27 May 2015

The FANUS 2015 conference: highlights and a lowlight

I just left the FANUS conference after 3 days of presentations and discussions.

There were plenty of highlights:
Isatou Jallow at NEPAD presenting on the key role of women in nutrition-an impassioned and evidence based presentation; Martha Ayagaya the new Africa Nutrition Director at CIFF gave a great talk on governance and accountability;  Ferew Lemma and Anne Bossuyt presented carefully but passionately on the new PSNP4, designed to be more nutrition-sensitive;  Lindewe Sibanda, FANRPAN, presented ATONU, a new initiative for integrating nutrition into agriculture programmes; Prof Amadeus Kamagenge on Tanzania’s promising new safety net programme; Prof Tola Atinmo on human rights and nutrition; Prof. Joyce Kinabo on Agri-Diet, the Irish Aid funded project on agriculture and nutrition; and Suneetha Kadiyala on Agriculture Nutrition Health Academy, launched on June 3 at the LCIRAH conference.  The academy aims to establish a global network of researchers to work on agriculture and nutrition linkages and how to strengthen them.  I hope they focus on the academy bit in particular and contribute to a new generation of researchers and practitioners for who linkage comes naturally.

And the odd lowlight….
One of the large pharmaceutical companies announced the introduction of a website billed as a one stop shop for nutrition.  Very unfortunately the information given was incorrect.  Under the “0-6 month baby feeding guide” it says that breastfeeding exclusively for the first 6 months is “suggested” and that “if you want to bottlefeed your baby start with …”.  Well, either the company was incredibly sloppy, or deliberately misleading, or both.  Either way they need to get their printed facts right and then put in place a set of scientists that are named and widely respected to validate the accuracy of their website so that it does not become a one stop shop of misinformation and harm.  This kind of thing spills over to more responsible companies, giving them all a bad name.  They should not tolerate it and nor should we.  

Perhaps the presentation that took me most out of my comfort zone, in terms of methods and biochemistry was that by Prof Andrew Prentice on the epigenetics of embryo development.  His work in the Gambia on this has been published in Nature and widely reported on but this was the first time I had heard it in person. 
Engaging as ever, Andrew took us through the research step by step.  He and colleagues found that babies conceived of in the hungry season, when preconception nutrition status of women was worse, had more methylated DNA (how cells lock genes in the “off” position) and there is some indication that the genes involved relate to immune system development in the early embryo.  One of the implications is that pre-conception nutrition status might be even more important than previously thought.  If this all holds true with another 18 months of research to check robustness then the strong implication is that we need to find practical programmatic ways of improving adolescent nutrition status (girls, but also boys).  Andrew was careful not to frame this as a challenge to the 1000 day window from conception to 2 years old, rather talking about the importance of getting ready for 1000 days.  So what would those practical programmatic interventions be?  Good question.   

There were some really talented African researchers at the Conference.  There needed to be more external support, however, as not many external agencies and not many researchers from outside Africa attended. 

Big thanks to Joyce Kinabo, Bjorn Lundqvist and the team--and Tanzania--for being such great hosts.

26 May 2015

FANUS 2015: African Nutrition at the Crossroads. But which one?

For the past day I have been attending the Federation of African Nutrition Society  (FANUS) conference in Arusha, Tanzania.  

The Conference is called “African nutrition at the crossroads”.  The question is, what does that mean?

Here are some potential meanings:

*Just as progress is being made on reducing stunting rates, overweight and obesity are increasing rapidly on the continent.   Africa’s choice?  How much effort to expend on preventing overweight, obesity and the related NCDs at risk of diluting the effort to reduce undernutrition? This is somewhat of a false (budget) choice because many of the nutrition related NCD choices are about policy rather than spending.  And the rise of nutrition related NCDs means an even greater focus on African food systems - they are at the heart of all forms of malnutrition reduction.  Again, no tradeoff there, just a strengthening of emphasis on health and nutrition.

*The commitment to reduce undernutrition on the continent is high—but will this be translated into actions and impact?  This will be harder than building commitment (which was not easy!)—the temptation to give up in the face of difficulties must be resisted. Budget allocations to nutrition need to be increased.  Frontline nutrition workers need to be hired.  The coverage of programmes needs to be expanded and monitored.  
*Economic growth is strong in many African countries.  Their Ministers of Finance face a decision: invest in the productivity of the next generation so that the coming demographic transition can be a demographic dividend or invest in unsustainable short term fixes that are electorally attractive?

