30 December 2014

6 New Year's Resolutions for Nutrition Policymakers

2015 could be a momentous year for nutrition or it could be a massive missed opportunity. 

Nutrition policymakers can make the difference.  Here's what I think they need to focus on in 2015. 

1.  Get nutrition more firmly entrenched in the Sustainable Development Goals

There are a number of recommendations on which indicators and targets to fight for.  All of them recommend inclusion of the 6 WHA indicators and usually the inclusion of a diet diversity indicator.  Come together, policymakers, engage with those who are at the centre of the SDG politicking and  convince them that without good nutrition, lives and livelihoods are built on quicksand. 

2.   Fund a data revolution in nutrition

Don't just talk about it, fund it.  The annual data bill for the MDGs (for all MDG countries) was $1 billion.  Small change, but vital to drive and monitor big changes.  Countries and UN agencies cannot do this on the cheap.  Invest in good data if you want change. 

3.   Convince economics colleagues that investing in nutrition is investing in growth

You have estimates that are summarised in the Global Nutrition Report--use them.  The benefit cost ratios are credible.  They are competitive with other investments.  They can be vote winners, just ask the Peruvian Government. 

4.   Work with sectoral counterparts to find win-win outcomes

Can an investment in nutrition sensitive agriculture be good for agriculture?  Yes!  For example, it can help Ministries of Agriculture show they are affecting all people's lives--not just farmers.  Ministries of Agriculture will need to reinvent themselves over the next 10 years, from departments that worry about farm output to departments that worry about the effect of farm output on human wellbeing.  A focus on nutrition can help jumpstart this. 

5.  Find ways to engage with major development debates in 2015

In addition to the SDGs, there will be major Climate and Finance negotiated outcomes in 2015.  For example, on climate, a focus on the first 1000 days of nutrition outcomes can help stress the damage done by the increased volatility in food prices caused by climate.  For innovative finance, can a focus on nutrition stimulate new thinking about cross-sectoral funding mechanisms?

6.  Model accountability

If you want people to take nutrition more seriously then you need to show others that you take it seriously.  This means identifying nutrition in your budgets, tracking nutrition spending, and analysing it.  This also means making your national data systems more interoperable with UN data systems.   

And for all of us who are not nutrition policymakers?  Let's support them (and occasionally nag them) in their pursuit of this kind of agenda.   

19 December 2014

Best Nutrition Reads of 2014 from the Global Nutrition Report's Independent Expert Group

Since professional decorum does not allow me to share my "best songs of 2014" on Development Horizons, I will instead list the Best Nutrition Reads of 2014 from the Global Nutrition Report's Independent Expert Group (IEG).

Some great ones are listed (many of which I missed in 2014) and they show the diversity of skills and interests within the IEG.

Here they are:

Mohamed Ag Bendech

Huffman, Sandra L., Ellen G. Piwoz, Stephen A. Vosti, and Kathryn G. Dewey. "Babies, soft drinks and snacks: a concern in low‐and middle‐income countries?." Maternal & child nutrition (2014).

The authors assessed the proportion of children 6-23 months of age consuming sugar snack foods in 18 countries in Asia and Africa using data from selected international and national sources and  highlighted the lack of good quantitative data on the purchase and consumption of snack foods by infant and young children and on associations between snack food consumption and stunting and overweight. The conclusions of this study are similar to those of 2014 GNR on the huge gap in food consumption data.

Mercedes de Onis

Villar, José, Aris T. Papageorghiou, Ruyan Pang, Eric O. Ohuma, Leila Cheikh Ismail, Fernando C. Barros, Ann Lambert et al. "The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21< sup> st
Project: the Fetal Growth Longitudinal Study and Newborn Cross-Sectional Study." The Lancet Diabetes & Endocrinology 2, no. 10 (2014): 781-792.

