The role of food gardens in addressing malnutrition in children (0-5 years)
THE ROLE OF FOOD GARDENS IN ADDRESSING MALNUTRITION IN CHILDREN (0-5 years)
This research was commissioned by the D G Murray Trust to enhance and support the work and strategy of the Early Childhood Development Portfolio.
Overview 2
Malnutrition in South Africa 2
Why is malnutrition an issue? 3
Interventions to improve nutrition 3
Food gardens as a nutrition intervention 5
Do food gardens improve the nutritional status of children? 6
Can food gardens provide sufficient nutrition? 6
The importance of micronutrients and Vitamin A 7
Income replacement 8
The importance of Nutrition education 9
Implementing successful food gardens 11
What to grow and how to grow it 11
Important elements for success 11
Setting: Rural versus Urban 12
Supplementary benefits of food gardens 14
Beyond Food Gardens 15
Conclusions 16
Way forward with this research 17
Justine Jowell
November 2011
Overview
Food insecurity, related to poverty, and low intakes of fruits, vegetables, energy and micronutrients, is widespread in South Africa. Despite the success of South Africa’s food security at a national level, there is little household food security, resulting in a range of social problems, including malnutrition.
Supporting the nutrition needs of children (0-5 years) is one of the aims of the DGMT’s ECD portfolio. The development of food gardens at an individual household level, in homes, ECD centres and schools, is a possible intervention to address this.
The nutritional impact of food garden projects is seldom measured, partly because this is difficult to do. This paper gathers relevant research from academic sources and informal interviews with NGOs working in food security and early childhood development, to attempt to reach some initial conclusions on the possible nutritional impact of food garden projects.
Malnutrition in South Africa
In 1999, children aged 1-9 years showed a national prevalence for underweight of 10.3%, stunting 21.6%, and wasting 3.7% which points to high rates of malnutrition in South Africa (National Food Consumption Survey (NFCS)). The prevalence of under-nutrition was highest in rural areas, particularly on commercial farms and in informal settlements, compared to urban areas.
According to the NFCS, dietary intake in most children was of low micronutrient status and was particularly inadequate in rural areas. One in two children had an intake less than half the recommended requirement for vitamins A, C, riboflavin, niacin, B6, folate, calcium, iron and zinc. This informed the basis of mandatory fortification of maize and wheat flour introduced in 2003.
Furthermore HIV contributes to an increased prevalence and severity of under-nutrition and micronutrient deficiency in children - more than 50% of HIV positive children become stunted or underweight and at least 1 in 5 develop wasting. Vitamin A deficiency has also been associated with increased morbidity and mortality in HIV-infected children, as well as increased mother-to-child transmission of HIV in pregnant women. Deficiencies in micronutrients required for normal functioning may also compound the risk of acquiring opportunistic infections and facilitate the progression to AIDS.
Even though South Africa is considered to be relatively food secure, more than 14 million people (35%) are vulnerable to food insecurity. Rural areas are particularly threatened as they include 70% of the country’s poorest households.
Hunger and under-nutrition are both outcomes of inadequate food intake but their meanings differ. Hunger is associated with not eating enough food, while under-nutrition refers to the lack of sufficient micronutrients. Addressing malnutrition is not just about ensuring access to food, but about ensuring that there is access to adequate types and diversity of food.
Hunger might have improved in South Africa, but malnutrition has not significantly improved because of the types of food consumed. The 2005 NFCS revealed that 1 out of every 5 children aged 1-9 years are stunted. This is only slightly better than the 1999 findings.
Why is malnutrition an issue?
Malnutrition remains the world’s most serious health problem and the single biggest contributor to child mortality. The Lancet estimates that malnutrition kills 3.5 million children and permanently damages 178 million globally. (The Lancet, Maternal and Child Under-nutrition Series, 2008).
Poverty and poor nutritional intake are significant causes of the high levels of poor infant and child physical growth and development. Poor nutrition can result in delayed cognitive development, long-term damaging effects on infants’ and children’s intellectual and psychological development, impaired immune functions and severe infection. As under-nutrition is a major contributor to the chances that an infant and child will succumb to a life threatening disease, it is estimated that poor nutrition accounts for about 40 per cent of under-five mortality in the developing world (www.gain.org).
