Paper writing

Human Antibodies 27 (2019) 213–220 213 DOI 10.3233/HAB-190369 IOS Press

Impact of food insecurity and malnutrition on the burden of Non-communicable diseases and death in Ethiopia: A situational analysis

Ali Mohammad Mosadeghrada, Addis Adera Gebrub,c,∗, Ali Akbari Sarid and Tadesse Bekele Tafessee aDepartment of Health Management and Economics, School of Public Health, Health Information Management Research Center, Tehran University of Medical Sciences, Tehran, Iran bDepartment of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran cDepartment of Nursing, Faculty of Health Sciences, Woldia University, Woldia, Ethiopia dDepartment of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran eSchool of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia

Abstract. BACKGROUND: Currently, Ethiopia is undergoing an epidemiological transition. Consequently, NCDs are becoming an in- creasingly important public health problem in the country. Furthermore, the country has faced a high level of food insecurity. METHODS: We conducted a comprehensive review based on published articles from 2010 to 2018 and WHO reports on food insecurity, malnutrition and their impacts on the burden of NCDs death in order to obtain a deeper understanding of the serious- ness of the NCDs cause of deaths in relation to food insecurity and malnutrition. In addition, policy for protecting vulnerability and the implementation of SDGs on food insecurity, malnutrition, and NCDs were also discussed. The results of this review highlight the progress that was made in the overall condition of food insecurity, nutrition, and diseases in the country. RESULTS: The finding shows that there has been large burden of recurrent food insecurity, which could be due to malnutrition that might be associated to inconsistent rainfall distribution and also the experience of violent conflict in recent periods. However, the prevalence of undernourishment was declined from 75% in 1990s to 32% in 2015 though the numbers indicate a marginal reduction. But unexpectedly still the child mortality rate of under-five that results from malnutrition accounts about 57% of all children deaths. As the result of malnutrition, obesity is recognized as the determinants for a number of NCDs such as diabetes, cancer, and cardiovascular diseases. Communicable diseases seems the only identified health problem in the country, however; the burden of NCDs is facing major aspects. Hence, NCDs like cardiovascular diseases and diabetes, currently, are among the leading causes of death among adults, which is responsible for 39% of deaths in the country in 2015 while the risk of premature NCDs mortality was reached about 15.2%. Of these deaths, 4% was due to cancer and 9% was related to other NCDs such as obesity and nutrition-related cases. Therefore, food insecurity has a high-flying impact in early death from chronic health condi- tions and the cause of undernutrition that leads to an augmented susceptibility and decreased flexibility to NCDs as a result of compromised nutrition. CONCLUSION: In order to sustain the economic growth, reduce poverty and achieving food security, the Ethiopian government has started discourse at high level of agenda hoping to avoid recurrent violent conflict, food insecurity and famine by targeting urban low-income households and empowering youth and women.

Keywords: Food insecurity, malnutrition, non communicable diseases, Ethiopia

∗Corresponding author: Addis Adera Gebru, Lecturer at De- partment of Nursing, Faculty of Health Sciences, Woldia Univer-

sity, Ethiopia. Tel.: +25 19 8483 1393; E-mail: addisaderagebru@ gmail.com.

ISSN 1093-2607/19/$35.00 c© 2019 – IOS Press and the authors. All rights reserved

214 A.M. Mosadeghrad et al. / Impact of food insecurity and malnutrition on the burden of NCDs

Abbreviations

NCDs: Non Communicable diseases. SGDs: Sustainable Development Goals. WHO : World Health Organization.

1. Background

Non-communicable diseases (NCDs) are account- able for 70% (39.5 million) of deaths globally in 2015 [1]. The most important NCDs are diabetes, can- cer, cardiovascular diseases (CVDs) and chronic res- piratory diseases [1,2] and they are the leading public health challenges that destabilize the social and eco- nomic development [3]. The burden of these diseases is intensifying strangely in low- and middle-income countries and populations, which is responsible for 48% (30.7 million) of deaths prior to the age of 70 as compared with high-income countries (26%) [1,2].

