A woman my age, had she lived in Nigeria 500 B.C, might have been nearly a half a foot shorter.
She might have had children, but being in the reproductive age, might still be expected to have some more. She would have had nutritional requirements that covered her need to function with the right energy levels, but also to possibly have a few more children, continuously retain skin and muscle repair, and avoid bone loss and de-mineralization as she moves into her post-menopausal stage.
Just like me, she would have been challenged to provide adequate nourishment, not just for herself, but for the rest of her family.
Had she been knowledgeable about protein as a food type, she might have undervalued its place in her nutrition, as it might not have given her the immediate energy source as other starchy foods might, but this would have been an essential mistake.
Balancing the nutritional requirements needed in the domestic home is a challenge that is thousands of years old. Even today when humans have more knowledge about how food, calories, growth and development works, the quest to balance this knowledge with food production, access and security, remains a never-ending task.
Carbohydrates, proteins, healthy fats and minerals all have their place in what should be the healthy diet composition of human beings. Some food classes have been prioritised over others in many homes.
Globally, protein malnutrition is an insidious aspect of under-nourishment because to the consumer, this class of food does not provide the quick energy that Carbohydrates do. Protein foods are considered as “second best”, or only an accompaniment to the main meal, often of a starch class.
Proteins, divided into plant-sourced and animal-sourced, are considered difficult to include in the domestic dietary requirements. When proteins are from the animal sources, they have to be caught and killed, or reared, to be available for food. And when proteins are from plant sources, they have to be grown, processed and consumed in significant quantities to deliver on their nutritional value.
The early human, sourcing foods by himself and only for his family, would have therefore unwittingly laid the grounds for the beliefs that de-prioritize proteins as part of the daily diet, because of this difficulty. Sadly, much of this belief still holds, in various forms, even up till today.
How have nutrition policies solved problems in the past?
Today’s human is better off than that woman, my ancestor. As human societies grew and technology improved, food production and access became less of an individual matter.
Governments become more empowered to be able to pull collective efforts together, improve the individual’s chances at food access, and therefore improvements in food security, for their citizens.
So much so, that to achieve globally determined goals on nutrition, health and well-being as an end to poverty, national food planning is an essential part of what many governments all around the world do.
National nutritional policies arise from the need to target measured problems like household food security, Under-5 and child undernutrition and malnutrition, maternal and child health, infectious disease prevention, amongst other national indicators.
Global health is essentially the health of its individual nations. The overall desire to improve the nutritional health of the citizen has meant targeting the base problems that exist in a country with its specific solutions.
Nutritional policies respond to identified problems in different ways:
A nutritional policy could target the public’s access to information about a nutrition-related health condition; e.g. WHO multi-country collaboration on protein-energy malnutrition in children. It could be about the benefits of consuming certain foods e.g: the United States public-private collaboration to influence the increase in public dairy consumption: “got milk?”
Nutrition policies have also targeted fortification of foods with minerals, to increase the public’s consumption of such nutrients through eating foods rich in them, and many examples of these exist in global health.
Wheat flour fortification program in Jordan was implemented from 2002. The staple flour was fortified with iron and folic acid. From 2006, other micronutrients such as zinc, niacin and vitamins A and B were also added to the wheat fortification. Today, the fortified wheat, through the government program, constitutes 92.5 per cent of wheat flour products in Jordan, ensuring its availability nationwide. To ensure also that the fortification program succeeds, the wheat is also subsidized to make sure that as many households as possible can afford it.
In the ’90s in Nigeria, iodine deficiency was also combated by increasing the public’s education of the benefits of iodine in the diet, improving the knowledge of iodine deficiency conditions and finally by fortifying domestic table salt with iodine, to increase the consumption of iodine in the home.
In Vietnam, iron-deficiency anaemia was targeted by delivering iron supplements, especially to women of childbearing age as a response to national surveys which identified anaemia as a prevalent national problem in that country. The supplements were delivered through the village health worker directly to the women, alongside de-worming medication.