This study shows that the growth of foetuses and newborns enrolled in the INTERGROWTH-21st Project was similar across the eight study sites, supporting the view that human growth potential is universal for healthy populations from conception to at least through 5 years of age when health, environmental, and care needs are met. It is true that tall parents tend to have tall children and that short parents tend to have short children, but such expectations reflect interindividual rather than interpopulation variation. Recent studies of the genetics of height have identified about 200 genes associated with the genetic control of stature explaining only approximately 10% of observed variability, much less than the 40-80% expected from earlier studies done before the availability of genomic approaches. The small proportion of variability explained by that large number of genes likely reflects the influences on linear growth by nutrition and other care and environmental variables in ways that remain not fully understood. These considerations lead to the expectation that most variation in growth exists among individuals rather than among populations, an expectation borne out by both the WHO Multicentre Growth Reference Study and the INTERGROWTH-21st Project

Rafael Flores-Ayala

H. Verhagen et al. Application of the BRAFO-Tiered Approach for Benefit-Risk Assessment to Case Studies on Dietary Interventions.  Food and Chemical Toxicology 2012;50 (Suppl.4):S710-723

I heard Hans Verhagen’s presentation on “Integrating risk-benefit assessment in food and nutrition” at the Micronutrient Forum this past June 2014 and afterwards I read this paper. For micronutrient interventions this paper is particularly important because it presents a methodology to deal with the issues of benefits and risks in an objective way so we can better inform policy decisions. 

Patrizia Fracassi

The 2014 National Geographic series on the Future of Food (digital version natgeofoodapp.com).

This is special. It addresses familiar topics from unusual angles, using big graphics and beautiful pictures.

Lawrence Haddad

Richard Bluhm, Denis de Crombrugghe and Adam Szirmai. Poor trends: The pace of poverty reduction after the Millennium Development Agenda.  UNU Merit Working Paper. February 2014. http://aquadoc.typepad.com/files/wp2014-006.pdf

Nothing to do with nutrition directly.  I read this one early in the year and it stuck with me.  It tries to predict if we can really get to zero poverty by 2030 (the World Bank said we could).  Bluhm and colleagues show we can, but it will take a very rapid decline in inequality combined with sustained growth in most countries to do it.  So it busts open a rather careless statement from the Bank, but gives us some hope that with business not as usual, we can do it.  Good caution and good inspiration for the nutrition world.

Elizabeth Kimani

Norris SA, Wrottesley S, Mohamed RS, Micklesfield LK: Africa in transition: growth trends in children and implications for nutrition. Annals of nutrition & metabolism 2014, 64 Suppl 2:8-13.

This paper systematically reviews literature to discuss child stunting within the context of economic growth and adult obesity, and concludes that many transitioning African countries face a complex challenge of the double burden of malnutrition and need to apply a multisectoral approach to arrest and prevent obesity as well as accelerate the reduction in stunting levels.

Yves Martin-Prevel

Tahmeed Ahmed, David Auble, James A. Berkley, Robert Black, Philip P. Ahern, Muttaquina Hossain, Andrea Hsieh, Santhia Ireen, Mandana Arabi and Jeffrey I. Gordon. An evolving perspective about the origins of childhood undernutrition and nutritional interventions that includes the gut microbiome. Annals of the New York Academy of Sciences 2014; doi: 10.1111/nyas.12487

This paper gives a really comprehensive summary of what we know and what we don’t know about mechanisms underlying child undernutrition. It opens the door to new research topics but also to new nutrition interventions to be developed.

Purnima Menon (new member)

Bredenkamp, Caryn, Leander R. Buisman, and Ellen Van de Poel. "Persistent inequalities in child undernutrition: evidence from 80 countries, from 1990 to today." International journal of epidemiology (2014): dyu075.

This paper reminds me that in the end undernutrition is about fundamental societal inequities and that without a social equity lens this problem is not going away.

Holly Newby

‪Global diets link environmental sustainability and human health.  ‪David Tilman & Michael Clark. ‪Nature. 515, 518–522 (27 November 2014). doi:10.1038/nature13959

This was a very readable article about an important subject.

Rachel Nugent

Bollyky, Tom, Mitch Daniels, Tom Donilon, “The Emerging Global Health Crisis: Noncommunicable Diseases in Low- and Middle-Income Countries,” December 2015, Council on Foreign Relations, New York.

