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Impact of Feed the Future initiative on nutrition in children aged less than 5 years in sub-Saharan Africa: difference-in-differences analysis

BMJ 2019; 367 doi: (Published 11 December 2019) Cite this as: BMJ 2019;367:l6540
  1. Theresa Ryckman, PhD candidate1,
  2. Margaret Robinson, medical student2,
  3. Courtney Pedersen, medical student2,
  4. Jay Bhattacharya, professor of medicine1 3,
  5. Eran Bendavid, associate professor of medicine1 4
  1. 1Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
  2. 2Stanford University School of Medicine, Stanford, CA 94305, USA
  3. 3National Bureau of Economic Research, Cambridge, MA, USA
  4. 4Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
  1. Correspondence to: T Ryckman ryckmant{at} (or @rycktessman on Twitter)
  • Accepted 7 November 2019


Objective To evaluate the impact of the US government’s Feed the Future initiative on nutrition outcomes in children younger than 5 years in sub-Saharan Africa.

Design Difference-in-differences quasi-experimental approach.

Setting Households in 33 low and lower middle income countries in sub-Saharan Africa.

Population 883 309 children aged less than 5 years with weight, height, and age recorded in 118 surveys conducted in 33 countries between 2000 and 2017: 388 052 children were from Feed the Future countries and 495 257 were from non-Feed the Future countries.

Main outcome measures A difference-in-differences approach was used to compare outcomes among children in intervention countries after implementation of the initiative with children before its introduction and children in non-intervention countries, controlling for relevant covariates, time invariant national differences, and time trends. The primary outcome was stunting (height for age >2 standard deviations below a reference median), a key indicator of undernutrition in children. Secondary outcomes were wasting (low weight for height) and underweight (low weight for age).

Results Across all years and countries, 38.3% of children in the study sample were stunted, 8.9% showed wasting, and 21.3% were underweight. In the first six years of Feed the Future’s implementation, children in 12 countries with the initiative exhibited a 3.9 percentage point (95% confidence interval 2.4 to 5.5) greater decline in stunting, a 1.1 percentage point (0.1 to 2.1) greater decline in wasting, and a 2.8 percentage point (1.6 to 4.0) greater decline in underweight levels compared with children in 21 countries without the initiative and compared with trends in undernutrition before Feed the Future was launched. These decreases translate to around two million fewer stunted and underweight children aged less than 5 years and around a half million fewer children with wasting. For context, about 22 million children were stunted, 11 million children were underweight, and four million children were wasted in the Feed the Future countries at baseline.

Conclusions Feed the Future’s activities were closely linked to notable improvements in stunting and underweight levels and moderate improvements in wasting in children younger than 5 years. These findings highlight the effectiveness of this large, country tailored initiative focused on agriculture and food security and have important implications for the future of this and other nutrition interventions worldwide.


  • Contributors: EB and TR were involved in initial conceptualization and methodology development. TR and MR cleaned, curated, and analyzed the data. CP, MR, and TR contributed to the first draft of the manuscript. EB, JB, TR, MR, and CP contributed to study design, interpretation of results, development of visualizations, writing, and initial editing. EB and JB were involved in validation of results and conclusions and act as guarantors of the study. All authors have read and approved the final draft of the manuscript. All authors had access to all data in the study and had final responsibility for the decision to submit for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This study received no specific funding.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: EB receives funding from the Doris Duke Charitable Foundation and the National Institute for Allergy and Infectious Diseases; JB was partially supported by the US National Institute on Aging through the Stanford Center for Demography and Economics of Health and Aging (grant No P20-AG17253); TR receives support for her PhD research as a National Science Foundation graduate research fellow and Stanford graduate fellow in science and engineering; no support from any organization specifically for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • Ethical approval: Not required.

  • Data sharing: All data used in the analysis are available through the Demographic and Health Surveys and Multiple Indicator Cluster Surveys websites for academic researchers.

  • The lead author (TR) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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