Addressing malnutrition in Ethiopia: A call for a systems approach to match the scope and complexity of the problem

comprehensive diagnostic of the problem of malnutrition in Ethiopia. The supplement provides a first attempt to collect evidence supporting the much ‐ needed transition towards a better alignment of food, health, education, and WASH systems to effectively address all forms of malnutrition in Ethiopia.

that the prevalence of child wasting peaks in the first 6 months of life, whereas that of stunting starts only to increase significantly after 6 months of age.This is in line with earlier findings that linked the timing of growth faltering with the complementary feeding period (Victora et al., 2010), but also signifies the beginning of the manifestations of sustained nutritional deprivation and recurrent infections faced in the first months of the child (Benjamin-Chung et al., 2023).Worth noting is also the high (15%-20%) prevalence of stunting reported to be present at birth; a finding that suggests that poor maternal nutritional status, particularly during pregnancy, is contributing to the high burden of malnutrition.
Indeed, the study by Hailu et al. (2021) showed that more than one in five women of reproductive age were anaemic in 2016, but with even higher prevalence (>50%) in some of the identified hotspots.Unlike child nutritional outcomes, the prevalence of anaemia was reported to have increased between the periods of 2000 and 2016, and these increases were primarily reflections of the widening of existing hotspot areas.Such subnational analyses and mapping help to identify priority areas, but also unmask disparities by highlighting areas that have made little or no progress.Similarly, the subnational estimates and analyses helped unravel the increasing problem of the Double Burden of Malnutrition (DBM), defined as the coexistence of undernutrition and overweight/obesity or diet-related noncommunicable diseases (NCDs), which could be at the individual, household, or population level (WHO, 2016).In cities like Addis Ababa, the prevalence of household-level DBM was quite high (22.8%),while relying on the national estimates only would have painted a very low prevalence of DBM (3.6%: 2016;Pradeilles et al., 2022).Such high prevalence of DBM in cities like Addis Ababa is not surprising and aligns with a recent multicountry study that related high DBM prevalence among the richest and in the most socially and economically globalized settings, which is the case for major cities like Addis Ababa (Seferidi et al., 2022).

| DRIVERS OF MALNUTRITION AND PREVAILING INEQUALITIES
Several drivers of malnutrition have been identified by the studies published in this supplement.More importantly, the studies identified shared drivers that can help us take the necessary steps to address nutritional problems (e.g., stunting and wasting) through more comprehensive interventions that capture the interrelationships between the different manifestations of malnutrition, rather than focusing on those that address them in isolation.

| Diet quality
The paper by Hirvonen et al. (2021a) found that both wasting and stunting were associated with limited consumption of nutrient-dense foods like animal-source foods, maternal IYCF knowledge, and increased number of under-5 children in households.Delayed introduction to complementary feeding was reported to be widespread and associated with gaps in maternal IYCF knowledge, and increased odds of linear growth faltering (Hirvonen et al., 2021b).
Progress in improving the dietary diversity of children was too little too slow (Tizazu et al., 2022), and was outpaced by increases in unhealthy feeding practices such as the consumption of ultraprocessed foods (UPFs) (Tizazu et al., 2022b).The increasing consumption of unhealthy foods was also highlighted to be widespread among adolescents in urban schools in Ethiopia, as highlighted by Iyasu et al.
(2023) in a qualitative study, also published in this supplement.Worth noting, is also the finding that food safety concerns determine adolescent's food choices and diet quality, underlying the need to integrate food safety considerations into the design of nutrition programmes.(CMAM) programme.The CMAM programme was reported to have averted ~34,000 child deaths per year and was reported as one of the cost-effective ways of preventing death related to child wasting.

| Access and quality of healthcare
While appreciating the progress made in the treatment of wasting, the authors call for more efforts to not only treat but prevent wasting.This aligns with UNICEFs call for a systems approach to nutrition, strengthening integration between various systems (e.g.food, water, education, and social protection) (UNICEF, 2020).
Using the co-coverage index, which is a count of essential reproductive, maternal, neonatal, and child health (RMNCH) interventions received, Baye et al. (2022) showed that access to health care reduces the odds of child wasting, stunting, but also increases dietary diversity.This is supported by the findings from the decomposition study by Girma et al. (2022) and the longitudinal study of Hirvonen et al. (2021a)-both in this supplement-that showed that infections were among the primary predictors of child wasting.The IYCF knowledge of health workers was also found associated with increased maternal IYCF knowledge and MDD, leading the authors to suggest that frequent and timely visits of households by health extension workers to provide messages on what, when, and how to feed the child are needed (Hirvonen et al., 2021b).On the other hand, the finding that IFA supplementation is associated with reduced odds of anaemia among women of reproductive age further suggests the need to strengthen the health system to expand coverage but also provide quality services (Hailu et al., 2021).

| Water, sanitation and hygiene (WASH)
Poor WASH conditions can expose vulnerable groups to diarrhoeal infections, compromise the safety of complementary foods, but also influence food choices away from perishable nutrient-dense foods.
The study by Girma et al. (2021) in this supplement showed that improvements in WASH conditions between 2000 and 2016 led to modest reductions in the risk of diarrhoea and stunting in children less than 5 years of age.However, with less than 10% of households having access to basic sanitation facilities, much remains to be done.
The timing of diarrhoea coincided with the complementary feeding period (6-23 months), a finding also reported in a multicountry study from Sub-Saharan Africa (Ogbo et al., 2017).Altogether, this suggests the need to ensure the safety of complementary foods through the implementation of baby WASH interventions (Waller et al., 2020).

| PREVENTING MALNUTRITION: PROMISING INTERVENTIONS AND WHAT COULD BE DONE BETTER?
Socioeconomic well-being, maternal knowledge/education, diet quality, and access to quality health care were common drivers of all forms of malnutrition.Thus, accelerating progress requires alignment of policies, programmes, and interventions and leveraging synergies across food, health, WASH, and education systems as highlighted in the UNICEF global strategy 2020-2030 (UNICEF, 2020).
First, inequalities in diet, access to health care, and WASH need to be addressed (Girma et al., 2021;Tizazu et al., 2022).According to the studies by Girma et al. (2021) and Tizazu et al. (2022), rural households and those from lower socioeconomic status were those that could not afford to consume nutrient-dense food groups, access essential health-and WASH services; hence, were the most affected by various forms of malnutrition.Increasing income and its distribution, but also boldly investing in women's empowerment could help improve maternal and child well-being.Indeed, in this supplement, Baye, Laillou, et al. (2021) showed that women empowerment measures (autonomy and decision-making) were more strongly associated with increased child dietary diversity (MDD) than wealth, child age, and urban residence.
Access and quality of health care are critical to prevent excess child death and improve diet quality and nutritional outcomes.The health system is indeed the primary vehicle for the delivery of nutritionspecific interventions that aim to reduce maternal and child malnutrition.In this supplement,Laillou et al. (2022) illustrate this by estimating the number of child deaths averted between 2008 and 2020 by the Community-based Management of Acute Malnutrition