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In Sub-Saharan Africa, the scale of undernutrition is staggering; 58 million children under the age of five are too short for their age (stunted), and 14 million weigh too little for their height (wasted). Poor diets in terms of diversity, quality, and quantity, combined with illness and poor water and sanitation facilities, are linked with deficiencies of micronutrients—such as iodine, vitamin A, and iron—associated with growth, development, and immune function. In the short term, inequities in access to the determinants of nutrition increase the incidence of undernutrition and diarrheal disease. In the long term, the chronic undernutrition of children has important consequences for individuals and societies: a high risk of stunting, impaired cognitive development, lower school attendance rates, reduced human capital attainment, and a higher risk of chronic disease and health problems in adulthood. Inequities in access to services early in life contribute to the intergenerational transmission of poverty. Recent World Bank estimates suggest that the income penalty a country incurs for not having eliminated stunting when today's workers were children is about 9–10 percent of gross domestic product per capita in Sub-Saharan Africa. Much of the effort to date has focused on the costing, financing, and impact of nutrition-specific interventions delivered mainly through the health sector to reach the global nutrition targets for stunting, anemia, and breastfeeding, and interventions for treating wasting. However, the determinants of undernutrition are multisectoral, and the solution to undernutrition requires multisectoral approaches. An acceleration of the progress to reduce stunting in Sub-Saharan Africa requires engaging additional sectors—such as agriculture; education; social protection; and water, sanitation, and hygiene (WASH)—to improve nutrition. This book lays the groundwork for more effective multisectoral action by analyzing and generating empirical evidence to inform the joint targeting of nutrition-sensitive interventions. Using information from 33 recent Demographic and Health Surveys (DHS), measures are constructed to capture a child's access to food security, care practices, health care, and WASH, to identify gaps in access among different socioeconomic groups; and to relate access to these nutrition drivers to nutrition outcomes. All Hands on Deck: Reducing Stunting through Multisectoral Efforts in Sub-Saharan Africa addresses three main questions: • Do children have inadequate access to the underlying determinants of nutrition? • What is the association between stunting and inadequate food, care practices, health, and WASH access? • Can the sectors that have the greatest impact on stunting be identified? This book provides country authorities with a holistic picture of the gaps in access to the drivers of nutrition within countries to assist them in the formulation of a more informed, evidence-based, and balanced multisectoral strategy against undernutrition.

The repercussions of climate change will be felt in various ways throughout both natural and human systems in Sub-Saharan Africa. Climate change projections for this region point to a warming trend, particularly in the inland subtropics; frequent occurrence of extreme heat events; increasing aridity; and changes in rainfall—with a particularly pronounced decline in southern Africa and an increase in East Africa. The region could also experience as much as one meter of sea-level rise by the end of this century under a 4 °C warming scenario. Sub-Saharan Africa’s already high rates of undernutrition and infectious disease can be expected to increase compared to a scenario without climate change. Particularly vulnerable to these climatic changes are the rainfed agricultural systems on which the livelihoods of a large proportion of the region’s population currently depend. As agricultural livelihoods become more precarious, the rate of rural–urban migration may be expected to grow, adding to the already significant urbanization trend in the region. The movement of people into informal settlements may expose them to a variety of risks different but no less serious than those faced in their place of origin, including outbreaks of infectious disease, flash flooding and food price increases. Impacts across sectors are likely to amplify the overall effect but remain little understood.

Maternal and child malnutrition in low-income and middle-income countries encompasses both undernutrition and a growing problem with overweight and obesity. Low body-mass index, indicative of maternal undernutrition, has declined somewhat in the past two decades but continues to be prevalent in Asia and Africa. Prevalence of maternal overweight has had a steady increase since 1980 and exceeds that of underweight in all regions. Prevalence of stunting of linear growth of children younger than 5 years has decreased during the past two decades, but is higher in south Asia and sub-Saharan Africa than elsewhere and globally affected at least 165 million children in 2011; wasting affected at least 52 million children. Deficiencies of vitamin A and zinc result in deaths; deficiencies of iodine and iron, together with stunting, can contribute to children not reaching their developmental potential. Maternal undernutrition contributes to fetal growth restriction, which increases the risk of neonatal deaths and, for survivors, of stunting by 2 years of age. Suboptimum breastfeeding results in an increased risk for mortality in the first 2 years of life. We estimate that undernutrition in the aggregate—including fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc along with suboptimum breastfeeding—is a cause of 3·1 million child deaths annually or 45% of all child deaths in 2011. Maternal overweight and obesity result in increased maternal morbidity and infant mortality. Childhood overweight is becoming an increasingly important contributor to adult obesity, diabetes, and non-communicable diseases. The high present and future disease burden caused by malnutrition in women of reproductive age, pregnancy, and children in the first 2 years of life should lead to interventions focused on these groups.

