27 November 2016

Fortification: It's a bit more complicated than "add, stir and distribute"

One of the great things about being at GAIN is that I have the chance to learn about lots of new things.

Surprisingly, one of the new things I am learning about is fortification.  Surprising to me, because if you are not an expert it is easy to think of fortification as "add fortificant,  stir and distribute".

A recent PLOS One paper (including two of my new GAIN colleagues) shows how misguided such simplistic thinking is.

The paper contains two pieces of analysis, both from the Indian state of Telangana (36 million people, containing the city of Hyderabad).  Both analyses are drawn from a survey of children 0-35 months of age residing in the catchment areas of all the ICDS centres in the state.   The survey found that 79% of all salt samples from the households of the selected children were adequately iodised.  BUT, the level of adequate iodisation varied significantly by District within the State and by iodised salt brand.  So even in one of the most easy to fortify substances, fortification is variable.  Work is needed just to maintain effective iodisation levels.

The second piece of analysis aims to examine the prospects for effective fortification of rice.  As I have written in an earlier gung-ho blog, I thought: rice fortification--its a no-brainer.  Well, its a little bit more complicated than that!

First, do the groups in the population that are micronutrient deficient actually consume rice?  Second, do they get rice from sources that can actually fortify rice?  Third, can the rice be fortified in a cost effective way?  Overall, the answers for Telangana are not encouraging.  First, no recent deficiency data exist for Telegana.  Second, if rice could be fortified it would make a big difference to the % of children and women meeting the RDA for various micronutrients (so this indicates the potential). But, third, a quarter of households consume rice they produced themselves and the households that do buy rice buy it from markets that are served by over 600 millers--a complex context for cost-effective fortification.

Of course the rice situation will likely change over time as more people buy rice from market sources and as rice milling and distribution becomes more concentrated, but for now the fortification of rice in Telegana does not look to be a promising solution to reducing micronutrient malnutrition in the state.  The authors examine if the government's Public Distribution System could be a viable delivery channel, but only 6% of households surveyed access rice from this source.  Still, 6% is not bad if the cost-effectiveness ratios look reasonable.

The rice fortification story just reinforces the need for policymakers in the State to look at their food systems to see what they can do to encourage the demand for and supply of affordable foods that are rich in nutrients.

Fortification: its not just "add, stir and distribute" -- but you already knew that!

19 November 2016

Evidence in nutrition: have we set the bar too high?

I’m going to be honest here, I don’t know the answer to this question, but I think it is a question worth asking:  is our quest for evidence enabling or inhibiting us when it comes to acting to end malnutrition?

I raise this now because over the past few weeks I have met senior people in various development organisations who think the quest for evidence about nutrition interventions may have gone too far.  

The arguments they put forward include:

* Randomised controlled trials are not the only credible source of evidence and in many cases are not the most appropriate.  Think of the recent BMJ evaluation of the soda tax in Mexico—this was done with good old-fashioned economic modelling.

* Does an intervention really have to show positive impacts in multiple geographies before we are convinced? Are we trying to find design-proof interventions?

* If the intervention we are implementing in the absence of cast iron evidence could do harm, then caution is of course warranted, but in the absence of the potential of harm, are the downsides of taking calculated gambles on interventions really that large?

* Do the tools we consider to be gold standard lead us away from exploring certain approaches?  Are we only exploring what is amenable to randomisation and not what is meaningful?

This is a familiar debate in development but not one I have heard voiced in nutrition.  Make no mistake about it: the Lancet series of 2008 was a massively positive game changer—a set of proven interventions (“proven” being largely determined by randomised baseline and endline kinds of evaluations) that policymakers could latch onto in their search for a response to the food price crisis of 2007-8. 

Nevertheless, I do have some sympathy for the above views.  I am a staunch advocate of rigorous evaluations, but this does not mean RCTs only (and I have been involved in the design of at least 2 RCTs).  Moreover only certain interventions--new ones, ones never tried in a certain context before—need the highest level of rigour.  “Rigorous enough” should be the guiding concept.  We are trying to figure this out for GAIN too—when do we go deep in our evaluations and when is something less heavy “rigorous enough”?

But does the quest for purity on evidence really matter?  Does it really stop action?  I feel like it might be—particularly in stopping creative thinking and experimentation on how to reduce adolescent malnutrition.  A recent meta review cycles through the current options: micronutrient supplementation, delaying age of first birth, increasing birth spacing, and the education of adolescents around healthy diets. OK, but we could have written this list 20 years ago—where is the creativity in this space?  