Income poverty (low levels of household income, expenditure on food, employment status) is firmly linked with inadequate food consumption Stunting in early years is associated with inadequate growth and sub-optimal educational achievements (0.7 grade loss of schooling and seven months’ delay in starting school). In turn, sub-optimal educational achievement contributes to a reduction in lifetime earnings, and hence to poverty. A vicious cycle is thus created that needs to be broken. Improving nutrition for children therefore also has the potential to make inroads into changing the cycle of poverty.
Interventions to improve nutrition
Recent findings have highlighted evidence-based interventions that make a positive change to malnutrition (www.gain.org). These have been grouped into Essential Nutritional Actions, which promote, protect and support these behaviours:
· Exclusive breastfeeding for six months
· Adequate complementary feeding starting at six months
· Appropriate nutritional care of the sick and severely malnourished children
· Adequate intake of Vitamin A for women and children
· Adequate intake of iron for women and children
· Adequate intake of iodine by all members of the family.
The target of these interventions needs to be women and children during the period from pregnancy to 24 months as this is a crucial window for reducing undernutrition and its adverse effects (Lancet series on Maternal and Children under nutrition).
Although food gardens are not specifically mentioned, they have the potential to impact on Vitamin A intake (and in a lesser way iron intake), provide support for malnourished and sick children and potentially provide nutritional diversity to support complementary feeding. This potential is discussed later.
Food gardens as a nutrition intervention
The World Health Organisation advocates that to maintain a healthy diet with enough essential micronutrients, five portions of fruit and vegetables (400g collectively) need to be consumed daily. In 1996 the UNDP proposed that urban agriculture could contribute significantly to combatting urban hunger and malnutrition by providing increased and consistent access to fresh, nutritional food at lower than market cost. Households engaged in food production appeared to achieve greater food security and their nutritional status tended to be better than non-farming families of the same socio-economic status.
This initially positive view of food gardens was then tempered by increasing scepticism about the impact of food garden production. There was, and still is, some uncertainty about the ability of food gardens to deliver on nutrition outcomes, especially at the subsistence level largely because (according to Webb):
· It has been shown that cultivation does not necessarily lead to more consumption
· Often growers opt to grow maize thereby limiting diversity and not ensuring vitamin intake
· Consumption of vegetables takes place sporadically and at low levels
· There is not enough education around what constitutes a nutritionally deficient diet
· Emphasis on cash income at the expense of home consumption
More recently, some cautiously positive research has emerged, largely from the Asia-pacific region, but there are encouraging South African cases too. A more careful and critical approach is needed to understand the limits and possibilities of what food gardens can deliver to poor people, particularly in urban areas.
Evidence shows that food gardens have some success in acting as a buffer against crisis. Beyond the arguments around food security, they are supported for their proposed ability to provide nutritious food (improved nutrition status) to those who grow them, to provide access to nutritional diversity where this is difficult to achieve (in rural or very poor contexts) and - because they can help to build communities and empower their members.
This paper collates information from these various academic sources to form some conclusions about the potential of food gardens to impact on the nutritional status of children (and pregnant mothers) and provide access to nutritional diversity.
Do food gardens improve the nutritional status of children?
There is conflicting evidence as to the nutritional value of food gardens and scepticism about their ability to deliver on nutrition outcomes. For example, research into urban agriculture in Atteridgeville, Pretoria, showed that it is used as a strategy to improve food security[1], but on average home gardening did not provide enough to meet the daily nutritional requirements of children (only 6.7% of RDA), indicating that from a nutritional perspective it does not make an important contribution to food security (van Averbeke).
However, more recent South African studies, and many from Kampala and Bangladesh, have found that small-scale agriculture has had a positive and significant association with higher nutritional status in children. It is cautiously proposed that the existence of a food garden has the potential to provide nutritional benefit in terms of an increase in micronutrient intake, and potentially beneficial income replacement options, but with certain limitations.
Understanding these conflicting conclusions and making a case for the nutritional impact of food gardens requires understanding of:
· What is improved nutrition,
· The impact that income replacement has on nutrition,
· And the need for nutrition education in food garden interventions.
Can food gardens provide sufficient nutrition?
