The Dietary Diversity Score Dilemma

Why do fortified foods go uncounted?

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Today, Sight and Life is joining hands with FAO to celebrate World Food Day. This year, in fact, marks the 75th Anniversary of the founding of FAO, and World Food Day 2020 aptly has the theme “Grow, nourish, sustain. Together. Our actions are our future.”

Here at Sight and Life, we have been working for many years on food fortification programs designed to enhance the diet quality of vulnerable populations. In this blog, we take a closer look at how micronutrient deficiencies are measured, and we challenge researchers and policy-makers to re-think current dietary metrics in the face of the Covid-19 pandemic.

Food Fortification

Improving the quality of diets worldwide

The latest SOFI report reminds us that access to nutritious food is one of the most pressing issues of our time (2). Globally, the majority of consumed calories are derived from grains (45%), followed by sugars and fats (20%), then fruit and vegetables (11%) (1). These numbers illustrate a recurring situation: people in low-income countries rely on the consumption of staples due to the high cost of fresh and nutritious foods such as fruit, vegetables, and animal-source foods. This is not surprising when we reflect that healthy and diverse diets are five times more expensive than staple-based diets (2).

The current pandemic has intensified an already unacceptable situation by compromising access to school feeding programs, disrupting nutritious food value chains, and further reducing the purchasing power of consumers. Food fortification is a recognized and cost-effective approach to improve the nutritional status of populations in both high-income and low-income countries. It benefits especially those who rely on a staple-based diet that is generally poor in essential micronutrients.

When access to nutritious foods is limited, the fortification of staple foods can help ensure an adequate intake of essential micronutrients. Moreover, fortified foods help support the body’s immune defenses against infections (3) (read more: the role of nutrition in the immune system). In short, food fortification enhances dietary diversity, a key element of diet quality, and has important health benefits too.

Dietary diversity: What is it and how do we measure it?

Dietary diversity was found to serve as a proxy indicator to assess and predict the intake of micronutrients (4,5,6). To easily assess the dietary diversity of a population, a practical tool was developed: the Dietary Diversity Score (DDS) (7). The score reflects the number of different (and pre-defined) food groups that have been consumed by a sample of the population during the previous 24 hours, as described by Krebs et al in 1987. The score is calculated by summing up the number of food groups consumed.

Dietary Diversity Score

Today, the DDS has been differentiated according to the intended target groups and counts up to 12 food groups, depending on the target group of the score (Figure 1). In both the DDS for women and the DDS for children, we find a differentiation for some specific fruits and vegetables to adequately reflect their specific micronutrient composition. Globally, less than one in three children aged 6–23 months (29%) were found to consume five out of eight pre-defined food groups and thus meet the minimum dietary diversity (MDD) (2).  The percentage of children meeting the MDD varies greatly across the globe. In Burkina Faso and Guinea respectively, for example, only 5.2% and 5.9% of children received the MDD, whereas in Turkmenistan and Peru respectively, 82.5% and 82.9% of children met the MDD score (8). The MDD-W (W = women) was included as a core indicator in the Demographic and Health Survey (DHS) in 2019. To date, three countries have published data (2). The available data indicate poor dietary diversity and consequent micronutrient inadequacy.

Overall, the advantage of DDS indicators is the ease with which the data can be collected, analyzed and interpreted. DDS is a practical tool for use in resource-poor settings, and its results can easily be communicated. The most remarkable limitation of DDS, however, is the fact that it does not reflect the intake of fortified food.

Even more astonishing is the fact that the DDS guideline strongly recommends documenting the consumption of these foods (9). The extent to which we can accurately predict micronutrient adequacy in populations with a diet based on cereals and/or other staples, which are often fortified, is still entirely unknown.

Figure 1: Food group classification for different dietary diversity scores

Figure reference: Muthini D, Nzuma JM, Qaim M. (2018). Subsistence production, markets, and dietary diversity in the Kenyan small farm sector (No. 127). Global Food Discussion Papers.

What about fortified foods?

In scientific literature, the lack of differentiation between fortified and non-fortified foods appears to be recognized by two studies only, both from the Philippines. One study by Tsz-Ning Mak et al, suggested to improve the sensitivity of DDS by differentiating between nutrient-rich or fortified foods and energy-dense foods that are low in micronutrients (10). Likewise, Daniel et al experienced difficulties when attempting to classify certain nutrient-dense foods, such as organ meat, in the DDS scoring system. This proved to be difficult, as great differences in micronutrient composition exist between the same foods within the same food group (11).

Interestingly, the World Food Programme (WFP) recently introduced a new scoring methodology to monitor the impact of the consumption of their Super Cereal, which is distributed among vulnerable groups of women. Based on its nutrient composition, the fortified Super Cereal is now considered to be part of the food group ‘meat’, whereas traditionally, it would have been part of the food group ‘grains’ (12).

The lack of attention from the global nutrition community to the assessment of fortified food consumption seems misaligned with the extensive efforts and resources expended on food fortification. Foods fortified with crucial micronutrients such as iron, folic acid, vitamin A and iodine are recognized as increasing diet quality. However, without differentiating between fortified and unfortified food in the DDS, it will be impossible to accurately measure and monitor the results of our efforts on food fortification.  Why do we acknowledge the varying micronutrient compositions of different groups of fruits and vegetables, but not those of fortified and non-fortified foods?

Conclusion

At Sight and Life, we urge researchers and policy-makers to re-think the need for a cost-efficient, practical, and rapid diet quality indicator that has the capacity to promote and acknowledge the contribution of fortified foods to diet quality worldwide. The necessity to re-think our dietary metrics was stressed in Miller et al’s recent review (13). Likewise, Walls et al’s recent paper highlights the inadequacy of existing dietary indicators for measuring the ongoing nutrition transition (14).

By adapting the DDS-W food classification to reflect the intake of the Super Cereal fortified food, WFP took a step in the right direction. However, we should not stop here. We therefore invite global stakeholders to tackle this issue. The inclusion of fortified foods in dietary metrics such as the DDS will enhance the visibility of their impact on the nutritional status of vulnerable populations. This, in turn, could encourage policy-makers (and other actors of the enabling environment) to strengthen food fortification standards, laws and regulatory monitoring.   

All graphics created by Sight and Life’s Architect and Design Specialist Anne Milan.
 
References

1 Future Food Systems: For people, our planet, and prosperity 2020. The Global Panel on Agriculture and Food Systems for Nutrition.

2 UNICEF. The State of Food Security and Nutrition in the World 2020. Transforming food systems for affordable healthy diets. Rome FAO 2020

3 FOOD FORTIFICATION: A WEAPON AGAINST COVID-19 Food Fortification Initiative http://www.ffinetwork.org/FFI_COVID-19andFortification.pdf

4 Hatloy A, Torheim LE, Oshaug A: Food variety-a good indicator of nutritional adequacy of the diet? A case study from an urban in Mali, West Africa. Eur J Clin Nutr 1998, 52:891–898.

5 Ogle MM, Hung PH, Tuyet HT: The significance of wild vegetables in micronutrient intakes of women in Vietnam: an analysis of food variety. APJCN 2001, 10:21–30.

6 Torheim LE, Barikmo I, Parr CL, et al: Validation of food variety as an indicator of diet quality assessed with a food frequency questionnaire for western Mali. Eur J Clin Nutr 2003, 57:1283–1291.

7 Krebs-Smith SM, Smiciklas-Wright H, Guthrie HA, Krebs-Smith J. (1987). The effects of variety in food choices on dietary quality. Journal of the American Dietetic Association, 87(7), 897-903.

8 UNICEF. Expanded Global Database Complementary Feeding. 2019. Online. Access October 15, 2020. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/

9 Kennedy G, Ballard T, Dop M. (2013). FAO Guidelines for Measuring Household and Individual Dietary Diversity. Rome, Italy: Food and Agriculture Organization of the United Nations.

10 Mak TN, Angeles-Agdeppa I, Lenighan YM, Capanzana MV, Montoliu I. Diet Diversity and Micronutrient Adequacy among Filipino School-Age Children.

11 Daniels MC, Adair LS, Popkin BM, Truong, YK (2009). Dietary diversity scores can be improved through the use of portion requirements: an analysis in young Filipino children. European Journal of Clinical Nutrition, 63(2), 199-208.

12 WFP. Minimum Dietary Diversity for Women (MDD-W), WFP Guidance. January 2019

13 Miller V, Webb P, Micha R, Mozaffarian D, Database GD. (2020). Defining diet quality: a synthesis of dietary quality metrics and their validity for the double burden of malnutrition. The Lancet Planetary Health, 4(8), e352-e370.

14 Walls HL, Johnston D, Mazalale J, Chirwa EW. (2018). Why we are still failing to measure the nutrition transition. BMJ global health, 3(1), e000657.

Alternative Proteins: The nutritionists perspective

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The world’s population is growing, and for many, the question of how we ensure an adequate food supply for all while sustaining our planet and natural resources is a crucial one. Fundamental to addressing the current global nutrition crisis is to deliver food that can guarantee delivery of adequate nutrients to people affected by all forms of malnutrition and the population as a whole. According to the Food and Agriculture Organization of the United Nations (FAO), sustainable diets have a low environmental impact while contributing to food and nutrition security for our present and future generations. In other words, sustainable diets should respect and protect ecosystems and biodiversity next to being culturally acceptable, affordable, accessible, safe and healthy [1].

The food industry has shown the capability to rapidly adapt and innovate to meet the growing demand for more sustainable diets. This initiative is particularly reflected in the growing market for alternative proteins, which are increasingly becoming available to consumers, albeit in the Global North rather than Global South. This innovation responds to the globally growing demand for protein and could potentially alleviate some of the pressures on the food system. However, do these products meet the need for higher quality (i.e., more nutritious) food and help us move towards global food security?

Key messages
– The increasing demand for protein has resulted in rapid innovations led by the food industry in categories such as alternative proteins, of which the nutritional content can still improve.
– Currently, many alternative protein products are less than ideal substitutes considering they are high in salt, low in some key nutrients and often ultra-processed.
– Transparency regarding the nutritional content of alternative proteins is needed to inform consumers, enabling them to make informed choices.
– Policymakers, the food industry, consumers and nutritionists are called to dialogue to deliver nutritious and sustainable alternative protein products.

Plant based meats

Alternative proteins – what are they?

Alternative protein sources encompass everything from algae to re-engineered plant-based legumes and a variety of meat substitutes. Think of lab-grown meat, plant-based meat, single-cell proteins from yeast or algae, and edible insects. The market share of alternative proteins has significantly increased in the past decade (read more in our blog post Alternative Protein: What’s the deal?), and a large variety of products are found in supermarkets throughout the Global North.

According to scientific literature, three factors have led to the increase of alternative protein consumption: animal welfare, environmental friendliness, and taste preferences [2]. Generally, the consumption of alternative proteins are found to be higher among women and the well-educated [2]. Women also tend to have a more positive attitude towards meat alternatives or alternative proteins than men due to perceptions of health and weight regulation. Overall, meat alternatives are perceived as healthier when compared to regular meat products. But besides the environmental and social marketing strategies (read more in our blog post Alternative Proteins: Speaking to consumers), what do we really know about alternative protein products’ nutritional value? How do alternative proteins fit in the transition towards healthy and sustainable diets for everyone, everywhere?

Beyond the headlines

Alternative proteins have the potential to disrupt the global food system in significant ways. Conscious of this movement, stakeholders’ interests are rapidly increasing.  A complete understanding of the entire alternative protein landscape and its impact on public health and nutrition is required for both public and private actors to fully comprehend alternative proteins’ role within the global scenario. At Sight and Life, we value the importance of going beyond the persuasive environmental (Save the plant, Earth Day every day) and health (cholesterol-free, plant-based) claims that are currently associated with such products, and strive to understand the science and nutritional benefits of this emerging trend.

In this blog, we dive into the nutritional content of five popular alternative protein products consumed in the Global North and compare them to their ‘natural’ counterparts (Table 1).

Table 1: Protein products compared to their ‘natural’ counterparts

Nutrient content 

Most consumers quickly glance at the nutrient label and generally focus on the calories or energy content of the product. The energy content of the alternative protein products we reviewed was found to be roughly equal to that of their ‘natural’ counterpart. However, because the energy content of a product has very little to do with its nutritional content, a deeper nutritional investigation is warranted.

Sodium

We took a look at the sodium (or salt) content – expressed in Daily Value % (DV) according to the U.S Food and Drugs Administration [3] – of alternative protein products compared with their natural counterparts. As illustrated in Figure 1, the same portion size of alternative protein and its natural counterpart contain varying DV% of sodium. In fact, the alternative protein products exceed the DV% of their natural equivalent. Remarkable is the sodium level found in the Chicken Chunks from The Vegetarian Butcher. One portion size of the vegetarian chicken chunks provides almost a quarter of your daily recommended salt intake whereas chicken is typically 4% DV. In other words, the consumption of one portion of the vegetarian Chicken Chunks leads to the intake of 1,36 grams of salt out of the 5 gram daily recommended by World Health Organization [4]. Scientific evidence shows that a high salt intake represents one of the major dietary risk factors for death worldwide [5] and is associated with an increased risk of high blood pressure, stroke, and cardiovascular diseases. Unfortunately, the findings from these five products are no exception. A study involving over 150 different plant-based products found only 4% of them to be low in salt [6].
 

Figure 1: Daily Value % Sodium per portion size

Essential nutrients: Iron, zinc, and vitamin B12

Key nutrients such as iron, zinc, and vitamin B12 are absent in most of the alternative products except for the Impossible Burger, which has been fortified. In the vegetarian diet, these are known nutrients of concern [7;8]. This subject matter has also been observed in Curtain and Grafenauer’s study. The authors found that less than a quarter of plant-based products (24%) were fortified with vitamin B12, 20% with iron and only 18% with zinc [6]. While fortification of alternative proteins may be a potential solution, there is an urgent need to examine fortification in the context of bioavailability of nutrients in plant-based products – this continues to be an important yet unexplored area to date.

Labeling

Getting a clear overview of the actual nutritional content of some of the alternative protein products has proven to be rather difficult as the information provided online or on the nutritional label of the product was found to be limited. Data on energy (calories), macronutrients, and fiber are provided for all five alternative protein products reviewed. However, the nutrition labels of The Vegetarian Butcher Chicken Chunks and Quorn Mince lack nutritional information regarding key minerals (calcium, zinc) and vitamins (vitamin A, D, and B complex) (Figure 2). Not only did most products not contain iron and vitamin B12, but the lack of nutrient information on the label was concerning considering alternative protein products are often chosen as alternatives to meat products, which are a natural source of iron and B12.
Lack of key nutritional information on the label of alternative protein products does not guarantee a complete overview of their nutrient profile. How does this affect the nutrient intake of the consumer?

Figure 2: Nutrient content list displayed on the nutritional labels of alternative protein products

Processing and ingredient list

According to the latest FAO recommendations on ultra-processed food [9], it was found that four out of five analyzed alternative protein products were classified as such (Table 2). To assess whether alternative protein products can be defined as ultra-processed foods, the products’ ingredient lists were investigated. In particular, the presence of at least one specific class of ingredients or food substances in the food list was sufficient to define such product as an ultra-processed food. In most alternative protein products ingredient lists, we found thickeners, colors, flavors, additives, and emulsifiers, which are part of food classes characteristic of the ultra-processed food group identified by the FAO [9;10]. The cricket flour was the only alternative protein not classifiable as ultra-processed food. Furthermore, from the labeling investigation, we noticed that alternative protein products consisted of up to 21 different ingredients – except for the cricket flour, which is exclusively composed of dry crickets.      

