Nutrition problems of Africa

Adequate nutrition has been recognised as an essential catalyst for economic and human development as well as for achieving the sustainable development goals⁽¹⁾. Yet, malnutrition continues to be a global problem, particularly in Africa. Despite the rich biodiversity of the African continent and the tremendous progress in food production and development programmes, Africa is still struggling to improve food insecurity, hunger and disease, but is experiencing a rapid increase in overnutrition linked to the development of non-communicable diseases (NCD). Sub-Saharan Africa has been described as ‘home to some of the most nutritionally insecure people in the world’⁽Reference Fanzo²⁾.

The world is experiencing the double burden of malnutrition, defined as the coexistence of undernutrition (wasting, stunting and micronutrient deficiencies) along with overweight and obesity and diet-related NCD within individuals, households and population throughout life⁽³⁾. These have been attributed to the nutrition, epidemiological and demographic transitions⁽³⁾. Reports show that while the global prevalence of stunting decreased between the year 2000 and 2015, the absolute number of children who are stunted in Africa are increasing^{(1, 4)}; from 50·4 million in 2000 to 59 million in 2016⁽⁵⁾. In many African countries, the report shows that wasting rates are ≥5 %; with seventeen countries having acceptable levels (5 %), twenty-five high levels (>30 %) or very high (>40 %) stunting rate. Overweight is also on the rise, increasing by more than 50 % between 2000 and 2015⁽⁴⁾ contrary to the global target of ‘no increase in childhood overweight’ of the sustainable development goals⁽⁵⁾. Obesity among women is 23·8 %; ranging from 5·7 % in Ethiopia to 50·5 % in Swaziland, while over twelve countries in Africa have prevalence rates of over 30 %⁽⁴⁾.

Micronutrient deficiencies (hidden hunger) are also major public health challenges in Africa. It has been shown that micronutrient deficiencies affect about 1·6 billion people and cause economic losses estimated at 2–5 % of gross domestic product in low- and middle-income countries (LMIC)⁽⁶⁾, particularly among pregnant and lactating women, young children and adolescent females⁽Reference McLean, Ogswell and Egli^7–Reference Thurnham⁹⁾. Micronutrients of public health importance include vitamin A, iron, iodine, zinc⁽Reference Harika, Faber and Samuel¹⁰⁾ and folate. They are necessary for growth and development of the child, for mother and child survival, cognitive development and learning potential of the child, preventing blindness and improving immunity⁽Reference Bleichrodt and Stanbury^11–Reference Rice, West, Black, Ezzati, Rodgers and Murray¹⁵⁾. Anaemia in women of reproductive age ranged from 22 to 23·4 % in Ethiopia and Rwanda to >60 % in Burkina Faso (72·5 %), Gambia (67·9 %), Guinea (64·9 %), Togo (64·1 %), Cote d'Ivoire (67·6 %) and Senegal (61·5 %). Furthermore, in eight countries, anaemia was shown to be 50–59 %⁽⁴⁾. For non-pregnant and non-lactating women, 39·8 % are anaemic⁽⁴⁾. Harika et al.⁽Reference Harika, Faber and Samuel¹⁰⁾ showed that anaemia was higher (23–53 %) than vitamin A deficiency (14–46 %) in all countries except South Africa, while zinc deficiency (>30 %) was higher in Ethiopia, Nigeria and South Africa.

There are also emerging NCD. Major NCD include CVD, diabetes, hypertension, chronic respiratory diseases, mental health and cancers^(3, Reference Greenberg, Deckelbaum, Eggersdorfer, Kraemer and Cordaro¹⁶⁾, while the main diet-related ones are diabetes and CVD⁽Reference Greenberg, Deckelbaum, Eggersdorfer, Kraemer and Cordaro¹⁶⁾. NCD were once regarded as diseases of the affluent but are now found in LMIC⁽Reference Popkin^17, Reference Thakur¹⁸⁾. It has been shown that in sub-Saharan Africa between 1990 and 2010, hypertension increased by 60 %, dietary risk factor by 45 %, high plasma glucose by nearly 30 %, while BMI has tripled⁽Reference Thakur¹⁸⁾. Death projections as a result of NCD in high-, middle- and low-income countries have been estimated to exceed the mortality attributed to the combined effect of HIV, tuberculosis, malaria and maternal–child undernutrition by 2030⁽Reference Rice, West, Black, Ezzati, Rodgers and Murray^15, Reference Thakur¹⁸⁾. NCD impact devastates social and economic burden. Estimates by the World Economic Forum⁽¹⁹⁾ revealed that the cost of NCD over a 15-year period in LMIC will reach US$14 T of which diabetes and heart diseases will take about US$8 T. The major risk factors for NCD are overweight/obesity, hyperglycaemia, elevated blood lipids and hypertension, all of which can be attributed to the nutrition transition⁽Reference Popkin¹⁷⁾ (shift to a western-type diet, which are high in saturated fat, sugar, salt and refined foods as well as low in fibre) taking place in LMIC. Other factors include smoking, alcohol consumption and reduced physical activity.