Evidence is the ideal driver of action, but if it is the only driver then we are stuck in its absence.  We can’t be hamstrung by the lack of evidence—we must be driven by it.  Driven to imagine, innovate, design, pilot and evaluate.  Lives depend on it.

12 November 2016

The world is urbanising. So is malnutrition. Time to think differently.

This past week GAIN organised an event, in partnership with the Scaling Up Nutrition Movement (SUN) and the Global Health Centre at the Graduate Institute in Geneva, on urbanisation and nutrition.  

Both of these issues have been the subject of major international conferences in  recent years.  The second International Conference on Nutrition less than 2 years ago was a major rallying call for food systems to do more for nutrition, 20 years after the first conference in the early 1990s.  Similarly last month’s Habitat III conference on cities was the first in 20 years.   While there have been some voices calling for these two issues to come together, this has not really happened, although things now seem to be changing.

Why has it taken so long?  For a long time the centre of gravity for poverty and deprivation in many low income countries resided in rural areas. In the 1960s and 1970s Michael Lipton was writing about urban bias—policymakers focusing on their potentially troublesome urban neighbours but ignoring the more deprived but “out of sight out of mind” rural counterparts.  As late as the 1990s we could see the massive resource mismatches in Mexico, with most anti poverty resources going to urban areas while most poverty was in the rural areas-this was a big spur to the redesign of Mexico’s social policy programs.

But this picture is changing.  Poverty is slowly becoming urbanised, and, probably, undernutrition is too.  I say probably because we don’t know definitively.  We can track nutrition indicators over time but the designation of households as urban or rural also changes over time.  A simple analysis I did with Natasha Ledlie of IFPRI and Tom Pullum of ICFI for the WHO-Habitat 2015 Global Report on Urban Health showed that in 9 out of 17 countries in the Figure below the urban share of stunting is growing, in 7 it is decreasing and in 1 it is constant.  

But the big game changer is the growth of adult overweight, obesity and diet related non communicable diseases such as type 2 diabetes.  These are increasing faster in urban areas--in part due to the spectacular rise of the consumption of highly processed foods in towns and cities. A recent study showed that in 6 Southern and Eastern African countries, the consumption of highly processed foods among the lowest income groups in urban areas is almost as high as the consumption of these foods in the highest income groups in rural areas. 

Not all highly processed foods are bad for health, but many are: think of sugary drinks, high fat, salt and sugar snacks and fast food made with processed meat products. These foods are more available in urban areas due to fast food outlets, small and large supermarket chains and because adults have less time for food preparation—often they have to travel long distances to work, they have no cooking facilities if in slums and women work outside the home--these outlets are the most convenient, and often the cheapest. 

So what are the solutions?  We certainly don’t need to completely reinvent the wheel—many interventions and approaches that work in rural areas will work in urban spaces (e.g. food fortification).  But the opportunity to work with “new policymakers” in the urban space--food buyers for supermarket chains, mayors and municipal leaders, and collectives of opinion formers and activists who are powered by social media—may well create new policy and program intervention opportunities. We need to find these. 

To do this, we need to change our perspectives.  Cities are places full of young people.  Cities can be drivers of growth and good nutrition for their residents and for the rural areas they are linked to.  But those of us over 40 probably need to reorientate our thinking.  We were brought up learning about--and experiencing-- rural development.  But rural contexts are different: less market based, with more social capital and more security but with less political power.  

We need to engage the new policymakers in our alliances against malnutrition: they are the "unusual suspect"s we need to unlock the seemingly intractable nutrition problems.  

For example, how can we incentivise supermarkets to source not only more ethically produced foods but also more healthily processed foods (we have FairTrade, what about HealthyTrade)?  How can we get mayors to care about human infrastructure as much as they care about building physical infrastructure?  How can we get social media leaders to get their followers interested in food systems as well as political systems?  How can we get the strong tech innovation hubs in cities to focus on disrupting food systems as well as disrupting car transport systems?

Malnutrition in all its forms is driven by confluences of powerful forces: poverty, inequality, urbanisation and globalisation to name a few.  To combat them we need powerful alliances of actors to come together to act.  Urban spaces provide many new challenges, but also many new opportunities.  We need to open our eyes and take them. 

30 October 2016

To blog or not to blog?