Table 2: Classification of alternative protein  products according to the food processing state proposed by the FAO

Conclusion

The growing demand for alternative proteins has resulted in rapid and impressive innovations from the food industry. It’s not yet perfect, but perhaps directing our efforts towards improved nutrition labeling, reformulation on nutrient content, and improved consumer awareness for these types of products will help us move towards a healthy and sustainable protein supply for all.

Consumer guidance and food industry regulations developed by policymakers could ease the transition to a plant-based diet in a healthy and sustainable manner. The EAT-Lancet report has also contributed to this debate by pushing for more sustainable (plant-focused) diets [11]. However, as a nutrition community, we should be cautious of the possible trade-offs and the potential impacts on health. The consumer and their access to safe, nutritious, affordable, and aspirational food should remain at the core of our endeavors.

When considering the potential of alternative protein sources, we should reflect upon their contribution to dietary diversity. As availability and access to nutritious food is highly related to dietary diversity, this should not be an exception for alternative protein sources. The promotion of dietary diversity is vital to guarantee sustainable and nutritious diets as it is an indicator of diet quality. Issues related to dietary diversity accessibility are present in both the Global North (food desert, food swamps) and the Global South[12].

When discussing alternative protein products, we need to acknowledge the wide and varying needs for animal-sourced protein intake worldwide. In the Global North, it is recommended to moderate the intake of these foods as it has been found to be a risk factor for several diet-related diseases. In contrast, an increased intake of animal-sourced foods is generally advised in the Global South. In fact, animal-sourced products remain a great source of essential vitamins and minerals, and the consumption of these foods has been found to be significantly associated with reducing stunting[13]. Therefore, it emerged that the replacement of meat with alternative protein products is not always suitable for all global circumstances.

Furthermore, consumers should have access to nutritious food and be informed and guided by clear, realistic, and up-to-date food-based dietary guidelines. Consumers should be conscious of how to identify a healthy choice out of the countless possibilities and, in the context of alternative protein sources, should be aware of the fact that ‘vegan’, ‘vegetarian’, or ‘plant-based’ does not necessarily equal a ‘healthy’ option. Finally, the discussion around the nutritional impact of alternative proteins should be embedded within the broader debate on dietary diversity. There is no ‘one size fits all’ solution, and this discussion should be adapted to the local context and nutritional needs of different populations.

All graphics created by Sight and Life’s Architect and Design Specialist Anne Milan.

References

1 FAO Burlingame B, Dernini S. Sustainable diets and biodiversity. 2010.

Michel F, Hartmann C, Siegrist M. Consumers’ associations, perceptions and acceptance of meat and plant-based meat alternatives. Food Quality and Preference. 2020 Aug 20:104063. 

U.S Food & Drugs Administration, Daily Value on the New Nutrition and Supplement Facts Labels. Accessed October 1, 2020. Online https://www.fda.gov/food/new-nutrition-facts-label/daily-value-new-nutrition-and-   supplement-facts-labels

4   WHO, Salt reduction fact sheet 2020. Accessed October 1, 2020. Online https://www.who.int/news-room/fact-sheets/detail/salt-reduction

 Afshin A, Sur PJ, Fay KA, Cornaby L, Ferrara G, Salama JS, Mullany EC, Abate KH, Abbafati C, Abebe Z, Afarideh M. Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2019 May 11;393(10184):1958-72.

6 Curtain F, Grafenauer S. Plant-based meat substitutes in the flexitarian age: An audit of products on supermarket shelves. Nutrients. 2019 Nov;11(11):2603.

 Ekmekcioglu C, Wallner P, Kundi M, Weisz U, Haas W, Hutter HP. Red meat, diseases, and healthy alternatives: A critical review. Critical reviews in food science and nutrition. 2018 Jan 22;58(2):247-61.

Craig WJ. Nutrition concerns and health effects of vegetarian diets. Nutrition in Clinical Practice. 2010 Dec;25(6):613-20.

Monteiro CA, Cannon G, Lawrence M, Costa Louzada MD, Pereira Machado P. Ultra-processed foods, diet quality, and health using the NOVA classification system. Rome, FAO. 2019.

10 Codex Alimentarius, FAO/WHO 2019 GSFA. Accessed October 1, 2020. Online http://www.fao.org/gsfaonline/additives/index.html

11 Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, Garnett T, Tilman D, DeClerck F, Wood A, Jonell M. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. The Lancet. 2019 Feb 2;393(10170):447-92

12 HLPE, Accessed October 1, 2020. Online http://www.fao.org/3/a-i7846e.pdf

13 FAO, IFAD, UNICEF, WFP and WHO. 2020. The State of Food Security and Nutrition in the World 2020. Transforming food systems for affordable healthy diets. Rome, FAO.

Alternative Proteins: Speaking to consumers

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The global food system is recalibrating in the wake of many factors, one of which is the increasing demand for traditional proteins, driven in large part by low-or-middle-income emerging markets in the Global South (see Alternative Proteins: What’s the deal?). What this has led to is the rise of a new category ‘Alternative Proteins’ encompassing everything from re-engineered plant-based legumes to lab-grown meats. The mushrooming of new brands in this category have been centered in the Global North, with some markets even reaching close to saturation point (read this to find out what all the hype is about). The market share is expected to change as the case for alternative proteins in the Global South gains traction.

At Sight and Life, we thought it would be interesting to study how some alternative protein brands have chosen to open conversations with their consumers in such a fresh, new category. It becomes easier to understand the way brands speak if one were to look at them through the archetype lens, providing the brand a more human feel. Similar to how fictional characters are written according to paradigms in order to help understand their actions, a brand archetype is a way of presenting a brand and define its symbology, values, behaviors, messages – as a persona, thus making it more recognizable and relatable to target audiences. We looked at the main sources of brand communications available to decode the semiotics – the official brand website, the major social media accounts, official digital/ television advertisements, if any, and digital banners.

Key messages:

– The novelty of the alternative proteins’ category allows for bold claims, bold brand names, bold imagery
– The current marketing is for a consumer higher up in Maslow’s Hierarchy of Needs – looking for a greater sense of purpose to participate in, a future-forward perspective
– Improving the world is an often-cited end goal and functions as the gratification – the product sensory experience is not usually the show runner
– Most brands in this space tend to speak to the public the same way they would to an investor – however, Impossible Foods and Beyond Meat have evolved and struck up new conversations with the consumer

Innocent vs. Hero Archetype 

First, we looked at Impossible Foods and Beyond Meat, both based out of the United States. Both these brands stand out as more evolved in their marketing to consumers in that they attempt to engage the consumer in a less technical and more emotional conversation. This strategy could be because both brands are available in retail and need to do more than highlighting the scientific angle to their products.

Take Impossible Foods, for instance. The brand talks about respecting the magical moments we celebrate (all in the company of good food), without harming the planet. Impossible Foods has set out on a mission to create ‘Paradise’, a world where everything and everyone lives in harmony. When it talks about its mission (#MissionEarth and #MissionImpossible), much of the brand imagery alludes to elements of an ideal world – happy adults, happy youth, happy children, happy creatures, happy trees, and a blue sky. If you pay attention to the brand’s vocabulary, you can see it is current, outspoken, and determined, and seems to speak to a younger audience – the millennials and Gen Z – fitting into the Innocent archetype. The Innocent is someone that dreams of the ideal, is an eternal optimist, and celebrates wholesomeness.

A screenshot of the Mission page on the brand’s website. Source: https://impossiblefoods.com/mission/

Impossible Foods is not just for vegetarians; it is for meat lovers and the environmentally conscious and the flexitarians who may be a bit of all three. It also spotlights its science story, the champion being ‘heme’ – this is what makes the meat ‘bleed’ and gives it the right texture and flavor. Impossible Foods celebrates great taste, as much as the lack of environmental repercussions – which is significant since it shows that it understands the consumer is ultimately tempted by indulgence and not delayed gratification, no matter how noble the cause. It works hard to lend a sense of purpose to the Impossible Foods consumer in a vibrant, cool way – pops of color, flat icons, catchy hashtags et al. On social media, you can see Impossible Foods stand up for causes that are outside of environmental concerns. The leadership team even writes on Medium.com, a popular online publishing platform. In short, the brand continues to leverage every opportunity and every channel to reach its target consumer.

Now, let’s look at Beyond Meat. This brand brings to mind the Hero archetype, looking to inspire others to do better, achieve more, truly test the limits, go beyond and not settle for the standard. The Hero is an archetype that strives for mastery, showing courage that improves the world and this is exemplified in Beyond Meat’s communication. For starters, the brand logo is a buffalo that’s wearing a cape. The Hero is all about action, and Beyond Meat is no exception.

Beyond Meat’s homepage featuring Kevin Hart as the Beyond Ambassador. Source: https://www.beyondmeat.com/

Most of the brand’s imagery is dark and grave – a great deal of black is used to convey the brand’s bold personality, and the green bits pop up in places for greater emphasis. Much of the copy in the brand’s videos and banners is serious or inspirational. Beyond Meat breaks down four main reasons to make meat from plants: improve human health, positively impact climate change, address global resource constraints, and improve animal welfare. It features well-known sports and television personalities who act as Beyond Ambassadors.

The Go Beyond page, which features inspiring stories from individuals and communities. Source: https://www.beyondmeat.com/go-beyond/

Here we see two brands communicating a sense of purpose to the consumer – Join #MissionImpossible or #GoBeyond. Impossible Foods does shine a spotlight on its all-star element, heme, assuring the consumer of an equally – if not more – fulfilling gastronomic experience. Still, the real hero is the consumer, who chooses to further this larger cause. Beyond Meat also places the responsibility on its consumer to challenge the status quo and find a better solution.

Talking Logic vs Talking Emotions

Let us now move to the last two brands we considered, which have not yet started speaking to consumers, but are looking to craft their identity. In Hong Kong, HK Avant Meats is a brand that has innovated the production of high quality, sustainable, and tasty fish products. The brand uses cell technology to harvest premium delicacies from our seas and oceans, without harming the water bodies. How well does the brand convey this to an outsider, a potential consumer? Based on the website, the brand’s vocabulary is currently more scientific and functional than emotional, with terms such as ‘cell technology’, ‘GMO-free’, ‘innovate’, ‘sustainable’ etc. There are two products under the Avant Meats banner – Avie and Zellulin. The imagery for both is opposite to the clinical environment the brand sets up on its homepage: Avie feels like a lifestyle brand for younger millennials while Zellulin cues a luxury category such as cosmetics or perfumes.

HK Avant Meats advertising samples for Avie and Zellulin.

Lastly, there is Clear Meat, a start-up from India. The brand is resting on scientific credentials at the moment and does not yet elaborate on product experience. If we were to delve into the semiotics here, we see the process is celebrated more than the end product. This message is also apparent as the brand speaks of gratification and the emphasis on the process continues to overshadow the product.

From even a glance as cursory as this, we can see that given the novelty of the conversation, brands run the risk of speaking to consumers the same way they would talk to a potential investor. The consumer that these brands are targeting (potentially targeting – in the case of the last two) is ahead of the curve, someone who is aligned to the brand’s journey and mission and advocates the cause and not the product alone. Such a consumer could appreciate the larger objective and may even be willing to compromise on indulgence. This leads us to question how alternative protein brands should be speaking to consumers in the Global South? Could we alter the manifestations of such archetypes such that they resonate with low-and-middle-income consumers? In the seesawing between purpose and indulgence, how much weight should each carry? Can the sense of purpose be made more personal and placed within the Global South consumer’s direct needs? And lastly, will the product be the hero, or should the consumer be the hero?

You might also ask, what is the nutritional value of these products? Read more about this subject matter in the next post in this series Alternative Proteins: The nutritionists perspective.

All graphics created by Sight and Life’s Architect and Design Specialist Anne Milan.

Alternative Proteins: What’s the deal?

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What are alternative proteins, and why are we talking about them?

Global Population 10 Billion

The global food system will need to feed 10 billion people by 2050 – including a nearly 75% increase in meat demand, driven mostly by low-and-middle-income emerging markets in the Global South[1]. Currently, the meat sector is a trillion-dollar market projected to increase by nearly 4% annually[2]. This tremendous growth in meat consumption poses significant resource challenges, and meeting this demand must occur in a holistically sustainable way. A promising alternative protein industry has recently emerged to address this challenge with products ranging from reconfigurations of the typical plant-based legumes into meat substitutes, like Impossible Burger, to using edible insects and introducing novel products such as lab-grown meat or single-cell proteins from algae, yeasts, or fungi. Compared to meat counterparts, alternative proteins’ projected positive impacts on climate and animal welfare and potential health benefits have piqued interest in this sector[3]

Investments in Plant-Based Food Companies (2010–2019)

Source: Good Food Institute

The alternative protein industry can be segmented by protein source and level of processing: fortified or otherwise modified plant-base (including fungi and algae), insect-based, and lab-grown meat or by application: direct consumption, animal feed, and supplements. With a current market capitalization of $2.2 billion and concentrated in the Global North, most alternative protein startups and associated funding focused initially on segments with existing demand and potential growth opportunities like plant-based products. However, there is a rising favorable environment for alternative protein in the Global South due to increasing disposable incomes, consumer affinity towards sustainable consumption, less competition, and growing venture capital funding for startups. Furthermore, as European and American markets are becoming saturated with alternative protein products and more competitive, we anticipate these companies expanding their business model to the Global South. This plant-based movement has also spurred new developments such as the European Alliance for Plant-based Foods (EAPF), bringing together like-minded organizations in the plant-based value chain around a unique mission: To put plant-based foods at the heart of the transition towards more sustainable and healthy food systems. 

At Sight and Life, we are working to advance innovations that need cross-sectoral expertise in nutrition, marketing, and business models in the Global South. We seek to pre-empt the movement of alternative protein into the Global South and identify priority focus areas as the industry shifts geographical focus. Two alternative protein segments relevant to these markets over the next five years are plant-based processed products and insect-based animal feed.

Why plant-based?

Plant based meats

The plant-based category is the largest source of alternative proteins today. In 2019, plant-based companies in the U.S. raised nearly US$ 750 million, or 90% of the total funding for alternative proteins[4]. These companies are sustainable and significantly less resource-intensive than animal husbandry and their products, due to the dominant use of ingredients of soy and pea. Paired with environmental benefits, the ability to closely mimic a range of meat variants at a competitive price, plant-based meats are well-positioned to cater to the Global South. Moreover, multi-national food companies and protein producers, which have a presence in low-and middle-income countries, are investing in plant-based products. 

Why insect-based animal feed?

Insect based animal feed

The demand for animal source foods in the Global South is witnessing a sharp rise, with demand projected to increase by 73% by 2050. The market has seen a spike in input costs as traditional feed ingredients such as soy and fishmeal commodity prices rise. More and more farms are therefore demanding cheaper feed sources such as insects, as meat consumption increases. Though large-scale production of insect feed occurs in the Global North, there is an opportunity to scale existing small and medium enterprises in the Global South by adopting and innovating new technologies.

To meet the unique nutrition needs, the share of wallet and palate of the consumers, three areas that need attention are accessibility, awareness, and local taste preferences. Along these lines, Sight and Life will share insights in a three-part blog series on approaches that would make alternative proteins relevant for consumers in the Global South.

Making alternative proteins aspirational

Marketing a new product becomes critical in a new category, especially when consumers do not have any previous food product perceptions. In the next blog post, we investigate how alternative protein brands have established themselves and communicate with their consumers. Puja Peyden Tshering, Sight and Life’s consumer insights specialist, analyses four brands through an archetype lens, understanding the brand through a more human feel. Look out for the thought-provoking questions she raises as companies start speaking to consumers in the Global South.

Alternative proteins through a nutritionist lens

With alternative proteins set to radically change our diets over the next few years, do we know if their nutritional value is as good as their substitutes, and whether they are appropriate for the Global South where the prevalence of malnutrition is high? Sight and Life’s nutritionists, Breda Gavin Smith, Kesso Gabrielle van Zutphen, and our interns Chiara Ferraboschi and Kris Woltering move beyond the headlines and provide a complete understanding of the entire alternative protein landscape and its impact on public health and nutrition in an upcoming piece.