Causes of malnutrition

The causes of malnutrition are multi-factorial and multi-dimensional; hence nutritional problems cannot be solved by any one sector. The UNICEF conceptual framework gives a detailed account of the various causes of malnutrition, ranging from immediate causes (inadequate food intake and disease) to underlying causes (food insecurity, inadequate care and basic health services) and basic causes (socio-economic factors, cultural practices, education, governance and others). Their solution requires multidisciplinary and multi-sectoral approaches. These approaches have become the main themes of all the development programmes and agenda in recent times. It is important to note that none of these programmes can be implemented efficiently and successfully without adequate food composition data (FCD) of the foods consumed.

Global and regional goals and targets

Several development programmes and agenda have been put in place at the global, regional and national levels. Apart from global commitments made at the International Conference on Nutrition (ICN) 1 in 1992, the World Food Summit in 1996, the Millennium Development Goals in 2000, International Conference on Nutrition 2 and its Framework of Action in 2014⁽²⁰⁾, the Sustainable Development Goals⁽⁵⁾, the Scaling-Up Nutrition (SUN)⁽²¹⁾ Movement 2016–2020 and the United Decade of Action on Nutrition 2016–2025⁽²²⁾, Africa has made several efforts to solve the nutritional challenges in the continent. These include the African Regional Nutrition Strategy (2015–2025)⁽²³⁾, the African Union Malabo Declaration (2014)⁽²⁴⁾ and the African Union Agenda 2063⁽²⁵⁾. Although these programmes have in some cases yielded positive results in some countries, malnutrition remains a public health problem in Africa. The question is why? What are we doing wrong? What can we do differently?

Food composition data: a neglected issue

Many reasons can be given for the slow progress in achieving most of these development goals and targets. Buba⁽Reference Babu²⁶⁾ summarised some of the likely reasons such as failure to invest enough money, lack of leadership or poor governance, poor programme implementation, inadequate research and human resources. In the African Regional Nutrition Strategy⁽²³⁾ document, inadequate capacity (nutritionists and dietitians) was recognised as a major challenge in addressing the problems of diet-related NCD and undernutrition. In addition, the ‘piece meal approach’ of development partners which favour rapid success leads to a narrow focus on limited number of micronutrients. While all these are correct, the 2017 Global Nutrition Report⁽¹⁾ has recognised that data gaps have hindered accountability and progress. One of the data gaps identified is the lack of knowledge of what people are eating (and their contents), which makes it difficult to design effective intervention to improve diets and malnutrition. The Malabo Montpellier Panel report⁽²⁷⁾ stated clearly that ‘African government lack the necessary data to combat malnutrition, few collect data required to inform decisions makers about what people eat, and there is no functioning global dietary database’. In another recent review on global dietary surveillance, Micha et al.⁽Reference Micha, Coates and Leclercq²⁸⁾ confirmed and identified the non-availability or inadequacy of country-specific food composition tables (FCT)/food composition database (FCDB) as one of the major data gaps and challenges for the limited availability of global dietary data which are necessary for a wide variety of purposes, including to ‘model, design and implement specific dietary policies to reduce disease and disparities in different nations’.

Uses and users of food composition data

The importance of FCD has been recognised as far back as the 1940s by McCance and Widdowson⁽Reference McCance and Widdowson³⁵⁾ who stated that ‘a knowledge of the chemical composition of food is the first essential in dietary treatment of disease or in any quantitative study of human nutrition’. This statement remains true. The uses of FCD have evolved since then and are now being used in a way not envisaged in the past⁽Reference Burlingame^41, Reference Finglas, Berry and Astley⁴²⁾. Apart from being very essential for nutrition and dietetics practice, they are used directly or indirectly by non-nutrition and dietetics professionals ranging from ‘consumers to manufacturers, from researchers to policy makers, from economists to agriculture professionals, and from patients to clinicians’⁽Reference Finglas, Berry and Astley⁴²⁾. The need for FCD varies depending on practice for nutrition and dietetics professional⁽Reference Pennington³⁰⁾. The different uses of FCD are summarised in Table 1⁽Reference Williamson⁴³⁾.

