17 April 2017

Which dimensions of household food expenditure are associated with child growth? New paper.

The title of this blog sounds like a really boring question.  But it's not.

We have known for a long time that household food expenditures are associated with child growth outcomes, but how is that association parcelled out: is it quantity or quality or both?

This is the question picked up in a new paper by the Young Lives research team, using data from Ethiopia, India, Peru and Vietnam in the "younger" cohort: pooling 3 rounds (when the kids are 5 years, 8 years and 12 years of age).

To answer the question the team looked for associations between height for age z score and 3 key variables: (a) total household food expenditures per adult equivalent, (b) patterns of household food expenditure (as determined by factor analysis) and (c) child dietary diversity score (number of food groups). Control variable applied included child age and sex and household location (rural/urban).

So why is this question important?   First, we know poor diet quality is the number one risk factor behind the global burden of disease.  Second, diet quality is really difficult to assess: 24 hour recall assessment is costly and often criticised for relying too much on such a short recall period.  Third, there is a LOT of household food expenditure data out there.  The World Bank, in partnership with National Governments collects it routinely in its Living Standards Measurement Surveys (LSMS) and there are plenty of other such surveys out there, typically collected every 3-5 years per country.  Finally, these data are not so difficult to collect: they usually cover 40-60 food types and use a 2 week recall period (covering food from purchase, gifts, in kind payment, own production and outside the home).

If only this commonly collected type of food expenditure data could be used as a credible proxy for the quality of diet.  If an index of food group expenditure diversity could be constructed that is significantly associated with standardised height for age (HAZ), and holds for a number of countries, that would be very useful.

So using ordinary linear regression methods, the authors regress HAZ on total food expenditure per adult equivalent, the household food group expenditure index (HFGEI, derived from a factor analysis of household food expenditure patterns) and child diet diversity scores.

In Ethiopia, India and Vietnam the authors find that HFGEI is significantly and positively associated with HAZ--even after accounting for total food expenditure per adult equivalent and child diet diversity score.  In Ethiopia and India the estimated coefficients on HAZ for a 1 SD change are larger for HFGEI than for child diet diversity. And in Ethiopia and India the estimated coefficient on household food expenditure per adult equivalent becomes insignificant once HFGEI and child diet diversity are introduced.

The authors also do this same exercise for BMI for age (BMI-Z) and find significant (positive)  results, but only for Ethiopia and Vietnam.

There are things I would like to see improved, namely some instrumental variables treatment on the 3 key right hand side variables (e.g. is there some unobserved factor driving HAZ and these 3 variables inducing a fake association?).  I'd also like to see village dummy variables included to take health environment into account. Parental education variables are also missing.  Finally, factor analysis always makes me a bit nervous given its black box propensity, but then again it is no less black box than regression analysis and the authors do a good job of unpacking their factor analysis results.

Nevertheless, this is a careful study which suggests that commonly available household food expenditure data may provide a good proxy for the quality of household food consumption (and perhaps even child food consumption).

In the absence of lots of actual food intake, these food expenditure data sets are likely to prove very valuable to anyone trying to assess their efforts to improve nutrition outcomes through increasing the consumption of nutritious foods.

24 March 2017

Reflections from 2 days at the 3rd International Congress on Hidden Hunger

This week I was at the 3rd International Congress on Hidden Hunger in Stuttgart, organised by the University of Hohenheim.  There were about 300 participants, drawn mostly from nutrition and agriculture; academia, civil society and business.  Hidden hunger means micronutrient malnutrition and we think that at least 2 billion people—in all countries—suffer from these deficiencies and we don’t know much about how quickly they are declining.  Not fast enough for sure.

Chatting with the German Academic Exchange Students (DAAD)
I gave 2 presentations: on food systems and diets and on the role of business in improving the consumption of safe nutritious foods.

Some takeaways from me:

The quality of presentations was high, but it was not always clear who the audience were: researchers or practitioners?  Diversity of audience is good, but not necessarily within the same session.  Often I felt that presentations could not build on each other because of this diversity of audience.

The latest research on RUTF and Home Fortification from Bangladesh is fascinating—and practical. There were two very interesting Bangladesh studies from ICDDR,B: one on ready to use therapeutic foods (RUTF) and one on Home Fortification (HF).  The first, on RUTF, was presented by Dr Tahmeed Ahmed but is not yet published. The conclusion from the study was that the promotion of locally produced RUTF is not in contradiction with efforts to improve infant and young child feeding strategies, do not lead to obesity and do not lead to commercialisation of foods for severely malnourished children.  These are 3 common perceptions about RUTF in Bangladesh and this scientific study provided evidence to the contrary.  The second paper, presented by Haribondhu Sarma, concluded that home fortification (HF) has not been well implemented in Bangladesh. When I asked whether there was something inherent about HF that made it difficult to implement, I was told no.  What is needed is greater care in generating demand for HF and working out how to ensure regular supply of HF to those who most need it.  GAIN works in both these areas and so these findings are really helpful to guide our efforts.