In public health, food and nutrition has a crucial im- pact on both at the community and individual levels on the quality of life that is related to health and the socio-economy aspects as well [4]. Healthy nutrition and health promotion are the direct consequences of the availability and accessibility of a variety of safe foods [5]. Food security is one of the three contiguous causal elements of child nutritional status, including adequate care and health [6].

Food insecurity is the incapability to have enough food for a dynamic healthy life, which is highly linked with adverse health outcomes, particularly among chil- dren [7]. Food insecurity has a high-flying impact in early death from chronic health conditions and the cause of undernutration that leads to an augmented susceptibility and decreased flexibility to NCDs as a result of compromised nutrition [8]. These situations bring physically inactive individuals, which is one of the leading causes of obesity, type 2 diabetes mellitus and cardiovascular diseases [8]. The predictable under- nourished people were increased from 777 million in 2015 to 815 million in 2016 though there was a decline as compared to 900 million in 2000 [9]. Food security condition has noticeably exacerbated in population of the sub-Saharan Africa and South-Eastern and Western Asia [9].

One of the main causes of food insecurity is poverty, which is closely allied to NCDs and sustainable im- provement in poverty reduction is decisive to progress access to food [2,10]. Corruption, conflicts, terrorism and intensified climate-related deteriorations such as

environmental degradation, droughts and/or floods has also contributed extensively to food insecurity [9,10]. Even though achieving food security is a complex assignment; resolving conflicts, developing policies that guarantee peace, political and economic stabil- ity, enabling environmental sustainability, and expand- ing services and infrastructure is crucial in order to assure food security and prevent the occurrence of NCDs [1,10,11]. According to World Health Organiza- tion report in 2014, an estimated of 10.3 million peo- ple were food insecure, with over 1.4 million children at risk of severe acute malnutrition [12].

Malnutrition is one of the fundamental causes of death for greater than 3.5 million under-five children each year worldwide. As the consequence, 13 million infants were born with low birth weight and 55 mil- lion children were wasted. Globally, nearly 178 mil- lion children were stunted, of which 90% live in only 36 countries and Ethiopia is one of them [6]. Indi- viduals’ productivity can be impaired by the influence of malnutrition, which includes undernutrition, over- weight and obesity and hence, it reduces the national growth of a country [13].

Under-nutrition have various unfavorable outcomes, in addition to its direct effect on the growth and mal- nutrition consequences on the community, to a pos- sible threat of mounting NCDs [14]. Malnutrition is one of the severe impediments of various malignant and non-malignant diseases including NCDs [15]. Consequently, under nutrition in fetal life and chil- dren are vulnerable for double burden diseases more commonly through overweight and other related co- morbidities [16]. Unbalanced diet and over-nutrition causes an inception of NCDs that accounts at least 75% of all deaths, which even amplifies in developing coun- tries as a result of espousal of Westernization lifestyle and diet [17].

According to the Council on Foreign Relations, In- dependent Task Force on NCDs report in 2014, the tar- gets has been focused on alleviate poor diets and nutri- tion, physical inactivity, and obesity [18]. Concerning these issues, sustainable development goals (SDGs) have consists of 169 targets; of which reducing prema- ture deaths from NCDs by one third and end malnutri- tion in all its forms are the primary concerns [19].

Famine, food insecurity and infectious diseases are common causes for underweight worldwide. More- over, these factors might contribute to the challenges for the health care system due to rise in obesity [20]. The estimated rate of deaths due to obesity based NCDs accounts about 46% by 2030 [21]. Hence, cop- ing up with obesity related NCDs are important.

A.M. Mosadeghrad et al. / Impact of food insecurity and malnutrition on the burden of NCDs 215

The global burden of diseases and impaired qual- ity of life are affected with poor nutrition persistence that is caused by inappropriate investments in the coun- tries and the low consumption of nutrients [22]. More- over, diet related NCDs are a leading cause of mortality and contributes an increasing prevalence rate rapidly in both low- and middle-income countries [23].