Post-implementation evaluations of these nutrition policies have always sought to find out if there was any significant improvement in the deficiency problems or diseases that the policies aimed to solve.
Nutrition policy evaluations always demonstrate that the dial movies in a positive shift in the direction aimed for. Even when there are differences in the degrees of success from place to place, the overall results are always an improvement from the problem intended to solve.
The Protein problem: A look at the Nigerian food plate.
The most recent DHS survey involved Nigerian adults from the age of 15 – 49, asked about household diet. The report indicates that 31.25 per cent consumed nuts and seeds, 20.38 per cent consumed a dairy product; cheese, yoghurt or milk, 70.68 per cent consumed meat/ fish/ poultry, 16.15 per cent consumed eggs, 72.9 per cent consumed dark green vegetables, and 7.47 per cent consumed insects or other small sources of protein.
Protein malnutrition and under-nourishment in Nigeria can be demonstrated from the successive national surveys done in both the adult and children population. Many argue that both stunting and protein-energy malnutrition figures in children and underdevelopment chronic anaemia in adult females, can be attributed to the poor diet of Nigerians, which includes poor inclusion of protein sources.
Body growth stunting can be measured across height for age, weight for height age and weight for age.
In the most recent survey of 1587 Nigerian children between 6 months and 5 years, stunting is demonstrated in the height for age as 19.2 per cent being -3 points in standard deviation from the mean, and 33.63 per cent being -2 points from the standard deviation from the square of the mean.
Similarly, weight for height stunting figures shows 9.45 per cent of the same children were -3 points standard deviation from the mean and 20.46 per cent -2 points from the square of standard deviation from the mean. In the last category of weight for age, 7.81 per cent were -3 point standard deviation from the mean and 21.45 per cent were -2 points standard deviation from the square of the mean. (data extracted from the Nigeria DHS 2018).
Data also extracted from the Nigeria Protein Deficiency Report 2019 also states that about 51 per cent of the survey respondents did not have access to protein-rich foods because of the costs.
Furthermore, this survey also highlighted the factors that influence the choice of meals in the home: availability of the food source, affordability of the food, taste of the food, knowledge of the nutritional value and personal choice or preference of the buyer.
Specifically, to protein, these knowledge, attitude and predispositions guiding the nutrition decision for it, include lack of information about the benefits of protein consumption, assumptions that proteins are only abundant in the animal form and that animal protein are expensive and prohibitive in costs.
Finally, cultural belief models about the Nigerian domestic diet entrenches carbohydrates/starchy foods as the main energy-giving foods, while proteins are only added as a small side complement to the meal.
The Policy design process: how to effectively target the surveyed points
To design an effective nutritional protein policy, the following watershed barriers should be targeted in a multi-pronged approach:
Education/ information: public knowledge and education about the benefits of protein should not be limited to school education and theory only. Re-learning and a lifelong familiarity about proteins’ benefits to the home-maker should be continued in public spaces like hospitals, primary health care centres, community centres and even in religious centres. Human education can be carried out by nurses, community health workers and community leaders.
Availability/ supply chain: Supply chain support can be entrenched by import/export policies that prioritise protein-rich foods. Agricultural and food production policies can also support farmers by way of fertiliser and farm-to-market transport subsidies or government-initiated protein produce purchase. This will encourage farmers to produce protein-rich plants and animal farmers to be able to produce proteins at a cheap-enough rate for the public to purchase and consume.
Affordability/ price/subsidy: Product availability will, through market forces, drive down the protein product cost and address price. However, to further ensure household affordability, subsidies can be used to further cheapen the price of the protein foods to a price point that can easily be afforded by household planners and providers.
Lessons learnt in global health, especially from developing nutritional policies in lower to middle-income countries, show that applying a multi-pronged approach to guide implementation gives the most lasting and sustainable results.
This means that to tackle stunting, malnutrition and protein deficiency through household food improvement, the policy must aim to tackle protein information, protein availability, protein affordability and protein price.
Dr. Adepeju Adeniran is a clinical and public health physician who has a career in global health policy development for LMIC. She is the Nigerian national co-chair of Women in Global Health.