01 May 2018

Ethiopia’s New Leadership: Will It Deliver for Nutrition?

This is an exciting time to be in Ethiopia.  A new Prime Minister, Dr. Abiy Ahmed Ali, was appointed in early April and the newly reshuffled cabinet was announced last week—a new generation radiating hope, with a focus on unity, youth, and economic growth.
But will this new dawn also generate added impetus in Ethiopia’s fight against malnutrition in all its forms?  There is certainly success to build on: under 5 stunting rates may be 38% but they have come down from 58% 16 years ago.  That is faster than one percentage point a year and is considered to be good performance.
But there are storm clouds a plenty.  The country continues to be hit by drought playing havoc with food availability and food prices.   On top of this, diabetes, hypertension and overweight rates, while still low compared to many other countries in Africa, are increasing fast, driven by rapid urbanisation and changing lifestyles among other things.
Food consumption is at the centre of all forms of malnutrition and recent researchby Kalle Hirvonen and colleagues at IFPRI has shown just how much the real price of nutritious foods has risen over the past 16 years while the real price of cereals has stayed constant and those of sugar, fats and salt have actually decreased.  Just imagine what the declines in stunting would have been if the price of nutritious foods had stayed constant or even declined.
The need for available, affordable and desirable nutritious food is at the heart of GAIN’s mission. We basically do two things: (1) make foods that vulnerable populations already eat more nutritious, and (2) make nutritious foods (typically unavailable or unaffordable) more likely to be consumed by the most vulnerable.
As I saw on my trip to Addis last week, GAIN in Ethiopia is working with partners to (1) help the Government implement its new voluntary fortification standards, (2) develop low cost home grown complementary foods that can be sustainably accessed by low income households and (3) reduce food loss in nutritious food value chains.  We are planning additional work in a number of new areas that draw on our experience of linking governments, business and civil society to improve the consumption of nutritious foods.
Our view at GAIN is that while business is often a part of the problem it is also a big part of the solution.  So we are happy to work with responsible businesses to find new solutions.  And Ethiopia is brimming with entrepreneurial talent, much of it in the form of social enterprise start-ups, often run by individuals barely out of their teens.  They relish the challenge of trying to reduce the price of nutritious foods.  We met several of them at Blue Moon which provides support to these start-ups.
Small and medium enterprise business platforms can help to develop investible propositions for governments and business to improve the consumption of nutritious foods by surfacing and connecting businesses with these ambitions, providing them with some market analysis, and helping them understand the legislative and policy environment they work in.
But we don’t have to rely solely on markets for scale because Ethiopia has of one of the largest social protection programmes in Africa, the PSNP (Productive Safety Net Programme).  The potential for this programme, reaching 8-10 million households every year, to serve as a platform for diet diversity via vouchers and choice of eligible foods must surely be high.
So will the new government deliver for nutrition?  Yes, if the rest of society plays its part.  We know that improved nutrition is everyone’s business AND everyone’s responsibility.
We will certainly be working with GAIN and partners in Ethiopia to try to convince the new PM and his team that malnutrition sits uncomfortably in a nation that sees itself as a middle income country by 2025, a leading light in Africa, and a source of manufacturing and innovation.  The motto, “Made in Ethiopia” will only become a reality when we have made malnutrition in Ethiopia a bad dream.

28 March 2018

The consumption of animal sourced foods by infants in low-income settings: Does it need to increase? And, if so, what is holding it back?