How to prioritise nutrition interventions in a given context?  Rolf Klemm from HKI gave a nice presentation on the challenges of implementing Vitamin A supplementation, Home Fortification and Enhanced Homestead Farming.  He concluded that all of them have implementation challenges, some similar, some unique to the intervention.  We should not be surprised--there are no design-proof nutrition interventions. Rolf presented only 3 interventions and I asked him how governments could prioritise across the dozens and dozens of interventions they could undertake? Which should be done first?  Rolf mentioned the LiST tool (Lives Saved Tool) as one guide but this seems like quite a blunt instrument (for example it does not take into account politics and capacity) and incomplete (it only covers a subset of interventions).  We need something more practical to help governments (and all stakeholders) to prioritise and sequence actions.  

Zero-sum tendencies persist in the micronutrient world.  This tension was simmering below the surface.  The most frequent question was: don’t fortification and bio fortification take away from efforts to generate a diverse diet?  My view on this is that needs, opportunities and capacities have to drive the balance of approaches, with government in the driving seat.  All approaches are important, at different levels, in different contexts, at different times.

There were too many environment-free nutrition papers. There was also a tension between those concerned with the environment and those concerned about nutrition.  For example, are we talking about reducing micronutrient malnutrition at any cost to the environment?  These two communities do not connect easily, but they have to.  They need to because the diet choices that affect nutrition outcomes also affect the use of water and energy and the emission of greenhouse gases.

A company’s BMS poor conduct will take away from the good nutrition work that other parts of that company may be doing.  In a coffee break I had an interesting conversation with an employee of one of the big BMS companies.  I had just presented some ATNI data on how poor the Code compliance of big BMS companies was.  This employee worked in a section of the company that focused on children over 4 years of age and politely made it clear to me that the employee’s team had nothing to do with BMS.  But clearly the failure of the  company’s willingness/ability to comply with the Code was damaging the perception of the work of done by the employee’s team.  Employees who work in companies that violate the Code can be quiet and powerful advocates of change from within.

I am grateful to Prof. Hans Biesalski at the University of Hohenheim, the Chair of the event, for the invitation to participate in the 3rd Congress and I look forward to the 4th in 2019.  I very much hope it focuses more on some of the following issues: environmental trade-offs, double burden issues and how to get hidden hunger higher on the political agenda.

20 March 2017

Universality and the SDGs: transforming development as we know it?

The SDGs have been in place now for 18 months. But already there is some disquiet over the attention that is being paid to them by some countries.  

The BOND Annual Conference took up this theme and one of the sessions, which I chaired, asked the panelists “how do we make the SDGs matter more?” It was framed as how are the SDGs connected and how do we leverage the opportunities they bring?  But really it was about how to make the SDGs matter more.

The SDGs are really different from the MDGs.  The SDGs focus on sustainability, on all people within a country and on all countries.  Many of the SDGs talk about ending a problem e.g. “ending malnutrition” rather than halving its rate. Plus the process of generating the SDGs was much more inclusive than the process that generated  the MDGs. This is all great.

But for the audience and the panel the key distinction was the fact that the SDGs apply to all countries—that they are “universal”. 

This means that it is not DFID that reports on the UK’s performance in meeting its own SDG targets, but the Prime Minister’s Cabinet. 

Universality opens up lots of opportunities:

* An understanding of how difficult it is to achieve lasting change in, say, the UK or the USA or the Netherlands within the strictures of typical 3-4 year funding cycles

* An appreciation of how intrusive and disrespectful the metrics culture can be in terms of naming and shaming high income governments, businesses and NGOs that do not meet their commitments

* Learning across contexts that seemingly have no connection (what about addressing the unaffordability of safe nutritious food in some neighbourhoods of Leeds, Lagos, Lima and Lahore?)

* Connecting and engaging the global and local realities of trying to improve development outcomes.  What do the SDGs mean to someone living in Geneva or Washington DC as well as rural Mozambique and slum dwellers in Dhaka?

