04 September 2017

Connecting the Dots to Set Up a Decade of Impact for Nutrition

BLawrence Haddad, Global Alliance for Improved Nutrition (GAIN) and Francesco Branca, World Health Organization (WHO)

The Challenge and the Opportunity
       
In its first year, the Decade of Action for Nutrition has helped to generate a series of glorious opportunities for stakeholders from all walks of life to expand and deepen their commitments to advancing nutrition status.  These opportunities will play out across the world in the eight months between September 2017 and April 2018.

Citizens of all countries would benefit from this intensification of intent and action. As the Global Nutrition Report (GNR) 2016 notes, three billion people are suffering from malnutrition in at least one of its forms. Put simply, undernutrition is not declining fast enough while other manifestations of malnutrition such as obesity and diabetes are rising rapidly.

Each of the opportunities crystallises around an event designed to make it more impossible than ever to ignore the challenge of malnutrition and more possible than ever to meet it.  The events are listed below. Each of these events will no doubt be inspiring and illuminating. But will they amount to less or more than the sum of their parts?

Stepping Stone to A Decade of Impact for Nutrition
Key audience
Interest in nutrition
United Nations General Assembly (UNGA) NY, September
UN Member Governments (mainly Foreign ministries; some Health & Development ministries), UN agencies
Indirect
CFS Rome, October
UN Member Governments (mainly Agricultural ministries)
Direct
IUNS Buenos Aires, October
Researchers
Direct
G7 Milan, November
G7 Donors, WB, EU (head of government level)
Direct
SUN GG Abidjan, November
SUN governments & networks
Direct
World Economic Forum (WEF) Davos, January 2018
Businesses & media & government (some heads of government)
Direct/Indirect
World Bank Spring Meetings DC, April 2018
IFIs, ministries of Finance
Direct/Indirect
EAT Forum Stockholm, June 2018
Businesses
Direct
G20 Summit; Buenos Aires; June or July 2018
Heads of Government
Probably Direct
UN High Level Political Forum; July 2018
Foreign, Development, some other ministries
Not clear

These opportunities have to compound the gains that each one makes along the way. There needs to be a steady and deliberate gathering of momentum for meaningful action. The need to reduce the suffering of billions of people demands it.

What To Do?

The question is, how to create stepping-stones out of these islands of engagement so that the Decade of Action for Nutrition becomes a Decade of Maximum Impact for Nutrition?
The meetings are too well defined to accommodate changes in themes at this stage, even if there was a willingness to do so.
So what can be done to maximise the impacts for nutrition? Imagine if the organisers of the meetings could agree to do the following:

  • Build momentum for action in three-four key topics by picking up where the previous event left off on a given topic. Candidates for topics? The G7 meeting will focus on food systems, women’s empowerment and cities, and the Scaling Up Nutrition (SUN) gathering will have a focus on complex emergencies. These issues will no doubt be raised at other fora—let’s link the debates.
  • Work with stakeholders across these fora to make commitments to act in these and other areas, guided by the 60 or so action areas in the Decade of Action’s Framework for Action. The commitments need not be the SMARTest at first, these can be honed later on—they key is to get public statements of intent on the table, to see what there is energy for and what is missing.  These commitments could kick start the Decade for Action, with pledges to act.
This building of momentum for action and the making of commitments for action would provide a template for each year in the Decade of Action.  Not every year will have 2017’s alignment of events – the Nutrition for Growth (N4G) and International Union of Nutritional Sciences (IUNS) events only happen once every three-four years-, but they will have a set that can be built on at the global level.  While the imperative is to convert energy at the global level into national and subnational action, it is also important to maintain the global energy. One way of feeding that energy is to provide many examples of where actions are taking place on the ground and the effects they are having.

How To Do It?

Who should do this? There is no overarching lead group for nutrition—this is sometimes a strength as it allows nutrition actions not to get stuck in top-down bureaucracy, but in this case it is a weakness as no one group is worried about weaving together all these golden strands of energy into a dazzling fabric that can support and catapult nutrition efforts upwards.

A two track process could be followed: (1) the organisers of each of these events could, this year and every year, get together and coordinate some elements of their meetings and (2) a light touch task force for the Decade of Action could be established under the leadership of, say, the UN Deputy Secretary General to provide a focal point for the efforts of all 193 UN members and to stimulate greater coordination across major events within a year and also across years to build dialogue and action to ensure the Decade of Action for Nutrition delivers a Decade of Impact.  Three billion people are owed that much—and more.



