The food, fuel, and financial crises affect the urban and rural poor disproportionately: a review of the evidence

Agriculture, health, and wealth convergence: bridging traditional food systems and modern agribusiness solutions

The causes of many vexing challenges facing 21st-century society are at the nexus of systems involved in agriculture, health and wealth production, consumption, and distribution. Using food as a test bed, and on the basis of emerging roadmaps that set achievable objectives over a 1- to 3-year horizon, we introduce this special feature with convergence thinking and practice at its core. Specifically, we discuss academic papers structured around four themes: (1) evidence for a need for convergence and underlying mechanisms at the individual and societal levels; (2) strategy for mainstreaming convergence as a driver of business engagement and innovation; (3) convergence in policy and governance; (4) convergence in metrics and methods. Academic papers under each theme are accompanied by a roadmap paper reporting on the current status of concrete transformative convergence-building projects associated with that theme. We believe that the insights provided by these papers have the potential to enable all actors throughout society to singly and collectively work to build supply and demand for nutritious food, in both traditional and modern food systems, while placing the burdens of malnutrition and ill health on their core strategic agendas.

A nutrition/health mindset on commercial Big Data and drivers of food demand in modern and traditional systems

Building greater reciprocity between traditional and modern food systems and better convergence of human and economic development outcomes may enable the production and consumption of accessible, affordable, and appealing nutritious food for all. Information being key to such transformations, this roadmap paper offers a strategy that capitalizes on Big Data and advanced analytics, setting the foundation for an integrative intersectoral knowledge platform to better inform and monitor behavioral change and ecosystem transformation. Building upon the four P's of marketing (product, price, promotion, placement), we examine digital commercial marketing data through the lenses of the four A's of food security (availability, accessibility, affordability, appeal) using advanced consumer choice analytics for archetypal traditional (fresh fruits and vegetables) and modern (soft drinks) product categories. We demonstrate that business practices typically associated with the latter also have an important, if not more important, impact on purchases of the former category. Implications and limitations of the approach are discussed.

Impact of the 2008 economic and financial crisis on child health: a systematic review

The aim of this study was to provide an overview of studies in which the impact of the 2008 economic crisis on child health was reported. Structured searches of PubMed, and ISI Web of Knowledge, were conducted. Quantitative and qualitative studies reporting health outcomes on children, published since 2007 and related to the 2008 economic crisis were included. Two reviewers independently assessed studies for inclusion. Data were synthesised as a narrative review. Five hundred and six titles and abstracts were reviewed, from which 22 studies were included. The risk of bias for quantitative studies was mixed while qualitative studies showed low risk of bias. An excess of 28,000–50,000 infant deaths in 2009 was estimated in sub-Saharan African countries, and increased infant mortality in Greece was reported. Increased price of foods was related to worsening nutrition habits in disadvantaged families worldwide. An increase in violence against children was reported in the U.S., and inequalities in health-related quality of life appeared in some countries. Most studies suggest that the economic crisis has harmed children’s health, and disproportionately affected the most vulnerable groups. There is an urgent need for further studies to monitor the child health effects of the global recession and to inform appropriate public policy responses.

Maternal resources and household food security: evidence from Nicaragua

OBJECTIVE

Women (especially mothers) are theorized as critical to reducing household food insecurity through their work and caregiver roles. The present study tests these assumptions, assessing how maternal economic and social resources are associated with food insecurity in households with young children.

DESIGN

Data from a population-based sample of households was collected in León, Nicaragua (n 443). Data include a newly validated measure of household food insecurity (ELCSA), maternal resource measures, and household economic status and demographics. Regression analysis tests the statistical associations (P<0·05) of maternal resources with household, adult-specific and child-specific food insecurity.

SETTING

Municipality of León, Nicaragua.

SUBJECTS

Households with children aged 3-11 years in rural and urban León.

RESULTS

Only 25% of households with young children were food secure, with 50% mildly food insecure and 25% moderately/severely food insecure. When mothers contributed substantially to household income, the odds of moderate/severe household food insecurity were 34% lower than when their spouse/partner was the main provider. The odds of food insecurity were 60% lower when mothers managed household money, 48% lower when mothers had a secondary (v. primary) education, 65% higher among single mothers and 16% lower with each indicator of social support. Results were similar for adult- and child-specific food insecurity.

CONCLUSIONS

This research provides new evidence that maternal economic and social resources are important for reducing household food insecurity and adult- and child-specific food insecurity. Women's social status, social support and access to economic resources need to be enhanced as a part of policies aimed to reduce food insecurity in high-poverty settings.