I'm often to be found encouraging my colleagues and friends to blog about their work.

I blog for many reasons (beyond the ego driven nature of it all).  I find it helps me get more familiar on an issue and it helps me organise and clarify my thoughts on it. It also forces me to read key documents.  It helps me write more succinctly and to the point.  It helps to share information and views (admittedly mine).  It also helps promote transparency.

I write about this now now because I just passed a million page views on the Development Horizons blog.  The blog has been running since 2009 and I have posted about 600 blogs during those 7 years.  That's about 1,600 page views per blog.  

For context my Google Scholar citation count is about 18,000 over about 120 articles over 30 years.  If we assume one citation for 10 article reads (and I have no idea if this ratio approximates reality, but it seems plausible) then that is 180,000 reads.

Apples and oranges, I know, but it is interesting that blogs are so widely read (not surprising when you think about it--they are short, free and one click away).

Are there risks? Yes, blogs can oversimplify, have no peer review process and are often data and link free.  They can be sheer vanity projects.   Still, these risks can be managed.  And finally, remember that content is king (or queen): if the blog is boring and uninformative no-one will read it.

So colleagues (and I use that term in the widest sense) I encourage you to blog now, blog often and blog responsibly!  (And if you can't do that, at least keep reading my blog!)

Nigeria: Can it be a driver of nutrition progress?

One of the great sessions at the recently completed Micronutrient Forum was on the implementation of Nigeria's National Strategic Plan of Action for Nutrition (2014-2019).

The national strategic plan of action focuses on direct nutrition interventions.

It is exemplary in that it has (1) SMART targets for the reduction of stunting, wasting, exclusive breastfeeding and complementary feeding, (2) is costed, (3) identifies current resource allocations and needed resource mobilisation, (4) identifies platforms for delivery and (5) tells policymakers what their investments will buy in terms of lives and DALYs saved.

The plan has buy in from the Ministry of Health, State Nutrition Offices, UNICEF, the World Bank, GAIN and others, so it reflects a collaborative consensus building process.

What needs to happen now?  Well, with the World Bank looking poised to increase funding to nutrition, the Government must now step up to allocate more of its own resources to increasing the coverage of effective and proven nutrition interventions.

I would have liked to see the opportunities within Nigeria to link with other sectors such as the food system, education, and water and sanitation (the plan is health sector focused), but perhaps they are in other documents.  Still, it would have been good to see how this fit in with the others.

If Nigeria can get stunting rates down to 28% by 2019, the whole of Africa will move forward.  If Ghana can do it, then so can Nigeria.  The world is watching.

28 October 2016

Have micronutrient powders been rolled out too fast? Yes and no.

Yesterday at the Micronutrient Forum in Mexico, there was a fascinating debate set up to answer the question: "have micronutrient powders been rolled out too quickly?".

Putting the case for "no, they have not" was Prof Stan Zlotkin and the case for "yes they have" was put forward by Dr. Omar Dary. Interestingly, both of them are on the GAIN Board!  Disclosure: GAIN works with partners to do work on scaling up micronutrient powders.

My former colleague Marie Ruel of IFPRI was the person tasked with penetrating the arguments and finding the areas of agreement and core differences.

The arguments seemed to boil down to why, when and how micronutrient powders are rolled out.

First, we need to demonstrate that there is a need to be met: is there widespread iron deficiency in infants and young children and might that deficiency be addressed through the better functioning of an existing program or interventions? Second, even if there is a deficiency and no way of meeting it with existing programs, does it make sense to address with micronutrient powders?  For example, can they be produced at the right quality at a low enough cost and is there a demand for such products? Finally, is the infant and young child nutrition infrastructure strong enough to support scale up and, indeed, will it be strengthened or undermined by such a scale up?  If the answer to these questions are in the affirmative then the scale up is probably going to make a positive contribution.

So the answer (at least this was my own takeaway) was, yes scale up if there is a need that cannot be met by existing interventions and if it is done thoughtfully in an evidence based way that supports health and food system infrastructure, but no, don't scale up where these kinds of conditions have not been met.

There should be more of these kinds of sessions in nutrition meetings: we faced a thorny issue head on, we showed that reasonable people can disagree without rancour, and we found some common ground in a serious but good natured way.  Lets keep it up!

What can we do to strengthen the enabling environment for micronutrient malnutrition?