Inclusive business models for alternative proteins

Alternative proteins currently cater to the premium segments, millennials, and Gen Z in the Global North, who enjoy a high spending power. But for alternative proteins to successfully cater to low-and-middle-income countries, affordability is a crucial lever. Sight and Life’s business model specialists, Kalpana Beesabathuni and Srujith Lingala, together with interns Hannah Wang and Emily Voorhies, identified market opportunities and viable business solutions that are sustainable and capable of producing protein alternatives to wrap up the series. 

Stay tuned!

All graphics created by Sight and Life’s Architect and Design Specialist Anne Milan.

References 

[1] Food Agriculture Organization (2011). World Livestock 2011: Livestock in Food Security. Rome: Food and Agriculture Organization. Accessed September 29, 2020. Available online via http://www.fao.org/docrep/014/i2373e/i2373e.pdf 

[2] ReportLinker (2017). Opportunities in the Global Meat Sector: Analysis of Opportunities Offered by High Growth Economies. Accessed September 29, 2020. Available online via https://www.reportlinker.com/p04826928/?utm_source=PRN

[3] World Economic Forum.(2019). Meat: the Future series Alternative Proteins. Accessed September 29, 2020. Available online via http://www3.weforum.org/docs/WEF_White_Paper_Alternative_Proteins.pdf

[4] The Good Food Institute. (2019). U.S. State of the Industry Report Plant-based Meat, Eggs, and Dairy. Accessed September 29, 2020. Available online via https://www.gfi.org/files/soti/INN-PBMED-SOTIR-2020-0507.pdf

Take-Home Rations

A route to nutrition security

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On August 28, 2020, Times of India published “Take-Home Rations: A route to nutrition security” by Dr. Rajan Sankar of TINI Tata Trusts (read the more about Dr Rajan Sankar here) and Kalpana Beesabathuni, Sight and Life’s Global Lead for Technology and Entrepreneurship. The full article can be read  here.

Abstract

The disruption of food systems by Covid-19 and its impact on the availability of nutritious food in large parts of the country has brought to light the importance of the Take-Home Rations (THR) programme and its potential to deliver fortified food to the last mile in the country. The THR programme is unique in its reach and scale; it is also well resourced with a budget of Rs. 13,500 crore and hundreds of millions of beneficiaries. The current crisis presents a window of opportunity for THR to fully realise its promise and transform India’s nutrition security scenario.

India is home to one-third of the world’s stunted children (4.7 crore) and half of the world’s wasted children (2.6 crore). Nearly 41% of children less than five years old are anaemic. To combat malnutrition, the Government of India launched the Integrated Child Development Services (ICDS) programme in 1975; it offers a variety of nutrition and health services for the first 1,000 days of life. This time span is vital for preventing long-term consequences associated with malnutrition, particularly during pregnancy and also when infants transition out of breastfeeding.

Read the full article on the Times on India website here. We also invite you to take a look at the Take-Home Rations Compendium, a recent analysis of the THR program here.  

Vestine Nyirahabimana 

Method and Evaluation Specialist for Sight and Life

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I grew up in a rural area where agriculture was the primary source of food and income. There were varieties of fresh food in our village, but many people, including me, had no idea how a healthy diet looks. It took me time to know that local fresh food provides more nutrients and flavor than a refined one.

Despite food availability and affordability, a good number of children would suffer from malnutrition. In today’s world, “more than 95% of all chronic disease is caused by food choice, toxic food ingredients, nutritional deficiencies, and lack of physical exercise,” explains author, investigative journalist, educator Mike Adams.

Vestine, Sight and Life

“I believe that a healthy eating education is needed to promote sustained adoption of healthy eating behaviors. My motivation in nutrition is that if we teach people to fix their diet, they can then correct their health issues!” 

 

Working for Sight and Life is an opportunity for me to contribute towards achieving this goal and give back to the community by using my technical skills. I will develop an effective monitoring and evaluation system that provides information, brings learnings, and influences decision making while measuring Sight and Life’s contribution to the anticipated change. Through this role, I also look to gain knowledge and expertise on how nutrition plays a vital role in improving people’s lives.

Exchange in Behavior Change

Making consumers feel, instead of do

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One of the most often expressed grievances related to the COVID-19 pandemic has been around wearing face masks. Everyone is made aware of its importance when stepping out. We can thank the hundreds of videos, posters (digital and offline), social media content, and articles on the subject. Not wearing a face mask outside today could mean instant scrutiny, even mockery or humiliation. Sometimes I wonder how many wear face masks to protect their health and that of others, and how many wear face masks because ‘everybody else is doing it’ or it is ‘cool’ or ‘popular’ or ‘this one is branded and oh so pretty’. Of course, this is not to say there is only one motivation at play here, or that one is better than the other. It just is an excellent example of how simple awareness-raising of the health benefits is not enough – motivation comes from a combination of individual and social factors as well as knowledge.  

Social marketing’s impact

In the context of social marketing, we briefly discussed the idea of ‘exchange’ in our blog post by social marketing expert Rowena Merritt, “It Makes Me Smile,” posted a fortnight back. We explained how, if the goal is to change a behavior, offer something in return. While most of us might think of cash incentives or gift vouchers as rewards, the exchange is often non-monetary, such as making someone feel unique, or creating a sense of control or ownership. At Sight and Life, we think about whom we are serving and what could be a compelling exchange for our target audience. 

Research is important

Let us look at the Eat More, Eat Better campaign* launched in Rajasthan – a state in Northern India – in 2018. The project aimed to improve food access and food choices for pregnant and lactating women (PLW), whose calorie intake was 40% below doctors’ recommendations. However, we quickly realized that we needed to do more than raise awareness; we needed to offer an exchange that our audience valued. To help us do this, we used social marketing techniques and tools and conducted in-depth formative research. 

The findings helped identify critical insights to develop a behavior change strategy, the most notable being:
  A. The kitchen was generally the mother-in-law’s domain, and she associated eating more with being indulgent, greedy or lazy. This perception was not relaxed even for her pregnant or lactating daughter-in-law!
  B. The husband tried to balance patriarchal norms with being more emotionally available to his wife. For instance, he would occasionally smuggle in goodies or fruits for his wife to eat.
  C. Snacking, rather than the three meals, carried greater permission for the PLW as it did not lead to territorial clashes in the kitchen and was also something that was not frowned upon by the mother-in-law.

Based on these findings, the social marketing project focused on introducing a new behavior – nutritive snacking for PLW. The habit of snacking was accepted and already practiced, making it a more natural behavior to change. PLW were provided a specially designed snack box that she could use when away from the kitchen and a small treat pouch that she could use to carry snacks in her sari.  The baby was dubbed a ‘Champion’ that would fill both the mother and father with pride and parents were encouraged to do what is best for their ‘Champion’. Fathers were also asked to sign a pledge to support the nutritional needs of their wives and babies actively. And the exchange? The PLW felt special and cared for by her husband and empowered when it came to looking after herself and her baby. 

This is a graphic for the Eat More, Eat Better campaign paying a tribute to the region’s unique Rajput painting style. It shows a husband urging his wife to eat more and calling her the mother of the ‘Champion’.

Another good example is our work in the 2017 Karnataka WASH (Water, Sanitation and Hygiene) behavior change project. As part of the larger objective to improve nutritional status among school-going children, Sight and Life worked with PATH and Karuna Trust on a strategy to prevent loss of nutrients among children by aiming to influence motivations regarding several behaviors:
  A. Washing hands with soap at key times, including before meals, after using the toilet, after play, and after handling garbage
  B. Drinking water from safe sources only
  C. Rejecting open defecation or urination
  D. Flushing the toilet with water after use
  E. Keeping their school tidy and free of garbage
  F. Eating vegetables and healthy snacks

The formative research delved into the physical, social-normative, and biological factors that drove eating and hygiene practices in school. The team conducted a combination of ethnographic interviews and focus group discussions exploring codes related to hygiene, sanitation, and social influence. Based on this information, the team designed a phased strategy where they tried to make the behavior changes as fun, easy, and as popular (the social norm) as they could by deploying the following:
  A. Physical cues – for example, rhymes and short messages, relevant signboards, installing a tippy tap, soap for handwashing and buckets and jugs made available in toilets (making it easy)
  B. Games – specially crafted games and someone entrusted with the responsibility of owning these games (making it fun)
  C. Role modeling – each class elected a role model, who would then encourage his/her classmates to adopt health behaviors (making it popular) 
  D. Helper crews – specifically created to ensure all tasks were fulfilled (making it fun, easy and popular!) 

In 2017 Sight and Life’s intern, Shannon King, worked in India to research the implementation of these school-based nutrition and WASH intervention strategies to develop healthy eating habits while improving hygiene and sanitation behaviors.

It is interesting to see how the ‘fun’ element was given great importance, and rightly so since the target audience was young children. The rhymes and games helped children identify ideal WASH behaviors; watching role models encourage the same outside of playtime helped build good habits. Rhymes and games acted as an essential feel-good factor and led to a higher recall for a topic that runs the risk of being regarded as boring and irrelevant by many children. 

Knowledge is key

Figuring out the exchange is an engaging journey, one which requires exploring the individual and society, the motivations at play, and the broader environment they are all delicately balanced within. This summer, Sight and Life is holding a three-day online course with the SSPH Lugano Summer School, “Generating Demand for better public health goods and services: A systems and consumer-centered approach”. The course will look at how to create demand for healthy products and healthy behaviors (and we will also talk about exchange). Further details regarding enrollment can be found here. We look forward to (virtually) meeting you there!

* The formative research for the Eat More, Eat Better campaign was completed by Eva Monterrosa, former Sight and Life Senior Research Manager.

It Makes Me Smile 

How can behavioral insights for unhealthy foods help create demand for healthy food?

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I had convinced my son that “fizzy” drinks were disgusting. I told him they were bad for him, that they are full of teeth rotting sugar and that they did not taste nice. He believed me and never wanted to try one. However, eventually, children reach an age where their friends become authorities on seemingly everything, and they start to listen more to their mates than their mum.

On the school run yesterday, my 8-year old son: “Oliver says, mixing red and blue makes green.”
Me: “No, I am sure that makes purple.”
My son: “No, Oliver knows Mummy.”*

Then later

Me: “Why are you digging a massive hole in our lawn?”
My son: “Freddy said we could find diamonds in our gardens.” 
Me: “Err no, darling, we don’t have diamond mining in the UK.” 
My son: “Yes, we do. Freddy told me so (as he carries on digging).”

When Oliver and Freddy told my son that he should try a “fizzy” drink as they were “fun”, he no longer listened to me and my warnings. He used his pocket money to buy a can of Cola-Cola. The result – he loved it! Why do you love it? I asked him.

“It makes me smile Mummy,” he replied simply.

For me, this uncomplicated response summed up everything – unless healthy and nutritious drinks such as milk and water make my eight-year-old “smile”, he will keep wanting Coca-Cola. And although I can use a metaphorical “stick” and ban him from drinking such drinks now, without the “carrot”, I will not win the battle in the long run. As soon as he is old enough to walk to school and go out by himself, he will just choose to buy unhealthy drinks with his pocket money.

Apart from my son’s questionable trust in his friend’s advice (and their questionable art and geological knowledge), what can we learn from his Coke experience? And how can we use such insights to create demand for nutritious food and drinks?

For me, the key is this

LISTEN. Listen to your target audience – the people whose behavior you want to change. Whatever people do, even if it seems foolish to you, they will have their reasons. These reasons might not be rational (as my son’s experience demonstrates), but then we are driven by emotion, and our decisions and actions are rarely logical.

Many of you might have focused on educational interventions in the past, believing that people simply need to know what is good for them and what is not. However, do not be fooled; education does not always work.

If we always made rational decisions, none of us would overeat, smoke, salute three times to magpie birds (which I do due to a silly old English superstition), or drive like lunatics. But rest assured, when you ask and listen, your target audience will have their reasons.

When I worked at the Department of Health England, they ran the 5-a-day campaign, trying to encourage people to eat more fruit and vegetables. However, during the campaign run, consumption went down. Why? They made the incorrect assumption that knowledge and changes in attitudes are sufficient, and ignored beliefs or benefits gained from eating unhealthy foods (do carrots and broccoli make my 8-year-old smile? You can guess the answer).

The whole social marketing discipline is based on the idea of exchange, and if you want people to change their behavior, you have to offer them something in return. Often this is non-monetary – a feeling of belonging, sophistication, or security. Or, an alternative product that gives them the same or greater benefits as the product they are currently using. These benefits must be immediate, as we value these more than longer-term ones.

You only can work out what the exchange should be by listening to your target audience and understanding the benefits they derive from the negative behavior, such as consuming high-sugar soft drinks. Coke gave my son immediate happiness; how can we create that same feeling with a healthy drink? 

For deeper insight on formative research, take a look at our Action in Brief on “Eat More, Eat Better”, a behavior change strategy to support improved food access and food choices for women in the northern Indian state of Rajasthan. 

Further Learnings

This summer Sight and Life are running a three-day course as part of the Swiss Lugano Summer School. The session “Generating demand for better public health goods and services: A systems and consumer-centered approach” and will explore how social marketing, behavioral insights, and innovations in behavioral science can be used to create demand for healthy products and behaviors. The course will also explore how public-private partnerships can make healthy products more attractive to consumers and develop sustainable business models. Further details and where you can enroll click here

I hope to “see” some of you there.

*In case you are wondering, mixing yellow and blue make green.

 

Nutrition in the Workplace is a Winning Solution During and Post-COVID-19

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The Food and Agriculture Organization of the United Nations (FAO) highlights the importance of good nutrition before, during and after an infection. While no foods or dietary supplements can prevent a COVID-19 infection, maintaining a nutritious diet is important to supporting a healthy immune system to fight infections. In addition, the World Health Organization (WHO) states that a well-balanced diet is critical to receive the essential vitamins, minerals, fiber, protein and anti-oxidants the body needs to be in good health and build a strong immune system to lower the risk of chronic illnesses and infectious diseases. Therefore, a nutritious diet is important for all age groups throughout the COVID-19 pandemic.

Diet and nutrition of the workforce during and post-COVID-19

The COVID‑19 crisis has had a dramatic impact on the world’s workforce; partial or total workplace closures have restricted business operations and have affected an estimated 80% of the global workforce. The worst-hit workers are those working in small and medium-sized enterprises, and low-wage workers in informal employment, with limited access to safety nets. For others, adjustments in the work process and arrangements to work from home have enabled them to retain their jobs during COVID‑19.

Currently, employers are facilitating a gradual return to the workplace. Workplace canteens are opening to workers if social distancing rules can be maintained or providing packaged meals to avoid fully opening staff canteens. Most workers eat at least one main meal during their working day. Workers who encounter time challenges to prepare home-cooked meals to rely on catered meals facilitated by their employer. Others bring their lunch or go to food outlets, markets, or takeaways. For many of them, it remains a daily task to obtain a diet containing all the recommended nutrients. In some labor-intensive sectors, nutrient requirements are so high that they are difficult to be obtained through the diet alone. Also pregnant or nursing women have elevated nutrient requirements that will need careful meal planning.

A survey among employees highlighted the main challenges workers face to eat healthily:
1) easiest food choices aren’t always the healthiest
2) “I don’t always have time to buy and prepare healthy food”
3) “it’s too expensive”
4) “the people I’m around don’t eat healthily.”

Cantina, workplace nutrition
Source: Pixabay

Nutrition and health at work

Nutrients, including vitamins and minerals, are critical in many functions of physical and mental health. The role of nutrition in immunity is not only to support preventing but also resolving infections that have been well established. Among other reported benefits of nutrition are increased energy and reduced fatigue, as well as enhanced alertness, cognitive and mental performance. Nutrition also plays a role in many other functions such as bone density and muscle strength and slowing progression of non-communicable diseases.