This report will be a game-changer because it is produced by diplomats and politicians, not just technocrats. It will help create the political will to fund and implement programs and policies to reduce NCDs and their risk factors, which are now nearly universal.

Stineke Oenema

The new book by the Right to Food and Nutrition Watch: http://www.rtfn-watch.org/.

It is oriented towards policies and politics, and focuses on underlying drivers of food and nutrition insecurity. It also provides good policy examples that are promising to contribute to better food and nutrition security. Especially the paper about Zanzibar.

Emorn Wasantwisut

Lachat C, Nago E, Roberfroid D, Holdsworth M, Smit K, et al (2014), Developing a Sustainable Nutrition Research Agenda in Sub-Saharan Africa-- Findings from the SUNRAY project.   PLoS Med 11(1): e1001593, doi: 10.1371/journal.pmed. 1001593

The project behind this paper showcased the importance of a nutrition research agenda that speaks to the 'demand' of countries in SSA, with active participation of the African stakeholders, and called for other stakeholders to align with it.  This is really inspiring, showing capacity, leadership, and a good practice model.

18 December 2014

New Paper from UN SCN: 10 Nutrition Indicators for the SDGs

The Standing Committee on Nutrition just released a useful new paper with recommendations for nutrition indicators to be embedded into the SDGs. 

They recommend the inclusion of:

1. The 6 WHA indicators

2. Two diet diversity indicators: minimum diet diversity (6-23 month old children) and minimum diet diversity for women of reproductive age
3. Adult overweight and obesity rates
4. Government spending on nutrition

I really like these 10 indicators.  They include the 8 I had suggested in my blog earlier this week, plus minimum diet diversity for infants and young children and government spending on nutrition. 

The indicators meet scientific credibility standards (do they measure what we think is most important?), have political legitimacy (e.g. the WHA indicators) and are measurable (although we currently do not have many data points for government spending, as the Global Nutrition Report notes, we could). 

What do others think?

The quicker we reach a consensus the quicker we can organise and influence as one community with one voice.  

15 December 2014

Positioning Nutrition Within the SDGs: A Proposal

As the SDG deadline day in September 2015 fast approaches, a consensus position needs to emerge on how to position in nutrition in the SDGs.

Without such a consensus lobbying activities will be unfocused.

Here is one proposal to react to.

Criteria for indicator inclusion:
  1. WHA indicators (all 6)
  2. Other indicators of adult nutrition (women's diet diversity, adult obesity)
  3. Indicators where there is a demonstrated association with under or over nutrition (about 10)
  4. Parsimony (18 indicators: 8 nutrition indicators, 10 nutrition relevant)
  5. Diversity: 8 nutrition indicators are in 3 Goals; 10 nutrition relevant indicators are in 7 Goals. Overall, 8 of 17 Goals are involved.
I don't know how we reach consensus, but more people need to be talking about how to position nutrition in the SDGs.

After 2015 the SDGs will be the main game in the development town.

Climate Change and Nutrition: What do we do differently?

It is good news that an agreement has been sketched out in Peru at the COP20 climate talks for a roadmap to longer lasting deal in Paris at the end of 2015.

Despite the criticisms from some groups that it is watered down, at least it keeps hope alive that something effective and realistic can be finalised in a years time.

But what does this mean for the way nutrition programmes and initiatives are designed and planned?

We think that climate change affects food production in a way that is not good for nutrition.  We also think that climate change increases the incidence of diarrheal diseases and other infectious diseases that negatively impact on nutrition. This set of slides from the London School of Hygiene and Tropical Medicine provides a good primer and summary of key studies.

Clearly, our nutrition strategies are going to have to adapt, but how?

On the adaptation side the changes that nutrition strategies will have to make will vary country by country and region by region, but the need to adapt means an ever greater emphasis on the need to link food and nutrition data with climate data such as temperature and rainfall data at the subnational level.

The problem is, we don't have much subnational nutrition data.  I wonder if there is a benefit to modelling nutrition outcomes much as we modelled poverty rates by combining surveys and censuses in the poverty mapping domain?