*The MDGs applied to all low and middle income countries, but were mainly focused on Africa.  This will not be the case for the Sustainable Development Goals.  Africa’s voice will be diluted in the SDGs unless the countries become more active in shaping the agenda, and nutrition--represented so poorly in the latest publicly available SDG drafts—desperately needs African outrage to move nutrition higher up that agenda.

Many other regions are at these crossroads, but it seems to me that the consequences of taking the wrong paths are intensified in Africa.  Africa has more time than Asia to deal with nutrition related NCDs and it needs to use that time well.  Africa faces more challenges than other regions in terms of low nutrition budget allocations and the low number of frontline nutrition workers, but these are also opportunities—the case for increasing the allocations has never been stronger, especially from such a low base.  Tax revenues are growing more rapidly in Africa than elsewhere, partly because from low levels, and decisions made around how to spend those taxes will be difficult to undo in later years.  Finally, Africa has a lot of moral authority to exert its influence over the SGDs—African countries are affected more than other regions by the actions of the high income countries (think climate) so African countries can use that authority to raise the profile of nutrition within the SDGs.

All of these crossroads are presenting themselves to African decision-makers—those within and outside nutrition. The consequences of getting it wrong have never been higher.  But so too the benefits of getting it right. 

22 May 2015

Stunting? Not a LoL matter

Today I gave a talk on malnutrition at my daughter's school.  An audience of ninety 14 year olds.  Scary.

I spent quite a lot of time on the presentation (here).

(Apologies to those whose infographics I stole. I was particularly shameless is stealing Generation Nutrition's We Can End It logo, which I love).

Key takeaways:

1.  Preparing for an audience of 14 year olds is a great exercise in communication. 

Not to say I nailed it, but the kids seemed engaged, did not throw anything at me and  did not giggle once. I had to use really plain English (Utilise, Food Security, Social Protection?  Waaay too complex.).  I just about got away with "stunting" although my daughter warned me it means practical joking (with accompanying LoLs) in their world.

2.  Infographics are great for this kind of audience.

BUT, there is no central repository of info graphics, categorised, for us all to use AND there are some pretty terrible infographics out there as well as the good.

3.  Katy Perry helped out.  (Actually 2 of her videos for UNICEF did.)  

Her videos were great--kept the kids' attention and had great messages (her leveraging of the spotlight on her for the kids, unconditional love for the kids from the communities despite their deprivation, and the first hand viewing of the conditions that convinced her to work with UNICEF).

4.  The Power of Nutrition video is great.  

I used this too.  It is very nice--simple without being simplistic.  It is also great because while it promotes the Power of Nutrition initiative it also deliberately promotes the power of nutrition, period.

5.  14 year olds can ask great questions. 

How is climate change affecting malnutrition?  Does preventing malnutrition increase population growth?  How long does it take to treat a malnourished child?  What do you do after the first 1000 days?

So, if you ever get a chance to communicate to a group of children, do it.

And my daughter?  She said she was proud.  Melt.

19 May 2015

Pearls, Bread and Iron: biofortified millet reduces iron deficiency in Indian schoolkids

Biofortification is one of those ideas that seems too simple to be true--good nutrition for crops is good nutrition for people.  But it also seems to face many hurdles to bring it to fruition.  For example, is it really possible to find or breed varieties of staple crops using conventional breeding methods, that are high in key micronutrients, that improve yields (or at least do not lower them), that don’t affect the appearance, texture or taste of the food, and can be afforded and consumed by micronutrient deficient populations in sufficient quantities (with their micronutrient content remaining bioavailable)--to make a difference to their micronutrient status?  I make that about 10 hurdles to overcome.  Well, for Pearl Millet in India, the race seems to have been won.  The answer to the multipart question is “yes”.

