19 July 2017

The World Bank Weighs in on Obesity and Food Systems

The World Bank and Obesity.  Not often terms we find in the same sentence.  But I am really glad to see the Bank pick up on this issue, particularly the links between food systems and obesity.
I’m referring to a new World Bank publication called “An Overview of Links Between Obesity and Food Systems”.  I can’t find it on the web, but here is a PDF.
The report is well written and sensible, but does not contain anything new in substance. Here are the entry points for “possible action”.

However, the Report is highly noteworthy for several reasons.
First, it is the World Bank. Love them or not, they matter. If they say we need to pay more attention to how food systems can mitigate obesity, others will pay attention. They reach constituencies that WHOFAO, the NCD Alliance and, ahem, GAIN cannot.
Second, this is an organisation steadfastly focused on poverty reduction (explicitly since 1999’s World Development Report) and obesity is routinely seen as a manifestation of wealth. Well, it is not. It is driven by inequality and, in some countries, by poverty.
Third, the Bank uses the Global Panel’s Conceptual Framework for Food Systems. This is great, not just because I was one of the authors of that, but because it means that the Bank is building on the work of others, something it has not always done, for whatever reason.
Fourth, the Bank report really accentuates the pattern of investments in of agricultural R&D and how too little of it is allocated to crops other than rice, wheat and maize. This matters because the Bank is the convenor and key financier of the Consultative Group on International Agricultural Research (CGIAR), which is the premier public research body on agriculture.
Fifth, the Bank report is realistic about evidence. It says there is not nearly enough, but it does not use this as an excuse for inaction. Refreshing.
So while the Report does not contain much new thinking, it is an important signal to those inside and outside the World Bank that obesity is not off the table, and that some of the Bank's investments in agriculture and food systems could be doing more to mitigate it and may even be inadvertently contributing to it.
Not every report has to be path-breaking in its content to be exciting.
Bravo to our H Street colleagues.

14 July 2017

The Geography of Malnutrition: Seemingly Worlds Apart (But Not Really)

This week I attended the UK Nutrition Society meetings in London. The theme of the conference was on nutrition issues in metropolitan contexts (i.e. urban spaces).   

Most of the conference was focused on high-income country issues.  I went because it was a new audience for me and for GAIN. 

The presentations in my session were on (a) the nutrition case for and against the consumption of artificially sweetened drinks (Professor Peter Rogers), (b) demand creation for water consumption (Dr. Emma Derbyshire) and (c) how public policy can shape food landscapes (Dr. Amelia Lake). I spoke about the challenges and solutions in urban areas in low and middle income countries. 

The first presentation was interesting as it tried to separate perceptions from evidence about the consumption of artificially sweetened soft drinks.  Based on the evidence presented, do they reduce overall calorie intake? (yes, although we don’t know enough about long term effects on weight managment) and do they develop an increased demand for sweetened foods? (the evidence suggests no). What was somewhat reassuring about the presentation was the use of systematic reviews and the citing of Barry Popkin’s work (the guru: see “The World is Fat”). What was less reassuring was that some of the research was funded by the soft drink industry (as declared by Prof. Rogers at the start of his talk).  The work would have presented much more powerfully if it had been more independently funded.

The Drink Up (water) talking fountain in the US
The second presentation focused on how to increase water consumption.  Most people are below the daily recommended levels.  The session included a couple of innovative demand creation campaigns for water and for activity (Drink Up -Drink Water in the US and the JOGG “free movement” campaign in the Netherlands)—the videos were fun and engaging.  We need more of this in nutrition in the lower and middle-income countries.  Of course the question is what impact do the campaigns have, especially after they end.  

The Jogg "movement" campaign in the Netherlands
Our BADUTA project with the Government of Indonesia, has a strong behaviour change component, and the project is showing good signs of changing behaviour and increasing diet diversity (I have seen the first draft of the independent evaluation by the University of Sydney—I will share it when it becomes publicly available).

The third presentation was all about “foodscapes” (i.e. how does the built environment shape the availability and affordability of healthy and unhealthy foods?).  Work was highlighted from an EU funded research programme called “Transforming the Foodscape: development and feasibility testing of interventions to promote healthier take-away, pub or restaurant food”. 