All around the world, inequalities persist in the complex web of social, economic, and ecological factors that mediate food security outcomes at different human and institutional scales. There have been rapid and continuous improvements in agricultural productivity and better food security in many regions of the world during the past 50 years due to an expansion in crop area, irrigation, and supportive policy and institutional initiatives. However, in Sub-Saharan Africa, the situation is inverted. Statistics show that food insecurity has risen since 2015 in Sub-Saharan African countries, and the situation has worsened owing to the Ukraine conflict and the ongoing implications of the COVID-19 threat. This review looks into multidimensional challenges to achieving the SDG2 goal of “End hunger, achieve food security and improved nutrition, and promote sustainable agriculture” in Sub-Saharan Africa and the prosper policy recommendations for action. Findings indicate that weak economic growth, gender inequality, high inflation, low crop productivity, low investment in irrigated agriculture and research, climate change, high population growth, poor policy frameworks, weak infrastructural development, and corruption are the major hurdles in the sustaining food security in Sub-Saharan Africa. Promoting investments in agricultural infrastructure and extension services together with implementing policies targeted at enhancing the households’ purchasing power, especially those in rural regions, appear to be essential drivers for improving both food availability and food access.

Malnutrition continues to threaten the lives of millions across the world, with children being hardest hit. Although inadequate access to food and infectious disease are the primary causes of childhood malnutrition, the gut microbiota may also contribute. This review considers the evidence on the role of diet in modifying the gut microbiota, and how the microbiota impacts childhood malnutrition. It is widely understood that the gut microbiota of children is influenced by diet, which, in turn, can impact child nutritional status. Additionally, diarrhoea, a major contributor to malnutrition, is induced by pathogenic elements of the gut microbiota. Diarrhoea leads to malabsorption of essential nutrients and reduced energy availability resulting in weight loss, which can lead to malnutrition. Alterations in gut microbiota of severe acute malnourished (SAM) children include increased Proteobacteria and decreased Bacteroides levels. Additionally, the gut microbiota of SAM children exhibits lower relative diversity compared with healthy children. Thus, the data indicate a link between gut microbiota and malnutrition in children, suggesting that treatment of childhood malnutrition should include measures that support a healthy gut microbiota. This could be of particular relevance in sub-Saharan Africa and Asia where prevalence of malnutrition remains a major threat to the lives of millions.

Background: Over the last two decades, many sub-Saharan African (SSA) countries have undergone dietary and nutrition transitions fuelled by rapid urbanisation, economic development, and globalisation. The aim of the current study was to examine outcomes of the nutrition transition and the epidemiologic transition in SSA countries in terms of food intake, health, and socioeconomic and development factors. Methods: Food balance sheet data—specifically, per capita energy intake per day and per capita gram intake per day—from the CountrySTAT framework of the Food and Agricultural Organization (FAO) were analysed for major food commodities. Additionally, selected health and development indicators supplied by UNICEF, the WHO and the World Bank were analysed. Results: Four dietary patterns emerged. The diet of the southern African/island cluster (South Africa, Mauritius, Eswatini, Namibia, Cabo Verde, and the outlier Seychelles) resembles a Westernised diet, with median values high on sugar/sweeteners, alcohol, meat, animal fats, eggs, and dairy. On the other hand, the diet of countries in the other three clusters appears to be more traditional, with countries in the desert/semi-arid cluster consuming more cereals and pulses/tree nuts, countries in the tropical coastal cluster consuming more fish and vegetable oils, and countries in the equatorial cluster consuming more starchy roots and fruit and vegetables. The resulting median values of health indicators also indicate a higher prevalence of non-communicable diseases in the southern African/island cluster, whereas stunting and anaemia are higher in the other three clusters. Conclusions: SSA countries are in different stages of the nutrition transition. By superimposing clusters generated using macronutrient intake values on a map of the climatic regions in Africa, one can clearly see the importance of climate on the availability of food and food intake patterns. Climate change presents a great challenge to healthy eating, as the link between climate regions and diets is illustrated.

Dietary diversity plays a major role in the health status of children. However, evidence on its crucial role on children’s health status remains inconclusive in sub-Saharan Africa (SSA). In this study, we examined the association between dietary diversity and undernutrition among children aged 6–23 months in SSA. We pooled data from the most recent Demographic and Health Surveys of 32 countries in SSA from 2010 to 2020. A sample of 48,968 mother-child pairs of children within the ages of 6–23 months and mothers aged 15–49 years were included in this study. Multilevel logistic regression analysis was carried out to examine the association between dietary diversity and stunting, wasting, and underweight. The results were presented as crude odds ratios (cOR) and adjusted odds ratios (aOR) with their 95% confidence intervals. Statistical significance was set at p < 0.05. The overall prevalence of minimum dietary diversity was 25.1%, with South Africa recording the highest prevalence (43.9%) and Burkina Faso recording the lowest prevalence (5.6%). The highest prevalence of stunting was recorded by Burundi (51.8%) while the lowest prevalence was found in Ghana (13.6%), with an overall regional prevalence of 28.6%. For wasting, prevalence from all countries was found to be 9.4%. South Africa recorded the lowest prevalence of wasting (2.1%) while Niger recorded the highest prevalence (27.3%). Lastly, the prevalence of underweight ranged from 5.3% in South Africa to 41.8% in Niger, with an all-country prevalence of 16.4%. Children who had adequate minimum dietary diversity had 12% less likelihood of being stunted (aOR = 0.88, 95% CI = 0.83, 0.94), compared to those who had inadequate minimum dietary diversity. Having an adequate minimum dietary diversity significantly lowered the risk of underweight among children by 17% (aOR = 0.83, 95% CI = 0.77, 0.91). Having an adequate minimum dietary diversity was associated with 13% reduced odds of wasting among children (aOR = 0.87, 95% CI = 0.78, 0.97), compared to those who had inadequate minimum dietary diversity. This study highlights the significant association between minimum dietary diversity and stunting, wasting, and underweight among 6–23 month-old children in SSA. There is an urgent need for additional nutrition-specific interventions and strengthening of existing interventions aimed at improving infant and young child feeding practices, including complementary feeding practices among children aged 6–23 months in the 32 countries in SSA. Such interventions should focus more on countries where the prevalence of adequate minimum dietary diversity was low and undernutrition was high.