Cultural globalization, mass migration, rapid un- intended urbanization, progressively more sedentary lives and worldwide travel are some other factors that rapidly increases the incidence of NCDs as a result of unusual utilization of alcohol and tobacco, unhealthy diet, excess calories, physical inactivity and increas- ing air pollution, which, in turn, causes overweight and obesity, elevated cholesterol and blood pressure level, and eventually diseased [1,24]. Moreover, a number of people die from NCDs than infections, pregnancy complications and famine in all regions excluding the sub-Saharan Africa cases.

In low- and middle-income countries (LMICs), both infectious and non-infectious diseases are well rec- ognized. Nevertheless, until recently, they had not been applied an integrated management properly [25]. Currently, one of the reasons for the rising burden of NCDs in developing countries is due to limited global health funds. As a result, the overall trends of death occurrences from NCDs are continued poten- tially [26,27]. NCDs account 29% and 13% of deaths in low- and middle-income and high-income countries, respectively among people who are under the age of 60 [8].

In Africa, both food insecurity and malnutrition are faced as a major public health problem in the regions. However, the problem progressed with newer but a growing burden of obesity and diet-related chronic dis- ease such as NCDs. WHO estimates that deaths from NCDs are likely to increase globally by 17% over the next 10 years while Africa will experience a 27% in- crease, that is, 28 million additional deaths, which are projected to exceed deaths due to communicable dis- eases by 2030 [12].

Ethiopia is one of the sub-Saharan African countries that are mostly affected by high diseases burden, short- age and imbalanced human resources, and socioeco- nomic factors [28] and has been largely burdened by famine, food insecurity and underweight [29]. Approx- imately 80% of the burden of diseases in the coun- try has considered preventable [30]. It seems that com- municable disease had been the only identified prob- lems in Ethiopia but burden of NCDs is facing major problems of public health importance in the country;

thus, NCDs such as cardiovascular and diabetes mel- litus currently are the leading cause of death among adults in the country [31], which is responsible for 39% of deaths in the country in 2015 while the risk of pre- mature death from target NCDs was 19% [1]. There- fore, the aim of this study was to analyze the impact of food insecurity and malnutrition on burden of NCDs and deaths in Ethiopia.

2. Methods

The search for this review was rooted in articles and WHO reports on food insecurity, malnutrition and NCDs published between January 1, 2010 and Decem- ber 31, 2017, using the PubMed, Scopus, Embase and Google Scholar databases as well as reports published by regional and international organizations. The com- prehensive review focuses on the Ethiopian food inse- curity and malnutrition and their impacts on burden of NCDs death was undertaken to obtain a deeper under- standing of the seriousness of the NCDs. In addition, policy for protecting the vulnerability and improving the prevention and control of the NCDs in Ethiopia was assessed. Using the results of this review, the pa- per highlights the progress and the overall condition of food insecurity, nutrition and diseases in the country. In order to understand the health patterns, it summa- rizes the situation regarding progress in (1) SDGs on food insecurity, Malnutrion and NCDs, (2) brief his- torical background of food insecurity, malnutrition and NCDs during Millennium development goals and their change, (3) vulnerability and death of NCDs as a result of food insecurity and malnutrition and, (4) policy im- plementation and strategy related with SDGs. The pa- per also outlines the future trends of NCDs burden in the country based on SDGs.

2.1. Millennium development goals (MDGs) on food insecurity, malnutrition and non-communicable diseases in Ethiopia

The first goal which addressed the MDGs was “Eradicate extreme poverty and hunger” from the world countries including Ethiopia. However, both in- sufficient economic growth and fair distribution among people had been critically required in order to address issues of undernourishment and obesity [32].

2.2. Food insecurity in Ethiopia

According to 2017 Global Hunger Index (GHI) scores, a 27% reduction in the level of hunger was ob-

216 A.M. Mosadeghrad et al. / Impact of food insecurity and malnutrition on the burden of NCDs

served as compared to 2000 worldwide based on the four component indicators: namely undernourishment, child wasting, child stunting, and child mortality [33].

In Ethiopia, the guarantee for securing food was among the highest priorities since shortage of food and occurrence of famine looked an unavoidable issue for several decades (IFRI). Historically, food insecurity in Ethiopia had been scored 43.7 in 1990; however, it was declined to 29.8 in 2008, which was considered the most absolute progress in improving food insecurity score. The prevalence of undernourishment was de- clined from 75% (37 million) in 1990 to 32% in 2015 (32 million) though the numbers indicate a marginal reduction (IFRI).