Interventions piloted in the North East of England included (a) Take Away Masterclass (working with staff from 18 takeaways--180 were invited--on how to improve the healthiness of cooking practices), (b) reducing portion size in fish and chip shops (working with wholesalers to create smaller portion options with half the calories of regular portions—there has been significant demand from customers for smaller portion options) and (c) a desk evaluation of the offerings of “healthier” flagship sit down/take away restaurants such as NOSH Healthy Kitchen (work not completed yet).  All very interesting and all very disconnected from similar work that is happening in Africa, Asia and Latin America--which is a major missed opportunity for all countries.

In the Q & A session, Dr. Alison Tedstone, the Director of Public Health England—the nation’s lead government agency for ensuring the health of the English population—asked me about my presentation: how do we avoid “tinkering around the edges” and zero in on the really big levers that can change food consumption?  She highlighted the effect the soft drinks levy on food manufacturers is having: they are changing their product formulation to avoid paying the levy, and more importantly the dialogue has changed completely, from foot dragging on voluntary codes to having to deal with the implications of legislation.  My answer was that every context is different and some preliminary work has to be done to find that lever—work which factors in technical, political and capacity considerations. In other words there are bound to be lots of promising options to effect change, but we need to look hard in a given context to find the best.

Other questions in the panel discussion related to (a) what is the role of researchers in lobbying for change based on balanced high quality evidence? (my answer: senior researchers should be active in advocating for change, as long as they are faithful to the evidence), (b) how do we persuade research funders to be more inclusive in their acceptance of a range of evaluation methods that are driven by the issue and context rather than a familiarity with and preference for a particular method? (my answer: again, use the evidence to show that other methods can work and engage with funders to show them the wealth of credible evaluative tools that are available), and (c) do we focus on demand or supply to change food environments? (my answer: both).

I enjoyed the conference session.  It was good to see the experiences from the high income countries and to think about how they may read across to countries that are trying to avoid their fate.  But it was a bit disappointing to see so few people present working on these issues in low and middle-income countries.  The continental boundaries are really very hard to cross, it seems.

The convergence in malnutrition problems between the high, middle and low-income countries continues at rapid pace (GNR 2016).  We better make sure the convergence in problem solving can keep up. In the SDG era, all countries have malnutrition problems and all need to share the solutions.  

01 July 2017

GAIN: straightforward answers to some "awkward" questions

This morning I had my first “awkward” media interview as Executive Director of GAIN, challenging some fundamentals about how we work and who we are. Here are some of them:

Doesn’t fortification prevent spending on other types of nutrition interventions that change the underlying determinants of malnutrition?

What about the negative effects of fortification, such as diarrhea?

Why do you have funders like the Bill and Melinda Gates Foundation on your Board?

By having businesses on your Board isn’t there a conflict of interest?  Won’t your strategic direction reflect their interests?

How can you work with companies that promote high sugar, salt and transfat foods?

I must admit I was not always brilliant at answering these questions on air, because I was led to believe this was a different type of interview.

Live and learn.

Nevertheless I need to get used to answering these questions, and so here are my (slightly) more considered answers.

First, on fortification.

Doesn’t fortification prevent spending on other types of nutrition interventions that change the underlying determinants of malnutrition? Fortification is one of the most effective interventions to improve certain nutrition outcomes particularly deficiencies which weaken immune systems, inhibit normal brain development or are essential in pregnancy (iron) or prevent specific diseases such as goitre and neural tube defects, and with high benefit cost ratios (Copenhagen Consensus, Lancet 2008 and 2013).  Does it take away from efforts to address the underlying determinants?  No, if only because the underlying determinants are related to things like female disempowerment, high fertility rates, poor water and sanitation, high poverty rates, large inequalities, poor governance and conflict—and solutions to these are found in the remaining 99.5% of government and donor budgets that are not spent on direct nutrition interventions in totality (of which fortification is a very small component). And these interventions are all supported by WHO.

What about the negative effects of fortification such as diarrhoea? This question was referring to a study in Pakistan on micronutrient powders, reported in the Lancet 2013 (Soofi et al.). A key quote from that study is “In our study the difference between micronutrient powder (MNP) groups and the control group in incidence for bloody diarrhoea was around 0·08 per child year which corresponds to about one additional episode of bloody diarrhoea per year for every 12–13 children treated.” (p.9).  The positive effects of the powders, from the same study, included halving the rates of iron deficiency anaemia from 57% for children at 18 months to 23-27% at the same age.  Bloody diarrhoea of course needs to be taken very seriously.  