Vulnerability to food insecurity in urban slums: experiences from Nairobi, Kenya

Food and nutrition security is critical for economic development due to the role of nutrition in healthy growth and human capital development. Slum residents, already grossly affected by chronic poverty, are highly vulnerable to different forms of shocks, including those arising from political instability. This study describes the food security situation among slum residents in Nairobi, with specific focus on vulnerability associated with the 2007/2008 postelection crisis in Kenya. The study from which the data is drawn was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS), which follows about 70,000 individuals from close to 30,000 households in two slums in Nairobi, Kenya. The study triangulates data from qualitative and quantitative sources. It uses qualitative data from 10 focus group discussions with community members and 12 key-informant interviews with community opinion leaders conducted in November 2010, and quantitative data involving about 3,000 households randomly sampled from the NUHDSS database in three rounds of data collection between March 2011 and January 2012. Food security was defined using the Household Food Insecurity Access Scale (HFIAS) criteria. The study found high prevalence of food insecurity; 85% of the households were food insecure, with 50% being severely food insecure. Factors associated with food security include level of income, source of livelihood, household size, dependence ratio; illness, perceived insecurity and slum of residence. The qualitative narratives highlighted household vulnerability to food insecurity as commonplace but critical during times of crisis. Respondents indicated that residents in the slums generally eat for bare survival, with little concern for quality. The narratives described heightened vulnerability during the 2007/2008 postelection violence in Kenya in the perception of slum residents. Prices of staple foods like maize flour doubled and simultaneously household purchasing power was eroded due to worsened unemployment situation. The use of negative coping strategies to address food insecurity such as reducing the number of meals, reducing food variety and quality, scavenging, and eating street foods was prevalent. In conclusion, this study describes the deeply intertwined nature of chronic poverty and acute crisis, and the subsequent high levels of food insecurity in urban slum settings. Households are extremely vulnerable to food insecurity; the situation worsening during periods of crisis in the perception of slum residents, engendering frequent use of negative coping strategies. Effective response to addressing vulnerability to household food insecurity among the urban poor should focus on both the underlying vulnerabilities of households due to chronic poverty and added impacts of acute crises.

The impact of the 2008 financial crisis on food security and food expenditures in Mexico: a disproportionate effect on the vulnerable

OBJECTIVE

The present paper investigated the impact of the 2008 financial crisis on food security in Mexico and how it disproportionally affected vulnerable households.

DESIGN

A generalized ordered logistic regression was estimated to assess the impact of the crisis on households' food security status. An ordinary least squares and a quantile regression were estimated to evaluate the effect of the financial crisis on a continuous proxy measure of food security defined as the share of a household's current income devoted to food expenditures. Setting Both analyses were performed using pooled cross-sectional data from the Mexican National Household Income and Expenditure Survey 2008 and 2010.

SUBJECTS

The analytical sample included 29,468 households in 2008 and 27,654 in 2010.

RESULTS

The generalized ordered logistic model showed that the financial crisis significantly (P<0·05) decreased the probability of being food secure, mildly or moderately food insecure, compared with being severely food insecure (OR=0·74). A similar but smaller effect was found when comparing severely and moderately food-insecure households with mildly food-insecure and food-secure households (OR=0·81). The ordinary least squares model showed that the crisis significantly (P<0·05) increased the share of total income spent on food (β coefficient of 0·02). The quantile regression confirmed the findings suggested by the generalized ordered logistic model, showing that the effects of the crisis were more profound among poorer households.

CONCLUSIONS

The results suggest that households that were more vulnerable before the financial crisis saw a worsened effect in terms of food insecurity with the crisis. Findings were consistent with both measures of food security--one based on self-reported experience and the other based on food spending.

Mainstreaming nutrition metrics in household surveys--toward a multidisciplinary convergence of data systems

Since the 2008 food price crisis, food and nutrition security are back on the global development agenda, with particular emphasis on agricultural pathways toward improved nutrition. Parallel efforts are being promoted to improve the data and metrics for monitoring progress toward positive nutritional outcomes, especially for women and children. Despite the increased investment in tracking nutritional outcomes, these efforts are often made in silos, which create challenges for integrating nutritional data with other sectoral data, such as those related to agriculture. This paper proposes a minimum set of nutrition indicators to be included in nationally representative agricultural (and multitopic) household surveys. Building multisectoral convergence across existing surveys will allow us to better identify priority interventions and to monitor progress toward improved nutrition targets.

Examining the influence of urban definition when assessing relative safety of drinking-water in Nigeria

Reducing inequalities is a priority from a human rights perspective and in water and public health initiatives. There are periodic calls for differential national and global standards for rural and urban areas, often justified by the suggestion that, for a given water source type, safety is worse in urban areas. For instance, initially proposed post-2015 water targets included classifying urban but not rural protected dug wells as unimproved. The objectives of this study were to: (i) examine the influence of urban extent definition on water safety in Nigeria, (ii) compare the frequency of thermotolerant coliform (TTC) contamination and prevalence of sanitary risks between rural and urban water sources of a given type and (iii) investigate differences in exposure to contaminated drinking-water in rural and urban areas. We use spatially referenced data from a Nigerian national randomized sample survey of five improved water source types to assess the extent of any disparities in urban-rural safety. We combined the survey data on TTC and sanitary risk with map layers depicting urban versus rural areas according to eight urban definitions. When examining water safety separately for each improved source type, we found no significant urban-rural differences in TTC contamination and sanitary risk for groundwater sources (boreholes and protected dug wells) and inconclusive findings for piped water and stored water. However, when improved and unimproved source types were combined, TTC contamination was 1.6 to 2.3 times more likely in rural compared to urban water sources depending on the urban definition. Our results suggest that different targets for urban and rural water safety are not justified and that rural dwellers are more exposed to unsafe water than urban dwellers. Additionally, urban-rural analyses should assess multiple definitions or indicators of urban to assess robustness of findings and to characterize a gradient that disaggregates the urban-rural dichotomy.