According to world food program report in 2010, an estimated 5.2 million people were needed food as- sistance in Ethiopia in 2010 [9] and according to the report of USAID and WFP in 2010, Ethiopia has ex- perienced recurrent food insecurity, which could be due to malnutrition subsequent developmental impair- ments [34]. Furthermore, most of the population relies on rain fed agriculture that makes them susceptible to food insecurity as a result of inconsistent rainfall distri- bution [33]. In 2017, for instance, the shortage of rain- fall in East Africa is harshly influencing the production of crops and livestock in Ethiopia and hence, keeping millions destitute of humanitarian support.

The other possible reason for the recurrent occur- rence of food insecurity in the country is the experi- ence of violent conflicts in recent periods, which cate- gorizes as the extreme alarming; however, in the 2017 GHI scores Ethiopia has lowered the problem by 42% and placed in the serious category though still a ma- jor confront to conquer. The stunting level (38.4%) and child mortality rate (5.9%) is improving from previous years [33]. Consequently, in order to sustained the eco- nomic growth, reduce poverty and achieving food se- curity, the Ethiopian government has started discourse at high level of agenda hoping to avoid recurrent vi- olent conflict, food insecurity and famine through tar- geting urban low-income households and empowering youth and women [35–37].

2.3. Malnutrition in Ethiopia

In developing countries, the impact of malnutrition for under-five children death is enormous and threat- ening their progress. Child malnutrition is linked with maternal malnutrition and the size of childbirth and hence, children who are smaller at birth are expected to be wasted, stunted, or underweight as compared to

children who are born as normal or larger size. Sim- ilarly, children whose mothers with body mass index are less than 18.5 are more likely to be wasted, stunted, or underweight [38].

In developing countries, malnutrition is a cause for 26 million (53%) of under-five children deaths di- rectly or indirectly [39]. Ethiopia, one of the devel- oping countries, has the highest under-five child mor- tality rate as the result of malnutrition, which ac- counts basically to 57% of all children deaths [40]. But, this figure was reduced according to the most re- cent Demographic and Health Survey report, where about 5.8 million (38%) children under-five years are suffering from chronic malnutrition [38]. Even though Ethiopian government has been working on preven- tion and promotion activities in collaboration with a range of non-governmental organizations to fight against child malnutrition, the result observed is still under expected [41]. Recent evidence indicated that the prevalence of stunting and underweight has re- duced noticeably from 58% and 41% in 2000 to 38% and 24% in 2016, respectively while the prevalence of wasting change was minute, only with a wasting rate of 10% [38].

Stunting for under-five children harshly augmented between age 6 and 23 months with the age of 24– 35 months reaches the highest peak, which indicates the influence of under nutrition in the first 1,000 days of life. Moreover, children in rural areas have higher prevalence of stunting, underweight, and wasting as compared to those children in urban areas [42]. The increases risk of under nutrition, illness, and mortality are due to unsuitable nourishing exercise among chil- dren age between 6 -23 months of ages [43].

2.4. Effect of food insecurity on malnutrition and malnutrition on non-communicable diseases in Ethiopia

Malnutrition has been contributed with 4% of child mortality attributable to under nutrition. As a result, it remains one of the main determinants of the global bur- den of NCDs [44]. Obesity, as the result of malnutri- tion, is recognized as a major risk factor for a number of chronic diseases including diabetes, CVDs and can- cer. According to the world health organization, obe- sity is responsible for approximately 3.4 million adult deaths each year which is increasing both developed and developing countries [30,45,46]. Over nutrition or hyper alimentation is a form of malnutrition in which the intake of nutrients is oversupplied, is also rising in

A.M. Mosadeghrad et al. / Impact of food insecurity and malnutrition on the burden of NCDs 217

Table 1 Percentage distribution of proportional mortality (total deaths for both sexes and all ages) in Ethiopia, 2011–2014