When one considers the impact on nutritional status of food gardens, one first needs to be clear on the definition of nutritional status. Good nutrition requires sufficient energy, protein and important micronutrients.
Insufficient intake of energy and protein (macronutrients), rather than vitamins and minerals (micronutrients), are at the root of most nutritional disorders in the developing world. Stunting and underweight are largely caused by the lack of sufficient energy-rich food and protein. Lack of micronutrients, such as Vitamin A, iron and iodine have impacts on disease immunity, illness and health in general. Depending on which outcomes you are trying to address, food gardens will have a greater or lesser nutritional impact.
In order to address stunting and underweight, increasing energy rich foods and protein is essential. Food gardens, unless they grow particularly calorie dense items like sweet potatoes and potatoes at a large scale, are generally not able to provide enough calories to support an energy-rich diet that is required to overcome the high incidence of stunting in South African children (Hendricks). This is ultimately provided by an increase in meat, calorie dense food and fats.
In order for food gardens to grow energy dense foods they need to be large enough and often semi-commercial. The ability for food gardens to make an impact on micronutrient status is, however, more encouraging.
The importance of micronutrients and Vitamin A
Many children and adults suffer from an inadequate intake of vitamins and minerals. In South Africa, 33% of pre-school children have vitamin A deficiency – this is severe enough to be considered a public health problem.
Currently Vitamin A is supplemented nationally through clinic health programmes for children aged 6 – 60 months. Compulsory iodization of table salt was introduced in 1995 and mandatory fortification of all of all maize meal and wheat flour with vitamin A, thiamine, niacin, riboflavin, pyridoxine, foliate, iron and zinc, came into effect in 2003. However these measures have had varying success.
Vitamin A supplementation does not reach all children, or for long enough. For children aged 6 to 11 months and 12 to 59 months, vitamin A supplementation coverage rates nationally were 72.8% and 13.9%, respectively (www.hst.co.za) - the low rates probably reflect the poor clinic attendance of children above 2 years after completing their infant immunisations.
Vitamin A deficiency results in a higher risk of maternal death, increased risk of death from measles and diarrhoea in children, reduced resistance to infections, delayed recovery from illness, and eye damage. Household food gardens have the potential to address this by providing an accessible source of micronutrients for family members.
In Bangladesh, food gardens are proven to provide dietary diversity and support the micronutrient intake for children. In South Africa, the research has been more divided, with a number of unenthusiastic conclusions made about its value in impacting on micronutrient intake. . However, recent research supports positive findings particularly in relation to Vitamin A intake.
Positive case stories in South Africa are reported by Faber et al (2002), with increased Vitamin A intake in children as a result of a home-based food production programme in rural KZN. One of the main reasons for this was the focus on growing Vitamin A rich foods. The project also had impact beyond those families with gardens. Increase in vitamin A intake was documented both for children from households with project gardens as well as for those without project gardens (although it was significantly higher for children with gardens.)
The Agricultural Research Council also conducted a food garden project in Lusikisiki, Eastern Cape, to investigate a food-based approach to dealing with Vitamin A deficiency. Evaluation of the project showed a favourable effect on child morbidity, nutritional knowledge and dietary intake of Vitamin A rich vegetables. Critically important to their success was the commitment of the health volunteers, and the use of staggered planting to ensure year round Vitamin A vegetables.
Income replacement
Although there is controversy about the ability of food gardens to generate a substantial income for gardeners, food gardens have the potential to both mitigate household expenditure on vegetables and, in some cases, generate a small income. This income ‘saving’ means that families are able to purchase more energy-dense foods and improve their nutrition because of the cost saving or income generated.
This is an important factor to consider when calculating the value of food gardens. In schools and ECD centres, the addition of vegetables to the school meals potentially frees some of the school-feeding budget to purchase additional foodstuffs. How regularly this happens in practise, and how large a saving is not clearly documented.
Studies show that an increase in income in rural areas results in increased expenditure on fresh and processed fruit and vegetables and meat, which has an impact on rural diets. The fact that social grants in South Africa appear to have been the most important contributor to reducing poverty and food insecurity in the poorest households, also illustrates the impact of income on nutrition (Aliber 2009).