Malnutrition is a global challenge with huge social and economic costs; nearly every country faces a public health challenge, whether from undernutrition, overweight/obesity, and/or micronutrient deficiencies. Malnutrition is a multisectoral, multi‐level problem that results from the complex interplay between household and individual decision‐making, agri‐food, health, and environmental systems that determine access to services and resources, and related policy processes. This paper reviews the theory and recent qualitative evidence (particularly from 2010 to 2016) in the public health and nutrition literature, on the role that agriculture plays in improving nutrition, how food systems are changing rapidly due to globalization, trade liberalization, and urbanization, and the implications this has for nutrition globally. The paper ends by summarizing recommendations that emerge from this research related to (i) knowledge, evidence, and communications, (ii) politics, governance, and policy, and (iii) capacity, leadership, and financing. A mother tends to her village garden in Burkina Faso. This review addresses the global challenge presented by agriculture–nutrition disconnects that prevail in many countries. The authors comprehensively review the theory and evidence related to agriculture and food systems and their relationship to, and impact on, nutrition outcomes, not only in relation to undernutrition but also regarding increasing problems of overweight and obesity. The paper applies a framework to characterize enabling (or disabling) environments for nutrition and to structure a set of key recommendations on how to, practically and more effectively, leverage agriculture and food systems for nutrition.

Background Child growth stunting remains a challenge in sub-Saharan Africa, where 34% of children under 5 years are stunted, and causing detrimental impact at individual and societal levels. Identifying risk factors to stunting is key to developing proper interventions. This study aimed at identifying risk factors of stunting in Rwanda. Methods We used data from the Rwanda Demographic and Health Survey (DHS) 2014–2015. Association between children’s characteristics and stunting was assessed using logistic regression analysis. Results A total of 3594 under 5 years were included; where 51% of them were boys. The prevalence of stunting was 38% (95% CI: 35.92–39.52) for all children. In adjusted analysis, the following factors were significant: boys (OR 1.51; 95% CI 1.25–1.82), children ages 6–23 months (OR 4.91; 95% CI 3.16–7.62) and children ages 24–59 months (OR 6.34; 95% CI 4.07–9.89) compared to ages 0–6 months, low birth weight (OR 2.12; 95% CI 1.39–3.23), low maternal height (OR 3.27; 95% CI 1.89–5.64), primary education for mothers (OR 1.71; 95% CI 1.25–2.34), illiterate mothers (OR 2.00; 95% CI 1.37–2.92), history of not taking deworming medicine during pregnancy (OR 1.29; 95%CI 1.09–1.53), poorest households (OR 1.45; 95% CI 1.12–1.86; and OR 1.82; 95%CI 1.45–2.29 respectively). Conclusion Family-level factors are major drivers of children’s growth stunting in Rwanda. Interventions to improve the nutrition of pregnant and lactating women so as to prevent low birth weight babies, reduce poverty, promote girls’ education and intervene early in cases of malnutrition are needed.

Undernutrition and anaemia (the commonest micronutrient deficiency), continue to remain prevalent and persistent in sub-Saharan Africa (SSA) alongside a rising prevalence of overweight and obesity. However, there has been little research on the co-existence of all three conditions in the same household in recent years. The current study examines the co-existence and correlates of the different conditions of household burden of malnutrition in the same household across SSA. The study involved twenty-three countries across SSA who conducted Demographic and Health Surveys between 2008 and 2017. The analytical sample includes 145 020 households with valid data on the nutritional status of women and children pairs (i.e. women of reproductive age; 15-49 years and children under 5 years). Logistic regression analyses were used to determine household correlates of household burden of malnutrition. Anaemia was the most common form of household burden of malnutrition, affecting about seven out of ten households. Double and triple burden of malnutrition, though less common, was also found to be present in 8 and 5 % of the households, respectively. The age of the household head, location of the household, access to improved toilet facilities and household wealth status were found to be associated with various conditions of household burden of malnutrition. The findings of the current study reveal that both double and triple burden of malnutrition is of public health concern in SSA, thus nutrition and health interventions in SSA must not be skewed towards addressing undernutrition only but also address overweight/obesity and anaemia.