Rural:urban inequalities in post 2015 targets and indicators for drinking-water

Disparities in access to drinking water between rural and urban areas are pronounced. Although use of improved sources has increased more rapidly in rural areas, rising from 62% in 1990 to 81% in 2011, the proportion of the rural population using an improved water source remains substantially lower than in urban areas. Inequalities in coverage are compounded by disparities in other aspects of water service. Not all improved sources are safe and evidence from a systematic review demonstrates that water is more likely to contain detectable fecal indicator bacteria in rural areas. Piped water on premises is a service enjoyed primarily by those living in urban areas so differentiating amongst improved sources would exacerbate rural:urban disparities yet further. We argue that an urban bias may have resulted due to apparent stagnation in urban coverage and the inequity observed between urban and peri-urban areas. The apparent stagnation at around 95% coverage in urban areas stems in part from relative population growth - over the last two decades more people gained access to improved water in urban areas. There are calls for setting higher standards in urban areas which would exacerbate the already extreme rural disadvantage. Instead of setting different targets, health, economic, and human rights perspectives, We suggest that the focus should be kept on achieving universal access to safe water (primarily in rural areas) while monitoring progress towards higher service levels, including greater water safety (both in rural and urban areas and among different economic strata).

Perinatally acquired HIV infection: long-term neuropsychological consequences and challenges ahead

Over the past three decades, perinatal HIV infection in the United States has evolved from a fatal disease to a manageable chronic illness. As the majority of youth with perinatal HIV infection age into adolescence and adulthood, management of this stigmatizing, transmittable disease in the backdrop of a cadre of environmental stressors presents challenges beyond those of other chronic illnesses. The neurologic and neuropsychological consequences of this neurotropic virus have important implications for the successful navigation of responsibilities related to increasingly independent living of this aging population. This article will review the neurologic and neuropsychological consequences of perinatal HIV infection and concomitant factors in the era of highly active antiretroviral therapy and will provide an overview of the neuropathology, pathogenesis, neuroimaging findings, and treatment of perinatal HIV infection, as well as recommendations for service provision and future research.

Climate-related hazards: a method for global assessment of urban and rural population exposure to cyclones, droughts, and floods

Global climate change (GCC) has led to increased focus on the occurrence of, and preparation for, climate-related extremes and hazards. Population exposure, the relative likelihood that a person in a given location was exposed to a given hazard event(s) in a given period of time, was the outcome for this analysis. Our objectives were to develop a method for estimating the population exposure at the country level to the climate-related hazards cyclone, drought, and flood; develop a method that readily allows the addition of better datasets to an automated model; differentiate population exposure of urban and rural populations; and calculate and present the results of exposure scores and ranking of countries based on the country-wide, urban, and rural population exposures to cyclone, drought, and flood. Gridded global datasets on cyclone, drought and flood occurrence as well as population density were combined and analysis was carried out using ArcGIS. Results presented include global maps of ranked country-level population exposure to cyclone, drought, flood and multiple hazards. Analyses by geography and human development index (HDI) are also included. The results and analyses of this exposure assessment have implications for country-level adaptation. It can also be used to help prioritize aid decisions and allocation of adaptation resources between countries and within a country. This model is designed to allow flexibility in applying cyclone, drought and flood exposure to a range of outcomes and adaptation measures.

Neighborhood socioeconomic characteristics and differences in the availability of healthy food stores and restaurants in Sao Paulo, Brazil

Differential access to healthy foods has been hypothesized to contribute to health disparities, but evidence from low and middle-income countries is still scarce. This study examines whether the access of healthy foods varies across store types and neighborhoods of different socioeconomic statuses (SES) in a large Brazilian city. A cross-sectional study was conducted in 2010-2011 across 52 census tracts. Healthy food access was measured by a comprehensive in-store data collection, summarized into two indexes developed for retail food stores (HFSI) and restaurants (HMRI). Descriptive analyses and multilevel models were used to examine associations of store type and neighborhood SES with healthy food access. Fast food restaurants were more likely to be located in low SES neighborhoods whereas supermarkets and full service restaurants were more likely to be found in higher SES neighborhoods. Multilevel analyses showed that both store type and neighborhood SES were independently associated with in-store food measures. We found differences in the availability of healthy food stores and restaurants in Sao Paulo city favoring middle and high SES neighborhoods.

Prevalence and socioeconomic and geographical inequalities of household food insecurity in the Paris region, France, 2010

Background

Food insecurity (FI) is the situation where people do not have, at all times, access to sufficient, safe and nutritious food that meets their dietary needs for an active and healthy life. The objectives of this study were to estimate the prevalence of FI in the Paris area by using, for the first time in France, a specific FI questionnaire and to identify the characteristics of food-insecure households, taking into account a potential neighbourhood effect.

Methods

This study is based on data from the third wave of the SIRS cohort study (a representative, population-based socioepidemiological study) that were analysed using a cross-sectional design. In 2010, 3000 individuals in the Paris metropolitan area (PMA) were interviewed. FI was investigated by means of the USDA’s HFSSM. We used stratified multilevel models across three household income categories to identify populations at risk for FI.

Results

In 2010, 6.30% (95% CI = [4.99-7.97]) of the households in the PMA experienced FI (up to 13.59% in the most underprivileged neighbourhoods). About 2.50% of the households experienced severe FI and 2.85% of household living with an income above 1666 € experienced food insecurity, whereas the percentage raises to 23.38% among those living below the poverty threshold (<791 €). Depending on the income level, different household characteristics emerged as being associated with FI. In the poorest households, the presence of a child under 3 years of age was associated with an increased risk of FI (OR = 2.11; p = 0.03). Among higher-income households, the household composition appeared to be strongly associated with FI.

Conclusion

FI exists in several social groups in France. Its prevalence in the most underprivileged households should be considered an indicator of vulnerability, which could permit targeted social assistance policies.