Future evaluations need to and will test MNPs for diarrhoea episodes so we can get a better idea of the conditions under which this may occur and the frequency and severity of occurrence.  As the 2013 paper notes, we need careful risk benefit assessments of MNPs.  Of course, every public policy intervention needs this.  Presently, however, WHO clearly recommends this intervention “In populations where the prevalence of anaemia in children under 2 years of age or under 5 years of age is 20% or higher, point-of-use fortification of complementary foods with iron-containing micronutrient powders in infants and young children aged 6–23 months is recommended, to improve iron status and reduce anaemia.” Incidentally, the senior author on the aforementioned Lancet 2013 Pakistan paper, Dr. Zulfiqar Bhutta, is a longstanding member of GAIN’s Partnership Council.

Now, to the even bigger questions. In development, who can be partners and sit at the table? Is business or are business people inherently anti-nutrition?

What about businesses on your Board—isn’t there a conflict of interest?  We strive for a balance of public and private sector backgrounds on our Board. We believe diversity of viewpoints and experiences is key.  My experience from being on and working with Boards over the past 20 years is that pretty much everyone sitting on any Board has a vested interest of some sort.  An NGO that favours a certain intervention or approach will consciously or unconsciously insert those views into discussions.  Similarly, academic researchers who have certain ways of looking at the world will do the same.  It is inevitable—our views are shaped by our experiences and values.  The key is to declare any vested, conflicted or competing interest, make sure there is a variety of viewpoints at the table and to have transparent mechanisms to manage the risks.  So it is really valuable to have people with business experience on our Board---if we want to engage businesses to become a bigger part of the solution we have to know more about how they think and operate. And we require all interests and potential conflicts – from every member – to be declared and recorded at each meeting.

What about working with companies that are promoting high sugar, salt and transfat foods?  For me this is perhaps the most difficult question.  Where the company is doing something good for nutrition in one domain but also promoting the sale of foods dense with these ingredients you can do one of three things: engage uncritically, engage critically, or not engage.  Not engaging seems like capitulation.  But engaging uncritically also seems like capitulation of a different sort.  We try to engage critically. Whether that is working with a company to highlight the damage it may be causing, or to change the product formulation (and we have had some success in medium sized firms in Africa), or to improve labeling, we try.  And we will strive to do even better in this area: just as we will with governments and NGOs that do good and bad things for nutrition.

Finally let me say we are really proud of our association with the Bill and Melinda Gates Foundation.  They support thousands of independent organisations in development and as the Global Nutrition Report data shows, they are the fifth largest funders of direct nutrition interventions (behind the US, Canada, EU and the UK).  But why do we have funders on our Board?  It is common to have funders on the Boards of organisations like GAVI and the Global Fund and this is the spirit in which GAIN was founded 15 years ago.  However, we are moving to a more standard international NGO model where funders are not on our Board. In our case they will sit on our Partnership Council (along with NGOs, independent researchers, UN, businesses and governments) - which is an advisory body.

So why am I sharing this with you folks?  We at GAIN want our work to be of the highest quality and transparency.  The challenge of working effectively with businesses is the struggle that many of us in nutrition are facing -- or will be facing in the future.  Since it is business that delivers the vast majority of all foods consumed, not to involve them seems illogical. We want to share our thinking behind the struggles and to promote dialogue. 

Remember the African proverb: if you want to change someone’s head, it is best if they are in the room!

28 June 2017

Narrowing the Gaps Take 2: Great for public investment, but what about private?

Back in 2010 I wrote a blog about UNICEF's efforts, under the leadership of Tony Lake, to resurrect equity as a prime issue in the child wellbeing debate.

The blog was about UNICEF's Narrowing the Gaps work which showed that while it might be more costly to reach those most in deprivation with child interventions, the benefits of doing so ore than outweighed he incremental costs in terms of Benefit Cost Ratios and, in doing so, narrowed the gaps in outcomes between children in poor and non poor households.

Now, for 51 countries, we have an update on this work 7 years on.  I'm happy to say that the new report shows:

1. The gaps in the coverage of programs (6 intervention packages, including neonatal and infant feeding and care) between poor and non poor groups has declined: 36% vs 59% in 2003 compared to 50% versus 65% in 2016.  The bad news for nutrition is that early initiation of breastfeeding showed the slowest rate of increase in coverage--for both income groups.

2. The reduction in under 5 mortality was nearly 3 times as fast in poor groups as in non poor groups.

3.  For those only moved by cold hard economic facts, the important news is that the benefit cost ratios are 1.8 times higher for those in poor groups compared to the non poor.  For every $1m invested in increasing the coverage of these 6 interventions, 166 deaths are averted in the poor group versus 92 deaths averted int he non poor group.  This is not terribly surprising--the response should be greatest for those most in need--but the relatively high cost of reaching the poor often preempts these kinds of returns.

