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!