The 2008 food price crisis negatively affected household food security and dietary diversity in urban Burkina Faso

Although the 2008 food price crisis presumably plunged millions of households into poverty and food insecurity, the real impact of the crisis has rarely been documented using field data. Our objective was to assess the consequences of this crisis for household food insecurity and dietary diversity in urban Burkina Faso. Two cross-sectional surveys were conducted among randomly selected households in Ouagadougou in July 2007 (n = 3017) and July 2008 (n = 3002). At each round, food insecurity assessed by the Household Food Insecurity Access Scale (HFIAS), the Dietary Diversity Score of an index-member of the household (IDDS = number of food groups consumed in the last 24 h), and food expenditure were collected. Food prices of the 17 most frequently consumed food items were recorded throughout the study area. Food prices at local markets increased considerably between 2007 and 2008, especially those of fish (113%), cereals (53%), and vegetable oil (44%), increasing the household monthly food expenditure by 18%. Thirty-three percent of households were food secure in 2007 and 22% in 2008 (P = 0.02). Individuals consumed fewer fruits and vegetables, dairy products, and meat/poultry in 2008 than in 2007 (mean IDDS = 5.7 ± 1.7 food groups in 2007 vs. 5.2 ± 1.5 in 2008; P < 0.0001). Differences in IDDS and HFIAS between the 2 y were even more marked after adjustment for confounding factors and food expenditure. Food security and dietary diversity significantly decreased between 2007 and 2008, whereas food prices increased. Households increased their food expenditure, but this was not sufficient to compensate the effects of the crisis.

Food prices and poverty negatively affect micronutrient intakes in Guatemala

Limited empirical evidence exists for how economic conditions affect micronutrient nutrition. We hypothesized that increasing poverty and rising food prices would reduce consumption of high-quality "luxury" foods, leading to an increased probability of inadequacy for several nutrients. The 2006 Guatemala National Living Conditions Survey was analyzed. First, energy and nutrient intakes and adequacy levels were calculated. Second, the income-nutrient relationships were investigated by assessing disparities in intakes, determining income-nutrient elasticities, and modeling nutrient intakes by reductions in income. Third, the food price-nutrient relationships were explored through determination of price-nutrient elasticities and modeling 2 price scenarios: an increase in food prices similar in magnitude to the food price crisis of 2007-2008 and a standardized 10% increase across all food groups. Disparities in nutrient intakes were greatest for vitamin B-12 (0.38 concentration index) and vitamin A (0.30 concentration index); these nutrients were highly and positively correlated with income (r = 0.22-0.54; P < 0.05). Although the baseline probability of inadequacy was highest for vitamin B-12 (83%), zinc showed the greatest increase in probability of inadequacy as income was reduced, followed by folate and vitamin A. With rising food prices, zinc intake was most acutely affected under both scenarios (P < 0.05) and folate intake in the poorest quintile (+7 percentage points) under the 10% scenario. Price-nutrient elasticities were highest for vitamin B-12 and the meat, poultry, and fish group (-0.503) and for folate and the legumes group (-0.343). The economic factors of food prices and income differentially influenced micronutrient intakes in Guatemala, notably zinc and folate intakes.

Climate change adaptation: where does global health fit in the agenda?

Human-induced climate change will affect the lives of most populations in the next decade and beyond. It will have greatest, and generally earliest, impact on the poorest and most disadvantaged populations on the planet. Changes in climatic conditions and increases in weather variability affect human wellbeing, safety, health and survival in many ways. Some impacts are direct-acting and immediate, such as impaired food yields and storm surges. Other health effects are less immediate and typically occur via more complex causal pathways that involve a range of underlying social conditions and sectors such as water and sanitation, agriculture and urban planning. Climate change adaptation is receiving much attention given the inevitability of climate change and its effects, particularly in developing contexts, where the effects of climate change will be experienced most strongly and the response mechanisms are weakest. Financial support towards adaptation activities from various actors including the World Bank, the European Union and the United Nations is increasing substantially. With this new global impetus and funding for adaptation action come challenges such as the importance of developing adaptation activities on a sound understanding of baseline community needs and vulnerabilities, and how these may alter with changes in climate. The global health community is paying heed to the strengthening focus on adaptation, albeit in a slow and unstructured manner. The aim of this paper is to provide an overview of adaptation and its relevance to global health, and highlight the opportunities to improve health and reduce health inequities via the new and additional funding that is available for climate change adaptation activities.

Multiple crises and global health: new and necessary frontiers of health politics

The world economy is entering an era of multiple crises, involving finance, food security and global environmental change. This article assesses the implications for global public health, describes the contours of post-2007 crises in food security and finance, and then briefly indicates the probable health impacts. There follows a discussion of the crisis of climate change, one that will unfold over a longer time frame but with manifestations that may already be upon us. The article then discusses the political economy of responses to these crises, noting the formidable obstacles that exist to equitable resolution. The article concludes by noting the threat that such crises present to recent progress in global health, arguing that global health researchers and practitioners must become more familiar with the relevant social processes, and that proposed solutions that neglect the continuing importance of the nation-state are misdirected.

Household food insufficiency, financial strain, work-family spillover, and depressive symptoms in the working class: the Work, Family, and Health Network study

OBJECTIVES

We evaluated the association of household-level stressors with depressive symptoms among low-wage nursing home employees.