Year 2011 Year 2014 Death conditions Percentage Death conditions Percentage Injuries 9 Injuries 10 Cardiovascular diseases 15 Cardiovascular diseases 9 Chronic respiratory diseases 4 Chronic respiratory diseases 3 Diabetes mellitus 2 Diabetes mellitus 1 Cancers 4 Cancers 6 Communicable, maternal, perinatal and nutritional condition

57 Communicable, maternal, perinatal and nutrition condition

60

Others NCDs 9 Others NCDs 11

Source: World Health Organization, 2011 & 2014- Non communicable diseases country profiles 2011 & 2014

Table 2 National nutritional status of women and children in Ethiopia, 2010/11–2014/15

Year (2010/11) Year (2014/15) Nutritional anthropometry (WHO) child growth standards % Nutritional anthropometry (WHO) child growth standards % Prevalence of stunting in children < 5 years age 44.4 Prevalence of stunting in children < 5 years age 30 Prevalence of wasting in children < 5 years of age 9.7 Prevalence of wasting in children < 5 years of age 3 Prevalence of underweight children < 5 years of age 28.7 Prevalence of underweight children < 5 years of age 21 Proportion of women (15–49 years) with a BMI < 18.5 Kg/m2

27 Proportion of women (15–49 years) with a BMI < 18.5 Kg/m2

19

Proportion of newborns who weighed < 2.5 Kg at birth 10.8 Proportion of newborns who weighed < 2.5 Kg at birth 9

Sources: FDRE (2015): National Nutritional Program (June 2013–2015).

some African countries, which could be coupled with an increase in CVDs and diabetes [46].

According to World Health Organization Report 2011, the total deaths 691,000 and NCDs were es- timated 30% of total deaths. Of which 4% of these deaths were due to Cancer and 9% with other NCDs as such obesity and nutrition related NCDs and others in 2011 [47]. However, the estimated deaths rate of NCDs is increased to 34% in 2014. When we compared the mortality due to Others NCDs is increasing to 11% and cancers to 6% in 2014 in Ethiopia. The finding indi- cated that there is a high degree of uncertainty between 2011 and 2014. Because, the report indicated that the country are not based on any national NCD mortality data [30].

The report in (Table 2) indicated that the prevalence of stunting I children less than 5 Years old are de- creased to reach 30% in 2014. The overall reduction of stunting in children was about 15% from 2010 to 2014. Concerning this, an evidence indicated that Ethiopia has been established an ambitious and revised national nutrition program since June, 2013. The program is contributes to transform the economic and develop- ment trajectory of millions of children and their moth- ers in order to address in the food and nutrition insecu- rity in the country [48].

The prevalence of wasting in children 5 years of age was 10% in 2010 but unexpectedly it declined to 5% by

2014. It indicated that the government has been given attention on child growth monitoring and diseases pre- vention follow up in the country. However, the preva- lence of underweight children < 5 years of age is de- creased by 8% from 2010 to 2014. It reached to 21% in 2014. A reproductive age women (15–49 years old) with a BMI < 18.5 Kg/m2 has been changed from 26.9% in 2010 to 19% in 2015. Nonetheless, there was slightly changed between 2010/11 and 2012/13 (29%). In the proportion of new born was 11% in 2010. But, after 5 years it was declined by only 2% and it reaches 9%. It indicated that till need of absolute follow up on nutritional anthropometry with standard children growth rate in the country.

3. The role of policy

3.1. Policy for protecting vulnerability and implementation of sustainable development goals (SDGs) on food insecurity, malnutrition and non-communicable diseases in Ethiopia

The nature and scope of nutrition and its health- related industries dictate the need for various regula- tions and accordingly the interaction with governing bodies. Some of the control regarding how evidence- based information is used and interpreted lies also with the ultimate consumer [11].