A pre-COVID-19 survey in the UK revealed that infections, musculoskeletal problems, mental health conditions, and diabetes were among the main health reasons for sick absence. However, nutrition as a direct modifiable factor for many of these health conditions is often overlooked by employers. Higher absence rates among workers can be expected post-COVID-19 due to “suspected infections” but also as a result of increased mental problems; approximately half of the young people reported anxiety or depression since the start of the pandemic. Therefore, during and post-COVID-19 pandemic, healthy eating, and nutrition programs in the workplace are important in fostering employee immunity, physical and mental health. Centrally distributed workplace nutrition provides the opportunity to reach many workers and contribute to employees’ essential nutrient requirements.

Evidence for nutrition programs at work

Workplace nutrition programs can include “education” or “coaching” programs to encourage workers to consume more nutritious foods. Access to nutrition consultation and personalized nutrition advice has a significant potential health improvement rate. Nutrition programs can also include (subsidized) nutritious food offers at work, such as healthy lunch choices or fruits, fortified lunches, or micronutrient supplements. The evidence for the health benefits of nutrition in the workplace is growing. Micronutrients provided to workers through fortified foods or supplements significantly improved workers’ nutrition status in various workplace settings. Anemia, common colds, urinary tract infections, and work absence were reduced in Bangladeshi women garment factory workers receiving multi-micronutrient-fortified rice along with iron and folic acid supplement and nutrition counseling for 10 months. Infection-related work absence was reduced by almost two-thirds in healthcare workers consuming multi-micronutrient supplements for one year. Other reported benefits of providing micronutrients in the workplace are manifold; reduced heart rate, improved body mass index scores, bone density, perceptual and cognitive functioning, improved mood, and reduced depression.

What are the benefits for the worker and employer?

Employers bear many of the costs related to absenteeism and presenteeism. On average, employees cost businesses the equivalent of three months per year in lost productivityUnhealthy eating (too much salt, sugar, saturated fat), as well as inadequate essential nutrient intake, raises the risk of low productivity. By optimizing workplace nutrition, workers receive the nutrition needed to stay alert and focused while employers benefit from reduced absenteeism and less presenteeism or unproductive use of time. Better nutrition also equates to improved resilience to infections and stress – other potential pathways to better work performance.

Workplace Nutrition Graphic

Employers’ social responsibility for the nutrition of own employees

Employers have an essential role to play during the COVID-19 crisis to provide good nutrition, especially for the most vulnerable in society. It is important that work environments facilitate good nutrition to support the physical and mental health of their workers. Investing in workplace nutrition is a high return on investment for the employer and can increase workers’ health, work attendance, morale, efficiency, and productivity. A recent report by GAIN-SUN-Eat Well demonstrated that “workforce nutrition” is a win-win for employers looking to improve both employee health and business outcomes. Moreover, it can contribute to the nutrition targets of the United Nations Sustainable Development Goals (SDGs), specifically SDG 2 (zero hunger), SDG 3 (good health and wellbeing), and SDG 8 (decent work and economic growth).

IMPact4Nutrition, Workplace nutrition, India
Nutrition awareness session for female garment workers at Arvind Ltd, an IMPAct4Nutrition private sector partner.

There is a growing awareness among the public and private sectors that workplace nutrition can benefit both employees and businesses. IMPAct4Nutrition (read more in our Action in Brief on IMPact4Nutrition) is an example of a public-private engagement that aims to bring together the diverse private sector interested in contributing to the Indian Government’s social movement named POSHAN Abhiyaan or National Nutrition Mission. Diverse partners are engaged including UNICEF, Sight and Life, CSRBox, Tata Trusts, and the Confederation of Indian Industries. The priority by IMPAct4Nutrition is promoting nutrition in the workplace by targeting key nutrition behaviors in the workplace in three areas; assets and core business for nutrition, cash/corporate social responsibility for nutrition, and employee engagement for nutrition. During COVID-19, IMPAct4Nutrition has developed digital training modules to support companies in promoting good nutrition across their business ecosystem with practical, easy to follow tips on how employees can maintain an appropriate nutritional status. Through these modules, the platform is reaching 10 million employees, their families, and communities in 51 companies across India.

In June 2020, IMPact4Nutrition was honored with a UNICEF global INSPIRE Award in the category ‘Best Multistakeholder Engagement’. Nearly 100 campaigns from 50 countries were nominated and voted on by UNICEF staff worldwide. 

The reward is high

A successful workplace nutrition program can be part of a broader organization’s framework tailored toward health and wellness. A successful program requires buy-in from leadership as well as a dedicated coordinator and resources for implementation. Quantitative data such as surveys, nutrition, and health data will help to evaluate if the program was a success. Besides the employer, trade unions, foodservice operators, and incentives by insurance companies can further contribute to a positive nutrition environment at work.

Nutrition programs in the workplace offer a direct opportunity to workers and employers; they have the potential to improve workers’ physical and mental health, and loyalty and thereby improve work attendance, productivity, and employer reputation. The potential return on investment of investing in workplace nutrition is high. Therefore, proper nutrition in the workplace is a win-win proposition for employers and employees. Investing in workers’ nutrition should be a goal if organizations are to thrive.

Reference Links:
http://www.fao.org/3/ca8380en/ca8380en.pdf
http://www.emro.who.int/images/stories/nutrition/documents/en_flyer_nutrition_adults_covid_19.pdf?ua=1
https://www.who.int/docs/default-source/searo/india/covid-19/food-donation-guidelines-22nd-may
https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/documents/briefingnote/wcms_740877.pdf
https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/documents/briefingnote/wcms_740877.pdf
https://news.un.org/en/story/2020/04/1061322
https://ilostat.ilo.org/topics/covid-19/
https://www.ilo.org/safework/areasofwork/WCMS_118393/lang–en/index.htm
https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/—publ/documents/publication/wcms_publ_9221170152_en.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5133081/
https://pubmed.ncbi.nlm.nih.gov/8840709/

https://meetzipongo.com/blog/top-4-challenges/
https://sightandlife.org/blog/nutrition-immunity/
https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/—publ/documents/publication/wcms_publ_9221170152_en.pdf
https://www.mdpi.com/2072-6643/11/1/85
https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/labourproductivity/articles/sicknessabsenceinthelabourmarket/2016
https://ilostat.ilo.org/topics/covid-19/
https://warwick.ac.uk/fac/sci/med/research/platform/wemwbs/
https://www.nutraingredients-usa.com/Article/2020/02/17/Public-health-expert-ringing-the-alarm-on-workplace-nutrition#
https://gccmarketing.blob.core.windows.net/marketing-site/marketo/resources/presenteeism/us-presenteeism-whitepaper.pdf
https://www.liebertpub.com/doi/10.1089/pop.2012.0003
https://www.who.int/news-room/fact-sheets/detail/malnutrition
https://www.nutraingredients-usa.com/Article/2020/02/17/Public-health-expert-ringing-the-alarm-on-workplace-nutrition#
https://nutritionconnect.org/nutrition-at-work
https://www.theconsumergoodsforum.com/health-wellness/healthier-lives/key-projects/employee-health-and-wellbeing/workforce-nutrition-alliance/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499225/
https://www.ilo.org/safework/areasofwork/WCMS_118393/lang–en/index.htm

Priyanka Kumari

Program Coordinator for Sight and Life

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Growing up in an agriculture family from east India, I would stroll past lush green fields of paddy, wheat, and corn during vacations. Behind this prosperity, there were scenes of hundreds of women farmers with their infants in cloth pouches at their back, working in the fields under the scorching heat. Although they satisfied the hunger of thousands, they themselves could not afford a meal due to income disparity and uneven margin distribution across the value chain. This pushed them and their children towards malnutrition.

These experiences began my endeavor to bring change at grassroots and uplift these households has strengthened with each of my experiences with farmers over the years. I wish to grasp every opportunity I get to change and improve the lives of millions of women farmers in India.

“I believe that agriculture and nutrition work in accordance, steering the health of millions. Sight and Life offers an opportunity to analyze food system holistically and share multi-sectoral findings creating innovations to prevent malnutrition.”

 

Innovations in supply chain and developing technical skills are crucial to improve production efficiency, streamline last-mile distribution, and boost technology adoption, ultimately increasing farmer’s share in the food system as an investor and consumer. This became my passion as an agribusiness professional and motivated me to take the next step. At Sight and Life, I get opportunities to enhance livelihoods and improve nutrition among low-income households. 

 

 

Elvis Gakuba

Rwanda Country Manager for Sight and Life

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Growing up as a refuge, in a region where conflict dominated the headlines, I saw people suffering firsthand and often due to the political situation and discriminative policies which unfairly affected women, children, and the elderly more. These experiences have deeply influenced my life and my choice of education eventually leading me to a career in nutrition. Now I can make a difference through my work to ensure there are not vulnerable people suffering from policies related to food or health. 

 

“I truly believe that we have enough quality food to feed us all, and no one should suffer from hunger or malnutrition, with the right policies, and political will, hunger, and malnutrition will be defeated.”

For the past 15 years, I have been involved in shaping policies and implementing them to address gender equality, food security, and fight all forms of malnutrition in Rwanda, Burundi, and East Africa. 

Feeding Families in Need During COVID-19 Pandemic

 

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There are many hungry bellies to feed around the world and we are merely scratching the surface to nourish the vulnerable populations of the world. Due to the current COVID-19 pandemic triggering lockdowns around the world, issues in nutrition such as food systems and malnutrition have been heightened and are now more of a global urgency than ever before. Here at Sight and Life, we are working on initiatives in Rwanda, South Africa and India to help improve the lives of those in need during this crisis.

“The only silver lining during this grave crisis has been how quickly and effectively we’ve been able to work together as a team and with our partner organizations to identify food insecurity hotspots and mobilize resources for emergency hunger relief. The guiding principle behind our efforts has been to look beyond just filling bellies but make sure adequate and critical nutritional needs are met,” expresses Sight and Life team members.

In India, we have partnered with grassroots NGOs across India, such as Aahawaan Foundation, based in Bangalore, and Kutumb, working in Uttar Pradesh, to donate grocery kits and nutritious food to the affected communities.

Kutumb is an organization attending to abandoned and slum children by giving them a sense of family. They are also dedicated to strengthening all units of marginalized and underprivileged families, realizing that children can be nurtured best in a family setting. Together with Kutumb, we provided nutritious food to over 1500 children with moderate acute malnutrition in 75 villages located in Uttar Pradesh. 

In Bangalore, we teamed up with the Aahawaan Foundation who is committed to providing basic requirements and facilitate the development of the overall potential of people and their communities. Together, we delivered 15-day grocery kits with staples and fortified kernels as top-up was delivered to migrant workers and their families ensuring that the nutritional needs are met, beyond just filling stomachs.

 “I was unsure of how I would provide for my own children and was hence, worried about feeding my neighbor’s children as well. This ration will help me cope with this crisis for some more time,” explains Sita Ben, one of the many women workers our partner reached with an essential food kit. She spoke about her difficulties during this pandemic as she is responsible for her children and neighbor’s children as they are unable to return due to the lockdown in India. Now she can sleep a little bit knowing she has the ability to feed her and her neighbor’s children.

Meanwhile, in Delhi, monthly ration kits made it to 200 daily-wage households. The kits contain additional essential supplies such as oil for cooking, grains, lentils, and an egg for a family of four in order to help ease the pain of many in unfortunate situations.

 “A great number of my fellow countrymen are forced to walk a thousand miles, often hungry, just to reach the safety and comfort of their families. We are grateful for the opportunity to raise funds on their behalf and support them with nutritious meals,” explains the Sight and Life team. 

We are committed to doing more however, we need support. Please donate to via our Milaap or GoFundMe crowdfunding page to further our efforts. We are also interested in partnering with organizations that have similar initiatives and are located in Rwanda, South Africa, or India.

Five-step plan to prevent an impending nutrition famine during COVID-19 in India

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India’s isolation measures in response to COVID-19 are having a far-reaching impact and is among one of the largest initiatives globally to impose strict limitations on its 1.3 billion citizens. People with pre-existing vulnerabilities, marginalized communities, pregnant and lactating women (PLW), daily wage earners, migrant workers, and the elderly have been the hardest hit as the protective measures disrupt the economy.

To ease the effects of the pandemic, the national and state governments have announced extensive stimulus packages and policy measures. The national government on 12th May announced a $265 billion relief package aimed at injecting liquidity into the economy. The first tranche of $ 22.6 billion included several social protection measures such as payment of ex gratia amount to marginalized populations, increased wages for workers under the National Rural Employment Guarantee Act, doubling rations for three months, collateral-free loans to women’s Self Help Groups (SHGs), the inclusion of support to COVID-19 under Corporate Social Responsibility (CSR), and financial assistance to villagers through farmer cooperatives. These aid benefits are aimed to help more than 810 million Indians and are a step in the right direction.

In addition, integrating nutrition in the current policies will be fundamental to improving nutritional status and building immunity of the population, especially high need groups like PLW and children under 5 years of age. The WHO guidance on diet during the COVID-19 pandemic states that “good nutrition is crucial for health, particularly in times when the immune system might need to fight back”. India is already battling a high prevalence of malnutrition (Table 1). As India, in unison with the rest of the world, battles an evolving pandemic of unprecedented proportions, policymakers must be vigilant, agile, and innovative to halt our population from sliding into hunger and acute malnutrition due to the COVID-19 outbreak.

Table 1:

Source: Comprehensive National Nutrition Survey 2016-2018, Ministry of Health and Family Welfare Govt. of India.

We propose a five-point plan to put nutrition-sensitive policy measures in place to combat the adverse effects of COVID-19:

1. Increase budget and coverage for essentials

Many state and national governments have gone beyond the entitlement provisions under the National Food Security Act – 2013 to announce a stimulus package, the key elements of which are grain and pulses, and cash transfers to lower-income households. While this is a necessary and commendable step, a much stronger nutrition-sensitive hunger mitigation and food programming scheme is crucial. A basic, nutritious diet, recommended by the EAT-Lancet Commission, would cost at least INR 33.69 per day. Accounting for a family of 4, cash transfer of INR 500 per month would only satisfy a family’s requirement for approximately four days a month! Most states’ announcement of transferring an additional INR 1,000 only satisfies their requirement for an additional eight days. India has surplus food grains to weather the current crisis. Universal access and 3x more rations, irrespective of possession of ration cards, will be effective in addressing hunger including the 70 million poor households who lack an identification document.

2. Address malnutrition through dietary diversity, supplementation, and fortification:

Current food supplies through the Targeted Public Distribution Systems (TPDS) are predominantly comprised of grain and pulses. In the current situation where farm supply chains are expected to take at least four months to be restored, essentials such as vegetables, milk, and eggs, could be sourced directly from the farmers and made available in the open markets, supplied through public distribution systems and provided as weekly take home supplies to children and PLW. A few state governments such as the Telangana government have directed Anganwadi workers to provide eggs to mothers and children. Scaling such initiatives to a national level will help improve nutrition outcomes during the pandemic.
 
The honorable Prime Minister of India, in his address to the nation, ‘Mann ki baat’ on 25th August 2019, announced fortification of rice that is distributed to India’s poor through the public distribution systems, Integrated Child Development Services (ICDS) and mid-day meals. This would be the right time to implement the policy and improve access to fortified products including salt, edible oil, flour, rice, and milk. The aforesaid initiative is critical in the current scenario when nutrient consumption is bound to be erratic due to cash and food shortages.