I have just finished reading a very useful new IFPRI Discussion Paper by Derek HeadeyKalle Hirvonen and John Hoddinott.  The paper pulls together data on the food intake of 112,553 children 6-23 months old contained within Demographic and Health Surveys (DHS) across 46 low and middle income countries since 2006 (when more standardised and disaggregated food recall data began to be collected).
The paper asks three questions: (1) how does infant food intake vary across country? (2) what is the association between food intake components and infant linear growth? and (3) how sensitive is a food’s intake to the price of the food in question? There is a specific focus on animal sourced foods (ASF), given the density of high quality proteins and micronutrients in these foods.
The paper has its limitations, for example the data are 24 hour recall data and so are subject to recall error and the statistical analysis (i.e. beyond describing the data) cannot go to the subnational level (because the prices are national). Nevertheless, this is by far the best attempt to pull together and analyse this type of data that we have and, for organisations such as GAIN, which deliver programmes with partners, it is invaluable, and, in some respects, startling.
So what does the paper tell us?
  1. Half of all 6-23 month old children in Sub Saharan Africa did not consume even one ASF in the previous 24 hours, whereas 84% of kids in Latin America and the Caribbean consume at least one ASF.
  2. Over 10% of all children in Asia and Africa consumed no food in the previous 24 hours (although it is not clear if that means no breastmilk was also consumed).
  3. Fish, eggs and legumes/nuts are the least consumed foods in all regions at 19.9%, 21.9% and 25.9% of infants, respectively.
  4. The consumption of any ASF and any fruit is positively associated with decreased likelihood of stunting, especially for infants over 18 months of age, but, curiously, vegetable and pulse consumption were not, even when looking only at the subset of infants who do not meet the minimum diet diversity score.
  5. For the group of infants as a whole, dairy, meat and fish consumption had the strongest and most significant associations with reductions in stunting prevalence (although egg consumption less so) and more so in the upper age groups, with fish significant in all age groups.
  6. By region, for 18-23 month olds, vegetable consumption (either Vitamin A rich or leafy green) had very little association with stunting rates in any region. Dairy was strongly associated with stunting reduction in Latin American and Caribbean, south, east and central Asia and east and southern Africa, but not elsewhere. Fish consumption was only significantly associated with stunting reduction in west and central Africa and Latin American and Caribbean (and in Latin America and the Caribbean the authors could not separate out fish and meat consumption). Vitamin A rich fruit consumption was only associated with stunting reduction in Latin American and Caribbean and egg consumption only in west and central Africa. Consumption of  “other fruit” was only significantly associated with stunting reduction in south, central and eastern Asia.  Surprisingly meat consumption was not significantly associated in any region at 5%–with the exception of Latin American and Caribbean (again, note the authors could not separate meat and fish consumption for this region).
  7. How important are prices in deterring consumption? Normalising food prices in each country (and we also have high income country data available from this ICMP source) relative to that country’s cheapest staple cereal, we find that it costs between 6.0 and 11.5 times as much to buy a calorie from leafy green vegetables as it does to buy a calorie from the country’s cheapest cereal (even in high income countries the ratio is 9).
  8. Prices of other foods relative to the cheapest staple are highest in the two African regions, which probably reflects, in part, high costs of moving foods around in this geography. The highest prices relative to the cheapest cereal are for fresh cows milk, vegetables and, interestingly, fortified baby cereal (which is 16-24 times as expensive as the cheapest cereal in Africa and Asian regions).
  9. Egg and dairy consumption is most sensitive to changes in their own price (as prices go up, consumption goes down) but the consumption of meat and fish is less sensitive to own prices.
So what does this all mean? First, the region, country (and presumably subnational area) really matters: consumption of different diet components is highly context specific. Second, the relationship between diet components and stunting is also quite context specific. Third, the relationship between the price of a food and its consumption is consistent (negative) although the magnitude varies by food.
The paper points out that if the public nutrition goal is to increase the consumption of animal source foods for infants (or any age group), then we need to reduce the price of these foods for all and this means expanding the availability of that food (while maintaining profit so that farmers actually grow it).  This strategy would of course raise issues of concern around sustainability – how can we make ASF cheaper for infants in low-income countries without leaving those very same children with fewer natural assets to manage when they grow up?
Current strategies to convince parents to increase the consumption of ASF for infants are hampered by the high price of ASFs because families will sell the foods for income to buy other foods and other things – but the food that is purchased is not as rich in high quality protein and micronutrients as the food that is sold. In this high price context it is less easy to convince farming parents to forego income to feed high priced nutrient rich food to their infants.
This paper resonates with GAIN’s mission—to make nutritious foods more available, affordable and desirable.  Affordability of nutritious food is a real constraint to nutrition status and this paper presents data from 46 countries to show this. But the results in the paper also point to potential sustainability trade-offs.  We need more science to chart any trade-offs (or synergies).
In short, we need to get the price of nutritious foods down in a sustainable way—if we don’t these foods will not be eaten by the people that need them the most.

