgent need to regulate the online marketing of milk formula and all food and beverage products for children under the age of 3.     

‘The second mother’: How the baby food industry captures science,health professions and civil society in France

Most babies in France are fed with infant formula and then commercial complementary foods, many of which are ultra‐processed and harmful to health. Internationally, there is opposition by the baby food industry to the introduction of public health policies that would limit the marketing and consumption of such products. Our aim was to identify the key baby food industry actors, describe their history and corporate political activity (CPA) in France. We sourced publicly available information, which we triangulated with data from 10 semi‐structured interviews. Qualitative thematic analysis was undertaken simultaneously to data collection, guided by an existing classification of the CPA of the food industry. The baby food industry in France has shaped the science on infant and young child nutrition and nurtured long‐established relationships with health professionals. This corporate science and these relationships helped baby food companies to portray themselves as experts on child‐related topics. The baby food industry has also engaged with a broad range of civil society organisations, particularly through the concept of the first 1000 days of life, and during the covid‐19 pandemic. We found evidence, although limited, that the baby food industry directly lobbied the French government. Since its early development in France in the 19th century, the baby food industry used its CPA to promote its products and protect and sustain its market. Our findings can be used to recognise, anticipate and address the CPA of this industry, and to minimise any negative influence it may have on babies'' and mother''s health.