The Voices of the Hungry Speak! What Do They Say?

The measurement of hunger is devilishly difficult.  And the world does it very badly.  FAO has come in for its fair share of criticism, providing the "undernourishment" figures which are based on food supply data, modified imperfectly, for purchasing power.  These are the "795 million" who go to bed hungry each night as reported on in the State of Food Insecurity (SOFI) and used in various hunger indicators, including the Global Hunger Index.

So it is to FAO's enormous credit that they have spearheaded an imaginative new initiative, the Voices of the Hungry programme.  The initiative was described in the Global Nutrition Report of 2014, and now it has some results, coming soon.

The initiative is called "Voices of the Hungry" because it involves asking people 8 questions aimed at assessing their "food insecurity experience". The questions have simply yes/no answers.

The simplicity of the module allows it to be included in Gallup World Poll questionnaires, administered to individuals of 15 years and older, in 147 nationally representative surveys.  Sample surveys are typically 1000 individuals although in larger countries the samples are several times larger (e.g. China and India).  Interviews are face to face, although in medium and high income countries with more than 80% telephone coverage, the interviews are done by phone.  So raw scores can range from 0-8, with ad-hoc, but reasonable, adjustments for maximum and minimum scores.  Thresholds are established for moderate hunger (FI-moderate) and for severe hunger (FI-severe).

But how can these experiences be converted into scores that allow comparisons across countries? A global standard is developed and then each country's score is adjusted to the global standard.  This part of the report is hard to follow and some worked examples would have really helped.  The assumptions behind the procedures are thoroughly tested, and, for nearly all countries, they hold.

So what are the results?

The report stresses that these are preliminary, nevertheless they are fascinating.

1. The country rankings are fairly closely related to the country rankings using the FAO undernourishment score.  Out of 21 potentially related country indicators, the VoH moderate food insecurity (FI-moderate) prevalence measure is most strongly correlated (Spearman Rank) with under 5 mortality rates.  The country rank on the FAO undernourishment score is the 11th most strongly correlated indicator at  0.757.   The link with under 5 stunting is the 15th most strongly ranked at 0.666

2. More interestingly, the levels of food insecurity are very different from the undernourishment prevalence estimates.  For example, South Africa has an undernourishment rate of less than 5% which signals not much food insecurity, but the FI-moderate for South Africa is 41.2% and FI-severe is 21%.  A very different picture.  Haiti and South Sudan both have FI-severe rates above 70% and this may not be too surprising given conditions in these contexts, but the high level of FI severe for Malawi (56.1% versus an undernourishment % of 20.7) is more surprising and the low level of FI-severe for Ethiopia (12.1% versus an undernourishment % of 32.0 ) might be a surprise to many.

3. The indicator FI-moderate sheds light on hunger in high income countries, which is really useful too.  FI-moderate for the US and the UK is around 10% (about 40 million people!) and only slightly lower than Indonesia (13%). The social democracies of Denmark, Germany, Japan, Netherlands, Norway, Sweden and Switzerland have FI-moderate rates below 5% although the authors say there were too few complete cases to allow robust estimation.

So, the VoH data are as yet fully robust, but are really welcomed.  They are collected face to face, at individual level, in a timely way (annually), and are comparable across countries.  I think they will grow to be a very useful way of measuring food security for all countries--and remember, the SDGs apply to all of us.

Some will be wary of Gallup's involvement. Are they doing this to sell products? To advance their bottom line? Perhaps. But they are doing it transparently.  This will obviously have to be watched.
 
I was an enthusiast of this proposed project back in 2011 and so I am pleased to see it come to initial fruition.  Well done to FAO, Gallup and DFID for having the imagination to see it -- and to do it.

Dietitians for Global Nutrition!

Last week I was invited to present the Global Nutrition Report 2015 at a Global Nutrition Forum in Amsterdam with 40 leaders—most of whom I did not know. I was thrilled. It is difficult to get out of one’s comfort zone, but these folks made it easy.

