My delight at being told that I was one of 2018’s World Food Prize Laureates was matched only by, well, sheer surprise. After all I have not led a team of scientists to develop a breakthrough technology like the founder of the Prize, Dr. Norman Borlaug. After talking to Ambassador Quinn, the President of the World Food Prize Foundation, it became clear that the contribution being recognised was the ability to be effective in multiple roles in order to help elevate nutrition to the “top table” of development. In other words, to help convince powerful decision makers that good nutrition is fundamental to delivering the Sustainable Development Goals.
My capacity to connect the roles of researcher, policy influencer, organisational leader and communicator of the issues to broader audiences was helped by a number of things, and shaped by the thousands of colleagues with whom I have worked.
First, somewhat freakishly, I have been interested in both nutrition and agricultural economics from the age of 18. My undergraduate degree at the University of Reading, UK, was a joint one: in food science and food economics. I followed these dual interests throughout subsequent studies at the University of Massachusetts and at Stanford University. Being an economist, and striving to see the bigger development picture – and where nutrition might fit in – has been invaluable for me as a champion for nutrition.
Second, the first 3 years of my post PhD work was in starting up a new MSc in Quantitative Development Economics at the University of Warwick, UK. I loved the “start up” feel of setting up the course and it was there that I learned to teach properly and communicate more clearly and effectively. However, being a clear communicator is necessary but far from sufficient condition for being persuasive. Influencing is key.
So the third thing that helped elevate nutrition on the agenda was the experience of trying to convince a wide range of people that nutrition matters – learning what they are interested in and finding ways to connect nutrition to that. Interestingly, being a member of the Consultative Group on International Agricultural Research (CGIAR) at the International Food Policy Research Institute (IFPRI) in the 1990s helped develop that skill. Back in those days there was not much interest in nutrition—just in crop and animal productivity enhancement. We had to think hard about ways to engage the agronomists and economists on nutrition. Working at GAIN involves helping to effect change with decision making constituencies working in a newer area – the way governments and businesses think about what and how they can do together to advance nutrition.
Finally, being forced to become a blogger at the Institute of Development Studies (in my role as Director) required me to write more succinctly, on a wider range of topics, and to leave the comfort zone of research to venture opinions based, as far as possible, on evidence (my Twitter accountdescriptor is “an evidence based champion of efforts to end malnutrition”).
Since the call with Ambassador Quinn, I have been refreshing my knowledge of Norman Borlaug. As Leon Hesser’s excellent Borlaug biography – The Man Who Fed the World—makes clear, Borlaug was unstoppable in his pursuit of improved varieties to stave off hunger in Mexico, Asia and Africa. His sheer hard work, relentless drive and single-minded focus –in the fields, labs, classrooms, boardrooms and Ministerial chambers – helped to bend the world to his view. His vision was forged on getting the ground level details right, always framed within a big picture political economy view. Connecting these two levels is a very unusual ability. His focus on capacity building, on organisational arrangements and on communications to help sustain his efforts is inspiring. It was a revelation to see how instrumental he was—working with the Rockefeller Foundation— in the creation of the CGIAR. Without him, IFPRI—where I learned how to be a policy researcher and was inspired by some of the great policy influencers—probably would not have existed and the course of my own career would probably have been very different.
The world that Norman Borlaug wanted to help feed in the 1950s-70s is both similar and different from today. It is similar in that, unfortunately, hunger is still with us. But while the absolute numbers of hungry people have not declined enough, they now account for a much smaller share of the world’s population and this is testimony to the work of Dr. Borlaug and many others. But it is different too. Dr. Borlaug surely could not have anticipated the explosion in obesity, diabetes, hypertension and other diet related noncommunicable diseases we have witnessed in the past 40 years. If he were alive I am sure he would now be arguing for improving the productivity of non-staple foods such as fruits, vegetables, pulses, eggs, dairy, fish and poultry. The prices of these foods, which are high in micronutrients such as minerals and vitamins, are increasing and productivity improvements would help drive their prices down. In the absence of such a focus, low and middle-income households are being priced out of nutritious food and lured into cheap, empty and unhealthy junk food calories. Good diet is fundamental to the prevention to malnutrition in all its forms.
So the central issue of our time is this: not how to feed the world, but how to nourish it. Were he here today I am sure Dr. Borlaug would have been at the forefront of this fight, perhaps recast by some as “The Man Who Nourished the World”. In his absence, we have to come together across government, research, business, foundations and civil society to pick up the mantle and focus on actions to nourish the world so we can end malnutrition by 2030.
As the 2016 Global Panel Report on Food Systems and Diets noted, average households in nearly all countries in the world acquire the majority of their food from the market (as opposed to growing it or receiving it in kind). Most of these purchases are of packaged foods. In addition, we know that the sales of processed foods (which has a strong overlap to packaged foods) are flat in high-income countries (but with a switch within the static sales towards products lower in sugar, salt and fat) while increasing in middle-income countries (and I would guess, low-income countries, although we have no data on that).
So there is a big business opportunity in packaged foods in low and middle-income countries, but is there also a nutrition opportunity? Given the trends in developing country markets (more food purchases from the market and a growing purchases of packaged foods), the answer is surely yes.
The format of the side-meeting included the introduction of 4 new packaged food products with nutritious food aspirations from 4 companies. The participants were then asked whether, based on what they had heard, they thought the foods were nutritious, environmentally and socially sustainable, with a viable business model. To do this participants tested the products, asked questions about 4 dimensions of performance–health, social, environmental and business–and gave the product a highly subjective summary score from 1-8 on each dimension.