23 February 2018

How Important are Businesses to Addressing Malnutrition in the “Many Kenyas”?

I just returned from a visit to our Kenya partners. Kenya was one of the Global Nutrition Report’s (GNR) star performers in 2017 in terms of stunting reduction – with levels nationally of 26%. But the rates vary wildly by the 47 counties: Kitui and West Pokot are both above 45% and Kilifi and Mandera are in the high 30’s (see the 2014 Kenya Demographic and Health Survey, p. 162).
At the same time, Kenya is experiencing an upsurge in overweight, obesity and other risk factors for diet-related non-communicable diseases (NCDs). The country is in full “double burden” mode with undernutrition and other manifestations of malnutrition such as obesity and diabetes running in parallel, often in the same communities or families.
In this context, a focus on improving diets makes sense because it is core to preventing all forms of malnutrition. Improving the consumption of nutritious safe food is the ultimate “double duty” action—one that addresses undernutrition as well as the diet related NCDs.
What is driving the phenomenon of the double burden? The usual suspects–urbanisation, income growth, increasing availability and glorification of cheap junk food– are probably to blame. We have to guess, because the last nationally representative individual food intake survey was conducted in 1994 (although this 2016 WFP survey of diet diversity via food frequency is very useful).
Are there causes for optimism that Kenya can counter this double burden? Yes, several.
First, the central government is just about to elevate nutrition to the Presidential level through the new National Food and Nutrition Security Policy Implementation Framework, which has been signed by all 47 County Governors. This is excellent because we know that attention and leadership from the very top of government pushes nutrition up the political and development agenda, with results in terms of funding, staffing and awareness across society.
Second, one of President Kenyatta’s 4 big priorities for his new term is Food Security and Nutrition. On closer inspection of the speech I find reference to diversifying production, improving water for agriculture and improving vegetable, fruits and fish production, and generating jobs. Coupled with commitments on universal health care and to improving the enabling environment for businesses to provide jobs for young people, this sounds promising. And it is really needed: a recent Save the Children Cost of Diet study in Turkana county found that the cost of a nutritious diet was 10 times the monthly cash transfer funded by the Government with help from DFID (and the highest cost was for adolescents due to their higher nutrient requirements). Now we look for government policies, legislation, tariffs, taxes and spending that support these promising goals.
Third, the Kenyan nutrition community, admittedly from my limited interactions, seems committed and coherent. I met senior government representatives including the Principal Secretary, Ministry of Health, Mr. Julius Korir, Dr. Peter Cherutich, the Director of Preventive and Promotive Health Services and Ms. Gladys Mugambi Head of Nutrition and Dietetics and Scaling Up Nutrition (SUN)Focal Point, as well as representatives of the UN community, researchers from CIAT, development partners, and business leaders. It was encouraging that everyone in the nutrition sector is so alert to the ravages of climate change and the uncertainty it generates in food production and consumption.
From a GAIN perspective our dynamic new Country Director Leah Kaguara is leading a short, sharp country strategy development process. GAIN works to improve the consumption of nutritious safe food required for healthier diets. So naturally a key strategic question we will have to answer is “should we work with partners in the most deprived areas where there are few businesses to bring together with government, and few markets to shape?” This is an important question and one that, at least for me, does not have an easy answer. Why?
First, do the counties with the highest prevalence of stunting actually have the largest number of stunted children? The counties where the largest number of stunted children are located may not be the most remote or deprived counties (see Andy Sumner’s work on the location of poverty): it is possible that these areas may have fairly well developed markets with availability of healthy foods better than others.
Second, just because markets are thin in some areas, does that mean they cannot be developed? For example, if a stronger cold chain is developed (such as through our PLAN programme) in order to reduce food price volatility by improving food storage, can that bring small and medium sized companies into the value chain?
Third, are we assuming that small enterprises are not present in poor and remote areas? Our experience with the Marketplace for Nutritious Foods suggests otherwise. (And let’s not forget that farmers are businesses.)
Fourth, county governments employ many people, and the workplace programmes we run with businesses could be adapted to public sector employment. Does the Ministry of Health, for example, make it easy for its employees to eat nutritious and safe food?
Finally, even in areas where humanitarian work is the main activity, small businesses can be crowded in, witness the World Food Programme’s programme for Syrian refugees which uses blockchain technology and vouchers to be redeemed with participating small vendors.
You can tell what my prior views are, but my colleagues and I will keep an open mind. Nevertheless, what is clear, even from my short trip, is that there are “many Kenyas” in terms of nutrition outcomes, governance, identity, capacity and programme coverage. Understanding context is always a vital principle, and in Kenya it is no exception.
There are green shoots everywhere, but we need to be under no illusions that tackling this double burden of malnutrition in Kenya will require a massive collective effort – by government, citizens, health professionals, businesses, and donors – to turn around. While Kenya is on track to meet global World Health Assembly targets – for under 5 stunting, wasting, overweight, and exclusive breastfeeding – for other critical indicators such as women’s anemia, adult obesity and adult diabetes it is off course (see the 2017 Kenya country profile from the Global Nutrition report).
Improving the quality of diet is a no-regrets “double duty” action to reduce malnutrition in all these forms. So we need to get behind the President’s commitment to improve food security and nutrition—and to hold the government, and other stakeholders, accountable for progress towards meeting that commitment.