Climate change also places a greater value on the diversity of the location of production and on the diversity of crops and products within production systems.  Diversity is one way of spreading the risks that a changing and uncertain climate brings.  Diversity of production should also have a positive impact on diet diversity where food markets are weak.

Social protection programmes should play an even bigger role in a context of more shocks and uncertainty as they help families smooth consumption without having to take kids out of school or forgoing health care.

WASH programmes will have to become more alert to changes in water tables and drainage systems.

The emphasis on prevention will be stronger and this strengthens the case for things like exclusive breastfeeding and fortification/supplementation with iodine, iron, folic acid, zinc and vitamin A.

On the mitigation side, we don't really know what the emissions consequences are of different nutrition strategies.  A first step in this regard is to measure the resource use and emission consequences of different strategies.  Technical Note 4 from the Global Nutrition Report was produced by the Standing Committee on Nutrition (SCN) and I think it represents a good summary of where we are and provides some good ideas of where we need to go and how to get there (see Table from the note, below).

The climate debate may seem a world away from the nutrition community, but the world where climate and nutrition interact is already here.  Just like everyone else, we need to be prepared.

11 December 2014

Don't kill off the data revolution before it has even started: review of new paper

There are many people, me included, who are calling for a data revolution nutrition. 

This means considering data as an essential rather than a luxury item, not tolerating data gaps when they are a block to effective action and not making do with old data. 

But the assumptions behind this are that (a) data are not prohibitively expensive to collect and (b) they actually have returns that are several multiples of the cost.

So I really welcome a new paper by Morten Jerven, under the Copenhagen Consensus banner, which asks the general question: is a data revolution for the SDGs a good investment? His answer is a resounding no.  However I think there are some fundamental problems with his analysis.

How does he come to this conclusion?
He proposes, for every country, a population census every 10 years, a demographic and health survey every 5 years, a living standards measurement survey every 5 years and an annual Core welfare Indicator Questionnaire.  He applies this to the 25 year MDG period, 1990-2015.
He gets cost estimates for each, based on published data.
He applies this to 138 countries for the 8 MDGs (18 targets and 60 indicators).
The grand total is $27 billion, which works out to just over $1 billion per year over the 1990-2015 period.  He suggests this is an underestimate because data collection capacity costs are not included.
He then notes that the 17 SDGs have 169 targets (we don’t know how many indicators) and therefore the SDGs will cost (169/18) x $27 billion or $256 billion.
He then compares this to official development assistance (ODA) and says it is nearly twice a large.
He also says it is really hard to get a sense of the returns to improved data and says the benefit-cost ratio is likely to be less than one.

There are a few problems with this. 
First, it is highly unlikely that the SDGs will have nearly 10 times as many targets and indicators as the MDGs.  That would be nearly 600 SDG indicators.  Simply not going to happen.  My guess would be fewer than 100 targets and less than 200 indicators, but it may well be a lot less than that.  So let’s increase the $27 billion by a factor of 5.  To about $100 bn.

Second, $100 bn is still a lot of money.  But this has to be divided by 15 years.  Per year this is about $7 billion.  Increase this to $10 billion, because the number of countries is increasing from 138 MDG countries to 193 SDG countries (i.e. all of them). 

Third, so $10 billion per year.  This is a lot of money but less than 10% of ODA. But the comparison with ODA is spurious, because most of the costs will be covered from domestic resources for all but the poorest countries.  I would imagine only about one fifth of the cost of indicator collection will come from ODA.  If so, that is $2bn a year, which is just under 2% of ODA.  Still a lot, but that is the lower bound ratio most organisations factor into their project costs for M&E.

The better arguments for caution, I think, lie on the benefits side.  Jerven rightly points out that data that guides action is most valuable.  He makes the argument that the most valuable of this type of data is collected frequently at a rather granular level and that most of the SDG indicators will not be like this, therefore they will be less valuable.   I’m less pessimistic.  First, we can try to get more of these intermediate indicators into the SDGs—things like spending, coverage and staffing.  Second, the impact indicators on nutrition status, say, are useful for civil society to put pressure on governments to act, and for governments to calibrate their actions.  These data are also essential for research and analysis to guide action.