3. Create awareness about nutrition practices:

Increasing evidence suggests that malnutrition increases susceptibility to infections including COVID-19. We, therefore, need to create awareness about better nutrition practices. The National Nutrition Mission (POSHAN Abhiyaan)’s Jan Andolan movement is a platform to engage in civil society and engage people to be committed to better nutrition. The Jan Andolan initiative can be utilized to implement a social behavior change campaign addressing food safety and feeding practices at the household level. Second, front-line workers can be empowered to halt the rise of malnutrition. They can be trained and equipped with behavior change communication equipment on nutrition care during pandemics. Empowering them with the right information and communication technology (ICT) equipment will enable them to spread information through digital platforms while following social distancing norms.

4. Incentivize farmers and small enterprises to produce nutrition-rich crops and food:

The following initiatives can improve the livelihoods of small-scale farmers and enterprises while improving access to nutrition. Incentivize smallholder farmers to produce nutrition-rich crops and staple foods and thus improving access to safe and nutritious diets across the value chain. Micro small and medium enterprises (MSMEs) can be motivated to produce and process nutritious and culturally appropriate foods using millets and legumes such as lentils, chickpea, groundnut, ragi which contain many nutrients and can store for long periods. They can also be prepared by women self-help groups authorized to prepare take-home rations and then the ICDS channel can distribute these foods to PLW and young children.


5. Harness technology for better nutrition:

India has a successful history of using technology to improve socio-economic and public health outcomes. For example, the Arogya Setu app, recently developed by the National Informatics Centre, uses technology to track coronavirus infections, thus providing a valuable tool in the fight against the pandemic. The government can similarly engage entrepreneurs to develop technologies to forecast the trend and pattern of disease burden in future months, rectify supply chain management of key food and nutrition supplies, revitalize already introduced software in public distribution systems to monitor food supplies.
 
Nutrition is a great equalizer. It can create the right environment to stimulate growth, economic development, and progress of an entire generation, thus propelling India on a path towards excellence. India has demonstrated early successes in managing the pandemic through strict isolation measures, innovative use of technology, and public health services. As we fight a pandemic of epic proportions, accounting for the nutritional needs of the world’s most vulnerable will not only give us the strength and immunity to fight COVID-19 but also save lives and give more babies the healthy start they deserve, irrespective of their socio-economic status.
 

Reaching Last-Mile Communities in South Africa with Fortified Food

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In South Africa during the current COVID-19 pandemic, massive food security issues have arisen in addition to the daily challenges of access to water and harsh living conditions. While under a nationwide lockdown, food distribution is critical to impoverished South African communities.

To help change the situation of many families living in South Africa, Sight and Life has provided Level Up, a fortified instant cereal full of nutritional benefits, through our longstanding partner Sizanani Mzanzi, supplier of the instant cereal. In partnership with organizations like Bambanani and Savanna Lodge, we have helped immensely in securing a meal a day for the most vulnerable members of the rural communities. These communities consist of young children and old age individuals who struggle with various health issues like HIV and AIDS, tuberculosis, diabetes, hypertension, and malnutrition. “The support and generous funding from Sight and Life allows this process to occur and provide nutritious meals to families for four to eight weeks,” states Ed Rakhorst, project manager for Bambanani.

Impact of nutrition

Typically, fortified cereals are offered in school to underprivileged and malnourished children ensuring they are consuming a healthy meal that contains all the essential vitamins and minerals required in their daily diet. Due to the lockdown putting a hold on children attending school this daily meal has not reached those who need it most.

Level Up cereal is endorsed by the South African Heart and Stroke Foundation and provides 13 vitamins and 4 minerals while also being high in fiber, energy and protein creating a nutritious meal.

Bambanani

In late April 2020, Sight and Life teamed up with long time partner Bambanani, a humanitarian organization based in Phalaborwa, Limpopo, South Africa, to deliver fortified food to last-mile communities, especially those children affected by school closings.

Bambanani focuses on the care, schooling, and nutrition needs of children from 0-6 years of age, including some orphaned and disabled children. Sight and Life donated Level Up cereal for children and their families to be distributed through the Bambanani network of schools.
“Most of these children are unable to receive adequate daily nutritional requirements due to the following socio-economic factors such as unemployment and overpopulated communal living,” explains Rakhorst.

At the Reneilwe School in Namakgale, there are many touching scenarios as to why these children and their families are in need. From unemployed or living on social grants to children with health concerns each story is important. For example, Blessing receives Level UP because he does not eat well, and his health is not good. Adding to this already difficult situation, his parents are unemployed and have no income or social grants for their family of six. Or there is Happy who lives in a household consisting of four uncles (one consumes alcohol), two aunts, and a total of five children all living together below the poverty line and receiving Level Up. These are just two of the many circumstances in which Bambanani can touch and change the lives of those in need.

Through Bambanani, the Level Up product is also fed to children that are diagnosed with HIV to get back on their feet, full of energy, and live their lives like normal children. These children will use the Level Up product seven days a week to maintain a healthy diet full of the needed vitamins and minerals.

Savanna Lodge

Located in Mpumalanga, South Africa, Savanna Lodge is a private game farm and dedicated to helping the local villages where many of their staff live. They have been delivering Level Up cereal, donated by Sight and Life, at least once a day to vulnerable orphans and children and elderly community members providing an extra boost of vitamins and minerals needed during this time.

“We have been able to distribute a box of cereal to every child at the center (Tiyimiseleni Project) and will continue to do so for as long as the lockdown continues. Thereafter, the cereal will be used at the center itself. It has been distributed to Hlayisekani Nursing Home, and stock is being kept for Mketsi Primary School,” explains Jennifer Harman, project manager for Savanna Lodge.

Tiyimiseleni Project is a community care center run as a social responsibility project by Savanna Lodge. It supports about 250 vulnerable children and HIV/AIDS orphans, giving them a safe place to go to where they get a nutritious meal, have an adult to talk to, can do their homework, and just be children for a while.

Mketse Primary School has approximately 650 students and is situated in an area where it is estimated that around 25% of the children come from child-headed households. The vision of the passionate Headmaster and dedicated staff is to provide knowledge and skills that will enable students to carry out a productive role in society and so give back to their community. Sight and Life has a longstanding relationship with the school and contribute towards this vision through its support of the school lunch program. In so doing, we are supporting keeping these children’s young bodies healthy, active, and ready to learn.

In the communities around Savanna Lodge, the situations are less than ideal. One such example is Maria’s family consisting of seven family members and both parents have passed away. She is 20 years old and unemployed and the siblings (ages 3 to 16) are in schools and they attend Tiyimiseleni home-based are for regular meals and medical assistance. Savanna built a house for Maria and her siblings to live in as they do not have identification documents making them unable to apply for state social grants. Currently, the schools and the home-based care centers are closed due to the COVID-19 pandemic and all of the children rely on the school feeding scheme from Tiyimiseleni for their daily meal. The donation of Level Up cereal made by Sight and Life provides them with at least one regular meal a day for many weeks.

The Nyambi family of three struggles as the mother is unemployed and undergoing HIV treatment and raising two children (8 and 14 years old). Due to the two children not having identification documents they are unable to claim state social grants to help support the family. Therefore, they have no income, or extended family members to assist them. The children are reliant on school feeding programs and meals from Tiyimiseleni home-based care thus making the Sight and Life contribution extremely important.

“This is just the beginning, there is more to be done during challenging times like this pandemic and in the long-term to take on malnutrition. We are proud to support and work with partners and organizations such as Bambanani and Savanna Lodge, who care for people and their futures,” remarks Klaus Kraemer, Managing Director for Sight and Life.

The Role of Nutrition in the Immune System

Should we pay more attention? Part II of II

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Vitamins and minerals, known as micronutrients, are nutrients needed by our body for optimal function and often required in only small amounts. These micronutrients are not produced in the body and thus must be obtained from our food (CDC, 2020). Micronutrient deficiencies can have devastating outcomes. At least half of children globally under 5 experience vitamin and mineral deficiencies (UNICEF, 2020) and globally 2 million people suffer ‘hidden hunger’. Micronutrient deficiency is often referred to as ‘hidden hunger’ because they develop slowly over time and their impact is often invisible until permanent damage has been done (UNICEF, 2020).

Is food a solution?

A recent article published in the Sight and Life Magazine concluded that nutrient requirements were not met in diets with high stable food consumption as is the case in many low- and middle-income countries (Depford et al, 2019). Many approaches have been adopted with the aim of eliminating micronutrient deficiencies including periodic vitamin A supplementation, iodized salt, targeted iron/folate supplementation, fortified flour, other fortified foods, home fortification with micronutrient powders, and homestead food production. Efforts continue globally to find approaches supporting the eradication of hidden hunger because of the impact deficiencies have on health and survival (Semba, 2012). During times of emergency, as we are currently experiencing with the coronavirus (COVID-19) pandemic, nutrition is of greater importance in order to ensure our immune system operation is optimized to fight such infections.

minerals, immunity, nutrition, immune system, immune response

What to consider? 

In The Role of Nutrition in Immunity: Should we pay more attention? Part 1 of II, we considered the research demonstrating the central role nutrition plays in effective functioning of our immune system. As surmised by Wu and colleagues, “There is little argument that deficiency in both macronutrients and micronutrients causes immune function impairment, which can be reversed by nutrient repletion” (Wu et al, 2019). Also highlighted was the World Health Organization’s (WHO) guidance on the importance of a healthy diet during the current pandemic where it states the crucial role of nutrition for health, particularly in times when the immune system might need to fight back such as is the case during COVID-19 (WHO, 2020). Included in the review was the current research and thinking on the factors that impact our immune system’s ability to fight infection focusing specially on the role of micronutrients. Gombart and colleagues concluded that indeed the complex, integrated immune system requires several micronutrients that have essential, often synergistic roles at every phase of the immune response (Gombart et al, 2020) with even marginal deficiencies impacting our immune response. Based on a variety of systematic and clinical data, vitamins AB6, B12C, D, E, and minerals copper, folateiron, selenium, and zinc (read our Vitamin and Mineral: a brief guide) are particularly important to boosting immune response and we looked specifically at the research supporting the role of vitamins in the immune response. If you have not read Part I already, the blog post can be found here

In this blog we will look specially at folate and the trace minerals thought to have a significant role in the immune system and examine if research backs up these claims.

Copper

After iron and zinc, copper is the most abundant dietary trace mineral. It is a component of many enzymes and is needed to produce red and white blood cells. Copper-dependent enzymes transport iron and load it into hemoglobin, a protein that carries oxygen through the blood. 

Copper-dependent enzymes also provide a natural defense against free radicals that damage the body; manufacture collagen (required by skin and bone); inactivate histamine, which is responsible for allergic reactions; and degrade dopamine into a neurotransmitter so cells can “talk” to each other.  

In a study by Djoko and colleagues they concluded that copper was essential for effective innate immune response and inadequate levels leads to increased susceptibility to bacterial infection (Djoko et al, 2015). Understanding coppers influence on these positive impacts requires further research.

Current advice on supplementation concludes that consuming a balanced diet provides all the necessary nutrition required but where there are challenges in meeting dietary recommendations, supplements are a useful addition in helping meet our nutritional needs (EUFIC, 2020).

Folate (B9)

Folate works together with vitamin B12 to form healthy red blood cells. It is also necessary for normal cell division, the normal structure of the nervous system and specifically in the development of the neural tube (which develops into the spinal cord and skull) in the embryo. Vitamins B6, B12, and folate are involved with maintenance of normal blood homocysteine levels.

While its role in DNA synthesis points to immunity, Dhur and colleagues found that cell-mediated immunity is particularly impacted by inadequate folate status (Dhur et al, 1991). More studies are required to confirm these findings. Mikkelsen and Apostolopoulos writing in the book Nutrition and Immunity did conclude that inadequate levels of folic acid and B12 can change our immune responses through a variety of processes including production of nucleic acid and protein synthesis as well as interfering negatively with the activity of immune cells (Mikkelsen and Apostolopoulos, 2019).

Immune System, Immunity, Folate, Nutrition

Iron

Iron is essential for the formation of hemoglobin in red blood cells; which transports oxygen around the body. Iron also serves as a cofactor to enzymes in oxidation/reduction reactions (i.e., accepts or donates electrons). These reactions are vital to cells’ energy metabolism.

Research suggests low iron levels affects our ability to have an adequate immune response (Gomez and Soyano, 1999). It is required for immune cell production and growth particularly lymphocytes, which are related to the initiation of specific responses to infection (Gomez and Soyaon, 1999).

A study by Dallman concluded that “abnormalities in cell-mediated immunity and ability of neutrophils to kill several types of bacteria’ is commonly seen in iron-deficient patients (Dallman, 1987).

Iron sequestration is an important innate host defense mechanism because many pathogens depend on this essential element. As a consequence, availability of body iron is strictly controlled and bound to proteins such as transferrin and ferritin (Cassat and Skaar 2013).

Iron, Nutrition, Minerals, Immunity, Immune system

Selenium

Selenium is an important component of the body’s antioxidant system, protecting the body against oxidative stress, a natural by-product of the body’s metabolism. There is now considerable evidence that selenium plays a key role in the functioning of the immune system.

This relates to its role in regulating oxidative stress, redox, and other cellular processes in nearly all tissues and cell types, including those involved in innate and adaptive immune responses (Hoffmann et al, 2008).

Interestingly research demonstrates that inadequate selenium status is linked to the incidence, severity, or disease advancement of some viral infections
(Broome et al, 2004 and Guillin et al 2019); Arthur and colleagues when examining selenium and immunity concluded that deficiency can result in the creation of proinflammatory compounds that would influence risk toward diseases such as heart disease and cancer (Arthur et al, 2003).

Zinc

Almost all cells in our body contain zinc, a vital nutrient for growth and development. The highest concentrations are found in muscle, testes and bone. The body tightly regulates zinc levels. Stress and infections for example cause plasma zinc levels to fall. Zinc has a key role as a catalyst in a wide range of reactions and a large number of enzymes. A study by Maret suggests this and he concluded that the human genome encodes up to 3,000 zinc proteins.

Much evidence points to zinc having a strong role in the immune system and wound healing. Research shows that zinc affects multiple elements of the immune system, from the barrier of the skin to gene regulation within lymphocytes (Shankar and Prasad, 1998). Maywald and colleagues reported that both zinc insufficiency as well as excess leads to changes in immune cell numbers and activities, which results in increased susceptibility to infections and development of inflammatory diseases (Maywald et al, 2017). Interestingly, zinc has the ability to reduce oxidative stress which has been shown to help ward off disease.


* Please note these are approximate values and can vary based on recommended reference values employed.
** Criteria for establishing zinc requirements are based on categorizing diets as high, medium and low bioavailability of zinc. For detailed information please refer to WHO Requirements 1998.
*** Iron requirements fluctuate throughout the life course. Iron needs increase during menstruation, pregnancy, and periods of rapid growth such as early childhood and adolescence. Recommended levels are based on bioavailability of iron from certain diets and vary from 15% bioavailability to 5%.
 