09 February 2018

Why Nutrition Needs to Find Blue Oceans

Funding for nutrition has increased significantly over the past 10 years, which is a very good thing. So has the number of initiatives, organisations and programmes addressing nutrition. But is this an unqualified good thing?
On the plus side, this could lead to a greater diversity of partners, approaches, ambition, reach and influence, and could result in stronger alliances and a bigger impact on nutrition status. But, if we have a monoculture—everyone chasing the same funds to do the same things without coordination– that is a likely to be bad for coherence, bad for nutrition outcomes and bad for eradicating malnutrition.
Business strategists call the latter outcome a Red Ocean scenario (everyone is fighting in the same space for the same resources, the red signifying blood) and the former a Blue Ocean scenario (stakeholders are trying to expand the nutrition space by venturing into waters where few nutrition actors are to be found). Here is the original Harvard Business Review article from 2004.
Clearly we need nutrition to move more quickly into blue oceans. Every Global Nutrition Report since 2014 has stressed this with calls to reach out to new sectors, new stakeholders, new disciplines, new alliances and new geographies. So we can clearly talk the talk. Our increasing realisation of the centrality of what we eat in preventing all forms of malnutrition should keep us less fractured and more coherent. But how do we get into those blue oceans? It is hard.  We all want to belong to a gang.  It is so much more comfortable to interact with people who use the same language, have similar frames of reference, and who commune regularly in the context of a series of major meetings.
I would argue that we have to do more to get out of our comfort zones, to meet people who don’t think much about malnutrition but who offer a new opportunity to advance nutrition all the while getting their own development goals met more sustainably. (We have one big advantage here, every family, community and each human being eats every day! So unlike advocating around many other critical topics, we have a common starting point.)
This past year I have written several blogs illustrating the benefits of ocean-going nutritionists! The mobile phone providers who can spread nutrition messaging, cold chain firms who can provide low cost refrigeration solutions, trade regime lawyers who can help strategize about how to reduce tariffs on key inputs to healthy food systems (e.g. insulation material), consumer rights groups who can work on class action litigation, human rights organisations that can document nutrition rights’ violations, infrastructure experts who can advise on what works and does not work in the PPP space, education specialists who can help design school based nutrition programmes that appeal to students. The list goes on……
Nutrition institutions need to give their nutrition champions the license, skills and support to roam in the blue oceans. And all of us need to share our nautical charts on where those oceans are and what is in them. The blue ocean is big. We need to operate in it.