So my conclusion is that this is a very partial paper.  Data collection costs are certainly not prohibitive.  And the benefits can be maximized by asking when is the absence of data a barrier to action that we know is effective.

The data revolution is just that—a call for better data, but also a different way of thinking about data in terms of costs and benefits and also in terms of effective actions supported and bad actions suspended due to better data.  

Don’t kill off the data revolution before it has even had a chance to turn things around.   

09 December 2014

Global Nutrition Report in a New York Minute: Launch summary

Groucho Marx once said "Practically everybody in New York has half a mind to write a book, and does." 

 Last night, at UNICEF HQ, we discussed the whole of the Global Nutrition Report.   It was organized by UNICEF, Columbia University and IFPRI.

It was a great line up.  Here are some of my takeaways from their presentations.

Kathy Spahn, CEO of HKI International

* we in the nutrition community have spent decades talking to each other--its good to see us having conversations outside the bubble
* civil society has to become more accountable and one way of doing that is to measure the impacts of your programmes
* 3 big areas for increase the focus on: (a) gender (dynamics), (b) WASH and (c) capacity building

Jeff Sachs (by video), Director of the Earth Institute

* nutrition community must engage with the other big 2 development conferences of 2015: on Development Finance (Addis, July) and Climate (Paris, December).  In general, engage with the wider development community
* nutrition might not be mentioned explicitly much in the SDGs but there are plenty of openings for nutrition indicators to be embedded

Glenn Denning, Director of the US branch of the Sustainable Development Solutions Network

* nutrition needs to break with incrementalism, just like HIV/AIDS did in in 2000
* how can we scale up financing for nutrition? why not think about a SUN Fund?  Donors pooling more funds for lower transactions costs and greater coordination. Can we learn from Global Fund and from GAFS?

Leith Greenslade, UN Special Envoy for Financing the Health Millennium development Goals.

* The Report firmly establishes nutrition as a post 2015 21st century global issue
* the nutrition community should try to insert nutrition into the Global Financing Facility
* build political power by setting more ambitious targets, demonstrating the power of coordination and integration, engaging with the private sector, financing, paying more attention to gender, especially focusing on the nutrition status of adolescent girls

Silke Pietzsch, Technical Director, Action Against Hunger

* there are many supply barriers to coverage--need to analyse them: lack of knowledge of intervention, distance and time to intervention, previous rejection by service providers, conflict that makes physical access difficult
* coverage is often low not because of supply, but demand.  But governments can increase demand through (a) information outreach, (b) focusing on the last mile -- what is the quality of service received and (c) incentivizing participation (e.g. payment)

Richard Decklebaum, Director, Institute of Human Nutrition, Columbia University

* the report is clearly written, now what do we do with it?
* need to grow the "nutrition community"
* need to train nutritionists to be boundary crossers--to reach to other disciplines, but also to other sectors

Madana Arabi, Executive Director, Sackler Institute for Nutrition science at the NY Academy of Sciences

* Welcomed the focus on implementation science in the Report
* the recommendation on the need for more country focused research resonated with her
* there is a big gap between data and knowledge--capacity is the bridge

Followed by a great discussion on , as yet, unanswered questions:

* SUN Fund or Global Finance Facility or no pooled fund?
* Who actually is going to be the advocate for nutrition in the SDG finalization? (no-one apparently)
* How will these new 2030 targets be set (UN organisations are committed to a consultation)
* What should FAO be doing (telling us what a dashboard set of indicators looks like for a healthy and sustainable food system)
* how many countries have set their own WHA targets? (no idea)
* which WHA targets are most in need of greater ambition? (my take: stunting and EBF)

Big thanks to Jessica Fanzo who shaped the meeting and pulled it together!

02 December 2014

Do We Really Need a Nutrition Data Revolution? Um, Yes.

The just released Global Nutrition Report makes the case for a “Nutrition Data Revolution”.  