METHODS

Data were collected in 2006 and 2007 from 452 multiethnic primary and nonprimary wage earners in 4 facilities in Massachusetts. We used logistic regression to estimate the association of depressive symptoms with household financial strain, food insufficiency, and work-family spillover (preoccupation with work-related concerns while at home and vice versa).

RESULTS

Depressive symptoms were significantly associated with household financial strain (odds ratio [OR] = 1.82; 95% confidence interval [CI] = 1.03, 3.21) and food insufficiency (OR = 2.10; 95% CI = 1.10, 4.18). Among primary earners, stratified analyses showed that food insufficiency was associated with depressive symptoms (OR = 3.60; 95% CI = 1.42, 9.11) but financial strain was not. Among nonprimary wage earners, depressive symptoms correlated with financial strain (OR = 3.65; 95% CI = 1.48, 9.01) and work-family spillover (OR = 3.22; 95% CI = 1.11, 9.35).

CONCLUSIONS

Household financial strain, food insufficiency, and work-family spillover are pervasive problems for working populations, but associations vary by primary wage earner status. The prevalence of food insufficiency among full-time employees was striking and might have a detrimental influence on depressive symptoms and the health of working-class families.

Seasonality of the dietary dimension of household food security in urban Burkina Faso

Food insecurity is affecting an increasing number of urban poor in the developing world. Yet seasonal characteristics of food intakes have rarely been studied in West African cities. The objective of the present study was to assess the seasonality of the dietary dimension of household food security in Ouagadougou (Burkina Faso). In 2007, two sets of data were collected during the lean and post-harvest seasons, respectively, on a representative sample of 1056 households. At each season, two non-consecutive 24 h recalls were performed at the household level. Food prices were also recorded. Household food security was assessed by the household's mean adequacy ratio (MAR) for energy and eleven micronutrients. Changes in the MAR according to the season were analysed by mixed multivariate linear regression. Results showed that intakes of energy and of ten micronutrients were significantly lower during the lean season than during the post-harvest season, leading to a lower MAR in the lean season (49·61 v. 53·57, P < 0·0001). This was related to less frequent consumption and consumption of smaller amounts of vegetables and of foods prepared at home. Food security relied heavily on food expenses (P < 0·0001) and on the price of meat/fish (P = 0·026). Households with economically dependent adults (P = 0·021) and larger households (P < 0·0001) were the most vulnerable, whereas education (P = 0·030), social network (P = 0·054) and urban origin other than Ouagadougou (P = 0·040) played a positive role in food security. To achieve food security in Ouagadougou, access to micronutrient-dense foods needs to be ensured in all seasons.

Urban health inequities and the added pressure of climate change: an action-oriented research agenda

Climate change will likely exacerbate already existing urban social inequities and health risks, thereby exacerbating existing urban health inequities. Cities in low- and middle-income countries are particularly vulnerable. Urbanization is both a cause of and potential solution to global climate change. Most population growth in the foreseeable future will occur in urban areas primarily in developing countries. How this growth is managed has enormous implications for climate change given the increasing concentration and magnitude of economic production in urban localities, as well as the higher consumption practices of urbanites, especially the middle classes, compared to rural populations. There is still much to learn about the extent to which climate change affects urban health equity and what can be done effectively in different socio-political and socio-economic contexts to improve the health of urban dwelling humans and the environment. But it is clear that equity-oriented climate change adaptation means attention to the social conditions in which urban populations live-this is not just a climate change policy issue, it requires inter-sectoral action. Policies and programs in urban planning and design, workplace health and safety, and urban agriculture can help mitigate further climate change and adapt to existing climate change. If done well, these will also be good for urban health equity.

Household capacities, vulnerabilities and food insecurity: shifts in food insecurity in urban and rural Ethiopia during the 2008 food crisis

The global food crisis of 2008 led to renewed interest in global food insecurity and how macro-level food prices impact household and individual level wellbeing. There is debate over the extent to which food price increases in 2008 eroded food security, the extent to which this effect was distributed across rural and urban locales, and the extent to which rural farmers might have benefited. Ethiopia's food prices increased particularly dramatically between 2005 and 2008 and here we ask whether there was a concomitant increase in household food insecurity, whether this decline was distributed equally across rural, urban, and semi-urban locales, and to what extent pre-crisis household capacities and vulnerabilities impacted 2008 household food insecurity levels. Data are drawn from a random sample of 2610 households in Southwest Ethiopia surveyed 2005/6 and again in mid to late 2008. Results show broad deterioration of household food insecurity relative to baseline but declines were most pronounced in the rural areas. Wealthier households and those that were relatively more food secure in 2005/6 tended to be more food secure in 2008, net of other factors, and these effects were most pronounced in urban areas. External shocks, such as a job loss or loss of crops, experienced by households were also associated with worse food insecurity in 2008 but few other household variables were associated with 2008 food insecurity. Our results also showed that rural farmers tended to produce small amounts for sale on markets, and thus were not able to enjoy the potential benefits that come from greater crop prices. We conclude that poverty, and not urban/rural difference, is the important variable for understanding the risk of food insecurity during a food crisis and that many rural farmers are too poor to take advantage of rapid rises in food prices.

Effect of worldwide oil price fluctuations on biomass fuel use and child respiratory health: evidence from Guatemala

OBJECTIVES

We examined the effect of worldwide oil price fluctuations on household fuel use and child respiratory health in Guatemala.