29 January 2018

How to Persuade People to Eat More Nutritious Food?

I just finished reading ‘Why you eat what you eat” by Professor Rachel Herz. Fascinating, and together with Professor Michael Spence’s “Gastrophysics” it caused me to reflect on the radical changes we need to effectively promote healthy and nutritious diets, and reverse the out-of-control trends in malnutrition affecting every country.
GAIN’s purpose is to advance nutrition by improving the consumption of nutritious and safe food. To do this at scale in a sustainable way we consider three aspects of food systems – demand for, supply of and the overall enabling environment to increase the consumption of such foods.
Of these perhaps the most difficult and often-ignored challenge is building the demand for more nutritious foods. Companies do build the demand for their food products —nutritious or otherwise—but they look to government to build the demand for more nutritious eating habits, and thus these types of foods. For companies to “go it alone” on this front is too expensive and can put them at a competitive disadvantage.
But here’s the problem. Governments are not good at developing the demand for nutritious foods. There are exceptions, but most public health campaigns emphasise “good for you” “high in fibre” type messaging. This approach utilises only one button out of a veritable airplane console of buttons that are available to change eating behaviours. To activate all of these buttons, governments need to work with marketing departments and advertising companies for whom identifying and pushing these buttons is their day-to-day job. In this way governments can stay true to their nutritional guidelines but employ engaging and memorable strategies.
So, what are these myriad buttons that can influence what people eat that Professor Herz analyses. First, I noticed that the word “price” comes up only once in the book and then to remind us that the higher the price of the bottle of wine, the better it tastes when compared to the same wine labelled at a lower price!  It is true that most people on low incomes are very price sensitive, but before they worry about price and affordability, they need to want to buy the food in the first place. Second, surprisingly, only 90 of the 270 pages of the book are devoted to taste and smell. The other 180 pages are devoted to everything else that makes us eat what we eat.
The global food industry spends $14bn a year on food adverts that push these non-taste and non-smell buttons. That is about the same as the entire UKAid budget. Why do they spend this amount (and by implication why do governments need to pair up with them in the effort to stimulate more healthy food)? They do it because the evidence shows that the how food is profiled and contextualised is profoundly influential on what we buy and eat. Some examples of this cornucopia of profiling:
  • When the same popcorn is described in two different ways, very different amounts are consumed. When the taste alone is described, less is eaten than when other senses are described such as the smell (of going to the movies), the texture (buttery), and the sound (crunch)
  • When Oreo cookies are described as “organic”, more are consumed
  • Trail mixes that have an image of running shoes on the front of the pack are considered healthier, even if they are not
  • Carrots wrapped in McDonalds paper are rated tastier than the same carrots wrapped in identical paper without the logo!
Colour & Shape
  • Round chocolate shapes are rated as sweeter, even when not
  • Blue angular plates mean food served on them is more likely to be rated salty
  • The occasional redder potato chip in those tube stacks act as traffic lights and are more likely to stop consumption of the next layer of less red chips
  • The more food that is piled on a plate, the less good we are at estimating its calorific value (we tend to underestimate the amount)
  • High pitched music makes foods taste sweeter, low pitched makes them taste more bitter
  • Accordion music in supermarkets results in more French wine being bought
  • Comfort food really works—it comforts you when you are stressed and because of that, you eat more and more of it (the Herz book reminds us that “stressed” is “desserts” spelled backwards)
  • Restaurant adverts work better when they tell you that this is a place where many engagements and anniversaries are hosted (love and emotion) versus talking about the quality of the food served at the restaurant
  • Labels that talk about “health” make us less guilty about eating more. Labels that say the food is “decadent” encourage diminished consumption
Are there examples of this kind of science and art being brought to campaigns for healthy food?  Most of the examples in Prof Herz’s book are from the US and other high-income countries. And a new example is VegPower (UK), which identifies vegetable consumption with superhero power.
In the middle and low-income countries there are some examples I know of:
But we need more, and they all need to be evaluated from a nutrition and business perspective.
But let’s get real–who will pay for this? I’d like to see some combination of government and foundation funding for this. Governments should be in the driver’s seat. Public funding could be earmarked from sin taxes. And why should they pay for it? Because, the market for healthy food is going to grow, but just not quickly enough. Governments should try to accelerate the nutritious food market development. Doing so will boost the health of their populations and lower health costs (remember poor diet is the biggest cause of global ill health, with massive social costs), incentivise companies to invest in their country (with the jobs and tax revenues that brings), and establish the country as a modern nutrition agenda setter for others.