References
 
Arthur, JR; McKenzie, RC and Beckett, GJ (2003) Selenium in the Immune System, The Journal of Nutrition, Vol 133 (5), pp:1457S–1459S [Online] Available at: https://academic.oup.com/jn/article/133/5/1457S/4558526 (Accessed on 15th April 2020)
 
Broome, Broome CS; McArdle, F; Kyle, JAM;  Andrews, F; Lowe, NM;  Hart, CA;  Arthur, JR and Jackson,MJ (2004) An increase in selenium intake improves immune function and poliovirus handling in adults with marginal selenium status. The American Journal of Clinical Nutrition, Vol 80 (1), pp:154–162 [Online] Available at: https://academic.oup.com/ajcn/article/80/1/154/4690273 (Accessed on 17th April 2020)
 
Cassat JE, Skaar EP (2013). Iron in infection and immunity. Cell Host Microbe. 13(5) pp:509–519. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676888/ (Accessed on 21st April 2020)
 
CDC (2020) Micronutrient Facts. [Online] Available at: https://www.cdc.gov/nutrition/micronutrient-malnutrition/micronutrients/index.html (Accessed on 20th April 2020)
 
Dallman, PR (1987) Iron Deficiency and the Immune Response Am J Clin Nutr 46(2):329-34.[Online] Available at: https://pubmed.ncbi.nlm.nih.gov/3303900/ (Accessed on 18th April 2020)
 
Depford, A; Baldi,G; Bose,I; Badham, J; Knight, F;Klemm, and dePee, S (2019) Requirements not Met by Diets High in Staple Foods [Online] Available at:
https://sightandlife.org/wp-content/uploads/2018/12/SALMZ_0218-1.pdf (Accessed on 21st April 2020)
 
Dhur, A and  Galan, P and  Hercberg, S (1991) Folate Status and the Immune System Prog Food Nutr Sci 15(1-2):43-60.[Online] Available at: https://pubmed.ncbi.nlm.nih.gov/1887065/ (Accessed on 17th April 2020)
 
Djoko, KY; Ong, CL Y; Walker, MJ and McEwan, AG (2015) The Role of Copper and Zinc Toxicity in Innate Immune Defense against Bacterial Pathogens J Biol Chem 290(31): pp18954–18961 [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521016/ (Accessed on 18th April 2020)

EFSA (2015) Scientific Opinion on Dietary Reference Values for copper. [Online] Available at: https://www.efsa.europa.eu/en/efsajournal/pub/4253 (Accessed on 18th April 2020)

Gombart AF; Pierre A and Maggini S (2020). A Review of Micronutrients and the Immune System-Working in Harmony to Reduce the Risk of Infection. Nutrients, Vol 12 (1) [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/31963293 (Accessed on 29th March 2020)
 
Guillin, O.M.; Vindry, C.; Ohlmann, T.; Chavatte, L (2019) Selenium, Selenoproteins and Viral Infection Nutrients2019, 11(9), 2101 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/31487871 (Accessed on 21st April 2020)

Hoffmann, PR and Marla J. Berry, MJ (2008) The influence of selenium on immune responses. Mol Nutr Food Res; 52(11): 1273–1280. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723386/ (Accessed on 15th April 2020)
 
Maret W (2013) Zinc biochemistry: from a single zinc enzyme to a key element of life. Adv Nutr. 4(1)pp:82–91. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3648744/  (Accessed on 20th April 2020)

Maywald, M; Wessels, I and  Rink, L (2017) Zinc Signals and Immunity Int J Mol Sci 18(10): 2222.[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5666901/ (Accessed on 17th April 2020)

Mikkelsen K., Apostolopoulos V. (2019) Vitamin B12, Folic Acid, and the Immune System. In: Mahmoudi M., Rezaei N. (eds) Nutrition and Immunity. Springer, Cham
 
Shankar ,  AH , and AS Prasad (1998)  Zinc and Immune Function: The Biological Basis of Altered Resistance to Infection Am J Clin Nut 68(2 Suppl):447S-463S. [Online] Available at: https://pubmed.ncbi.nlm.nih.gov/9701160/ (Accessed on 17th April 2020)

Soyano, A and M Gómez M (2008) Role of Iron in Immunity and Its Relation With Infections Arch Latinoam Nutr 49(3 Suppl 2):40S-46S [Online] Available at: https://pubmed.ncbi.nlm.nih.gov/10971835/ (Accessed on 15th April 2020)

Semba RD (2012). The historical evolution of thought regarding multiple micronutrient nutrition. J Nutr 142(1):pp:143S–56S. [Online]Available at: https://pubmed.ncbi.nlm.nih.gov/22157539/ (Accessed on 20th April 2020)

UNICEF (2020) Micronutrients [Online] Available at: https://www.unicef.org/nutrition/index_iodine.html (Accessed on 20th April 2020)

World Health Organization (2020) Food and Nutrition tips during self-quarantine [Online] Available at: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/food-and-nutrition-tips-during-self-quarantine (Accessed on 2nd April 2019)

World Health Organization (2020) WHO launches new global influenza strategy [Online] Available at: https://www.who.int/news-room/detail/11-03-2019-who-launches-new-global-influenza-strategy (Accessed on April 7th 2020)

WHO (1998) Vitamin and mineral requirements in human nutrition Second edition. https://apps.who.int/iris/bitstream/handle/10665/42716/9241546123.pdf?ua=1

Wu D; Lewis E D., Pae M and Meydani Simin N (2019) Nutritional Modulation of Immune Function: Analysis of Evidence, Mechanisms, and Clinical Relevance Frontiers in Immunology  Vol 9 pp 31-60  [Online] Available at: https://www.frontiersin.org/articles/10.3389/fimmu.2018.03160/full (Accessed on 17th April 2020)

The Convergence of COVID-19, Climate Change and Malnutrition

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When I set out to write this piece about COVID-19, climate change and malnutrition, I asked myself whether there might be anything new that I could add to the debate, given the myriad blogs, commentaries and webinars already proliferating on the subject. In my quest for lasting solutions to the global scourge of malnutrition, it is important for me not to lose sight of the big picture, to learn from the past, and not to jump on the bandwagon when global priorities change.

In my hometown in Germany, from where I am writing these lines, the lockdown following the outbreak of the COVID-19 pandemic has been relaxed slightly this week; in addition to grocery stores and pharmacies, small shops are now permitted to open again. We have not been hit really hard here in terms of food supply over the past weeks. Following the initial wave of panic buying, the supermarket shelves are now restocked, and innovations are occurring in the supply chain. Besides home delivery, a drive-in system for purchasing fruit and vegetables has been set up. You order and pay at a booth, and the guys take the pre-packed box with fresh produce from the ramp and load it into the trunk of your car. This development allows certain businesses to keep trading during this difficult time, certain jobs to be protected, and the supply of fresh produce to the population to be continued.

Nevertheless, in Germany ­– a country well known for its generous social security system ­– even before the crisis, no fewer than 1.65 million people were dependent on food banks. Many food banks in the country have temporarily stopped operating in order to protect their employees and volunteers, with the inevitable effect of depriving customers of essential food supplies.

So much for the situation in Germany. To reflect on the situation in the USA – which is in consequence of COVID-19 is experiencing job losses of 26.4 million, unprecedented since the Great Depression – would far exceed the scope of this commentary.

The potential for a new global food and nutrition crisis

COVID-19 is having its most devastating impact, however, on low-wage and migrant laborers (and their families) in low- and middle-income countries (LMICs) as a result of the lockdowns and border closures imposed to contain the spread of the virus. When these workers lose their jobs, they don’t get paid, and neither they nor their families can eat. The expected economic downturn triggered by COVID-19 will exacerbate this dire situation all around the world. It will come as no surprise that there are people already today who claim that they are more scared to die of hunger than of COVID-19. In 2019, according to the 2020 Global Report on Food Crises, 135 million people were affected by acute food insecurity, with an additional 183 million people subsisting on its fringes. These individuals are likely to slide into hunger and even starvation due to the COVID-19 outbreak this year. Moreover, according to the World Food Programme (WFP), some 300 million primary school children have been robbed of their regular, and often sole, daily nutritious meal at school due to school closures.

Although the UN Food and Agriculture Organization (FAO) expects a record wheat harvest in 2020 and reported low food commodity prices for March of this year, countries in Southeast Asia have increased trade barriers and imposed export bans on food items such as eggs (Thailand) and rice (Vietnam and Cambodia, on a temporary basis). Moreover, the lockdown has already led to rioting in the streets in some countries. There is an uncomfortable sense of reliving the 2007­–2008 food price crisis when “…weather shocks, greater demand for grain-fed livestock among a growing global middle class, biofuel development from grain crops, food stock hoarding, and globalized trade in food commodities … increased prices and dwindling grain stockpiles have caused civil strife and political instability.”

‘Nutrition in the Perfect Storm’

This quote is taken from an article entitled ‘Nutrition in the Perfect Storm’ that we published in Sight and Life Magazine in 2008, raising concerns about widespread micronutrient deficiencies during the food price crisis and the detrimental consequences of this development for nutritional status, health and wellbeing. During crises such as drought, flooding and locust plagues, poor families suffer reduced dietary diversity and forgo the consumption of relatively expensive micronutrient-rich foods such as eggs, meat, fruit and vegetables in order to fill their bellies with empty calories from starchy staples and energy-dense processed foods. The recommendations provided in our 2008 paper are still relevant for the current crisis: “… support micronutrient supplementation, fortification and food-based strategies to address micronutrient malnutrition among vulnerable population groups…” to mitigate the development of “a potential ‘lost generation’ of unhealthy children, and irreversible economic loss.”

The food price crisis of 2007–2008 was a contributory factor in the Arab Spring in the early 2010s – a protest movement across North Africa and the Middle East that in many cases triggered violent crackdowns whose long-term consequences are still being felt around the world today. With its power to destroy lives and livelihoods, COVID-19 has the potential not just to damage the health and wellbeing of populations but to trigger civil unrest, violence, new wars and increased tides of migration unless it is tackled effectively not only in the wealthy West but particularly in LMICs. Its effects are insidious and its ramifications far-reaching.

In this context, it is also worrying that the COVID-19 pandemic has led to the deferral of measles immunization campaigns even in countries that are experiencing a measles outbreak. This will likely be compounded by the UN recommendation to suspend planned mass vitamin A supplementation for children under 5. It is questionable how well alternative distribution routes will work as suggested. The re-emergence of vitamin A deficiency-related blindness and mortality in children will be the grim consequences. Granaries may be full for the moment at least, but the expected supply chain disruptions caused by the COVID-19 pandemic will probably cause more severe malnutrition than was witnessed in the aftermath of the 2007–2008 crisis. Sight and Life has responded to the COVID-19 pandemic by coordinating demand for food, with a supply of fortified food and supplements to a number of grassroots NGOs in India, Rwanda and South Africa and with a GoFundMe crowdfunding page to raise additional resources.

The compounding effect of climate change

The COVID-19 pandemic would seem to overshadow previous global priorities. This week’s 50th Earth Day, with its theme of climate action, has reminded me of a silent disaster that has the potential to compound the present situation. Rising levels of carbon dioxide in the atmosphere not only heat up the globe, creating drought and other weather shocks, but also reduce the concentrations of essential micronutrients in major food crops such as rice, wheat, maize, pluses and potatoes, potentially compromising the nutritional intake and consequent health of future generations.  In the wake of the 2019 EAT-Lancet Report on Food, Planet and Health, Greg Garret and colleagues raised an intriguing concept: Can Food Fortification Help Tackle Climate Change? Data to support this notion is still limited, but given the massive contribution of food (and micronutrient) production to greenhouse gas (GHG) emissions, along with the fact that food and micronutrient production will need to increase in order to meet the needs of 10 billion people by 2050, this question certainly deserves further exploration. Relevant approaches involve analyzing agricultural and food value chains, assessing losses during food production, and identifying entry points to improve food quality and safety, including biofortification and post-harvest fortification.

Interest in climate-smart innovations is rising rapidly among the young entrepreneurs. At Sight and Life, we nurture and encourage such enthusiastic and passionate young professionals through the Elevator Pitch Contest by Sight and Life (EPC). Our most recent  EPC attracted entries from 45 countries and three times more applications than previous contests.

The time to act was yesterday

The time to act to mitigate the consequences that the combination of COVID-19 and climate change will have on nutrition was yesterday. Many countries around the world have policies in place for micronutrient supplementation and food fortification, but in many cases these are not well implemented or effectively enforced. A considerable increase of effort is required, despite the pressing challenges of COVID-19. This will be more than a stop-gap solution: it will also be an investment for the long-term future of individuals, societies, and economies as a whole – even, I have no doubt, of the global economy itself. For all we know, adequate micronutrient intakes as part of nutritious and safe diets can only increase population resilience in the face of crises – present and future.

COVID-19, climate change and malnutrition have converged to create an unprecedented challenge for the global nutrition community. The dangers for millions of people around the world are imminent and very real. More than ever before, the knowledge, insight and commitment of nutrition professionals are in demand. In crisis, however bleak, there is always a sliver of opportunity. We may be obliged to distance ourselves physically at this challenging time, but we stand united as never before in our passion to end malnutrition in all its forms.

Our nutrition community has successfully engaged with other disciplines and sectors in the past decade, turning exciting new scientific insights into policies and programs that have the potential to deliver better nutrition for everyone on the planet. Now, as we face a universal enemy in the form of COVID-19, is the time for us to truly act as one to combat its effects.

The Role of Nutrition in the Immune System

Should we pay more attention? Part I of II

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As the coronavirus (COVID-19) is spreading rapidly across the globe, it is important to take note of the approaches that can help prevent and fight infections, particularly viral infections. Evidence already suggests that viral infections are one of the world’s greatest public health challenges (WHO, 2020). The World Health Organization (WHO) estimates seasonal influenza results in 3-5 million cases annually. Today we understand hygiene and social distancing play a key role in protecting yourself and others from contracting a virus while also slowing the spread of infections. Here are a few simple ways to reduce your risk to infections:

– Wash your hands regularly for 20 seconds with soap and water or alcohol-based hand rub.
– Cover your nose and mouth when you sneeze or cough with a disposable tissue or flexed elbow.
– Avoid close contact with people who are sick.
– Stay at home and self-isolate from others if you feel unwell.

Incorporating nutrition

Good nutrition is fundamental to improving immunity. The immune system is the body’s defense against disease and infection and it has long been established that several factors influence the function of the immune system including stress, sleep and nutrition (Song et al, 2019; Patel et al 2012 and Gombart et al 2020). The WHO guidance on diet, especially during the current pandemic states that “good nutrition is crucial for health, particularly in times when the immune system might need to fight back” (WHO, 2020). Providing a diet high in nutritious foods rich in vitamins and minerals supports optimal function of the immune system by providing antioxidants to slow damage of cells caused by free radicals (Lobo 2010) or assisting in T-cell production (Cohen 2017). 

Although, presently, we do not have data concerning nutritional factors in relation to the risk and severity of viral diseases such as COVID-19 the role of nutrition in immunity has been well established. For example, a study on the role of vitamin A in the treatment of measles in children found a reduced risk of mortality and pneumonia when vitamin A was administered over two days (D’Souza and D’Souza, 2002). The European Journal of Clinical Nutrition concluded that “Without adequate nutrition, the immune system is clearly deprived of the components needed to generate an effective immune response” (Marcos et al, 2003). Good nutrition is thus important in supporting an optimum immune system which can reduce the risk of viral infections (Beck and Levander, 2000).

It is now recognized that the complex, integrated immune system requires several micronutrients that have essential, often synergistic roles at every phase of the immune response (Gombart et al, 2020). In fact, even marginal deficiencies in certain nutrients have been shown to impair the immune system (Gombart et al, 2020). Micronutrients are believed to work collectively to support an optimum immune system. Based on a variety of systematic and clinical data, vitamins AB6, B12C, D, E, folate, zinc, iron, copper, and selenium (read our Vitamin and Mineral: a brief guide) are particularly important to boosting immune response.

The chart below identifies the role of these vitamins in immunity and shares recommended amounts and sources in the diet. In a forthcoming post, we will highlight the important minerals supporting the immune system and the work Sight and Life has achieved over the past 30 years to ensure access to vital nutrients, especially for children and women of childbearing age.

*Current advice on supplementation concludes that consuming a balanced diet provides all the necessary nutrition required but where there are challenges in meeting dietary recommendations, supplements are a useful addition in helping meet our nutritional needs (EUFIC, 2020).

*Please note these are approximate values and can vary based on recommended reference values employed.

Interested in learning more, read Part II HERE.