But is there a risk from this universality? If those who work on international development perpetuate the divide with domestic development then, I think, yes. If these two worlds remain separate there is a real risk that one will cannibalise the other for attention and resources. If, for example, we draw attention to poor school outcomes in deprived areas of the UK without drawing out commonalities and contrasts with, say, deprived parts of Africa then we run the risk of losing resources for development but we also lose a sense of context and humanity, not to mention opportunities to foster a sense of solidarity.

True universality of the SDGs should challenge international development actors to bridge the easy “us and them” dichotomies. It should disrupt our thinking and organisation sufficiently that we gradually move from international development driven by aid to global development driven sustainably by domestic resources—public and private.


11 March 2017

The Access to Nutrition Spotlight Falls on India: What Does it Reveal?

I'm a big fan of the Access to Nutrition Index (ATNI).

The Index was conceived of at GAIN and partners and became independent a few years ago.  Its first report was in 2013 and I blogged about it favourably then.

Now comes the next logical extension of the Index--a country spotlight index.

The first spotlight is in India, where 1/6th of the world's population lives and are governed by a national and international set of food system regulations.


I really like the spotlight report (although I have only read the 60 page executive summary!).

The report selects the 10 largest Indian food and beverage manufacturers and evaluates them on three key dimensions:

* Corporate profile (company nutrition commitments, policies, practices and disclosure--analysis done by Sustainalytics based on publicly available documents supplemented by information provided by the companies upon request)

* Product profile (assessing nutrition quality of company products, based on food types and labels--analysis done by the George Institute for Global Health in Australia)

* Breastmilk Substitute (BMS) compliance (with The Code and Indian Milk Substitutes/IMS act--done in Mumbai by Westat in partnership with the Delhi Centre for Media Studies)
Indian company scores on product and corporate profiles


Key findings (from my perspective):

1. The Indian companies do well relative to the Indian multinational subsidiaries when it comes to product profiles (they derive larger shares of their sales from more nutritious products based on the Health Star Rating system which accounts for positive components such as fruits and vegetables and more negative ones such as salts, sugars and fats).

2. The Indian multinationals do better on corporate profiles, having access to their parent multinational capacities in this area.

3.  The 8 companies that are assessed on BMS behaviour (only 2 --Nestle India and Amul--overlap with the 10 largest food and beverage companies) comply, in large part, with the Code and IMS.  The exceptions seem to be (1) for products that are "parallel imports", i.e. to be consumed in other countries and (2) in marketing online sites, inviting mothers to sign up to information -- which is not subject to the same level of scrutiny.

As usual the report has clear recommendations for companies and for governments.

As I've noted before I think the overall score adjustment for BMS compliance performance should be multiplicative rather than deductive (because of the multiplier lifetime effects of undermining nutrition in first 1000 days) -- it would be an interesting analysis to see if this changes rankings.

Of course, the true test of ATNI scores is whether they are used to change behaviour.  The most important type of behaviour from a business perspective is whether the ATNI score affects investor/creditor behaviour.

At GAIN we are looking to see if we can work with ATNI to develop scores for companies in some of the key countries we work in.  For example can we use ATNI scores to screen investments in companies from our Marketplace for Nutritious Research and then use ATNI score improvements as one factor in the decision of formal lenders to transact with companies.

The public private space in nutrition desperately needs to become more transparent and accountable.  This is how trust is built up and more effective resource allocation decisions can be made.

ATNI is one important contribution towards doing this--but we need more.

18 February 2017

Can Tanzania emulate Ghana's nutrition achievements? Don't bet against it

Small businesses need support to lower the price of nutritious foods
I was in Tanzania this week to work with our Country Representative, Enock Musinguzi and the rest of the terrific GAIN Team.  We spent a few days talking to the government and its development partners on the country’s nutrition needs and how GAIN’s next generation of projects could help advance agreed priorities. 

It has been about 18 months since I was last in Tanzania and in that time the country’s road map to improved nutrition, the National Multisectoral Nutrition Action Plan (NMNAP—which I can’t find on the net) has been published (October 2016).  

It is an impressive document: compelling in making the case for nutrition, clear about where it wants to get (yes the targets are smart—e.g. 28% stunting by 2021), comprehensive in how it is going to get there, who is going to pay for what, and all evidence based. 

But it is more than a document--all the development partners I met talked about how important a framing it was for their own action.  So it really feels like it is a roadmap for all stakeholders.  My main worry is about priorities—when there is so much to do, where to start?  And there is no study that helps to explain which determinants of undernutrition have, say, driven down stunting rates in the past 6-7 years.  At a pragmatic level we have to act and go where the political energy and the capacity to deliver are, although it would be good to have the confidence of knowing that we were helping to relax a truly binding constraint to improved nutrition. 

