Interview: Unpacking integrated nutrition with IFPRI’s Harold Alderman

Harold Alderman: Food security is one of the pillars of good nutrition—it’s a necessary condition, but not a sufficient condition. Often countries wrongly think providing food is enough. But your question raises the issue—how does nutrition relate to productivity? For food security, it’s got some elements of manual strength, which is a documented subset of the role of nutrition. Research from Bangladesh shows returns to investments in health vary across gender: Males go towards agriculture and those who are stronger do better, while women tend to go towards schooling. Iron particularly leads to higher work capacity. Our research on nutrition and productivity shows nutrition leads to earlier and more schooling, better comprehension and retention, and eventually higher wages. It probably holds true for making better agricultural decisions, say for instance, from understanding fertilizer ratios, as agricultural productivity tends to work in the same direction as non-agriculture wages, but that is harder to document. There are a lot of studies on schooling, education, and adoption of technology. And we know there are a lot of studies on nutrition and schooling, so one can infer that nutrition will affect adoption of technologies, which is fully consistent with a large body of literature on nutrition and education in general; and literature on education and agriculture. I haven’t seen the two put together in the same study, but it’s not much of a leap to go from nutrition to the food security question.

What are the various kinds of integrated nutrition approaches, and why are they important?

One integrated nutrition approach is social protection and nutrition; we generally target the malnourished or those at the risk of malnourishment. The second integrated approach is nutrition and agricultural, both on the policy and the program level. On the project level, this can be viewed as home gardens and diet diversity; homegrown school feeding which brings in agriculture, social protection, and nutrition. Evidence indicates local demand for things like eggs, vegetables and fruits; but in general, it depends on market integration, which hasn’t been studied enough. Another approach is the integration of nutrition and early childhood development. Nutrition as a program works best in the first 1,000 days; however, there’s a renewed emphasis now in the next 7,000 days, taking a child into adolescence. It should be seamless to transition from nutrition programs to childhood development programs, as they have the same infrastructure for implementation. One exception to these integrated nutrition agriculture programs is breeding research, which is predominantly biofortification. In my co-authored Lancet paper, we determined biofortification has enormous potential, given the examples of Ugandan sweet potatoes, iron-fortified beans in East Africa and central America, and various beans, as well as biofortified maize and cassava, which are expanding in coverage.

From your experience, what are some of the integrated nutrition approaches that had highest impact and the most sustainable results?

In social protection, we have much evidence now on linking social protection through either conditional or unconditional targeted transfers to nutrition. In cash transfer programs, one question is how much of it goes to diet diversity. We know beneficiaries allocate transfer funds to greater use of health services, but most studies on conditional or unconditional transfers haven’t documented anthropometric improvements. While there is access to better food, do they get better health? Can they obtain better preventative health? Do mothers take their iron pills? If income goes up $10 a month, will that help buy better health services or better sanitation? Better sanitation is necessary, but can’t be purchased without other programs. Conditional cash transfers are promising, but not quite the panacea. Conditional transfers aren’t the best investments for nutrition, but provide the best investments for equity.

One promising area comes from an IFPRI study that found if you tie the transfers to the nutritional education and behavior change communication, you get better nutrition results. Several countries have included nutritional educational programs in their social welfare reforms, including Mexico and Nepal. Other cash transfer programs have included actual supplementary food, however, there are challenges. For instance, supplementary food should not replace breastfeeding. Can that supplementary food also be used to prevent malnutrition or seasonal famine relief? In my recent book, I conclude the kind of transfers are situational and contextual.

How can social protection programs be made nutrition-sensitive and designed to deliver better nutrition outcomes?

To make social protection programs nutrition-sensitive, we must look at each region and see what is possible. Historically, animal-sourced protein, also containing adequate calories, has been shown to be valuable, although often out of reach for those in low-income countries. However, countries such as Nigeria have been providing eggs in school feeding programs. This is a model that states can follow. Eggs provide nutrition and can avoid food safety problems, as well as create local linkages.

How can nutrition be integrated into public health programs?

There are various approaches to integrate them: Some have failed, some have seen a modicum of success, while others have thrived. In India, they had the Accredited Social Health Activists (ASHA), social workers that were intended to link health center workers and communities. However, ASHAs were incentivized to bring down maternal mortality rates, so the focus became safe delivery. Instead of a nutrition worker, they became more of an obstetric assistant. When you incentivize one aspect, it’s a disincentive for the other. However, there are possibilities for integrating with the larger health system, and there are success stories too. For example, the Ethiopian public health system was clinic-based with limited impact; this has changed as they reorganized to trained health extension workers.

What is the role of gender in nutrition?

Better education and greater sense of autonomy in a mother leads to better nutrition outcomes. My 600,000 children study with Derek Headey showed that it is not just basic literacy, but the ability to learn and comprehend that results in better outcomes. The gap in primary education for girls has closed significantly; however, for older girls and women the gender gap increases, and is related to women’s empowerment. For example, if women cannot go out of their house without their husbands, they cannot go to the clinic; and even if they get an education but aren’t allowed to go to the clinic, then that education has negligible impact. IFPRI’s Women’s Empowerment in Agriculture Index (WEAI) studies education as it relates to better nutritional outcomes and domestic violence. Another aspect of gender and how it affects nutrition depends upon decision makers within the household. For instance, India, has designed programs where women need to have access to bank accounts, but all too often, the bank accounts are in the name of their husbands. This creates a barrier to access the programs. Programs that seek women as recipients must consider household separation of duties. Household duties are often separated by gender, with women producing food for the household, whereas men are involved in agricultural production. But if extension officers meet with only men, women don’t learn to grow better crops.

What are the various challenges to implementing integrated nutritional approaches?

There are multiple challenges for successful integrated nutrition programs. But if the plan is integrated and two-pronged, and sets goals for each, then programs can succeed. For example, in an integrated nutritional program, the goal is both agricultural productivity as well as diet diversity and nutritional outcomes. However, one doesn’t supersede the other.

Historically, researchers and those in the field have wanted to accomplish success in both areas, but that level of integration is difficult to achieve on ground. The best-case scenario for a successful integrated nutritional program is motivated local policymakers working together on issues as varied as home gardening, school feeding, obesity, and undernutrition.

You have worked extensively with the 2018 World Food Prize laureate, Dr. Lawrence Haddad, a former colleague at IFPRI. Could you please walk us through some of your most notable work with him?

Lawrence joined IFPRI first as a research assistant shortly after I had completed my dissertation and had become a fellow at the institute. With backgrounds in both nutrition and economics, our strong overlap of professional interests fostered regular conversations on puzzles either of us faced in our research. This included the question of how individual preferences become household investments in health as well as in agriculture. Following Lawrence’s initial forays into this question with Ravi Kanbur and also with John Hoddinott, I teamed up with him to synthesize the nascent literature on what is now a widely accepted perspective on intra-household bargaining over resources.

Norman Borlaug’s contribution to agriculture is immense and wide-ranging. Which aspect of his work stands out most to you, and may have influenced you on a personal level?

I can trace a “butterfly effect” of Dr. Borlaug’s work to my career choice. I traveled to India while still an undergraduate and volunteered at a rural residential school for children who had been purchased out of debt bondage in Bihar. The goal was to teach the latest agricultural techniques and have the children become change agents in their communities. The instructors were excited about the new varieties of wheat which were just being introduced in the state. Their enthusiasm was infectious and led to a lifetime respect for the CGIAR system and the innovations it has generated.

The post first appeared on the World Food Prize’s The Borlaug Blog.