The Forum was organized by the US Academy of Nutrition and Dietetics, the European Federation of Associations of Dietitians and the International Confederations of Dietetic Associations. Basically, lots of leaders of dieticians, representing hundreds of thousands of members from all over the world.
Dieticians work in clinical practice but also in programmes and in policy arenas. They are an incredible resource in the fight against global nutrition. Are their contributions fully realised? Could they do more? The leaders of these Associations and Federations clearly thought so, hence the Forum.

A number of interesting points were made, for example: (1) we need to start advocating not for nutrition as an “add on” to other programs, but as “a miss” if not included, (2) many new dieticians entering the field have a desire to shape the wider nutrition rules of the game in ways that their predecessors were not encouraged to do, and (3) the number of dieticians per 1000 population is highest in Scandinavian countries (the very countries that are not allocating much to nutrition specific ODA funding!).
 
I made three recommendations to the group on where they could increase the leverage that their members have:

First, establish a World Nutrition Day. There is no World Day for nutrition (they exist for Food and for Obesity, but not for Nutrition). If anyone has the credibility to establish one, these representatives of the nutrition profession do. I used to think these World Days were not that important, but World AIDS Day made me change my thinking—what a rallying point for their community! We need one of our own rather than riding on the coattails of food and obesity.

Second, do more on influencing the food environment. Dieticians focus a lot on dealing with the consequences of the food environment we have. This is invaluable, but they can also help to shape that environment so that the number of cases they have to deal with is diminished? Do they have an incentive to do so (after all it reduces their client base)? The code of ethics that they sign up to would suggest yes. The British Dietetics Association has been quite proactive on the sugar tax debate in the UK—can the federations and associations do more of this? Any ties to industry obviously make this much more difficult.

Third, advocate for and propose new methods for the collection of better diet data. Currently, we have to make do with FAO’s Food Balance Sheet data, Euromonitor retails sales and a gaggle of subnational diet surveys using lots of different methods. Diet is the number one risk factor for the global burden of disease—and yet we cannot measure diets convincingly.

I really enjoyed my day of discussion with these folks. I learned a few things and got some very positive feedback on the Global Nutrition Report. Working with unusual suspects is usually very refreshing and this was no exception.

50 Numbers to Help End Malnutrition by 2030

The 2015 Global Nutrition Report contains a lot of numbers. We have been asking panellists at various launch events which they find most interesting and why. Here is our top 50 list of  statistics, organised around key points. They are intended to be useful for your briefing notes, speeches, power points, press releases, tweets, blogs, opinion pieces and conversations. Please use them — numbers are just numbers until you bring them to life to contribute to a movement for change. 

The scale of malnutrition worldwide is staggering.              
                                      

1 in 3	proportion of people on the planet who are malnourished
1 in 12	number of adults with raised blood glucose levels or diabetes
45	percentage of countries that face a double burden of malnutrition—that is, undernutrition combined with overweight, obesity, and/or nutrition-related noncommunicable diseases
more than 50	percentage of children under age 5 who are stunted or wasted in 5 countries studied (Bangladesh, Democratic Republic of the Congo, Ethiopia, Pakistan, Nigeria)
193	number of countries, out of 193 UN member countries, with a serious malnutrition problem
42 million	number of children under age 5 worldwide who are overweight or obese
51 million	number of children under age 5 worldwide who are wasted (too thin)
161 million	number of children under age 5 worldwide who are stunted (too short)
795 million	number of people who are hungry
1.9 billion	number of people worldwide who are overweight or obese
2 billion	number of people who are micronutrient deficient (do not get enough vitamins and minerals)

We are paying high human and financial costs for malnutrition.

2–20%	share of health costs around the world that go to obesity treatment
10%	cost of malnutrition in Malawi as a share of GDP
45%	percentage of deaths of children under age 3 that are linked to malnutrition

And investing in nutrition has high returns.