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22 December 2017

Favourite songs from 2017 (a blog not about nutrition)

Readers, apart from my family, friends, nutrition and Manchester United, music is one of my great passions.

Here are my favourites from 2017, in no particular order (song, band).  Enjoy.

Over Everything – Courtney Barnett and Kurt Vile

Put two laid back storytellers together and what do you get? A masterpiece of a song. Sounds like it took them 5 minutes to write it, but sure it was more like 5 days.  Pity the rest of the album is not quite as good.

On Hold – The xx

I always find this band a bit twee and morose, but they have really nailed it on this great pop song.  Message to the xx: cheer up.

Drew Barrymore – SZA

New artist, pronounced “scissor”.  Great debut and the rest of the album is just as good.  My wife introduced this artist to me: reminds me of Amy Winehouse, Lolo and Mary J Blige.

Put Your Money on Me—Arcade Fire

OK, it sounds a lot like Abba, but who cares?  Easy to be a snob about this band, but I think they are supremely talented and brave to give their pop sensibilities free rein.  The album is underrated.

The Underside of Power—Algiers

There’s something about this song that reminds me of The Clash.  It’s a highly structured song that sounds unstructured.  The Clash did that a lot, but it also reminds me of The Clash because it is political.

Moonshine Freeze – This is the Kit

Saw this band in a record shop in Brighton. Had heard them before, but never live.  Blew me away.  Great debut album.  Folky but playful, with great melodies.  Think they will go far.

Tonite—LCD Soundsystem

Have loved James Murphy’s music for the last 10 years and I was sad when LCD Soundsystem retired in 2011.  So glad they are back.  Album is great (Bowie-esque) but this song is a standout for me—just lots of fun. 

Up All Night –War on Drugs

It must have been daunting to follow up 2014’s sublime album “Lost in the Dream” but 2017’s “A Deeper Understanding” nearly does it.  My favourite is the opening track which just makes me happy.

Pa’lante – Hurray for the Riff Raff

Meaning “Go Ahead” or “Go For It” in Spanish, this song is really 3 songs in one—the first a personal challenge to “be someone”, the second part a Beatle-esque interlude and the third part a reprise of the first, but with a more political angle.  A striking and moving song.

Love without Violins—The Gift and Brian Eno

Had the privilege of seeing The Gift (a Portuguese band) in Brighton this year.  A large group of talented musicians that can play a wide variety of styles, I thought this collaboration with the unique Brian Eno was surprising and spectacular.

20 December 2017

Stuck in the Middle: Nutrition Programming for Adolescents

Adolescents (or “Generation Z” as businesses call them) are a group that are both talked about and ignored by the nutrition community.
Everyone is talking about them right now. There are two workshops that I know of on the topic in the past couple of months: one in Washington organised by Pan American Health Organization/World Health Organization (WHO)USAID/SPRING and partners, and one in London organised by ENNSave the Children UK and the London School of Hygiene and Tropical Medicine (LSHTM). There are probably more. And yet adolescents are also ignored: there is little data on them, and few nutrition interventions designed by or even for them.
I attended the London workshop earlier this week. It was very well organised around population groups, outcomes and interventions.
Some things I noted/learned/realised:
  1. Adolescents can make good nutrition status time travel. Adolescents are a bridge across generations, biologically of course due to the growth spurts they experience and in terms of their future role as parents, but also in terms of norm setting and social and emotional development.