So we have the great position of reducing inequality--an important goal per se--and generating the highest returns in doing so.  Win-wins don't get much more satisfying than this.

For commercial interventions in the food marketplace, however, the arithmetic is not quite so comforting.

We at GAIN are working on demand side interventions for healthy foods that bring the best of public and private approaches to the table.  But businesses tell us they not able to make these approaches work for those in the very poorest households.  Those living on less than $3 a day don't--at the moment--seem to provide businesses with enough purchasing power to de-risk their investments. This is why interventions such as public cash transfer schemes are so valuable--they enable the consumption of healthier but more expensive foods (although they also enable the consumption of less healthy food).  For those living on more than $3 a day (and this threshold is a guess--we need some serious research on what it is for different contexts), commercial solutions to improve the consumption of nutritious foods are more possible.

Can demand creation targeted to those above $3 a day work?  And can it help those below $3 a day by creating an aspiration for healthier food?  These some of the  challenges we have set ourselves at GAIN because most people buy food via markets.  We need to be able to draw on some serious research about what is the limiting factor stopping different income groups in different contexts from purchasing nutritious food: income, physical availability, affordability, or desirability.

The UNICEF work provides a convincing rationale for public sector interventions to be more equity enhancing.  Can it provide some inspiration for businesses to develop nutritious but loss leading food brands to inspire customer loyalty in preparation for the time when their incomes grow?  Working with our partners, we will keep exploring this space at GAIN.  We want nutritious foods to be available, affordable and consumed by all income groups--especially by those who are most malnourished.

23 June 2017

Innovative funding models to support research innovation in nutrition: The BPNR example

This week I was at an event showcasing nutrition research, held in Ottawa at the Aga Khan Foundation’s Canada headquarters, in partnership with them and the Global Affairs Canada (GAC), the Canadian Government’s Foreign Assistance agency.
So far, so normal, you may think.  But this was no ordinary research programme. It was the GAIN-GAC Business Platform for Nutrition Research (BPNR). And the distinguishing feature of the Platform is that it supports “pre-competitive” research that is useful to business sectors that are hoping to have a positive impact on nutrition status.
Precompetitive research provides answers to questions that all businesses in an industry want an answer to: questions that can be best answered though collective effort rather than by any business trying to go it alone.  The results are available to all, even if they did not collaborate in the research.  Once businesses have the research outcomes they can use them to develop competitive products. This approach tends to support activities where it makes no sense to have multiple answers (e.g. measurement methods and standards development), or where undertaking research requires alliances of stakeholders because of complexity of the issue (e.g. understanding the impact of climate change on food safety).
The BPNR platform works on a matching basis between GAC and the businesses that contribute a documented and certified amount of resources to the project (but not to GAIN).
The current themes under BPNR are:
  • Development of diet quality indicators using the Gallup World Poll as a platform. This work builds on the success of the FAO-Gallup Voices of Hungry work (the indicator was adopted as an official SDG indicator).  The protocol is being developed but it will focus on about 20 different foods.
  • Finding complementary foods (e.g. Lipid-Based Nutrient Supplements) that do not rely on the addition of sugar to increase palatability. This work is designed to find out if we can promote palatability at low levels of sweetness. This will involve Nutriset.
  • Development of mobile phone based markers of Aflatoxin – a blood or urine sample analysed by a small piece of kit in 10 minutes and plugged into a mobile phone to give a detailed quantitative read out. About $1 a test. (Cornell University and Mars).
Watch this space for more news on BPNR research as it generates interesting and useful findings over the next 18 months.
And this is just the beginning, with opportunities for new partners to come together around a range of new research questions that help us all to understand the complexity we are trying to navigate in improving nutrition, and that can shape investments in the demand for and access to nutritious foods, and the legislation and policies that enable these.
There were lots of good questions from the audience, many asking a variant of “what is in it for partners to work with the BPNR?” Answer: for businesses new resources are worth giving up intellectual property rights; for researchers there is a de-risking of the work with companies, because the BPNR platform has collectively agreed on the research question and it guarantees a fair and transparent peer review process.
The Government of Canada deserves a lot of credit for taking a risk on BPNR—it is a new mechanism for nutrition although quite common elsewhere.  It has taken longer than we thought to build relationships between businesses and researchers, and then to identify specific research questions around which there is a consensus, but it feels like the effort will be worth it because the relationships will be enduring, are transparent and will result in open access results in peer reviewed publications.
Several of the researchers present said they would not have pursued their research in the absence of the BPNR. So, if you aim to generate  innovative solutions in the food and nutrition space, think about developing innovative funding sources too.
The innovation in the second might well stimulate innovation in the first.
For more information about BPNR, please contact Lynnette Neufeld at GAIN lneufeld@gainhealth.org