What is the evidence?  Well, a new paper in the Journal of Nutrition reports on a randomized trial of iron-fortified pearl millet in school children of 12-16 years of age in the Indian state of Maharashtra.  The trial, overseen by the highly experienced Cornell nutritionist, Jere Haas, finds that the consumption of biofortified Pearl Millet (eaten in the form of Bhakri bread) for 4 months by the 12-16 year old children resulted in them being 1.6 times as likely to be iron-replete as the children eating non-biofortified Pearl Millet.
The study has limitations.  It was done in a boarding school setting and so the school meals provided more structure than family meals.  Also 28% of the study population was anemic, which is lower than many such populations.   These factors limit the external validity of the study (i.e. how likely is it to be generalizable?).  The authors recognize these limitations and outline how future studies should deal with these issues.
Nevertheless this is a big step forward for biofortification and the HarvestPlus programme behind it. This is the first such trial to show such strong effects on iron deficiency.  With over 2 billion people deficient in one or more micronutrients, we should be looking for all potential pathways—diet diversity, supplementation, fortification, and biofortification—to perform at high levels to eliminate this hidden form of malnutrition.

Biofortication seems to be charting one clear pathway to improved nutrient status, but they are all important.  I very much hope we get many more of these biofortification efficacy (and effectiveness) studies and that as many as possible show positive impacts.  
If the pearl is the oyster’s autobiography, as the saying goes, then this study may be the midpoint of biofortification’s biography. 

29 April 2015

Why is UNICEF such a vital nutrition champion and could it do more?

Today, the UNICEF nutrition leads from their Eastern and Southern African Regional Offices (ESARO) invited me to make a video link presentation of the GNR at their regional meeting in Nairobi.

I was delighted to do so.  In the Q and A a number of questions came up about UNICEF's role.  What could it do more of?

Well, I've never been employed by UNICEF and I'm not an expert on it, but I am of course familiar with some of its work.

So my answers were:

1.  Continue to be strong champions.
At the global level we see this, for example, via UNICEF's strong advocacy and messaging, Tony Lake's leadership and activism, and UNICEF-Nutrition's ability to leverage resources (e.g. its critical role in the Power of Nutrition).

But there are three areas in which they do great work but I think can be even more ramped up:

2.  Be boundary champions.  UNICEF works in education, health, child protection, gender, water and sanitation etc. We need these sectors to become more animated about nutrition.  UNICEF with its fingers in many pies can help to link them up.

3. Be accountability champions.  UNICEF supports governments to collect a multitude of nutrition data via, for example, the Multiple Indicator Cluster surveys (MICs).  These are incredibly valuable.  How could they do more?  Innovate with community scorecards for improving nutrition service delivery.  Experiment with mobile operators to improve knowledge about nutrition practices.  Evaluate rigorously. Share learning.

4. Be story champions.  Stories about nutrition improvements are too often sliced and diced.  This intervention, that policy, this investor.  But in truth we need to see the wider angle view.  Which things come together to accelerate nutrition? Which things come together to generate the perfect storm to hold it back?  UNICEF is in a unique position to tell such stories--again, it must be rigorously done--because it works across sectors and from the community to policy and back. These stories help everyone better understand progress, learn from it and by inspired by it.

UNICEF, thank you for the great work, now can you take it to the next level?  I think you can--and I hope you will.

27 April 2015

New: Healthy Food for a Healthy World (But how to make it happen?)

The influential Chicago Council on GlobalAffairs has produced a new report “Healthy Food for a Healthy World” with an analysis and recommendations for the US Government on how agriculture and food can better leverage improved nutrition.

The report does a good job of outlining a series of outcomes that we would like to see along the food system chain: from natural resources and inputs (e.g. secure land tenure for women) to health and nutrition (e.g. coordinate food system interventions with health and social protection programmes).

The report notes that (1) the improvements in agricultural productivity, if focused on smallholder farming families, can lead to income generation that is very pro-poor and if women in the food system can be empowered then this is doubly good for nutrition, (2) the food system is much too tolerant of lots of food waste—much of it affecting foods that are rich in micronutrients but which need cold storage such as animal products, fruits and vegetables, (3) only ¾ of harvests are not contaminated by the poisonous fungus mycotoxin, (4) the food system is tending towards producing more and more ultraprocessed foods which are, in large part, unhealthy and (5) climate change and urbanization are challenges for--but also opportunities to rethink--our food systems.

I also really liked the panels from Roger Thurow, breaking through the statistics to let us see the stories and hear the voices of those most affected by malnutrition.  The inspired use of photographs to bring home the paucity of diets in many parts of the world is also hard hitting.