METHODS

We regressed measures of household fuel use and child respiratory health on the average worldwide oil price and a rich set of covariates. We leveraged variation in oil prices over the 6-month period of the survey to identify associations between fuel prices, fuel choice, and child respiratory outcomes.

RESULTS

A $1 (3.4% point) increase in worldwide fuel prices was associated with a 2.8% point decrease in liquid propane gasoline use (P < .05), a 0.75% point increase in wood use (P < .05), and a 1.5% point increase in the likelihood of the child reporting a respiratory symptom (P < .1). The association between oil prices and the fuel choice indicators was largest for households in the middle of the income distribution.

CONCLUSIONS

Fluctuations in worldwide fuel prices affected household fuel use and, consequently, child health. Policies to help households tide over fuel price shocks or reduce pollution from biomass sources would confer positive health benefits. Such policies would be most effective if they targeted both poor and middle-income households.

Why are some settings resource-poor and others not? The global marketplace, perfect economic storms, and the right to health

Analyses of how health system priorities should be set in resource-poor settings are routine in the health ethics and policy analysis literature. Less attention is devoted to asking why some settings are resource-poor and others not. Asking this question must be considered a central task of global health research. Comparison of the relatively meager resources devoted to improving the health of the poor with the sums routinely mobilized for other purposes serves as a basis for ethical reflection and a route into necessary questioning of power imbalances in the world economy. The 2008 financial crisis and related developments underscore the urgency of such questioning, and the value of research and advocacy collaborations (for example, between the human rights and public health research and practice communities) focused specifically on the destructive consequences of the global marketplace for health.

The household food insecurity access scale and an index-member dietary diversity score contribute valid and complementary information on household food insecurity in an urban West-African setting

The number of urban poor is increasing quickly in West Africa, yet food security early warning systems still do not include urban areas. One reason is the lack of appropriate and internationally agreed-upon indicators to measure urban household food insecurity. Our objective was to assess the performance of the household food insecurity access scale (HFIAS) and an index-member's dietary diversity score (IDDS) to approximate the adequacy of urban households' diets. A survey was performed on a random cluster sample of 1056 households in Ouagadougou, Burkina Faso. Data on HFIAS and IDDS and 2 nonconsecutive household quantitative 24-h recalls were collected twice, in June-July and in November-December 2007. Diet adequacy was assessed through the household's mean adequacy ratio (MAR) using energy and 11 micronutrients. Structural equation modeling was used to quantify the association of each candidate indicator with the MAR and receiver-operating characteristic (ROC) analyses were performed to assess their targeting performance in predicting low or high MAR. HFIAS was negatively associated with the MAR [path coefficient (P) = -7.95 × 10(-3) ± 1.45 × 10(-3); P < 0.001], whereas IDDS was positively associated with it (P = 5.19 × 10(-2) ± 1.27 × 10(-2); P < 0.001). Areas under the ROC curves ranged from 0.585 to 0.661 for HFIAS and from 0.536 to 0.629 for IDDS. In conclusion, HFIAS and IDDS performed well in approximating adequacy of urban households' diets. They are informative indicators about urban food insecurity, promising for evaluation and monitoring but not for household targeting given their insufficient predictive power.

Micronutrient adequacy of women's diet in urban Burkina Faso is low

In developing countries, urban populations are deemed to have better access to a wider variety of foods than their rural counterparts. Yet, data on micronutrient status are scarce and the impact of urban food consumption behaviors on micronutrient adequacy is not well known. The objective of this study was to assess individual micronutrient adequacy of the diet along with food consumption behaviors of women of reproductive age in Ouagadougou, Burkina Faso. A cross-sectional survey of 182 women was conducted in 2 districts of the city. Nutrient intakes were derived from 3 nonconsecutive quantitative 24-h recalls for each woman. Balance in macronutrients was in the range of recommendations except that mean sugar intake was somewhat high. Mean probability of adequacy across 11 micronutrients was low (0.38). The most problematic micronutrients were vitamin B-12 (only 4% of our sample had sufficient intake), folate (12%), riboflavin (13%), and niacin (20%). Higher intakes of organ meat, flesh foods, vitamin A- and vitamin C-rich fruits and vegetables, and legumes and nuts were significantly associated with lower risk of micronutrient inadequacy. Ready-to-eat foods bought outside the home provided 46% of overall energy intake, 52% of fat intake, and 72% of sugar intake but were not associated with micronutrient inadequacy (P > 0.05). These results highlight the low micronutrient intakes among women of reproductive age in Burkina Faso, even in an urban area.

Preventing food crises using a food policy approach

A food crisis occurs when rates of hunger and malnutrition rise sharply at local, national, or global levels. This definition distinguishes a food crisis from chronic hunger, although food crises are far more likely among populations already suffering from prolonged hunger and malnutrition. A food crisis is usually set off by a shock to either supply or demand for food and often involves a sudden spike in food prices. It is important to remember that in a market economy, food prices measure the scarcity of food, not its value in any nutritional sense. Except in rare circumstances, the straightforward way to prevent a food crisis is to have rapidly rising labor productivity through economic growth and keep food prices stable while maintaining access by the poor. The formula is easier to state than to implement, especially on a global scale, but it is good to have both the objective, reducing short-run spikes in hunger, and the deep mechanisms, pro-poor economic growth and stable food prices, clearly in mind. A coherent food policy seeks to use these mechanisms, and others, to achieve a sustained reduction in chronic hunger over the long run while preventing spikes in hunger in the short run.