This was the exam question I was set by the 2016 Micronutrient Forum organisers. My slides are found here and the stats below are referenced in them. The enabling environment is important. If strong, it makes it easier for people with power—at all levels, in all sectors—to make positive decisions for reducing micronutrient malnutrition. If the magnitude and distribution of the problem is unknown, the consequences unclear and the solutions unheard of, then not much is going to happen. Additionally if there is no pressure on the decision makers to act, this also makes decisive action less likely.

So, how good is the enabling environment for micronutrients?

Well, we have some data, but not nearly enough, on the state of micronutrient deficiency. To start with there is the “2 billion people who have a micronutrient deficiency” number, the origins of which are lost in the mists of time. Then we have the hidden hunger index which averages the prevalence of stunting, women’s anaemia and vitamin A deficiency. We also know that infants’ diets are appallingly monotonous – only about a quarter of them in 60 countries achieve even minimum diet diversity. Also for eight African countries we know that women’s diet diversity is shockingly low. We also know that progress in reducing micronutrient malnutrition is barely perceptible. At current rates of progress the WHA target for women’s anaemia will only be reached in 2084, not 2025.

So given this picture, how much talk, outrage or urgency is there about the need to do something about micronutrient malnutrition? It is difficult to measure outrage.  But I have two measures of “talk” for you, both from Google. The first is the Google Ngram reader which tracks the occurrence of words in the 5 million books that Google have digitized. According to this metric we reached “peak micronutrients” around 2002. The number of mentions has been declining since then. The second is the number of times “micronutrients” are mentioned in Google News, ever.  The number for obesity is 2 million. The number for acute malnutrition is 8,810. The number for micronutrients is 327.

OK, so maybe micronutrients have not really captured the public’s imagination, but are nutrition policymakers taking it seriously?  Is there any urgency? Less than you would think.  Only 33% of national nutrition plans contain targets for women’s anaemia reduction compared to 48% for stunting.  In addition, no one seems to be tracking the price of micronutrient rich foods. They are creeping up relative to staple prices. In South Asia, the purchase of 5 a day fruit and vegetables would take up to more than half of a household on $2 a day.

So, I would conclude, from this rather imperfect analysis that the enabling environment for accelerating reductions in micronutrient malnutrition is weak.  What needs to change?

First, we need to find ways to advocate more effectively for the reduction of micronutrient malnutrition.  The very word “micronutrients” gets us into technical waters very quickly, waters that journalists are mostly unwilling to navigate.  We need to get simple messages across: “low quality diets are a bigger risk factor that unsafe sex, drug, alcohol or tobacco use”; “from food quantity to food quality”; and we need to highlight the monotony of most people’s diets by hypothetically transposing that same monotony to the diets of the well off. We could learn a few things from the techniques that businesses use so effectively to shape and influence consumer choices.  Building alliances with global and national networks of celebrity chefs might be a useful approach: they have a reach we can only dream of. 

Second, we need to drastically ramp up accountability.  How are we doing on reducing micronutrient malnutrition rates? Are we improving target setting on these dimensions? What is happening to legislation on fortification and policies to improve diet quality? What is happening on coverage rates of direct micronutrient interventions?  What is happening to spending of governments, donors and businesses on enabling greater access to micronutrients and healthy foods? We have precious little data, but accountability tools need to be developed that highlight this data dearth and make suggestions for filling the gaps.  There are obvious opportunities for teaming up with the Global Nutrition Report team to deepen the accountability around micronutrients, perhaps in a complementary Global Micronutrient Report.

Finally, we need to come together.  As a relative newcomer to the micronutrient world, I am really struck by the tribalism that flares up more often than is productive. You know how it goes:  “diet diversity is the only sustainable approach”; “large scale food fortification violates people’s rights”; “home fortification and supplements are vertical interventions that undermine food systems and medicalize nutrition”; “biofortification is the Trojan horse for GMOs and give plant breeders even less incentives to invest in non-staples.”

I reject these divisions. We need all of these approaches—the mix will differ by context and must be determined by governments themselves. Together they intertwine to form powerful bonds that we can rely on to overcome micronutrient malnutrition. If we work together we can really make a massive dent in micronutrient malnutrition by 2030. We have to check our own self-interests and pet interventions at the doors of government offices and at the doors of the huts, shacks and isolated high rises of those actually living with micronutrient malnutrition. Those who experience the devastation of micronutrient malnutrition should not even have to wait until 2030, let alone until 2084.