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Published 4 September 2017

31 August 2017

Starting life strong in slums: the role of engaging vulnerable groups on sanitation and nutrition

Crowded slums, poor sanitation and unhealthy diets.  It’s a potent cocktail and for too many families across the world, a daily reality.  Right now, an estimated one billion people live in slums and that number is expected to double by 2030. Slums are where the many deprivations facing the urban poor collide, including lack of access to clean drinking water, sanitation, safe and nutritious foods, sufficient living space, durable housing and secure tenure (UN Habitat).  They’re where human waste is routinely emptied into streets, canals, and garbage dumps. And where overcrowding and low rates of immunization and breastfeeding combine to exacerbate the already perilous problems children face.
Children growing up in these surroundings are at a higher risk of death and disease and are more likely to be chronically malnourished (Ezeh et al. 2017). For example, forthcoming World Bank research from Bangladesh shows that children living in slums are 50 percent more likely to be stunted than children living in other urban areas. This doesn’t just have implications for today – children who are stunted early in life go on to learn and earn less, and face a higher risk of chronic disease as they grow older. Tragically, these effects are often passed on to offspring, trapping families in poverty and malnutrition for generations, as per findings in a forthcoming World Bank report called Uncharted Waters.
So it is crucial that the response is commensurate to the challenge.  In the sanitation sector a ‘radical shift’ is underway to deliver Citywide Inclusive Sanitation, with a focus on ensuring sustained service delivery rather than focusing solely on building infrastructure. The end goal is to eliminate fecal contamination from the urban environment, providing the conditions for children to grow up strong, healthy and prosperous.
Improvements in sanitation are a necessary but insufficient contribution to eliminate stunting and malnutrition among the urban poor. They have to go hand in hand with creating food systems that are better able to promote healthy diets. Following the recommendations of the just launched report on WASH Poverty Diagnostic, the water, sanitation, health and nutrition sectors need to work jointly to ensure that improvements in WASH services and nutritious food systems translate into improvements in child health. We recommend the following three actions:
Firstly, nutrition and WASH services need to be inclusive of all groups to have the greatest impact on child nutrition.Women and children are most vulnerable to the effects of poor nutrition, but traditionally lack the political voice needed to secure services. Poor urban households and those living in slums are often in a similar position – bearing the high health costs of poor service while being ignored by decision makers. These groups can be effectively targeted and engaged using community and social outreach workers.
In Ethiopia, a new Urban Water Supply and Sanitation Project includes support to slum areas and uses urban health extension workers to carry out sanitation and hygiene behavior change. These extension workers are a potential channel to reach groups not just in need of WASH, but other social and health services.
In Indonesia, the Global Alliance for Improved Nutrition (GAIN) is working in partnership with the Ministry of Health and Nazava Water Filters to improve nutrition in East Java under the Baduta Program. One of the key components of this program is the establishment of a sustainable supply chain of household drinking water filters that help households to filter their tap, well or rain water without the need to boil or use electricity. Filtering water is three times cheaper than boiling it and nine times cheaper than buying water. As part of this project, partners are piloting a micro-entrepreneurship model for women entrepreneurs for the distribution of community water filters.
Secondly, behavior change remains crucial.  Research in Ghana shows that uncooked vegetables, grown in areas surrounding slum households and irrigated with wastewater from open drains, are the main way young children are exposed to fecal contamination (Robb et al. 2017). This suggests that a range of actors, including those from agriculture, nutrition and WASH, are needed to influence household behaviors around wastewater reuse, food safety, food safety, feeding practices, and handwashing with soap.  Educating those who care for small children is particularly important.
Another key component of the Baduta project in Indonesia is a behavior change campaign called Rumpi Sehat (Healthy Gossip), designed to promote exclusive breastfeeding, optimal complementary feeding and safe WASH practices. As part of this campaign, village volunteers in East Java conduct various Emo-Demos (emotional-demonstrations) that are 20 to 40 minute highly interactive, game-like sessions with mothers that aim to create surprise, grab attention, spark emotion and challenge social norms. The village volunteers ensure a consistent experience in order to engage and motivate mothers to participate, giving them the confidence to practice the right feeding and hygiene behaviors. GAIN’s team worked closely with the London School of Hygiene and Tropical Medicine to develop the various props and simple discussion guides used for the Emo Demos.
Ultimately, behavior change also plays a key role in helping create demand for nutritious foods and health services, turning communities into active participants in the fight against malnutrition and poor WASH.
Finally, slum households that are counted are better served. Governments are sometimes reluctant to recognize the existence of informal settlements or include them in official statistics – and they can face technical difficulties doing so. But their inclusion is vital to adequately assess needs, obtain budgets, and get services like health, nutrition, housing, water and sanitation to the places where they are needed most. Convergence of these critical services is the first step to a strong start and bright future for every child born into a slum.
Today, at Stockholm World Water Week, stakeholders from the water and nutrition sectors are coming together to discuss the evidence, policy and practice examples of how we can effectively address stunting in slums and informal settlements. We can no longer afford to overlook the complex problems faced by urban slums residents. By working together, we have the power to find sustainable solutions to improve their futures and help to build healthy communities and nutritious food systems.