Household dietary diversity and food expenditures are closely linked in rural Bangladesh, increasing the risk of malnutrition due to the financial crisis

In Bangladesh, rice prices are known to be positively associated with the prevalence of child underweight and inversely associated with household nongrain food expenditures, an indicator of dietary quality. The collection of reliable data on household expenditures is relatively time consuming and requires extensive training. Simple dietary diversity scores are increasingly used as measures of food security and as proxies for nutrient adequacy. This study examines associations between a simple dietary diversity score and commonly used indicators of socioeconomic status in Bangladesh. Data representative of rural Bangladesh was collected from 188,835 households over 18 rounds of bi-monthly data collection from 2003-2005. A simple household dietary diversity score was developed by summing the number of days each household consumed an item from each of 7 food groups over a 7-d period. The dietary diversity score was associated with per capita nongrain food expenditures (r = 0.415), total food expenditures (r = 0.327), and total household expenditures (r = 0.332) using Spearman correlations (all P < 0.0001). The frequency of meat and egg consumption showed greater variation across quintiles of total monthly expenditure than other items contributing to the dietary diversity score. After controlling for other measures of socioeconomic status in multiple linear regression models, the dietary diversity score was significantly associated with monthly per capita food and total expenditures. Low dietary diversity during the period prior to major food price increases indicates potential risk for worsening of micronutrient deficiencies and child malnutrition in Bangladesh.

Macronutrient supplementation and food prices in HIV treatment

Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.

Vitamin A intake and status in populations facing economic stress

Dietary quality and diversity reflect adequacy of vitamin A. Both can deteriorate in response to economic crises. Although the nutritional consequences of the 2008 world food price crisis remain unclear, past studies of diet, status, and socioeconomic standing under usual (deprived) and unusually disruptive times suggest dietary quality and vitamin A status decline in mothers and young children. This is presumably the result of shifting diets to include less preformed vitamin A-rich animal source foods and, to a lesser extent, vegetables and fruits. Cross-sectional assessments of diet, deficiency, and socioeconomic status in a number of countries and surveillance data collected during the Indonesian economic crisis of 1997-8 indicate that the prevalence of vitamin A deficiency, night blindness, and other related disorders (e.g., anemia) may have increased during the 2008 crisis, and that it might not have necessarily recovered once food prices waned later in 2008. Lost employment may be a factor in slow nutritional recovery, despite some easing of food prices. Vitamin A deficiency should still be preventable amid economic instabilities through breast feeding promotion, vitamin A supplementation, fortification of foods targeted to the poor, and homestead food production that can bolster income and diversify the diet.

Castel Gandolfo workshop: an introduction to the impact of climate change, the economic crisis, and the increase in the food prices on malnutrition

The global food supply system is facing serious new challenges from economic and related crises and climate change, which directly affect the nutritional well-being of the poor by reducing their access to nutritious food. To cope, vulnerable populations prioritize consumption of calorie-rich but nutrient-poor food. Consequently, dietary quality and eventually quantity decline, increasing micronutrient malnutrition (or hidden hunger) and exacerbating preexisting vulnerabilities that lead to poorer health, lower incomes, and reduced physical and intellectual capabilities. This article introduces the series of papers in this supplement, which explore the relationships between crises and their cumulative impacts among vulnerable populations, particularly through hidden hunger.

Medium- to long-run implications of high food prices for global nutrition

The combined food, fuel, and financial crises of 2007-2009 had severe and widespread negative impacts around the world. Two key questions challenging governments were: how long would the high prices last and with what effects on food security and nutrition over the longer run? This paper considers the drivers of the crisis and explores if, unlike past shocks, the recent price increases reflect structural changes in food price formation that will have lasting global implications. New cross-commodity relationships allowed prices to spike, although there was no shortage of food at the global level nor indeed a significant downturn in recent yields. Yet recent record levels of farm production were also mirrored by growing numbers of people chronically undernourished and/or micronutrient deficient. The gap between supply and need was underpinned by growing urban demand, consumption of processed and higher-value foods (including meat), biofuel policy, and purchasing power erosion, but also by short-term market-distorting policies implemented by governments responding to perceived shortages of food. Thus, the impact of future food price crises will depend largely on what policymakers chose to do in response to the peaks and what they do not do during the troughs. Appropriate investments are urgently needed not just in smallholder developing country agriculture, but in effective food policies and targeted programming that can reverse the recent negative trends in nutrition and that support access globally to improved diet quality as well as food quantity.

Maternal and young child nutrition adversely affected by external shocks such as increasing global food prices

Rising food prices, resulting from the ongoing global economic crisis, fuel price volatility, and climate change, have an adverse impact upon the poor, especially those in food-importing, resource-limited countries. The conventional approach by large organizations has been to advocate for increased staple crop yields of mainly cereals. High food prices are predicted to continue to at least 2015. Past shocks and their known impacts upon nutrition were reviewed. Price instability and increases have long been an existing global problem, which has been exacerbated by recent macroeconomic shocks such as acute emergencies due to war and civil strife, acute climatic events, increase in food prices, fuel price volatility, dysfunction of the global financial systems, long-term climate change, and the emergence of failed states. The FAO estimated that there were 815 million "hungry" people in 2006, with a now additional 75-135 million with increased vulnerability, and currently it is estimated that there are one billion people at risk of food insecurity. The shocks initially compromise maternal and child nutrition, mainly through a reduction in dietary quality and an increase in micronutrient deficiencies and concomitant increases in infectious disease morbidity and mortality. A further reduction in the quantity of diet may follow with greater underweight and wasting. Recent macroeconomic shocks have greatly increased the number of people who are vulnerable to hunger in developing countries. Nutritional surveillance systems need to be strengthened and expanded to inform policy decisions.