218 A.M. Mosadeghrad et al. / Impact of food insecurity and malnutrition on the burden of NCDs

Table 3 Comparison of estimates of prevalence of overweight and obesity, Mean Body Mass Index (BMI), and premature NCDs mortality in Ethiopia (population aged 18 + years), 2011–2014

Nutritional anthropometry Year (WHO) child growth standards 2010 2014

Male Female Both sexes Male Female Both sexes Mean BMI estimate 20.0 [19.3–20.7] 20.7 [20–21.4] 20.3 [19.8–20.8] 20.2 [19.3–21] F 21.0 [20.1–21.9] 20.6 [20–21.2] Overweight (BMI > 25) Crude adjusted estimate

9.6 [6.8–12.6] 20.6 [16.7–24.9] 15.1 [12.5–17.5] 10.1 [6.5–14.4] 22.9 [17.6–28.9] 16.5 [13.1–20.2]

Overweight (BMI > 25) Age-standard adjusted estimates

10.8 [7.7–14.2] 23.6 [19.3–28.3] 17.2 [14.2–20] 11.5 [7.4–16.3] 26.3 [20.4–32.8] 18.9 [15.1–23.1]

Obesity (BMI > 30) Crude adjusted estimate

1.1 [0.6–1.8] 4.3 [2.8–6.2] 2.7 [1.8–3.6] 1.3 [0.6–2.4] 5.4 [3.2–8.4] 3.3 [1.9–4.7]

Obesity (BMI > 30) Age-standard adjusted estimates

1.2 [0.6–2.1] 5.3 [3.4–7.5] 3.3 [2.3–4.5] 1.5 [0.7–2.7] 6.6 [4–10.1] 4.0 [2.6–5.5]

Premature NCDs mortality 15.9% 15.2%

Source: World Health Organization. 2014. Global Status Report on NCDs 2014; WHO. 2011.

Malnutrition in SDGs is often invisible, pernicious and impediment for successful achievement in various countries including Ethiopia [6,13,17]. As a result, it is one of the major issue recently. In addition, Food inse- curity is not only problem for specific country but also world notion. According to the State of food insecurity report that it is critical issues which need the sustained political commitment as the first prerequisite in order to eradicate the hunger from the environment [49].

Currently, an increasing of awareness on prevention and control of NCDs and its advocacy including mo- bilization of resources in order to combat NCDS with great attention has been taken by the United Nation in- teragency task on the prevention and control of NCDs in 2016 [50]. As evidence indicated that epidemiologi- cal transition is undergoing in Ethiopia. Consequently, NCDs are becoming an increasingly important public health problem in the country. The condition that could initiate the Ethiopian government to implement vari- ous activities in order to have addressed these impacts on nation development. As result, in 2012 (EFY 2005), mental health has been focused as a major concern in Ethiopia. In addition, the prevention and control of major NCDs five year implementation program draft strategic framework has been prepared. The framework is under implemented in the country [51].

4. Conclusion

The finding concluded that unless a better balance between the food insecurity and nutritional status is achieved in Ethiopia, the country is most unlikely to adopt the implementation of prevention and control of NCDs remunerations. Because NCDs are complex and having shared various risk factors and many of them

developed as serious complications of infectious dis- eases including their treatments [16]. In addition, this finding was assessed the MDGs target and newly de- signed SDGs on these problem in the country. Accord- ing to Food and Agricultural Organization report in 2016, the SDGs are a target to call for comprehen- sive and it should have participatory approaches world- wide. Furthermore, it is not divisible and non-split goals direction from one component to another [52]. Therefore, we expected that the Ethiopian government and all policy makers should be given great attention in order to improve the overall problems in the coun- try. Especially, it requires the knowledge, commitment and responsibilities of politicians, researchers, health professionals and all stakeholders in the country. Age- specific death rates due to NCDs are generally higher in countries with low-income levels. The NCD epi- demic exacts a massive socioeconomic toll throughout the world. It is rising rapidly in lower-income coun- tries and among the poor in middle- and high-income countries.

Authors contributions

AAG, AMM, AAK and TBT have made substan- tial contributions to beginning and design, collection of data, analysis and interpretation of data and in drafting the manuscripts and correcting the comment given by the advisors. Furthermore, all authors have been involved in revising the research paper and the manuscript critically for important intellectual context and approval of the final version to be published and participated in its design and coordination including over all work in this manuscript.

A.M. Mosadeghrad et al. / Impact of food insecurity and malnutrition on the burden of NCDs 219

Conflict of interest

The authors declare that they have no competing in- terests.

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