31 August 2017

Starting life strong in slums: the role of engaging vulnerable groups on sanitation and nutrition

Crowded slums, poor sanitation and unhealthy diets.  It’s a potent cocktail and for too many families across the world, a daily reality.  Right now, an estimated one billion people live in slums and that number is expected to double by 2030. Slums are where the many deprivations facing the urban poor collide, including lack of access to clean drinking water, sanitation, safe and nutritious foods, sufficient living space, durable housing and secure tenure (UN Habitat).  They’re where human waste is routinely emptied into streets, canals, and garbage dumps. And where overcrowding and low rates of immunization and breastfeeding combine to exacerbate the already perilous problems children face.
Children growing up in these surroundings are at a higher risk of death and disease and are more likely to be chronically malnourished (Ezeh et al. 2017). For example, forthcoming World Bank research from Bangladesh shows that children living in slums are 50 percent more likely to be stunted than children living in other urban areas. This doesn’t just have implications for today – children who are stunted early in life go on to learn and earn less, and face a higher risk of chronic disease as they grow older. Tragically, these effects are often passed on to offspring, trapping families in poverty and malnutrition for generations, as per findings in a forthcoming World Bank report called Uncharted Waters.
So it is crucial that the response is commensurate to the challenge.  In the sanitation sector a ‘radical shift’ is underway to deliver Citywide Inclusive Sanitation, with a focus on ensuring sustained service delivery rather than focusing solely on building infrastructure. The end goal is to eliminate fecal contamination from the urban environment, providing the conditions for children to grow up strong, healthy and prosperous.
Improvements in sanitation are a necessary but insufficient contribution to eliminate stunting and malnutrition among the urban poor. They have to go hand in hand with creating food systems that are better able to promote healthy diets. Following the recommendations of the just launched report on WASH Poverty Diagnostic, the water, sanitation, health and nutrition sectors need to work jointly to ensure that improvements in WASH services and nutritious food systems translate into improvements in child health. We recommend the following three actions:
Firstly, nutrition and WASH services need to be inclusive of all groups to have the greatest impact on child nutrition.Women and children are most vulnerable to the effects of poor nutrition, but traditionally lack the political voice needed to secure services. Poor urban households and those living in slums are often in a similar position – bearing the high health costs of poor service while being ignored by decision makers. These groups can be effectively targeted and engaged using community and social outreach workers.
In Ethiopia, a new Urban Water Supply and Sanitation Project includes support to slum areas and uses urban health extension workers to carry out sanitation and hygiene behavior change. These extension workers are a potential channel to reach groups not just in need of WASH, but other social and health services.
In Indonesia, the Global Alliance for Improved Nutrition (GAIN) is working in partnership with the Ministry of Health and Nazava Water Filters to improve nutrition in East Java under the Baduta Program. One of the key components of this program is the establishment of a sustainable supply chain of household drinking water filters that help households to filter their tap, well or rain water without the need to boil or use electricity. Filtering water is three times cheaper than boiling it and nine times cheaper than buying water. As part of this project, partners are piloting a micro-entrepreneurship model for women entrepreneurs for the distribution of community water filters.
Secondly, behavior change remains crucial.  Research in Ghana shows that uncooked vegetables, grown in areas surrounding slum households and irrigated with wastewater from open drains, are the main way young children are exposed to fecal contamination (Robb et al. 2017). This suggests that a range of actors, including those from agriculture, nutrition and WASH, are needed to influence household behaviors around wastewater reuse, food safety, food safety, feeding practices, and handwashing with soap.  Educating those who care for small children is particularly important.
Another key component of the Baduta project in Indonesia is a behavior change campaign called Rumpi Sehat (Healthy Gossip), designed to promote exclusive breastfeeding, optimal complementary feeding and safe WASH practices. As part of this campaign, village volunteers in East Java conduct various Emo-Demos (emotional-demonstrations) that are 20 to 40 minute highly interactive, game-like sessions with mothers that aim to create surprise, grab attention, spark emotion and challenge social norms. The village volunteers ensure a consistent experience in order to engage and motivate mothers to participate, giving them the confidence to practice the right feeding and hygiene behaviors. GAIN’s team worked closely with the London School of Hygiene and Tropical Medicine to develop the various props and simple discussion guides used for the Emo Demos.
Ultimately, behavior change also plays a key role in helping create demand for nutritious foods and health services, turning communities into active participants in the fight against malnutrition and poor WASH.
Finally, slum households that are counted are better served. Governments are sometimes reluctant to recognize the existence of informal settlements or include them in official statistics – and they can face technical difficulties doing so. But their inclusion is vital to adequately assess needs, obtain budgets, and get services like health, nutrition, housing, water and sanitation to the places where they are needed most. Convergence of these critical services is the first step to a strong start and bright future for every child born into a slum.
Today, at Stockholm World Water Week, stakeholders from the water and nutrition sectors are coming together to discuss the evidence, policy and practice examples of how we can effectively address stunting in slums and informal settlements. We can no longer afford to overlook the complex problems faced by urban slums residents. By working together, we have the power to find sustainable solutions to improve their futures and help to build healthy communities and nutritious food systems.

Follow the discussion @WorldBankWater with #NutritionMeetsWASH and check back here next week for a post-event interview with participants.  
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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).