On December 5th, 2016, Transform Nutrition Co-Research Director John Hoddinott gave a seminar on issues surrounding chronic undernutrition in Ethiopia. In addition to reviewing current trends and the factors associated with these, Dr Hoddinott summarized TN research on chronic undernutrition in Ethiopia, conveying key messages and outlining areas requiring attention in the future. The lecture was attended by representatives from civil society organizations, academics, government officials and researchers.

1. Reducing chronic undernutrition in Ethiopia:
Retrospect and prospects
John Hoddinott
Cornell University
* Drawing on work undertaken with Guush
Berhane,Yaeeun Han, Derek Headey, Kalle
Hirvonen, Neha Kumar, Bart Minten, Seollee
Park, and David Stifel

2. Chronic undernutrition
Given age and sex:
(HAZ) Height for age Z score = (measured height – median height for
reference child) / SD
• Low HAZ reflects limited skeletal (linear) growth – it captures the
cumulative effects of poor nutrition (food intake, illness or both). Low HAZ
reflects chronic undernutrition
• A child is considered:
– Moderately stunted if she has a HAZ ≤ -2
– Severely stunted if she has a HAZ ≤ -3

3. Consequences of chronic undernutrition:
Motor cortex dentrites by child nutritional status
Well nourished
children
Undernourished
children
Cordero et al, 1993

4. Neurological consequences of chronic undernutrition in
the first two years of life
• In the brain, development of axonal and dentritic systems is complete by 24 months.
In children who are chronically undernourished:
• Dentrites in the motor cortex and the occipital lobe (responsible for the processing of visual
information) are shorter, having fewer spines and greater numbers of abnormalities;
consequently, chronic malnutrition leads to delays in the evolution of locomotor skills
• There is reduced dentrite density in the hippocampus. This adversely affects spatial
navigation and memory formation
• There is reduced production of glia cells (cells in the brain responsible for producing myelin);
reduced myelination of axon fibers slows the speed at which signals are transmitted across
neurons
• There is a decrease in the number of neurons in the locus coeruleus which plays a role in
signalling the need to inhibit the production of cortisol. Thus early-life chronic undernutrition
diminishes the ability to exhibit down regulation and handle stressful situations.

5. Further consequences of chronic undernutrition
• Considerable evidence now exists showing that chronically
undernourished children attain fewer grades of school, drop out earlier
and score poorly on tests of cognitive ability
– None of this is surprising given the adverse neurological consequences of chronic
undernutrition
• Reduced schooling leads to lower economic productivity, lower incomes
and higher rates of poverty
• A study that traced individuals over a 35 year period found that a 1SD ↑ in
HAZ at age 24m was causally linked to a 21% ↑ in per capita consumption
in adulthood and a 10 percentage point reduction in the likelihood of
living in poverty (Hoddinott et al, 2013)

6. Trends in chronic undernutrition in Ethiopia
(Source: DHS)
55.4
51.3
44.4
38.4
0
10
20
30
40
50
60
2000 2005 2011 2016
17 p.p reduction
1.06% py
Among top five developing
countries

7. Drivers of change in stunting: 2000 – 2011
(Source: Headey, Hoddinott and Park, 2016)
• Regression decomposition analysis using DHS data from 2000 and 2011
shows that rise in assets (proxy for income) accounts for about 20 percent
of the reduction in stunting
• Improvements in health care (% mothers receiving 4+ ANC visits; child
being born in a health center) also contribute
• Improvements in maternal schooling and reductions in open defecation
play a role but the magnitudes of these effects are small

8. Selected growth rates: 2000-2015
(Source:WDI)
9
8.5
3.9
1.1
-2
0
2
4
6
8
10
Mean annual
growth in
GDP
Mean annual
reduction in
child
mortality
Mean annual
growth in
agricultural
production
Mean annual
reduction in
stunting

9. Prevalence of stunting by child age and DHS round
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
<6 months 6 to 8 months 9 to 11 months 12 to 17 months 18 to 23 months 24 to 35 months 36 to 47 months 48 to 59 months
2005 2011 2016

10. Change in prevalence of stunting across age groups and
DHS round
% stunted 2005
6-8m 26.6
18 – 23m 61.7
Increase 35.1
% stunted 2011
6-8m 12.2
18 – 23m 49.9
Increase 37.7
% stunted 2016
6-8m 15.3
18 – 23m 47.2
Increase 31.9

11. From retrospect to prospect:
Addressing chronic undernutrition in children 6-23m
• So why does stunting continue to rise so dramatically between ages 6 and
23 months in a country where agricultural production has risen by 8.5
percent per year for the last 10 years?
• Some of this is related to delays in the introduction of complementary
foods, some is related to the lack of caloric density in foods given to
infants and some may be related to insufficient meal frequency
• Further, children in this age group consume a remarkably monotonous
diet

12. Addressing chronic undernutrition in children 6-23m:
Diet quality
• Why might this lack of diversity matter?
– Children consuming more diverse diets consume more calories
And/or
– There is something specifically important about the foods found in a diverse diet
• For example, cow’s milk (in addition to being an important source of
animal-source protein, amino acids, calcium, iron, and vitamin B-12)
stimulates the secretion of insulin-like growth factor I (IGF-I), the hormone
that stimulates bone and tissue growth