So far, so good.  What are the recommendations for the US Government?

The first set of recommendations is very pragmatic—what should be done within existing instruments?  Have a whole of government approach to healthy food systems—not just USAID but USDA and other agencies.  Make food aid more efficient (untie from US shipping, allow more food to be purchased locally) and support efforts to make social protection more nutrition sensitive (as in Ethiopia with the Productive Safety Net Programme). Align all interventions around the 6 World Health Assembly targets.  Encourage more trans-disciplinary research, i.e. mash ups of existing approaches to address complex issues such as nutrition. This is all good sense—first change things that are more under US government control (although untying aid is far from “simple”).

The second set of recommendations is around research.  Incentivise international and national agricultural research to do more work on fruits and vegetables to increase profits and lower their cost in the marketplace.  Close data gaps between agriculture and nutrition surveys.  Invest more in biofortification.  Measure the nutrition impact of agricultural interventions, and so on.  This is important set of recommendations—how can we begin to get a sense of which agricultural investments, under which circumstances, are most nutrition enhancing?  Vital information.

The third set is perhaps the most exciting because while important it is usually ignored—develop leaders for whom making the link between food systems and nutrition is second nature.  Invest in research centres in the US and overseas that are committed to this.  Invest in leadership programmes that stress whole of society working.  Invest in innovation awards that set new norms about what agriculture is for.  Train Peace Corps volunteers in what nutrition sensitive development looks like. 

Finally, develop public-private partnerships that can incentivize businesses towards healthier food systems: support infrastructure to reduce food losses and promote food safety, support entities that monitor firm behaviour, support budding nutrition-oriented SMEs, increase technical assistance on monitoring food safety in Africa, and support stronger global advocacy of voluntary guidelines on nutrition sensitive marketing to children.

For me, the thing that is missing from the analysis is the political economy of it all.  

Why should members of the Congress and the Senate support these measures to promote voluntary guidelines on marketing unhealthy food to children if they risk upsetting businesses who have located in their state?  What is in it for agricultural and nutrition researchers to work together more closely?  How can infrastructure investments that will promote fresh fruit and vegetable access be made more attractive? If food aid has been tied for decades, why might it become untied now?  Having a whole of government approach to a healthy food system is great, but why has it not happened before? How can we encourage trans-disciplinary research when most journals prefer disciplinary research?

I’m not suggesting these questions are easy to answer.  Far from it. But I would have liked to have seen some recognition of this and some ideas for moving forward. 

Nevertheless, I very much enjoyed reading this report—it is a thoughtful analysis, well written, and contains many pragmatic good ideas. If its recommendations were acted on they would make a big difference to nutrition status the world over.  

I hope the Council will maintain a scorecard and tell us which of its recommendations have been taken up and which have not.  And explain why. 

23 April 2015

What the Different UK Political Parties Really Think about DFID

14 days to go to the closest UK General Election in recent history and we have not heard much about DFID/UKAid/Overseas spending, except from UKIP which is not keen at all.

This lack of election fever debate is good in the short run and reflects a consensus that having a sizable international development budget is the right and smart thing to do.

But in the medium run it would be good to have a discussion of when and how the aid budget changes and evolves. An election is exactly the wrong time to do this because everything in the discourse becomes binary, simplistic and shrill.

However, we do need a debate on the long term future of UK Aid and I hope the new Government starts thinking and consulting about it.

In any case, a friend asked me if I was going to do a blog on the different parties' views on DFID--as I did back in 2010.  I told him I thought there was not enough grist for a decent blog.

But behind the harmony of the public positions, what are the UK political parties really thinking about DFID?

Here is my entirely non-serious attempt to read their minds (apologies to non UK readers for the in-jokes):

Conservatives: well, that was a real vote winner!

Greens: we'll double the 0.7% to 1.0%. Er, hold on..

Labour: blimey, I hope we're not supporting zero hours jobs overseas

Plaid Cymru (Welsh Nationalists): it already sounds like a Welsh town & Wales is international, right?

Scottish Nationalist Party: it supports strong national governments all over the world ;)

UK Independence Party: nuke it, nuke it, and then nuke it again

Liberal Democrats: what they said...