References

Beck,MA and Levander, OA (2000) Host Nutritional Status and Its Effect on a Viral Pathogen The Journal of Infectious Diseases, Volume 182, Issue Supplement_1, Pages S93–S96 [Online] Available at: https://academic.oup.com/jid/article/182/Supplement_1/S93/2191642) (Accessed on 1st April 2020)

Cohen S, Danzaki K, MacIver NJ. Nutritional effects on T-cell immunometabolism. Eur J Immunol. 2017;47(2):225–235. doi:10.1002/eji.201646423

Charan, J; Goyal JP; Saxena, D and Yadav, P (2012) Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. J Pharmacol Pharmacother.3(4): 300–303. [Online] Available at:http://www.jpharmacol.com/article.asp?issn=0976-500X;year=2012;volume=3;issue=4;spage=300;epage=303;aulast=Charan (Accessed on 30th March 2020)

D’Souza RM and D’Souza R(2002). Vitamin A for treating measles in children. Cochrane Database Syst Rev.(1) [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/11869601 (Accessed on 8th April 2020)

EUFIC (2020) Food and coronavirus (COVID-19): what you need to know [Online] Available at: https://www.eufic.org/en/page/food-and-coronavirus-covid-19-what-you-need-to-know (Accessed on 2nd April 2020)

Gombart AFPierre A and Maggini S (2020). A Review of Micronutrients and the Immune System-Working in Harmony to Reduce the Risk of Infection. Nutrients, Vol 12 (1) [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/31963293. (Accessed on 29th March 2020)

Gysin DV, Dao D, Gysin CM, Lytvyn L, Loeb M (2016). Effect of vitamin D3 supplementation on respiratory tract infections in healthy individuals: a systematic review and meta-analysis of randomized controlled trials. PloS one.11(9).[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025082/ (Accessed on 1st April 2020)

Hemilä H, Louhiala P (2013). Vitamin C for preventing and treating pneumonia. Cochrane database of systematic reviews (Issue 8) [Online] Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005532.pub3/abstract (Accessed 2nd April 2020)

Song, H  Fall,K; Fang,F; Erlendsdóttir,H; Lu, D; Mataix-Cols, D; Fernández de la Cruz, L;  D’Onofrio; BM; Gottfreðsson,M; Almqvist, C; Unnur A Valdimarsdóttir (2019) Stress related disorders and subsequent risk of life threatening infections: population based sibling controlled cohort study. BMJ 367: l5784 [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812608/ (Accessed of 7th April 2020)

Charan, J; Goyal JP; Saxena, D and Yadav, P (2012) Vitamin D for prevention of respiratory tract infections: A systematic review and meta-analysis. J Pharmacol Pharmacother.3(4): 300–303. [Online] Available at:http://www.jpharmacol.com/article.asp?issn=0976-500X;year=2012;volume=3;issue=4;spage=300;epage=303;aulast=Charan  (Accessed on 30th March 2020)

Lee, GY and Nim Han, S (2018) The role of Vitamin E in Immunity. Nutrients 10(11): 1614 [Online] Available at :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6266234/ (Accessed on 2nd April 2020)

Lobo V, Patil A, Phatak A, Chandra N. Free radicals, antioxidants and functional foods: Impact on human health. Pharmacogn Rev. 2010;4(8):118–126. doi:10.4103/0973-7847.70902

Marcos, A., Nova, E. & Montero, A (2003). Changes in the immune system are conditioned by nutrition. Eur J Clinical Nutrition 57, S66–S69 [Online] Available at: https://www.nature.com/articles/1601819 (Accessed on 7th April 2020)

Meydani SN1, Han SN, Wu D. Vitamin E and immune response in the aged: molecular mechanisms and clinical implications. Immunol Rev.205pp:269-84.[Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/15882360 (Accessed on 8th April 2020)

Mikkelsen K., Apostolopoulos V. (2019) Vitamin B12, Folic Acid, and the Immune System. In: Mahmoudi M., Rezaei N. (eds) Nutrition and Immunity. Springer, Cham

Moriguchi S and Muraga M (2000) Vitamin E and immunity. Vitam Horm.(Vol 59) pp:305-36 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/10714244  (Accessed on 1st April 2020)

Patel SRMalhotra AGao XHu FBNeuman MIFawzi WW (2012) A prospective study of sleep duration and pneumonia risk in women. Sleep1;35(1):97-101 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/22215923(Accessed on 8th April 2020)

Rall LC  and Meydani SN (1993) Vitamin B6 and immune competence. Nutr Rev. Vol 51(8):217-25 [Online] Available at: https://www.ncbi.nlm.nih.gov/pubmed/8302491 (Accessed on 2nd April 2020)

Tamure; J; Kubota,K; Murakami H; Sawamura, M; Matsushima T; T;Tamura, Saitoh, T; Kurabayshi, H and Naruse, T(1999)  Immunomodulation by vitamin B12: augmentation of CD8+ T lymphocytes and natural killer (NK) cell activity in vitamin B12-deficient patients by methyl-B12 treatment Clin Exp Immunol Vol 116(1): 28–32.[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1905232/ (Accessed on 13th April 2020)

WHO (2020) Food and Nutrition tips during self-quarantine [Online] Available at: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/food-and-nutrition-tips-during-self-quarantine  (Accessed on 2nd April 2019)

World Health Organization (2020) WHO launches new global influenza strategy [Online] Available at: https://www.who.int/news-room/detail/11-03-2019-who-launches-new-global-influenza-strategy (Accessed on April 7th2020)

WHO (1998) Vitamin and mineral requirements in human nutrition Second edition. https://apps.who.int/iris/bitstream/handle/10665/42716/9241546123.pdf?ua=1

Zhiyi Huang;Yu Liu;Guangying Qi; David Brand and Song Guo Zheng (2018) Role of Vitamin A in the Immune System. J Clin Med  7(9): 258. [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162863/(Accessed on 28th March 2020)

Zhou, Jian MD*; Du, Juan MD*; Huang, Leting MD; Wang, Youcheng MD; Shi, Yimei MD; Lin, Hailong MD(2018) Preventive Effects of Vitamin D on Seasonal Influenza A in Infants – A Multicenter, Randomized, Open, Controlled Clinical Trial The Pediatric Infectious Disease Journal Vol 37 (8) pp 749-754 [Online] https://journals.lww.com/pidj/fulltext/2018/08000/Preventive_Effects_of_Vitamin_D_on_Seasonal.5.aspx (Accessed on 2nd April 2011)

Spotlight: Gratitude to frontline workers at the time of coronavirus

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At nearly six months pregnant, Vidyarani learned that her neighborhood anganwadi center was closing due to the coronavirus (COVID-19) control measures. She depends on the anganwadi for a daily hot cooked meal to feed herself and her two-year-old daughter. Adding to her growing concerns, the lockdown caused her husband to lose his job. 

Anganwadis, or courtyard shelters, are primary childcare centers providing basic health care activities and nutritious meals for families while also serving as a pre-school for young children. Across all states in India, anganwadis serve either hot cooked meals or provide monthly rations that can be cooked at home. The Telangana state government, for instance, serves approximately half a million hot cooked nutritious meals daily to pregnant and lactating women through the anganwadis. As a part of this program, all beneficiaries also receive one egg every day. Here at Sight and Life, we know the importance of including eggs in a diet.

As COVID-19 quickly spreads around the globe, India has enforced a nation-wide lockdown to contain the disease creating unprecedented challenges for people like Vidyarani and their families. In addition to the closure of primary schools and anganwadi centers, children in rural India are now not attending school and therefore have to do without their guaranteed school meal, potentially worsening an already “severe” malnutrition problem in India. Even though the government has ordered state authorities to ensure provision of take-home rations and cash allowance during the lockdown, efforts to tackle acute malnutrition could still take a hit. It is in times like these that India’s frontline workers are making sure that no one in their communities goes hungry. Many anganwadi teachers are going door-to-door to deliver their weekly rations of rice, lentils, oil and eggs to beneficiaries.

COVID-19 Essentials Delivery

In this photo, tweeted by the Women and Child Development Ministry of Telangana, an anganwadi teacher delivers take-home rations including eggs to the homes of lactating mothers in the tribal region of Mulugu district via her scooter. Women like Vidyarani and their families are grateful for these workers delivering essential food items.
 

Opinion: Engaging nutrition to improve pregnancy outcomes

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On December 17, 2019, Devex published “Opinion: Engaging nutrition to improve pregnancy outcomes” by Klaus Kraemer, managing director of Sight and Life and adjunct associate professor at the Johns Hopkins Bloomberg School of Public Health. The full article can be read here on Devex.

Abstract

Good nutrition sets off a ripple effect. It can dismantle inequity, poverty, and poor health and drive progress at every stage in life. It supports physical and cognitive development, helps prevent a number of medical conditions — from spina bifida to diabetes — and saves lives.

During and after pregnancy, nutrition demands are greater — as are the consequences of not meeting them. For mothers, ensuring a healthy pregnancy limits the risk of life-threatening complications. And for their children, good nutrition during pregnancy can be the difference between being born healthy and being born physically or mentally disadvantaged.

It is critical that we sustain our momentum on nutrition, a task that requires greater investment in cultivating a cadre of leaders to take us there, argues Klaus Kraemer, director at Sight and Life.

While diet diversity remains the preferred means for women to meet nutrient requirements during pregnancy, many nutrient needs cannot be met through diet alone, especially in resource-constrained settings. As such, it is imperative that we reach women and girls with effective interventions for improving maternal nutrition that are ready for global scale-up now. Multiple micronutrient supplementation, or MMS, during pregnancy could be one way to help meet maternal nutrition needs.

Read the full article on Devex here.

Elevator Pitch Contest: 

Where Are They Now? Part II

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The Elevator Pitch Contest (EPC), founded by Sight and Life, is a competitive platform for students and young professionals to present their innovative ideas in front of a distinguished team of experts, investors, and the nutrition science community. It is an interactive approach whereby an entrepreneur must boil down their concept into a precise and persuasive pitch in order to spark interest from potential financiers – a critical part of the entrepreneurial process as competition for research and investment funds increases.
 
To date, there have been three EPCs held, the first in Cancun during the Micronutrient Forum in 2016, the second in Boston during the American Society for Nutrition (ASN) in 2018 and recently in Mumbai during the 19th World Congress of the International Union of Food Science and Technology (IUFoST) in 2018. Three finalists sat down to chat with us about their progress and success since the competition.
 
The three finalists are:
 
Andrea Spray, London School of Hygiene and Tropical Medicine

At the EPC in Boston, Andrea presented a dietary intake innovation called INATU that measures the impact of women’s time on nutrition.

“[EPC] is a great opportunity to hone new practical skills, and to engage with top experts in your field. It really was a great honor to participate. It was a lot of work, but I think that you get as much out of it as you put in. This type of opportunity is rare for young entrepreneurs/students/innovators.” – Andrea Spray (EPC Boston)
 
EPC, Elevator Pitch Contest FinalistsAnne-Julie Tessier, Keenoa

During the EPC in Boston, Anne-Julie walked away with the first-place prize for her innovative artificial intelligence (AI) based food diary.

 “I would recommend EPC without a doubt! Because it is a unique and enriching experience to kick-start your company.” – Anne-Julie Tessier (EPC Boston)
 
Alex Warrington, Future Food Now

Pitched her solution for using aflatoxin at-risk groundnut cake as a by-product from oil crushing to be used as a feed source for insect farming at IUFoST and won. Find out more about her innovation here

“The EPC has helped me to better define my project and given me more confidence when presenting. I also met some great people whom I continue to speak with today.” – Alex Warrington (EPC Mumbai)

How has the EPC contest helped you? 

Andrea Spray (EPC Boston): Having just completed field work on the INATU pilot, the EPC helped me to quickly synthesize and prioritize key messages about our innovation, try to articulate them in a way that our target audience would find compelling, and really push the horizon of my own thinking about what comes next. 
 
Anne-Julie Tessier (EPC Boston): My team and I had pitched Keenoa to investors, but never had participated in such an event in the context of a scientific meeting before. The EPC helped me tailor my pitch to scientists and permitted us to reach a wider audience by presenting at ASN. It was an occasion of increasing awareness of our innovation among scientists and nutrition experts and it permitted us to grow our network globally.
 
Alex Warrington (EPC Mumbai): The EPC gave me the impetus to make my idea happen.

What did participating in the contest mean to you personally and your innovation?

Andrea Spray (EPC Boston): For me personally, it was the first time I was presenting my PhD dissertation research to a truly public audience, and to some of my “hero” experts in the field of nutrition. It was also the first time I had done an elevator pitch, and so I put in a lot of effort into optimizing my presentation for that purpose. Finally, I had never thought of the path of entrepreneurship before; the EPC provided insight into that world that I definitely would not have otherwise been exposed to. For the innovation, it was the first time to solicit feedback and impressions from a broad audience, and it provided helpful visibility to our work. 
 
Anne-Julie Tessier (EPC Boston): While some of my PhD colleagues were presenting their work in poster or oral sessions at the ASN conference, I was proud to attend the meeting as one of the Sight and Life elevator pitch finalist to present Keenoa. Participating and winning the EPC marked an important milestone for our company as it was the first time showcasing our innovation to international scientists.
 
Alex Warrington (EPC Mumbai): Before participating, I just had a concept which I was not sure I could see to fruition, but through participating I began to realize how important my project had become to me. I wanted to succeed and make my idea a reality.

Simone Frey, Managing Director of Atlantic Food Labs GmbH and EPC judge, with EPC finalist Anne-Julie Tessier.

Did you find the entire EPC experience useful? Why?

Andrea Spray (EPC Boston): The platform to present my research in such a dynamic format was the primary benefit of having participated in the EPC. The preparation alone prompted numerous conversations about the work that I otherwise would not have had at such an early point in the research process. I found the in-depth engagement with various Sight and Life colleagues enriching, as was the opportunity to learn about related work of my peers.
 
Anne-Julie Tessier (EPC Boston): The overall EPC experience was useful on many levels. One of the highlights of the EPC experience was our inspirational meeting with Simone Frey, Managing Director at Atlantic Food Labs GmbH and EPC judge. I could highly relate to her career path; it was refreshing and motivating to learn from a woman in entrepreneurship who also has a doctorate degree. It was also an honor to meet with other students from various universities who all work towards improving nutritional assessment; sharing our ideas and learning from their experience was enriching. The overall discussions with mentors, students and the incredible Sight and Life team, without whom this experience would have not been possible, were insightful with regards to entrepreneurship, graduate studies, intellectual property and much more.
 
Alex Warrington (EPC Mumbai): We had some great coaching on presentation content and delivery from Nirjhor Rahman of YGAP Bangladesh. I really appreciated meeting fellow finalists who were all so inspiring, and it was exciting to talk about possible solutions to problems such as aflatoxin contamination with like-minded entrepreneurs. The social media coverage and videos also provide me with quality future marketing materials for my project.

Klaus Kraemer, Managing Director of Sight and Life and EPC judge, along with Simone Frey, Managing Director of Atlantic Food Labs GmbH and EPC judge, award 2nd place to EPC finalist Andrea Spray for INATU.

What lesson(s) did you learn from your experience?

Andrea Spray (EPC Boston): So many things! First and foremost, I learned a lot about presenting research with an entrepreneurial mindset. The experience also reinforced for me how very different the circumstances are in low-income and high-income country settings for nutrition assessment. Several of my EPC “competitors” are working with state-of-the-art technology, whereas working in rural low-income settings we’re interested in low-tech solutions that can be transformative for the field. Our challenge is less the technology and more the overall system.
 
Anne-Julie Tessier (EPC Boston): I grasped the importance of networking with entrepreneurs and students; it is key in creating future collaborations and getting surrounded by insightful mentors.
 
Alex Warrington (EPC Mumbai): How to successfully pitch in only five minutes! I also had not been involved in filming before so I hope I have learnt some skills for being in front of the camera!