13. Addressing chronic undernutrition in children 6-23m:
Diet quality
• Rapid advances are occurring in metabolomics – the study of small
molecule chemicals that are the consequence of metabolic processes.
• For example, recent work has shown that when essential amino acids are
absent from diets:
– The body represses protein and lipid synthesis and cellular growth
– Bone growth is restricted
• Essential amino acids cannot be synthesized from scratch within the
human body; these must be obtained via diet. The best sources are animal
sourced foods (meat, poultry, fish, eggs). Plant sources also contain these,
but typically in much lower concentrations.
• Biochemical analysis by Semba et al (2016a) of serum blood samples in
Malawi showed that stunted children lacked all essential amino acids.

14. Addressing chronic undernutrition in children 6-23m:
Diet quality
• Metabolomic work has also focused attention on choline, an essential nutrient
• Choline is needed for the synthesis of phosphatidycholines; this synthesis is
needed for bone formation and cell membrane formation.
• Choline also appears to play a role in neurotransmitter synthesis which plays a role
in the transmission of chemicals across synapses in the brain
• Eggs are an excellent source of choline. Flesh foods (beef, chicken) are another
source as are groundnuts, though the latter contain much less choline than eggs
• Semba (2016b) find that in Malawi, children with low serum choline
concentrations are more likely to have experienced linear growth failure

15. Addressing chronic undernutrition in children 6-23m:
Diet quality
• What do diets of Ethiopian children look like?
• Most recent example comes from 2016 survey of Highland households
where the PSNP operates. In this sample, 47 percent of children age 6-
23m are stunted. Looking at their diets:
– 19.5% consume dairy products
– 1.3% consume flesh foods (meat, poultry, fish)
– 3.5% consume eggs
– (Earlier DHS data show similar results)
• With the important caveat that I am describing associations in these data:
– Recent advances in nutritional sciences tell us that animal source foods (dairy, meat,
chicken, fish, eggs) contain nutrients critical for child growth
– The vast majority of Ethiopian children aged 6-23m do not consume these foods
– And we continue to observe high prevalences of stunting in this age group

16. Improving diet quality in children 6-23m (1)
The role of knowledge and beliefs
• One reason why diet quality is poor is that mothers may be unaware of
the nutritional benefits of these foods or may even perceive them to be
harmful
– For example (Han, 2016 unpublished) finds in focus group discussions that mothers do
not feed children 6-12m eggs or meat because they are perceived to cause digestive
problems
• So is poor dietary quality a consequence of poor nutrition knowledge?
• Hirvonen et al (2016) show that a 1SD ↑ in mother’s nutrition knowledge
increases the number of food groups children <60m consume by 0.85 even
after controlling for household wealth and the endogeneity of nutrition
knowledge.
• But the Hirvonen et al results disappear for households most remote from
food markets

17. Maternal nutrition knowledge and diet quality by market
access

18. Improving diet quality in children 6-23m (2)
The role of income
• A second reason why diet quality is poor is that many households may be
too poor to afford the foods needed for a high quality diet
• Analysis of DHS data from Ethiopia shows that growth in asset ownership
is associated with reductions in stunting
• But … first results from the 2016 Ethiopian DHS show that:
– 27% of children in the highest wealth quintile are stunted
• Analysis of earlier phase of PSNP (Hoddinott, Berhane and Kumar, 2016)
showed that PSNP participation had:
– No impact on stunting
– No impact on diet quality

19. Improving diet quality in children 6-23m (3)
The role of home production
• Using FtF data, Hirvonen and Hoddinott (forthcoming) show that a one
food group ↑ in household food production leads to a 0.6 ↑ in the
number of food groups consumed by children 6-59m
• Using AGP baseline data, Hoddinott, Headey and Dereje (2015) find that
after controlling for household wealth and income, ownership of dairy
cows reduces the prevalence of stunting in children 12-24m by 9.1
percentage points
• Hirvonen and Headey (2016) find that ownership of poultry is associated
with an increase in HAZ of children 0-59m by 0.29
• So does the solution to diet quality lie in home production?

20. Improving diet quality in children 6-23m (3)
The role of home production
• The Hoddinott et al “milk” results disappears for children residing in
households where there is a local food market
• The Hirvonen and Hoddinott results disappear for households living less
than 3km from a food market
• Hirvonen and Headey’s beneficial association of poultry and HAZ is
completely offset when poultry are kept in the house
• Unpublished preliminary work by Han, Kim and Park replicating the “milk”
results in Bangladesh find that ownership of livestock (primarily dairy
cattle) increases HAZ but nearly all of this beneficial effect is offset when
cattle are allowed to roam within the homestead