Table 1. Different uses of food composition data by area of work⁽Reference Williamson⁴³⁾

Reliability of food consumption table/food composition database

It has been established that the practice of nutrition and dietetics requires reliable FCT/FCDB. The Merriam–Webster⁽⁴⁵⁾ dictionary defines reliability as the extent to which an experiment, test or measuring procedure yields the same results on repeated trials. In the case of FCD, reliability may simply mean accurate, dependable or good quality data. This is because the food system is very dynamic and so FCD may change from time to time as a result of more sensitive analytical equipment and procedures, discovery of new components that affect health, effect of climate and dynamic food supply. The quality of FCD is determined by a lot of factors, namely, how well the foods in the FCT/FCDB have been described, component identification and the appropriateness of the analytical procedures, and the representativeness of the sample (sampling), including sample handling. It is necessary also that the FCT/FCDB be as comprehensive as possible in terms of food as well as components of public health importance. According to Charrondiere et al.⁽Reference Charrondiere, Stadlmayr and Wijesinha-Bettoni⁴⁶⁾ three pillars are needed to ensure that high-quality FCD are generated, compiled, disseminated and used. They are: (i) international standards, guidelines and tools on the generation and compilation of FCD must be developed and used; (ii) national and/or regional food composition programmes must exist, which are updated regularly, and (iii) professionals must be trained in all aspects related to food composition.

In order to address the first pillar, the INFOODS has developed series of guidelines and tools to ensure that good quality FCT/FCDB are established. Some of these standards and guidelines are: (i) Identification of food components for INFOODS data interchange⁽Reference Klensin, Feskanich and Lin⁴⁷⁾; (ii) FAO/INFOODS guidelines for checking FCD prior to the publication of a user table/database, version 1·0⁽⁴⁸⁾; (iii) FAO/INFOODS guidelines for food matching 2012, version 1·2⁽⁴⁹⁾; (iv) FAO/INFOODS guidelines for converting units, denominators and expressions, version 1·0⁽⁵⁰⁾.

A FCDB management system has also been developed, namely: FAO/INFOODS compilation tool, version 1·2·1 and user guideline⁽⁵¹⁾. It is a simple FCDB management system in MS Excel format that allows countries to store, document and manage FCD electronically in accordance with FAO/INFOODS standards. The compiler has 151 components with their INFOODS tagname, three recipe calculation systems and a set of nutrient retention factors. It is the first FCDB developed for global use. Other FCDB management systems were developed by the EuroFIR which are ‘FoodCASE⁽Reference Presser, Weber and Norrie⁵²⁾: Food Composition, Consumption and Total Diet Studies data and Management’ designed to enable compilers create, complete and manage FCD and FoodExplorer⁽⁵³⁾ tool (a user-friendly web interface that houses the database of thirty countries with a harmonised food description and standardised value documentation).

The need for regional and country-specific FCT/FCDB cannot be overemphasised. Country-specific (national) FCT/FCDB are very useful because the composition of foods can vary from one geographical location to the other⁽Reference Greenfield and Southgate^29, Reference Pennington³⁰⁾; besides countries have different food habits in terms of the type of food they eat, the way they are processed, prepared, preserved and stored them⁽Reference Wolmarans and Danster⁵⁴⁾. All these have profound influence on their nutrient composition of foods. Apart from their existence, they need to be regularly updated as to reflect some of the changes occurring as a result of the advances in the science of nutrition and in the food system. As already mentioned, the 2012 West African Food Composition Table is already being updated. A few country-specific FCT have recently been updated, namely the Nigeria Food Composition Database⁽⁵⁵⁾ and the Kenyan Food Composition Table⁽⁵⁶⁾, while a few are in the process of updating.

Another aspect of high-quality FCT/FCDB as stated previously is that professionals must be trained in all aspects related to food composition. Food composition programme is complicated and involves data generation, compilation, dissemination and use by professionals; all of which require adequate knowledge. It has been observed that in all these activities, there is inadequate knowledge among generators, compilers and users. The use of inadequate analytical procedures, data calculations and estimation; wrong definitions and expression of units and denominators have been identified in some publications bringing about the dissemination of wrong information⁽Reference Stadlmayr, Charrondiere and Eisenwagen⁵⁷⁾. Poor quality data have grave consequences. According to Charrondiere⁽Reference Charrondiere⁵⁸⁾, inadequate FCD and their use may (then) lead to erroneous research results, wrong policy decisions (particularly in nutrition, agriculture and health), misleading food labels, false health claims and inadequate food choices.