Learn more about GAIN’s work here

18 June 2017

Food Must Fix It: The 2017 EAT Forum

The convening power of Gunhild Stordalen is astonishing.  The Crown Princess of Sweden, the President of Mauritius, Sir Bob Geldof and a large group of other influential leaders, doers, and thinkers.

This was my first visit to the EAT Forum, although I had worked with Gunhild on a joint newspaper article for the Norway launch of the 2015 GNR and knew how committed she was to making a difference.  Her commitment is contagious.

At the Forum, I gave a talk on 3 inequalities at the heart of the food system that generate poor nutrition outcomes. First, our rather conventional public health attempts to stimulate behaviour change in food choice which focus on “wholesomeness” and “good for you” exhortations and worthy messaging—all in comparison to commercial advertising efforts which persuade us to buy certain foods based on their convenience, deliciousness, crave-ability and status. Second, I noted the stark inability of most of the world to afford healthy diets: 52% of household incomes in South Asia would be needed to buy 5 fruits and vegetables a day.  Third, I argued that the lack of information, evidence and data on the impacts of business-government partnerships beyond profits (i.e. on people and the planet) hampers collaboration.

These are three areas where GAIN is working with a wide range of public and private stakeholders to increase the demand for healthy food, to increase the capacity of small and medium and large enterprises to meet that demand and make nutritious food available at a lower price, and to create an environment that enables businesses to do good things for nutrition and discourages them from doing unhelpful things.

My takeaways from the 2 days (disclosure, GAIN is on the EAT Advisory Board):

*As a newcomer to EAT Forum, I found the fact that I only knew about 10% of the participants to be really refreshing.  New organisation, new perspectives, and a fair amount of new thinking. Great.

*Businesses were very present, although mainly European and American ones.  It was great that they were there because, as the African proverb goes, “to change someone’s head they have to be in the room”: no engagement means fewer opportunities to influence.

*But, in general, the event was high income country focused.  Sure, there were people like me focused on low and middle income issues, but still from a European and North American perspective.  If the audience were more geographically diverse it would really accelerate the convergence of the 2 sets of conversations happening in the Forum: the high income and middle/low income ones.  It is clear that the Forum is very much hastening this convergence, but a more rounded and grounded set of perspectives would help us co-create a more unified vision and set of approaches to solution generation.

*A number of the presentations dwelled on the achievements of the presenters and their organisations. This was fine given that were many such fine achievements and the presenters were amazing people and communicators.  But, I wanted a bit more on the challenges they faced and how they overcome them—also, what did not work and why?  For sure there was some of this (and more than you would find at an academic audience!) but more would have been welcome.

*The focus on the links between food, health and the planet were really strong and quite seamless. But I am a data hound and I would have liked a few shamelessly scientific sessions, although perhaps that would have reduced the uniqueness of the meeting.

*The EAT Forum has been disruptive--in a good way.  It has challenged conventional wisdom and now it is rewriting conventional wisdom. So what does it do for a second act?  Bob Geldof reminded us that social change occurs when there is an initial disruption, then an amplification of the message around a set of leaders, followed by consolidation and organisation of the movement, and, underpinning it all, a relentless devotion to a cause.  So what is the future disruption role of the EAT Forum?  Does it just keep going and wait for others to get on the bus, or does it park the bus outside the halls of power and lure them in?  I don’t know.  I suspect the former.   But the disruption question remains. In many ways the EAT Forum could be more unconventional.  It would, for example, be great to get more schoolkids involved to talk about what they think, expect and can do; more journalists talking about what their readers want to read and how that can be influenced; more political activists teaching us about their strategies; and more people from the arts helping us connect outside the policy and business wonkosphere.  Perhaps I am being too demanding, but if so that is because the EAT Forum has raised expectations in a world that is desperately lacking the hope and energy of the period just before the global financial crisis—a world where dreams have been harshly dampened by the austerity our politicians have responded with.

The rallying point for the Forum was “food can fix it” whether health, climate, sustainability or access to a nutritious, safe, affordable and desirable diet.  This simple phrase was deceptively helpful in providing a focal point and, as Johan Rockstrom, the scientific lead for EAT, said at the end, it really should be “food must fix it”.  Agreed.