21. Chronic undernutrition and exposure to animal fecal matter
• The Hirvonen and Headey and the Han et al results are consistent with recent
work on environmental enteropathy, also known as tropical
enteropathy or Environmental Enteric Dysfunction (EED), a subclinical disorder
believed to result from frequent intestinal infections.
• The basic idea is that in resource-poor settings, very young children are
continually exposed to bacterial infections, particularly through contact (or
consumption) with animal (or human) fecal material in places where they eat
or play. Often, the acute symptoms are minimal.
• However, this means that on an ongoing basis, the child’s body is diverting
energy to fit off infection.
• The longer term consequence of this are a series of changes in the child’s
intestinal system. These changes result in poor absorption of energy and
micronutrients. Reduced energy absorption reduces growth.
21

22. Reducing chronic undernutrition in Ethiopia:
Summary and Prospects
• Some caveats before we begin
• I have not talked about
– Other dimensions of undernutrition such as wasting and micro-nutrient deficiencies
– Other important nutrition behaviors including the importance of maternal nutrition and
breastfeeding
– Programmatic interventions including those undertaken by the Government of Ethiopia
(for example, the role of Health Extension Workers) and its development partners (for
example: Alive and Thrive; and ENGINE)
• These are all clearly important; there simply is not enough time today to
discuss them all
• In some aspects of the material discussed today, I have talked about causal
relations but in others, the relationships described are associational

23. Reducing chronic undernutrition in Ethiopia:
Summary and Prospects
• Reducing chronic undernutrition has both intrinsic and instrumental value.
In the long run, given the links from:
– Chronic undernutrition to neurological development
– Neurological development to schooling
– Schooling to income
• Reducing chronic undernutrition is a prerequisite for sustainable poverty
reduction
• Ethiopia has made impressive progress in reducing chronic undernutrition;
this progress is amongst the fastest in the developing world

24. Reducing chronic undernutrition in Ethiopia:
Summary and Prospects
• That said, the rate of change in chronic undernutrition is slow when
compared to country income growth, agricultural production and
reductions in child mortality
• The rate of increase in chronic undernutrition from ages 6-8m (when
complementary foods are introduced) to 18-23m (when neurological
development is largely complete) has barely changed since 2005
• Growing body of work in nutritional sciences suggests that animal source
foods (dairy; flesh foods; eggs) are necessary for linear growth
• But in Ethiopia, children 6-23m almost never consume flesh foods or eggs
and even milk consumption is low

25. Reducing chronic undernutrition in Ethiopia:
Summary and Prospects
• It is tempting to believe that “single solutions” can reduce chronic
undernutrition, especially in children 6-23m. But this would seem to be
wishful thinking
• Improving knowledge of good nutritional practices will improve diet
quality:
– But not if food markets are inaccessible
• Increasing incomes will solve the problem of undernutrition
– But not always
• Let’s give everyone a cow! Or some chickens!
– But if these animals roam free, these possible benefits will not materialize
– And market access may act as a substitute for these

26. Reducing chronic undernutrition in Ethiopia:
Summary and Prospects
• Instead, prospects for reducing chronic undernutrition may
well hinge on the interplay between:
– Improving nutrition knowledge
– Having the resources income to acquire diverse foods, especially
animal source foods
– Enhancing access to diverse foods through markets or, where it makes
economic and agro-ecological sense, through own production
– Increased attention to both human and animal hygiene

27. References
Cordero, M., et al, 1993. “Dentric development in neocortex of infants with early postnatal life undernutrition”, Pediatric
Neurology 9(6): 457-464.
Headey, D., J. Hoddinott and S. Park, 2016. “Accounting for nutritional changes in six success stories: A regression-decomposition
approach”, mimeo.
Headey, D. and K. Hirvonen, 2016. “Is exposure to poultry harmful to child nutrition? An observational analysis for Ethiopia”, PLoS
One 11(8) e0160590
Hoddinott, J., G. Berhane and N. Kumar, 2016. “The impact of Ethiopia’s Productive Safety Net Programmme on the Nutritional
Status of Children: 2008 – 2012”, mimeo.
Hoddinott, J., D. Headey, and M. Dereje, 2015. “Cows, missing milk markets and nutrition in rural Ethiopia,” Journal of
Development Studies, 51(8): 958-975.
Hoddinott, J., J. Maluccio, J. Behrman, R. Martorell, Paul Melgar, Agnes R. Quisumbing, Manuel Ramirez-Zea, Aryeh D. Stein, and
Kathryn M. Yount, 2013. “Adult consequences of growth failure in early childhood,” American Journal of Clinical Nutrition, 98:
1170-1178.
Hirvonen, K. and J. Hoddinott, forthcoming “Agricultural production and children’s diets: Evidence from rural Ethiopia”,
Agricultural Economics.
Hirvonen, K., J. Hoddinott, B. Minten and D. Stifel, 2016. “Children’s diets, nutrition knowledge, and access to markets", mimeo.
Semba, R., et al, 2016a. “Child stunting is associated with low circulating amino acids”, EBioMedicine 6: 246-252.
Semba. R., et al, 2016b. “The association of serum choline with linear growth failure in young children from rural Malawi”,
American Journal of Clinical Nutrition 104: 191-7.