Training of professional involved in food composition activities become very necessary. FAO/INFOODS has played a leading role in this aspect of capacity building. AFROFOODS members have been involved in several food compositions training courses in order to build capacity. Schonfeldt and Hall⁽Reference Schonfeldt and Hall⁵⁹⁾ summarised the trainings that took place from 1997 to 2010. More recently, AFROFOODS FAO/INFOODS have carried out numerous training workshops on food composition in Accra, Ghana in 2014; in Arusha, Tanzania in 2015, in Marrakech, Morocco in 2016 and recently in Ethiopia in 2018. In February 2018, the Global Challenge Research Fund/Quadram Institute organised a training workshop in Pretoria for African food composition compilers and researchers. FAO has also published a number of resources for training on food composition, such as the FAO/INFOODS Food Composition Study Guide (available in English, French and Spanish) or the FAO/INFOODS e-Learning Course on Food Composition Data published in English in 2013 and in French in 2018, they all can be accessed on the FAO website⁽⁶⁰⁾, free-of-charge. Notably, the e-learning course on food composition was designed for use by university students, but also very useful for professionals. It is an interactive, learner-centred course organised into fourteen lessons, for a total of about 10 h of self-paced learning. The e-learning course offers a wealth of examples, exercises and case studies based on best practices. Efforts are almost being concluded to incorporate the e-learning course into programmes in nutrition, food science, agriculture, public health and other nutrition-related disciplines, especially for the West African sub-region.

Availability/accessibility of reliable food consumption table/food composition database

Not many African countries have reliable FCT/FCDB; <50 % have FCT/FCDB, of which the majority are outdated. Most are in print form and so have very limited circulation or out of print. The limited availability of reliable FCT/FCDB in Africa has also been attributed to challenges with all aspects of FCD: generation, compilation and use as well as lack of human and material resources. Most countries lack the technical capacity to embark on this activity. Even where the technical experts are available, food composition activities are not adequately recognised and funded. Reliable FCD depend on standardised analytical methods and procedures. Currently only very few countries in Africa have standard analytical laboratories and facilities. It has also been observed that even where some analytical equipment exists, technical staff to install, operate and maintain them are lacking. All these are hindrances to FCD generation. FCT/FCDB are obtained from published data. It has been observed that the quality of some published FCT/FCDB cannot be relied upon due to poor documentation: including poor food description, lack of units, wrong sum of proximate, inability to identify whether values were expressed on dry or fresh weight basis, imprecise description of analytical procedures and implausible values⁽Reference Bruyn, Ferguson and Allman-Farinelli⁶²⁾. These challenges call for adequate training of all concerned with FCD generation, compilation and use. Professionals such as nutritionists and dietitians should be adequately trained in all aspects of FCD so that they will be able to identify some of these problems so as to guard and control them.

Poor coverage of foods and components

Apart from the reliability of any FCT/FCDB, it needs to be as comprehensive as possible. It is true that most FCT/FCDB can never be complete⁽Reference Pennington³⁰⁾. A good quality database should cover traditional foods, cooked/mixed dishes and recipes, manufactured and new foods, bio-fortified foods as well as components such as dietary fibre, cholesterol, amino acids, fatty acids, vitamins, minerals, bioactive substances, and contaminants, e.g. aflatoxin content of foods. All these components have been found to impact significantly (positively or negatively) on the health of population groups. The absence of these has made professionals borrow data from other databases⁽Reference Bruyn, Ferguson and Allman-Farinelli⁶²⁾. Table 2 shows the FCT used by nutritionists in Kenya⁽Reference Chege and Ndungu⁶³⁾. This was before the recent update of the Kenyan FCT. It revealed the limited use of FCT and the fact that they were mainly used for diet counselling and planning. The implication of this is the underutilisation of FCT/FCDB by nutritionists. It could also indicate the fact that these professionals are not actively engaged in other fields requiring the use of FCT/FCDB. This limited participation of nutrition professional in other intervention areas may also explain why nutrition problems persist in Africa.

Table 2. Usage of food composition tables (FCT) by nutritionist in Kenya⁽Reference Chege and Ndungu⁶³⁾

There are many problems with the use of borrowed data. One major reason is the unreliability of the data borrowed due to several factors that cause variability in the nutrient content of foods, such as soil, planting conditions, climate, level of technology, e.g. food fortification, to mention a few. A study comparing the mineral content of Iranian foods with United States Department of Agriculture FCDB, which is the commonly used table in Iran, showed large differences in the calcium content followed by iron, phosphorus and zinc⁽Reference Ghaemmaghamia, Mahdavib and Nikniaz⁶⁴⁾. The authors therefore advised that caution should be exercised when using data from other countries particularly in the case of evaluating nutrient adequacy and in designing nutrition policy. It is possible that some of the food and nutrition decisions taken in the past were not actually based on sound evidences.