All in all I found the EAT Forum to be a very refreshing change from the same old meetings where you know everyone and you know what they are going to say well before they say it. Long may it continue to reinvent itself, to keep challenging tired conventional wisdom while catalysing unlikely partnerships that generate ideas and approaches that are truly transformative. 

In short, if the EAT Forum did not exist we would need to invent it.

04 June 2017

No Excuses for Inaction on Adolescent Nutrition

This years World Health Assembly (WHA) meetings (all the Ministers of Health attend) had a big focus on one sixth of the world’s population: adolescents.  The WHA launched the Accelerated Action for the Health of Adolescents (AA-HA!) a major report from all the key UN agencies on why we need to act now to improve adolescent health and what to do. In this context, I participated in two panels on adolescent nutrition.

My key takeaways were:

Adolescents are invisible in nutrition data.  It is ironic because adolescents are typically hard to miss: frequently opinionated, critical and emotional and deafening in their exuberance and silences. Yet in nutrition data, they are absent. Essentially, we don’t collect nutrition data on adolescent boys of 10-19 years of age or on adolescent girls in the 10-14 year age group.  This is extraordinary.  Attitudes and preferences are highly fluid in this 10-14 age group—like liquid concrete waiting to be set for life.  Also, why no interest in boys?  Yes, adolescent girls have higher micronutrient needs due to menstruation, but boys are just as important in shaping attitudes, norms and boundaries in nutrition practices—now and in the future.  This relative invisibility of adolescents to the nutrition community is all the more puzzling because iron deficiency anaemia is the number one cause of adolescent DALYs for girls and boys (see below). 

There are few nutrition interventions that are designed FOR adolescents.  Yes, there are plenty of interventions aimed at the wider population that should benefit adolescents (see here), but none are designed for adolescents particular needs save for iron-folate supplementation (IFA).  IFA seems to work when administered through schools, but not through communities (see here).  This is a problem because only 30% of adolescents in South Asia and Sub-Saharan Africa complete secondary school (see here).  Why do adolescents merit specially designed interventions?  It is primarily because of the plasticity of their attitudes and the rapid velocity with which these attitudes become relatively fixed but also the widening opportunity to act as the gap between biological maturity and social transition to adulthood increases.   The graphic below from the AA-HA! Report summarises things well.

There are even fewer interventions that are designed WITH adolescents.  Adolescents have increasing autonomy and they know what they like and don’t like and I would guess most nutrition intervention and policy wonks don’t have a clue what these likes are and how they can be leveraged and shaped.  Adolescents will have a better idea of where, why and how they can be engaged around nutrition choices.  But adolescents are also more vulnerable to risky food and nutrition options.  Adolescents will help us to think laterally and holistically about their lives, to find opportunities to work with them to influence and shape food and nutrition preferences via sports, clubs, social media, schools, music, film and comics.  Engaging with them will take us outside of our comfort zone and that is where innovation and change happens.

We are paralysed by the lack of evidence.  We are in a “lack of evidence, lack of action, lack of evidence” low level equilibrium when it comes to actions on adolescent nutrition. The consequences of trying something and getting it wrong are not negligible, but these have to be weighted against the consequences of inaction.  The adolescent window is opening and closing without any fresh thinking or action making it through the gap all while nutrition status is eroded throughout the lifecycle. Funders and development agencies need to be braver. They should support (a) the development of new approaches and actions that are grounded in formative adolescent centred research, (b) their implementation, (c) their evaluation, (d) share their results and (e) scale the promising ones.  Adolescents deserve no less.

The private sector has a big role to play, because adolescents are more engaged with the private sector than many other demographic groups: they are tied to their social media platforms (see below from Indonesia—90% of rural adolescents in Indonesia use Facebook!), they buy junk food after school, they buy street food on breaks from their factory work, they listen to commercial radio and watch commercial TV.  For example, how can we combine earnest public sector behaviour change efforts with the more calculated but creative private sector demand shaping efforts.  How can we create hybrid approaches that are greater than the sum of their parts?

The new AA-HA! Initiative from the UN is a great step forward and countries should use it as a guide to raise funds for this agenda and a guide on how to allocate those funds.  GAIN is using the above principles, working in Bangladesh, Pakistan, Indonesia and Mozambique, forming alliances for and with adolescents to generate and implement solutions to accelerate adolescent nutrition.  

Watch this space.