10%	the 30-year compound rate of return to scaling up nutrition programs in 40 countries (the US stock market would have given you less over the past 30 years)
13%	the compound rate of return to scaling up nutrition-specific interventions in Democratic Republic of the Congo, Mali , Nigeria, and Togo
16 to 1	the benefit-cost ratio of investing in scaling up nutrition interventions in 40 countries

Unfortunately, nutrition is scarcely mentioned in the Sustainable Development Goals (SDGs).

0	number of times obesity is mentioned in the SDG outcome document
1	number of SDG targets, out of 169, that mention nutrition
2	number of SDG indicators that mention nutrition
8	number of SDG indicators that should deal with nutrition, according to the UN Standing Committee on Nutrition and other organisations

We are making some progress, in some places, on tackling undernutrition.

39	number of countries on track to meet the World Health Assembly (WHA) global target on reducing child stunting, up from 24 in 2014
67	number of countries on track to meet WHA target on reducing child wasting, up from 59 in 2014
63	number of countries on track to meet WHA target on reducing child overweight, up from 55 in 2014
39%	share of children under age 5 who are stunted in India, down from 48% in 2005/2006
50%	amount by which the worst-affected Indian states reduced child wasting between 2005 and 2013
100%	amount by which the worst-affected Indian states increased exclusive breastfeeding between 2005 and 2013

In other places, nutrition is improving far too slowly or even getting worse.

0	number of countries that have reversed the tide of adult obesity
1	number of countries on track to meet all 5 WHA targets: Kenya
5	number of countries on track to meet global target for reducing anemia in women of reproductive age
6	number of countries that are not on track to meet any WHA targets
30–50%	projected increase in level of child stunting by 2050 because of climate change
63	number of countries that have low and increasing rates of overweight and obesity
127	number of countries that have high and increasing rates of overweight and obesity

We still know too little about people’s nutrition status and the actions being taken to improve it.

3	number of high-impact nutrition interventions, out of 12, for which we have comparable national data on coverage
5	number of the 6 World Health Assembly global nutrition targets for which we can track progress (child stunting, child wasting, child overweight, exclusive breastfeeding, anemia in women of reproductive age; work on determining progress for low birth weight is ongoing)
9	number of the 151 new data points added to the WHO/UNICEF database that are from OECD countries (Australia, Chile, and Japan)
58	number of countries that can track only one WHA target
108	number of counties that can track four WHA targets, up from 99 in 2014
115	number of countries without enough data to assess progress on exclusive breastfeeding

Actions by nutrition stakeholders show areas of both progress and failure.

1.3	average share of government budget allocated to nutrition-specific and nutrition-sensitive spending in 14 SUN member countries
6	number of donors that made commitments at the 2013 Nutrition for Growth (N4G) summit, out of 13, that failed to report on the full set of financial data requested by the Global Nutrition Report
10	number of SUN member countries’ nutrition plans, out of 26, that mention climate explicitly
13	number of donors that spent less than US$1 million on nutrition-specific interventions in 2013
21%	share of N4G commitments that were not reported on, up from 10% in 2014
24	number of Access to Nutrition Index (ATNI) indicators, out of 178, for which all 25 companies assessed scored zero
30	number of counties undertaking a nutrition accounting process within their government budgets, up from 3 in 2014
30%	share of the 284 commitments made at the 2013 N4G summit that are specific, measurable, assignable, realistic, and timely (SMART)
~US$1 billion	donors’ nutrition-specific disbursements in 2013, up from US$0.5 billion in 2012
~US$5 billion	donors’ nutrition-specific and nutrition-sensitive official development assistance (ODA) disbursements, in 2013; equal to 4 percent of ODA

The First Thousand What? Making nutrition more visible to economists. Guest blog from Yassir Islam, HarvestPlus

More than 1,200 economists descended on Milan this past August for their triennial gathering under the auspices of the International Conference of Agricultural Economists (ICAE). Among the bewildering array of topics covered, nutrition was very much on the agenda reflecting the development zeitgeist of our time. Indeed, a full plenary session was devoted to it. Also on the agenda was a symposium on whether consumers will accept foods that have been biofortified with vitamins and minerals.