  1. The cost of the adolescent girl diet is one of the most expensive in a household as found by the World Food Programme (WFP)’s research. This is because girl adolescents have a high nutrient requirement and these are found in relatively expensive foods.

  1. Age matters – for nutrition and neuroscience. GAIN is finding different anthropometric trends among adolescents 10-14 and 15-19 years in Bangladesh. There is an accelerated decrease in stunting and underweight among younger adolescents, but also an increased acceleration of overweight and obesity as compared to the older adolescents. Behavioural research from the UK finds that adolescents 12-15 years of age are more likely to pay attention to health messages whereas 15-19 year olds are more distracted by competing issues. Also the younger age group is more likely to be influenced by parental views, whereas the older group are influenced by their peers. In fact, the risk loving behaviour of adolescents is similar to those of people in their 20s, but only if peers are not involved. Once they are involved the 15 year olds get heavily influenced by peer pressure. We cannot treat adolescents as a single target group.

  1. There are likely important rural/urban differences. For example we heard about how all adolescents in Malawi tell us their food choices are influenced by resources (cost, time, knowledge), context (availability, family dynamics, information sources) and ideals (modernity, tradition). Yet for the urban groups modernity was much more valued than for rural groups.

  1. Function matters. There is a need to put more focus on function when it comes to indicators: height and body mass index are important to predict risk of birth obstruction (on one end of the malnutrition spectrum) and non-communicable disease (on the other end). But in the nutrition world we rarely measure function (physical, cognitive and psychosocial). Can’t we do so more directly if that is what we are interested in?

  1. The nutrition community is coming late to the adolescent party. For example, adolescent health has been championed by WHO through its longstanding efforts on adolescent responsive health systems and the more recent call to action: Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation.  The human immunodeficiency virus (HIV) and sexual reproductive health colleagues have for years been experimenting and learning how to work with adolescents. In nutrition, we are just starting to understand the challenges of programming for adolescent nutrition. We don’t even routinely break out reporting from survey data such as Demographic Health Survey (DHS) & Multiple Indicator Cluster Surveys (MICS) for adolescent girls from the women of reproductive age group (15-49).

  1. The unintended consequences of getting programming wrong for adolescents are not trivial. For example early puberty may be one outcome, which may lead to early age at first pregnancy and poor outcomes for mother and child. In addition, programs that target girls only may risk backlash from boys who feel excluded.

  1. Most programmes aimed at improving adolescent nutrition will have to work through other sectors. This is because there are many different (but short lived opportunities) to find the “hour in the day” that adolescents can control and engage with programs. This means that nutrition champions have to really think hard about what they have to offer these other sectors.  For instance, can improved adolescent nutrition really improve school outcomes in a cost effective way? If yes, why wouldn’t education leaders embrace it? We need to do the research and then influence the education leaders.

For me the key is for nutrition to learn from others. How do those who design policies and programmes for adolescents in education, HIV prevention, sports and recreation, the prevention of violence and decent work reach these age groups?
In fact, is there even a role for stand-alone nutrition interventions for adolescents beyond micronutrient supplements? Will all the effective interventions be found in the nutrition sensitive space? Should the nutrition field put more effort into shaping the food systems (access) in which adolescents live or preparing adolescents to make the best food choices possible (demand)? I don’t know.
What I do know is that we have to learn from others, adapt the learning, try the most plausible, evaluate them rigorously and then share the findings in an engaging way. What we can’t do is nothing.  One of the most memorable quotes from the presentations in London was from a Cambodian girl drawing a picture of herself crossing a line, saying “This is me—in the middle”.
When adolescents are going through such rapid transitions we can’t leave them stranded in the middle without adequate support. We need to design and implement new approaches to address adolescent nutrition. Adolescents are looking for allies, for people to listen to them, and for investors and others to take a chance on programmes that will help them through the sometimes wonderful, sometimes frightening turbulence of this time in their lives.
As the 2017 World Health Assembly said, lack of evidence is no longer an adequate excuse for inaction.
I would like to thank Alison Tumilowicz who leads GAIN’s adolescent research for her valuable inputs to this blog.

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