Follow the discussion @WorldBankWater with #NutritionMeetsWASH and check back here next week for a post-event interview with participants.  
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08 August 2017

Future elevated CO2: another reason to cure our "Anemia Amnesia "

I have written about our collective "Anemia Amnesia" before.  Anaemia is the nutrition condition that has high prevalence worldwide and is decreasing at a snails pace (see any Global Nutrition Report). It has serious consequences for cognitive ability, work capability, and greater rate of maternal and child mortality. 

So it is doubly alarming to read a paper by Smith, Golden and Myers in the latest GeoHealth which concludes that this situation is likely to worsen due to elevated levels of carbon dioxide as we move towards 2050.   

The paper combines FAO food balance sheet data at the national level, uses the Global Dietary Database to get some granularity on iron availability for 1-5 year olds and women of reproductive age, and then combines this with the 2014 estimates from Myers et al. on the impacts of elevated CO2 on zinc and iron concentrations of key crops.  This latest paper answers the "so what?" from the 2014 paper: what impact will these lower concentrations have on potential iron deficiency numbers?

The paper labels countries as high, medium and low risk of increased anaemia due to elevated CO2. Countries classified as high risk have levels of anaemia >20% AND modelled loss in dietary iron that would be most severe (over 3.8%).

For sure, the estimates of impacts on risk of iron deficiency are built on a series of big assumptions (including on the relevance of elevated CO2 estimates beyond the country the data are from, food group aggregation, the distribution of bioavailability and the changing nature of diets), but they seem reasonable to me.  

So what do they find?  The figure below shows the key result. 

You can see that South Asia, South-Eastern Africa and North Africa are the most at risk of a potential rise in iron deficiency prevalences. They contain 1.4 billion at risk children 1-5 and women of reproductive ages (not to mention older children and men who also suffer from anemia). Across all countries, the estimated percentages of lost dietary iron under elevated CO2 ranged from modest to more severe: 1.5–5.5%. Estimates for all countries are available in the open access paper. 

Why are the populations in these countries most at risk?  First the populations of these countries have high levels of anaemia and second they consume large amounts of the foods that are most at risk of iron concentration loss due to elevated CO2 (rice, wheat flour, maize and fresh vegetables). 

What are the policy implications of this work?  The authors state: 

"The potential risk of increased iron deficiency adds greater incentive for mitigating anthropogenic CO2 emissions and highlights the need to address anticipated health impacts via improved health delivery systems, dietary behavioral changes, or agricultural innovation. Because these are effects on content rather than yield, it is unlikely that consumers will perceive this health threat and adapt to it without education."

I agree with this.  The policy pay off to this work is more on the adaptation than the mitigation side. In other words while this result adds to the case for reducing CO2 emissions, more importantly, I think, it is a real wake up call to the nutrition community.  Act now on micronutrient content of the diet because it is not going to get much easier in the future.  The two systems that need to become more attuned to this problem are health systems (to address diseases that reduce iron absorption) and food systems (to make iron rich foods more available and affordable).  

But arguably the most important sentence in the authors' conclusion is the the last one.  Unlike food quantity the effects on the nutrition content of foods (whether from elevated CO2, seed varieties selected, storage, transport or processing lose) are hard to detect.  So we need more mechanisms for signalling nutrition content of foods in ways that inform the consumer: whether certification, labelling or behaviour change campaigns.  