Other reflections:

Large scale fortification fatigue has set in, but the fatigue must be shrugged off.  I don’t think one of the development partners we spoke to (with the exception of MI and HKI) were enthusiastic about this.  I found this amazing in a context where effective coverage rates are much lower than anticipated (see the 2015 FACT survey, for example even universal salt iodisation is only at 69% effective coverage levels) and where children and women’s anemia is actually increasing.

Diet related non-communicable disease is being talked about.  Adult overweight and obesity together stand at about 26% and the numbers are rising.  The risk is that treatment for the related diseases such as type 2 diabetes, hypertension and heart disease will divert health system resources away from efforts to reduce undernutrition.  The government has featured NCD reduction in its nutrition plan and clearly some donors are beginning to wonder what they can do to make a contribution (answer: make safe and nutritious foods more affordable, keep promoting exclusive breastfeeding, and work to influence the diet and nutrition choices of adolescents, wherever they are found). They must keep working on this. 

There is an increasing recognition of what businesses can contribute to the national nutrition plan.  Mr. Obey Assery, the key driver of nutrition in the Prime Minister’s Office, has stressed this and the NMNAP counts on businesses for 10% of its budget.  But nutrition development partners are only now beginning to look for ways to engage with businesses.  After brainstorming with each of them for 30 minutes or so, together we can usually identify opportunities within value chains, or in workplace policies, or in behaviour change/demand creation for healthy foods, or in building the capacity of small and medium enterprises to comply with food and nutrition legislation.

Multistakeholder working is strong.  One example was the monthly meeting of development partners for nutrition, to which I was invited to. I was enthused by the energy and commitment of those who support the government in its nutrition plans. It is great for knowledge sharing and action coordination. Moving forward, it would be good to draw in more business knowledge and action through the SUN Business Network to complete the multisectoral loop that the NMNAP champions.

Tanzania clearly wants to be the “next Ghana” a country that halved stunting rates to 19% within a 10 year period. 

After having witnessed the leadership, energy and determination within the country right now, I wouldn’t bet against it happening.

15 February 2017

Dropping the price of healthy diets: 2 SMEs that are helping to do this because it is good business

Earlier this week I was in Maputo working with the dynamic GAIN Mozambique team under the excellent leadership of Katia Santos Dias.  It was the first time I had been to Mozambique in the past 20 years and while many things have changed rapidly, the rate of stunting has changed very slowly indeed.

Why has stunting declined so slowly?  There are lots of ideas: rapid economic growth which has bypassed all but those on high incomes, high levels of corruption, El Nino of 2015-2016, the collapse of the national currency, the return of civil unrest in the north, poor donor coordination and performance, and low levels of supporting public services (for example, 75% of the population have no access to improved sanitation, only 25% of girls are enrolled in secondary school and only 1 nurse or midwife for every 2500 people—see the Global Nutrition Report for more data). 

In a context such as Mozambique, where leadership to improve nutrition is patchy, it was really refreshing to meet with two of the Marketplace for Nutritious Food grantees that GAIN works with.  

Neither of them is primarily driven by a desire to improve nutrition, but they are driven by a desire to be a successful business, and that means finding a way to get their products (meat patties and peanut butter) to a price point where even very low income families can afford them.   I took the picture (left). It is from the wall of one of the grantees and, effectively, it is their mission statement: how to get the price point of their food to a place where low income consumers at the “bottom of the pyramid” can afford them.

In a context where trust in public agencies is low, perhaps we should put more faith in supporting small and medium businesses (including farmers) as an engine of growth.  

Yes, they will have their fair share of untrustworthy characters, but I really don’t see where else widespread inclusive growth is going to come from.  If they grow, these businesses will employ more people, drive wages up, stimulate the demand for other products, eventually generate more tax revenue to spend on public services and, if they are producing foods that are compatible with a healthy diet, they will improve nutrition status.


It seems to me that a key priority for the Government of Mozambique and their development partners is to make it easier for businesses to do business, finding the businesses that want to do positive things for nutrition—and then backing them.

14 February 2017

The EIU/Barilla Food Sustainability Index: how to get from Index to Instigation?

Food systems are driving food availability, access, affordability and food choices across the globe.  We know that about 1 in 3 people are eating poorly.  We also know that these poor diets are the number one risk factor in the global burden of disease: ahead of the consumption of tobacco, alcohol, illegal drugs and ahead of unsafe sex and poor sanitation and drinking water quality.