Some companies have made substantial changes to their products’ profiles (e.g. towards lower sugar, higher fibre) over the past 5-10 years—and we saw some interesting data from Nesquik/Nestle. Small but frequent and persistent changes can add up to big changes. They are not transformational in a big bang sense, but they are a reaction to a transformation in consumer preferences or government regulation. Interestingly it is very difficult to track these changes over time as the databases are not public and it is difficult to find public info on food product labels from 5 or 10 years ago. (Although it is easy enough to track if the formulations are different in different geographies.)
How much effort should big food companies put into reformulating existing core products versus introducing new “healthier” products? The latter are less likely to upset consumers “stop tampering with our favourite foods!” but are at risk of small sales/termination, or of simply replacing an equally healthy natural option with a more expensive processed and packaged product (e.g. if froosh replaced an apple in a lunchbox). The answer to this portfolio balance issue is obviously context and outcome specific, but it is clear that some companies are struggling with this question.
Are the companies that are providing business-to-business (B2B) products (like DSM with ModuMax) the ones that are going to help the whole system change given their massive indirect consumer reach via their business customers? How much effort should system changers invest in the B2B companies vis a vis the companies that sell direct to consumers? Again, context specific.
Packaged food companies need to be aware of the narrative: processed foods=unhealthy foods. Processed foods can provide nutrition, convenience, safety and affordability if those are the key design criteria guiding the processing. Don’t blame the technology; rather blame the bigger incentives that drive companies towards unhealthy processed foods (weak incentives—carrots and sticks– from some governments combined with weak consumer demand for nutritious foods in many contexts, together with unscrupulous behaviour from some businesses).
The completion of the 4-dimension assessment (health, business, environmental, social) was not easy in the absence of data (preferably independently verified data). In addition, just exactly what the social dimension means was not clear—is this where affordability comes in or is this about the working conditions in the supply chains, both, or is it about something else?
Finally, it is important to note that all the company representatives in the room (about a quarter of the participants) emphasised the need for nutritious foods to lead with flavour. If a more nutritious food is not tastier and more delicious than the less nutritious variants or brands, then it is highly unlikely to be a market success. Those of us in the public sector need to embrace this idea—typically we just focus on acceptability and palatability of nutritious foods.
That is why GAIN is exploring the development of a relationship with Firmenich to begin to focus on flavour issues in nutritious foods.
And the scores? Wildly different among the 4 assessing groups! Delicious.
The consistent evidence that childhood stunting is associated with poor child development and school performance (Perkins et al. 2017) and health and human capital development more generally (Victora et al 2008) has elevated nutrition in the development agenda. The result has been an unprecedented focus on addressing stunting and some renewed development resources focused on doing so.
But the focus on stunting may be a double-edged sword for the nutrition and development communities if we are not careful with the use and interpretation of this measure. The recent commentary in the Journal of Nutrition by Pirumal and colleagues provides an excellent overview of the potential risks and pitfalls of using stunting in an unthinking way.
The paper highlights the origin of the indicator (height for age below a designated cut-off, usually 2 standard deviations below the reference mean, i.e., Z-score of < -2, referred to as HAZ) as a population level marker of sub-optimal human capital development, poverty and deprivation. For this reason, the prevalence of stunting can be a powerful and appropriate tool for advocacy for greater action to reduce undernutrition.
The paper also reminds us that at an individual level there is nothing inherently wrong with being short unless one is short because of growth faltering (i.e., failing to reach genetic potential due to deprivations in food consumption, care and the health environment). It also surfaces the key limitation of stunting as a summary indicator of lost human capital, namely that it ignores any growth faltering that occurs elsewhere along the height for age distribution, not just below a -2 HAZ.
This leads to several potential misuses and misinterpretations of stunting. Specifically:
Stunting prevalence understates the magnitude of the problem of growth faltering at the population level. Many of those even with HAZ > -2 may have experienced growth faltering and we are missing these children in all of our counts of the magnitude of the problem.
An HAZ of < - 2 is not a threshold marker of malnutrition or disease for any single individual child. The associations between growth faltering and adverse outcomes exist regardless of the magnitude of that growth faltering and there is no documented strengthening of the relationship between growth faltering and adverse outcomes at the threshold of - 2 HAZ.
While several direct causes of growth faltering have been identified, poverty, deprivation and inequality lie at its core and it is unrealistic for program designers and investors to expect individual, household and community level interventions that focus on only one or even several of the more direct causes to have much of an impact on stunting, particularly over short project cycles.
So what to use to assess changes in child nutrition over time? In addition to stunting we should be looking at mean and standard deviation of HAZ and at the slope of change in HAZ by age (we want it to be close to zero). In other words, in countries with evidence of growth faltering, we want to see rightward shifts of the entire HAZ distribution because this will reflect positive improvement in growth of all children.
At GAIN we and our partners strive to improve the consumption of nutritious safe food for all, especially the most vulnerable and we want our programmatic efforts to contribute to improving child growth. We recognise however, that the indicators we can change in the shorter term as a direct result of our programs are more likely to relate to the nutritional quality of diets.
Program investors need to recognise that the prevention of growth faltering requires many factors to move simultaneously in the right direction over a significant time period. Several countries have made substantial progress in doing so, typically based on a solid foundation of progress in development indicators such as GDP, inequality and women’s status. But designing and scaling nutrition programs that effectively address key drivers of stunting, such as GAIN’s focus on diet quality, is also vital. The right program indicators are those that are achievable within a program context but have a clear path to progress towards ultimate outcomes, like improved growth. Getting this balance right should lay the ground for sounder and more transformative nutrition investments.