Lack of food is relatively easy to observe, but a lack of nutrients is not.  Governments and businesses in food systems need to focus more on nutrient content.  They will be rewarded with healthier--and wealthier--citizens and consumers.

04 August 2017

Gastrophysics: the new science of eating

I was trained as an economist and although we work with "preferences" we tend to think of consumption behaviour being driven by prices, income, gender based rules and convenience, with preferences relatively fixed.

So it is refreshing to read Charles Spence's book: Gastrophysics: The new science of eating because it focuses on pretty much everything else that drives preferences and choices.

Spence is a Professor at Oxford University's Crossmodal Research Laboratory.  Crossmodal because his team examines how different senses connect with each other (e.g. when someone puts on red lighting and suddenly the red wine in your black glass tastes sweeter). He is an experimental psychologist and he has defined the term gastrophysics as "the factors that affect our multi sensory experience while tasting food and drink".  Watch an interview with him here.


For instance:

* Sound: when a potato crisp makes a louder crunch, it enhances perceptions of freshness
* Sight: crab flavoured ice cream that is pink will not work in the Western world because the colour pink is associated with sweetness
* Name: the real name for the popular Chilean sea bass is Patagonian tooth fish (not too many people will order that)
* Expectations: "Pasta salad" does not sound as healthy as "salad with pasta"
* Atmosphere (literally): 27% of drinks bought on airplanes are tomato juice because its flavour is strong enough to survive the sensory dimming effects of high altitude and loud noise
* Labelling: using phoney farms in the labelling of foods (e.g. Rosedene and Nightingale) makes consumers feel the food is healthier
* Shapes: customers were convinced that a famous brand of chocolate had become more sweet when the corners of the blocks became more rounded.  The formula had stayed the same but people associated smooth corners with sweetness.
* Silence is golden: labelling a product lower in sugar or fat --when it it really has been lowered--is a risky business for companies because it might make consumers taste it differently
* People: we all live in our different taste worlds, some are "super tasters" with 16 times as many papillae on the front of their tongues as the rest of us.
* Smell: a rose oil soaked sugar cube in a glass of sparkling water or champagne, transports you to a rose garden
* Shapes: beer labels tend to have sharp angular logos connoting bitterness
* Colour: using blue plates in hospitals increases the consumption of food because bland hospital food tends to look even blander against white plates
* Orientation: the rotation of the plate matters (we tend to prefer food in pyramids)
* Motion: yolks, oozing chocolate, juice flowing into a glass (all imply freshness)
* Look: the more beautiful a source of food tends to look, the less aromatic it tends to be (ugly fruit lovers take note)
* Sound: the sounds that coffee machines make affects the taste of the coffee made
* Touch: "the first taste is with the hands" -- what do the eating implements feel like? (Textured spoons anyone?)
* Touch: are hamburgers more popular because we eat them with our hands and not with sharp, cold metallic objects being inserted into our mouths?
* Sound: accompanying music must not be too loud, and it can stimulate preferences for certain kinds of food (accordions for French music etc)
* Social: the tapas-isation of eating--sharing can enhance flavour

So what has all this to do with making the world more well nourished?   For me, these are the takeaways (no pun intended):

1. I don't hear the words flavour, desirability, cravings or delicious at many nutrition meetings or events.  We need to talk about these attributes and dimensions if we want to create a greater demand for healthy foods

2. Many of the examples in the book are from Europe and North America, but as Spence notes this is just a reflection of where the research has been conducted to date--the approach is likely to be universally useful, although of course it needs adapting to context.

3. Changing some of the drivers of consumption are not necessarily expensive.  Colours, shapes, names.  We just need to clue into the psychology of eating.

4. Businesses are better than the public sector at this type of gastrophysics research (I suspect) and when they invest in it, little will ever make it into the public domain.  We need to find ways of working with them to get more of it geared towards healthy eating and into a shareable space.

Just as nutrition is not only about food, food is not only about nutrients.  It is about eating.  Getting people to eat differently is not easy.  This new science promises to give us a few more tools and ideas to do so.  Let's be open to it and not just dismiss it as fluff (pink coloured, of course).

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!