Higher household expenditure on animal-source and nongrain foods lowers the risk of stunting among children 0-59 months old in Indonesia: implications of rising food prices

Because the global financial crisis and high food prices affect food consumption, we characterized the relationship between stunting and nongrain food expenditure at the household level among children 0-59 mo old in Indonesia's rural and urban poor population. Expenditure and height-for-age data were obtained from a population-based sample of 446,473 children in rural and 143,807 in urban poor areas in Indonesia. Expenditure on food was grouped into categories: animal, plant, total nongrain, and grain. The prevalence of stunting in rural and urban poor areas was 33.8 and 31.2%, respectively. In rural areas, the odds ratios (OR) (5th vs. first quintile) for stunting were similar for proportion of household expenditure on animal (0.87; 95% CI = 0.85-0.90; P < 0.0001), plant (0.86; 95% CI = 0.84-0.88; P < 0.0001), and total nongrain (0.85; 95% CI = 0.83-0.87; P < 0.0001). In urban poor areas, the relationship between stunting and proportion of household expenditure on animal sources was stronger than in rural areas (OR 0.78; 95% CI = 0.74-0.81; P < 0.0001), whereas the relationship with nongrain was similar to rural areas (OR 0.88; 95% CI = 0.85-0.92; P < 0.0001) and no relationship was observed with plant sources (OR 0.97; 95% CI = 0.93-1.01; P = 0.13). For grain expenditure, OR for stunting in highest vs. lowest quintile was 1.21 (95% CI = 1.18-1.24; P < 0.0001) in rural and 1.09 (95%CI = 1.04-1.13; P < 0.0001) in urban poor areas. Thus, households that spent a greater proportion on nongrain foods, in particular animal source foods, had a lower prevalence of child stunting. This suggests potential increased risk of malnutrition associated with reductions of household expenditure due to the current global crises.

Household rice expenditure and maternal and child nutritional status in Bangladesh

In Bangladesh, poor rural families often deal with high food costs by purchasing primarily rice. Our objective was to characterize the relationship between household expenditure on rice and nonrice foods with maternal and child malnutrition. Food expenditure data and anthropometry were obtained in a population-based sample of 304,856 households in the Bangladesh Nutrition Surveillance Project, 2000-2005. Food expenditures were categorized as rice and nonrice foods and expressed as quintiles of proportional food expenditure. Of children aged 6-11, 12-23, and 24-59 mo, the prevalence of stunting was 33.5, 56.3, and 53.1%, respectively. The prevalence of maternal underweight (BMI < 18.5 kg/m(2)) was 37.3%. Among children aged 6-11, 12-23, and 24-59 mo, rice expenditures were associated with stunting [odds ratio (OR) 1.11, 95% CI 1.02-1.20, P = 0.01; OR 1.09, 95% CI 1.04-1.13, P < 0.0001; OR 1.13, 95% CI 1.08-1.18, P < 0.0001), respectively, among families in the highest compared with the lowest quintile, adjusting for potential confounders, and nonrice food expenditures were associated with stunting (OR 0.87, 95% CI 0.80-0.95, P = 0.002; OR 0.86, 95% CI 0.83-0.90, P < 0.0001; OR 0.89, 95% CI 0.85-0.94, P < 0.0001) among families in the highest compared with the lowest quintile, adjusting for potential confounders. In the highest compared with the lowest quintile, rice expenditures (OR 1.12, 95% CI 1.08-1.15, P < 0.0001) and nonrice food expenditures (OR 0.93, 95% CI 0.90-0.96, P < 0.0001) were associated with maternal underweight. Households that spent a greater proportion on nonrice foods and less on rice had a lower prevalence of maternal and child malnutrition.

The role of expanded coverage of the national vitamin A program in preventing morbidity and mortality among preschool children in India

Higher food prices increase the risk of vitamin A deficiency among preschool children in poor families, because a larger part of the household food budget is spent on grain foods and less on vitamin A-rich foods. Vitamin A supplementation is an important source of vitamin A for children. Our objective was to characterize coverage of the India national vitamin A program for preschool children and identify risk factors for not receiving vitamin A. Anthropometric and demographic data were examined in 23,008 children aged 12-59 mo in the India National Family Health Survey, 2005-2006. Within the last 6 mo, 20.2% of children received vitamin A supplementation. The prevalence of stunting, severe stunting, underweight, and severe underweight was higher among children who did not receive vitamin A compared with those who received vitamin A (P < 0.0001). In families with a child who did and did not receive vitamin A, respectively, the proportion with a history of under-5 child mortality was 8.4 vs. 11.4% (P < 0.0001). By state, vitamin A program coverage was inversely proportional to the under-5 child mortality rate (r = -0.51; P = 0.004). Maternal education of > or =10 y [odds ratio (OR) 2.22; 95% CI 1.69-2.91], 7-9 y (OR 1.99; 95% CI 1.57-2.53), or 1-6 y (OR 1.65; 95% CI 1.28-2.13) compared with no education was an important factor related to receipt of vitamin A. Poor coverage of the vitamin A supplementation program in India has serious implications in the face of rising food prices. Expanded coverage of the vitamin A program in India will help protect children from morbidity, mortality, and blindness.