So the performance of food systems really matters. If they do not improve, we run the risk of moving to a world where 1 in 2 people have poor diets.  That is why I welcome the EIU/Barilla Food Sustainability Index (FSI) which ranks 25 countries comprising over 85% of global GDP.  The index covers appropriate areas: food loss and waste, sustainable agriculture and nutritional challenges.  These 3 areas are divided into 8 sub areas, 35 indicators and 58 sub-indicators.

As a researcher I would have liked it to be easier to find the methodology details.  For example, how were the indicators selected?  OK, by a group of listed experts—which includes some of my colleagues from GAIN---but why were these experts chosen?  They don’t seem very geographically diverse.  Another example of methodological fogginess: some of the sub indicators are very specific (e.g. the % of under 5’s who are stunted) but some of the others could be calculated in many ways (e.g. the quality of policies to address dietary patterns).  Also it is not clear how the indicators are combined—are all 58 sub indicators given equal weight or are all 35 indicators or are all 8 sub areas or are all 3 areas? You see what I mean—these different routes to an index have implications for the weighting of the 58 sub indicators.  Some of this fogginess can be dispersed by playing with the data and so I really commend EIU and Barilla for making the data available so we can all experiment with the sub indicators and see how different the rankings are by different ways of combining indicators. 

But while the above is not quite methodological quibbling, my three main suggestions for strengthening the index are, I think, more significant and are as follows. 

First, the index does not have enough indicators from the middle of the value chain.  There are plenty of indicators about agriculture and about nutrition and health outcomes but there are too few on food transformation, food marketing, food retailing and food advertising.  I suspect this is because the data are not so easy to dig up here, but some do exist (e.g. sales of processed foods) and they should be included.  They should be included because may of the nutrition and affordability problems are generated in the middle of the value chain and many of the solutions can be found here too.  My GAIN colleague Bonnie McClafferty makes the same point in her recent blog on the FSI. 

Second, the goals of the index are described as benchmarking performance of country food systems, measuring progress over time and offering best practices from national and city levels.   The index certainly does this, but it is not clear how the best practices are selected and whether they are backed up with some hard evidence that they actually work.  The index report needs something a bit more systematic—what works for each element of the food system and do these solutions need to all be working at the same time: where are the weakest links?  Additionally, if the index is to be used as an accountability and improvement tool, I would really like to see country scorecards with suggestions for priorities, country by country, with some kind of attempt to get a response from each country on what they will do differently in the future to try to improve their score.  With only 25 countries involved in the report, it should be possible to do this.

Third, few of the indicators relate to business structure, conduct and performance.  The food system is populated by businesses: small, medium and large.  They drive demand and supply.  Their conduct is shaped by consumer demand, government regulation and other companies’ competitive strategies.  So it is important to measure their behaviour. For example, what do we know about the compliance of businesses with the code of conduct on the marketing of breast milk substitutes or the percentage of companies (weighted by size) that have workplace policies for improved nutrition, or the percentage of companies (weighted by size) that have announced reductions in salt and sugar in their product formulations or have initiated schemes to minimise food loss and waste?

Finally, I congratulate EIU and Barilla for zeroing in on cities with their “City Monitor” pilot on urban food systems.  This is entirely appropriate for several reasons.  First, countries are actually characterised by several food systems, not one.  We tend to default to one because most data are not disaggregated below the national level, but a move to characterise cities is a good first step at unpacking a country’s food systems.  Second, the world is urbanising and, unfortunately, malnutrition is urbanising with it, so urgent analysis and action is required in these domains.  Third, cities may actually be able to be more decisive than national governments.  They may have more control and authority to act to change food systems.  Finally a focus on cities brings in new actors such as municipal leaders and those who tend to be more densely represented in urban spaces such as the tech sector, impact investors and social media aggregators.  These new actors bring new ideas, energy and relationships to the table.

The above issues are not easy to address and they are ones we are all struggling with.  The Global Alliance for Improved Nutrition (GAIN), which I lead, is no different.  Our aim is to improve the availability, affordability and realisation of healthy diets for all people, especially the most vulnerable.  Because most people buy their food in the marketplace and because more and more of it is processed, this inevitably involves working with businesses that are responsible, ethical and have values consistent with GAIN’s. Where we see irresponsible behaviour by businesses and other stakeholders we call it out.  The index could do more of this at the country government level.  Let’s be clear: we don’t have time for anything that takes away from improvements in diets and nutrition if we are to end malnutrition in all its forms by 2030 as the SDGs challenge us to.  People’s diets, health, productivity, wellbeing, and sometimes their very survival depend on it.