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!

28 June 2017

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

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

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

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

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

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

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

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

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

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

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

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

23 June 2017

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

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

Learn more about GAIN’s work here