Data collection, storage and analysis costs money – so why do we need to invest in it?  Consider a few facts from the Report:

  1. 49% of 193 countries lack the data to be able to track if they are on or off course for even 4 of 6 World Health Assembly (WHA) indicator targets.  And these targets were set nearly 3 years ago.
  2. 40% of the most recent child growth surveys (anthropometry) are over 5 years old.  Economic policymakers could not run their economies on data that were over 5 years old—why would nutrition policymakers think they could?
  3. For the WHA indicator that shows least progress--anaemia in women of reproductive age—we have the weakest data. How can we reduce anemia if we do not have a good sense of who is most affected and when and where progress is greatest.
  4. There is no Global Database on Food Consumption.  For hunger data we rely on food supply data, heroically adjusted by FAO, but still with severe limitations.   We cannot even measure individual trends in the most immediate manifestation of malnutrition: hunger.
  5. Data on nutrition intervention coverage is very sparse. For example, only 37 countries have data on all five of the nutrition interventions and practices with the most extensive coverage data.  We know that increased coverage will reduce stunting and yet little attention is paid to monitoring that coverage.
  6. We know how important the first 1000 days post conception is for nutrition status throughout the lifecourse and yet data on weight at birth is so poor, the Global Nutrition Report could not even report trends in low birth weight.

What to do?  Invest in data collection and in building the demand for data collection.  And while they interact, the first is easier than the second.  Globally the data priorities are reflected in the points above: food consumption, anaemia, low birth weight, and nutrition programme coverage.  Nationally, the priorities will need to be set by national stakeholders.   

How can we convince funders to invest in data? A 2012 independent evaluation of the ESRC’s UK Data Service estimated that the return on investment to the research community alone range from 2.5: 1 to 10:1.  If we believe that research has wider benefits then the return on investment to wider society will be very large indeed. 

How to stimulate the demand for data?  We must promote accountability.  The more accountable public officials are for programme coverage, spending money wisely, and reducing malnutrition the more they will demand data and evidence.  Accountability can be strengthened by civil society working with the media, researchers and champions within public agencies to identify, track, assess and publicise commitments made (or not made).

So more data needs to be demanded and supplied, but do we really need a revolution?  Absolutely.  We need a marked change in our attitude to data.  The data systems we have designed are stuck in the 20th century and don’t respond to the information demands of the mobile technology age nor take advantage of its possibilities.

Information is power and power shapes information.  Until nutrition data collection and availability are revolutionised, nutrition data cannot be democratised.  And without democratisation of nutrition data it remains too easy to ignore malnutrition--unless you happen to be one of the 2-3 billion people suffering from it.  
(Note: This blog first appeared on the blog site of the British Medical Journal)

01 December 2014

Who's On Course to Meet their N4G Commitments? And Who is Not?

The 2014 Global Nutrition Report sticks it's neck out and makes assessments of whether the 100 or so Nutrition for Growth 2013 signatories are meeting their publicly stated commitments to nutrition (financial and non financial).

The Tables from the report are pasted in below.

You can find them in Chapter 8 of the Report. If you want to see the actual commitments made and the progress reported against the commitments, see the detailed tracking tables here.  You may use them to disagree with the assessment we made.

The good news is that of the 168 commitments made by the 100 or so organisations, 43% are on course with only 9% off course.

The less good news is that in 37% of the cases it was not possible to determine if the responses were on or off course either because the commitments were vague or the responses were (or both).

Only 11% of the commitments were not reported on.

The assessments were made independently by 2 of the writing team, and then reviewed jointly, and then reviewed jointly again.

The assessment threw up some key points:

* some organisations had made heroic commitments and fallen just short which others had made weak commitments and exceeded them.  The former got an off course while the latter an on course. This does not feel satisfactory.

* a substantial minority of commitments were made by someone  in the organisation who is not longer in that role and with the subsequent institutional knowledge about the commitment being vague and unclear.

* given the small numbers of organisations in each group, the on course/off course proportions are broadly similar across groups.

We are going to try to make the whole process more streamlined and automated next time around.

We also figure that the organisations will understand the stakes a little better for 2015 which will lead to some of them requiring a little less nagging!


Civil Society Organizations

UN Agencies


Other Organisations