In tandem with these developments, I set up shop hosting a HarvestPlus booth at ICAE for the first time. I was in good company, sandwiched between one of our parent institutes, the International Food Policy Research Institute, and the United States Department of Agriculture's Economic Research Service.

As a communicator, this grunt work of sitting behind a booth and trying to engage passersbys can be both frustrating and rewarding. Frustrating because there is a pecking order at these conferences and being at a booth usually places you at the lower end; rewarding because of the rich opportunities for conversations that you just don't get by sitting at your desk, sometimes even with luminaries of the development world.

After a week in the trenches, I made some surprising discoveries.  Many delegates, regardless of whether they were from richer or poorer countries, were hazy on hidden hunger. They had heard about it, but struggled to hone in on what it was exactly. Similarly, when I began asking those curious enough to stop by the booth if they had heard of the first thousand days, I was surprised by the number of blank stares I received in return. This, despite then U.S. Secretary of State Hillary Clinton being the face that launched the thousand days challenge five years ago, and despite more than 100 governments signing up to the global Scaling Up Nutrition movement which had embraced the thousand days challenge.

The intention here is not to chastise agricultural economists, or to generalize. (I will admit to having an M.Sc. in agricultural economics myself.)  I certainly could not have talked to everyone, and so perhaps my sample size was drawn from those who knew least about our work and were curious enough to find out. The lesson here is for those of us concerned that nutrition is invisible. Guess what? It still is. We are still not getting through, even to the broader development community, to the extent we think we are.

One reason might be the complicated lexicon around nutrition. I've been to events, for example, where nutritionists have argued about whether to use the term malnutrition or undernutrition and failed to agree. Today the nutrition community may have moved beyond these debates; but if we are still not getting through to people with a brilliant encapsulation of what matters most—the first thousand days of life, a concept that lends itself to powerful storytelling—then we have a problem. 

A second reason is that we simply don't tell enough stories. Human beings are wired for storytelling; statistics and graphs are simply not sticky enough, unless you are preaching to the choir, and even now and then a choir needs its spirits lifted.

Third, as Lawrence Haddad and others have pointed out, there are still no “Departments of Nutrition,” and so nutrition tends to fall through the cracks. As for hidden hunger, while insidious and far-reaching in its effects, it does its damage from within—there are no images of famine-scarred children to share through social media with audiences that are increasingly inured to the quieter suffering in the world.

Here’s how I finally got through to my audience:  I made nutrition more relevant to the work and interests of each member. One delegate said he worked on improving economic productivity in his country. How, I asked, will you do that when 20 percent of your work force will grow up to be compromised because of hidden hunger in childhood?  Another was concerned about the impacts of climate change on agricultural yield. What about the nutritional quality of food? I asked. There is some evidence that nutritional quality will decline for some staples along with yields. How will you nourish your citizens with a smaller and less nutritious harvest at the end of the day? Asking these questions led to some “aha” moments, and as a communicator, nothing is more satisfying than that.

But we need to continue to hammer away at this, and find ways to communicate why nutrition still needs to move up the agenda of researchers, policymakers, and donors. We still talk—too much I would argue--—within our silos.

Reductionist disciplinary investigations may give us greater insights into the world's problems, but holistic inter-disciplinary conversations is what it will take to solve them.

Yassir Islam is Head of Communications at HarvestPlus, a global program that improve nutrition and public health by developing and promoting biofortfied food crops that are rich in vitamins and minerals. HarvestPlus is part of the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH). CGIAR is a global agriculture research partnership for a food secure future. The HarvestPlus program is coordinated by two of these centers, the International Center for Tropical Agriculture (CIAT) and the International Food Policy Research Institute (IFPRI).