What is the current status of your idea/project?

Andrea Spray (EPC Boston): I am currently writing up results of the validation of using our innovative approach (i.e. wearable cameras and image-assisted 24-hour recall) to assess diet diversity and time allocation. That combined with results of our feasibility and acceptability research will be crucial in identifying next steps.
 
Anne-Julie Tessier (EPC Boston): Nutrition is key in chronic diseases prevention. Our mission at Keenoa is to empower dietitians by giving them state-of-the-art technologies to maximize their impact on the health of the population. We have reached a product market fit in Quebec, Canada. Now our goal is to expand commercialization in Canada and United States. We have initiated validation of Keenoa as a tool to assess dietary intake in research, results should be published soon!
 
Alex Warrington (EPC Mumbai): I am currently in discussions with universities and business to determine the best feed source and location for the pilot insect farm in Africa. I am slowly teaching myself WordPress and have created a website where you can follow the project’s progress: futurefooodnow.co.uk

Winners of the Elevator Pitch Contest, Alexandra Warrington and Alexandra Sanderson with Benedikt Suter, Board Member of Sight and Life, and Dr. V. Prakash, Chairman of IUFoST.

 

How has the funding from EPC help further your innovation?

Andrea Spray (EPC Boston): EPC funding covered my travel expenses to attend and participate in the ASN conference in Boston, thus enabling exposure to an audience of experts we would not otherwise have reached. With that exposure, I received truly valuable bits of feedback that I suspect will be incorporated into future work.
 
Anne-Julie Tessier (EPC Boston): The monetary award from the EPC helped us creating what we call food builders to be integrated in the Keenoa mobile app. These are to further facilitate data entry by the end user and increase accuracy of dietary assessment; it was the natural prolongation of food recognition from pictures of meals. 
 
Alex Warrington (EPC Mumbai): The funds are going to be used for the initial costs of research into the food safety of insects fed on the chosen aflatoxin contaminated feed source.

What are your future plans?

Andrea Spray (EPC Boston): With the conclusion of the validation research, I am wrapping up my PhD dissertation. I hope to defend that by the end of the calendar year. In the meantime, I am also ramping back up my nutrition consulting/research work, including a follow-on Drivers of Food Choice grant. It has been an incredibly challenging few months trying to get this research done, so in the near future I am looking forward to some much-needed R&R.
 
Anne-Julie Tessier (EPC Boston): With Keenoa, we aim to fundamentally change dietary assessment in dietetics practice and research field. My vision for Keenoa is to see all dietitians and nutrition researchers use it to accurately and precisely quantify the impact of nutritional interventions on the health of individuals and communities. Our future plans are to accelerate commercialization worldwide. To do so we will grow our team. On the tech side, as we collect data, we train our algorithms to get better at predicting food items from pictures.
 
Alex Warrington (EPC Mumbai): Once the food safety research has begun, I intend to apply for more funding to ensure that the business model is viable – exploring market opportunities for insects as food and feed.

For information on future Elevator Pitch Contests visit elevator-pitch-contest.org

Eggs and EGG-sternalities

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On August 6th, at the 2019 Asian Congress of Nutrition in Bali, Sight and Life organized a symposium on the topic of eggs, which represents one of its flagship programs. The session entitled “Achieving Improved Nutrition in a Sustainable Way – The Case of Increased Egg Consumption” gathered experts in the field of nutrition, sustainable business models, environmental sustainability, science and research and was skillfully moderated by Dr Regina Moench-Pfanner (ibn360).

The session made an important case on how crucial it is to go beyond nutrition and to increasingly account for externalities in our way of thinking and in the way we implement programs and projects. This shift in thinking has become necessary in light of pressing global issues such as climate change. Eggs provide a useful example to start unpacking some of these challenges.

The science can no longer be EGG-nored

The days where eggs were blamed for driving up cholesterol levels are thankfully over. Evidence is mounting regarding the benefits of eggs for child nutrition and potential benefits for women during pregnancy and birth outcomes. This power food is at last getting the attention it deserves.

Think of it – there is no food such as the egg. Dr Jeya Henry of the Clinical Nutrition Research Center in Singapore reminded the audience of the astonishing properties of this functional food: “from gelling, to emulsifying, to thickening and foaming properties, eggs’ form of proteins is simply incredible” he adds that “an average egg is roughly 50-60 g in weight. No other food on the planet has almost all the micronutrients and the most significant amino acid patterns packed in such a small quantity”.

Ms Gulshan Ara from icddr,b shared the recent and fascinating results from a trial conducted in Bangladesh where the effect of an egg-based nutritious snack was tested on child growth. Results showed that on average, intervention children became 2.55 cm taller compared to control children. Egg based nutritious snacks contribute to improving both linear growth and cognitive development in children <2 years of age.

Yet, although eggs’ nutritional value is undebatable, it would be presumptuous to assume they are the magic bullet… 

Indeed, there is an array of known and unknown externalities that come along the way and must be understood; acknowledged; and addressed.

“Eggs have the potential to be considered in 2020s as a sustainable and irreplaceable animal source food for improved nutrition.” Dr Klaus Kraemer

Environmental consequences of egg production

One of the key obstacles relates to the environmental consequences of the production of eggs, but also animal welfare issues. Using Life Cycle Assessment (LCA) methods, a recent study by Abín et al, conducted in Spain revealed that natural land transformation, terrestrial ecotoxicity and freshwater ecotoxicity were the top three most notably affected categories and that the highest source of environmental impact was production of hen feed (specifically soybean and palm oil cultivation), but also the breeding of young chicks to replace the exhausted laying hens. Such findings encourage the development of innovative triple duty solutions addressing the environmental externalities, without failing to address the over and under nutrition components.

“It’s time for nutritionists to design and adapt their solutions in the context of the entire supply chain and the environmental consequences of it.”  Dr Martin Bloem

Luckily, there are solutions. During the session, one of these solutions was shared by Srujith Lingala from Sight and Life. Through its Eggciting project, Sight and Life is working on making eggs available and affordable to low income households by supporting the introduction of innovative poultry business models in Ethiopia, India, Indonesia, and Malawi.

The Egg Hub

The ‘Egg hub’, one of Sight and Life’s recent innovations, is a centralized unit offering farmers high-quality, affordable inputs, extension services, training and market access. Through aggregation, egg hubs solve the supply-side challenges typically faced by small- and medium-

scale poultry farms. They can help countries with low-yield production systems make the transition to the efficient, high-yield systems that are associated with much lower market prices.

In Malawi, where the egg hub model was tested, initial findings point towards the fact that the egg hub has enabled 60 farmers to receive inputs and produce 4.5 million fresh eggs every year, but also to resell them within their communities. Each farmer makes a net income of USD 922 per year, 2.3 x the minimum wage in Malawi. Innovative farming models such as the egg hub are an effective and sustainable means of improving nutrition and increasing incomes of small and medium scale farmers.

In the present landscape where commitment for nutrition is at its peak and where the climate change debate is ever increasing, economically viable and sustainable solutions are welcomed as the interest to invest in these is significant.

Filling the egg gap

Public solutions exist as well. Dr Saskia de Pee (Fill the Nutrient Gap, WFP) shared the example of Indonesia where a social safety net program called Bantuan Pangan Non-Tunai (BPNT), that enables poor households to buy 15 kg of rice per month at a very low price, is transitioning to a commodity specific e-voucher. Following a cost of the diet analysis, FNG analyzed which locally available foods should be included in BPNT’s pre-determined local food basket to meet the household members’ recommended nutrient intake in the most cost-effective way. The results showed that the cost of a nutritious diet was approximately 1.2 million IDR/month per household, and the voucher value of 110 000 IDR/month per household (10% of the cost of nutritious diet). Eggs, rice, and green leafy vegetables were identified as the foods able to meet the most nutritional requirements for the lowest cost. Since then, they have been selected for the ‘Nutritious Package’ that was modeled for the BPNT program.

Watch out for unknown EGG-sternalities

What about other readily solutions that are coming to the market, such as JUST Egg and Impossible Burgers? Dr Martin Bloem, Director of the John Hopkins Center for a Livable Future, warns that “there are many unknown unintended consequences related to the production of these types of alternative forms of meat, particularly in terms of their nutrient composition, their use of antibiotics and water, as well as other chemical properties”. From a nutritional and environmental perspective, these alternative forms of meat need to be critically assessed.

Prioritize and compromise

Whilst animal welfare may be a priority in higher income countries, Environmental Enteric Dysfunction (EED) for instance, is more prevalent in lower resources settings and therefore present a higher priority to address. “At this stage, cages are critical to help reduce contact with feces and other hazards” explains Dr Klaus Kraemer from Sight and Life. “Chicken feces can affect the gut microbiota of children, and the difficulty of avoiding contact of children with feces can lead to chronic inflammation causing the gut to leak whereby the body burns the nutrients instead of using them for growth”. Klaus argues for the need to price externalities and to innovate even further for improved caging to successfully separate chickens from the children. It is our duty as nutritionists not only to help decision makers prioritize actions but to ensure the access of this power food to those who need it the most.

Are eggs EGG-citing?

Last but not least, consumer insights are primordial. Cultural factors play a role in many nutrition practices, including taboos or beliefs around egg consumption. Some of these insights were uncovered by Dr Maria Adrijanti from World Vision Indonesia, who throughout her presentation, made the case of increased egg consumption in Indonesia. The Eggciting project, a collaboration between Sight and Life, World Vision and DSM aims to increase availability, accessibility and consumption of eggs in Indonesia at the household level by addressing bottlenecks in the supply chain and boosting consumer demand. In terms of consumer demand, the project uses a social marketing approach to better understand some key issues including but not limited to: understanding household food purchasing power and decision-making; understanding how eggs are used in the daily diet; examining the awareness, knowledge, attitudes and beliefs around egg consumption; identifying key community influencers, their role and motivations in offering dietary advice, and specifically their view on eggs.

One initial insight regarding the traditional Indonesian diet and Sulawesi diet and egg consumption revealed that there are two kinds of chicken eggs that are popular in Indonesia – the native egg and the ‘broiler’ egg. The former is perceived as more delicious, and fresher compared to the broiler eggs and is usually used as medicine.

Thinking in systems

Daring to think beyond our current actions, daring to imagine the far-reaching and unintended dramatic consequences of our actions can be daunting and uncomfortable. A systems way of thinking isn’t easy for those of us who’ve been programmed to think in siloes, but our attitude of denial is catching up with us. The nutrition community can no longer play deaf towards the ever-increasing global environmental cries and concerns of the planet, which must go hand in hand with what we are trying to achieve. The fight against malnutrition is a complex one, which requires innovative solutions which can address that complexity. Learning from our mistakes isn’t just the cumbersome thing to do, it’s the ethical thing to do. This session was an egg-cellent example of the kinds of conversations we should increasingly be having – conversations that aim to understand the perspectives of the different sectors involved, and whose objective is to not only design new solutions but to adapt and re-adapt existing ones to the current context.

The egg isn’t unbeatable, it’s adaptable

“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn” – Alvin Toffler

ACN 2019

A Tale of Two Conferences, One Ultimate Goal

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The 2019 summer conference season opened in an intense way for me. With barely one intervening week, I had the privilege of attending two fascinating conferences that differed in most aspects but converged on the complementary pathways towards the common and ultimate goal of a better-nourished and healthier world.

Reflections from Baltimore

The first conference was Nutrition 2019, the annual meeting of the American Society for Nutrition, hosted in Baltimore, home to Johns Hopkins University, one of the leading nutrition research institutions in the world. Five intense days with hundreds of lectures, presentations, panels and posters organized in themes ranging from cellular and physiological metabolism to global and public health nutrition. As expected, great learning and networking, accompanied by the recurring wish one could multiply oneself so as not to miss one or more exciting parallel sessions. Nearly 3,500 participants from scores of countries, albeit with diminished participation from Africa and Asia compared to last year’s edition. I had the opportunity to present a poster on complementary food safety and quality in Rwanda (poster shown below), the detailed content of which was recently published in Maternal & Child Nutrition.

A few topics stood out. Perhaps the most emergent was the microbiome, a theme that has now migrated from the margins to the center of clinical and translational nutrition. The most thought-provoking microbiome presentation in my view was by Dan Knights from the University of Minnesota. In a panel titled “You Are What Your Microbes Eat” exploring the interplay between diets and the gut microbiome, he borrowed from physics the metaphor of dark matter to describe the countless compounds present in foods that are not captured on any nutrition label yet strongly influence microbiome composition and metabolism. Intriguingly, responses of specific gut microbes to the same foods are often different from person to person, pointing to the need for a personalized approach to the microbiome and nutrition and mirroring the emergence of nutrigenomics and personalized nutrition, another salient topic in the conference.

Sustainability was another theme on the move towards the mainstream of nutrition, certainly influenced by the EAT-Lancet Food in the Anthropocene report[i]. The challenges of nudging consumers and food systems towards healthy diets and sustainability, and the multiple tradeoffs involved, were highlighted in several sessions, including a dense panel discussion moderated by Klaus Kraemer, Managing Director of Sight and Life, and Eileen Kennedy, Dean of the Friedman School of Nutrition Science and Policy at Tufts University.

A special event, rich in historical perspective and fond memories, was the Kellogg Prize for Lifetime Achievements in International Nutrition Lectureship. Marie Ruel, Director of IFPRI’s Poverty, Health, and Nutrition Division, was this year’s prize recipient, recognized for her outstanding work of more than 25 years on policies and programs to alleviate poverty, food insecurity and malnutrition in developing countries. What made the ceremony particularly touching was the presence of many other leaders in the field who were mentors, colleagues, or mentees of Marie’s, a testimony to the expanse and depth of her contributions.

My overall perception of the field, partly from having attended both the 2018 and 2019 editions of ASN, is that it is currently in a stage of incremental and relatively modest advances; areas such as the microbiome and personalized nutrition show tantalizing promise, yet they involve complex science in its early stages, which likely implies a translational pathway a few years long, not to mention translational challenges to low-resource contexts.

Impressions from Hyderabad

The second conference was the Agriculture, Nutrition & Health (ANH) Academy Week 2019. Held in Hyderabad, the bustling and sprawling high tech hub of Southern India, this was a much smaller and more intimate event of about 400 participants from a broad array of food system-related disciplines. It was the Academy Week’s fourth edition, the previous ones having been held in Addis Ababa, Kathmandu and Accra. The first two days were dedicated to learning labs, followed by a three-day research conference. Overall, a superb interdisciplinary and cross-sectoral gathering that stretched participants’ world views and thinking across boundaries.

Srujith Lingala of Sight and Life participating during ANH.

And it was the progress in the interdisciplinary dialogue on food systems that impressed me the most. We have been talking about ag-nutrition integration for a few years now, but the road has been bumpy and uphill, with dissonances ranging from language to priorities and expectations. It felt so much smoother and fluid at this Academy Week. To me, this gathering was one among a number of signals that we are now reaching an upland in which we can switch gears towards more integrative thinking and holistic approaches to the food system. These refined approaches incorporate not just nutrition and health but also sustainability – now inextricably linked with agriculture –, equity and socioeconomic development, while acknowledging the need for inclusive governance to co-create win-wins and negotiate inevitable tradeoffs with fairness. The good research presented at the conference included innovative tools (such as Agrifood) to facilitate the complex and consequential decision-making involved.

ANH, Acedemic Week, India, Nutrition, Agriculture
Group photo from Agriculture, Nutrition & Health (ANH) Academy Week 2019 held in Hyderabad, India.

Final Thoughts

I thus stepped into the second half of 2019 with renewed optimism from these two conferences and the complementary and increasingly convergent learning agendas they represent. Health system-based approaches and the first thousand-day focus remain vital, but are insufficient to address the multiple burdens of malnutrition. Food system-based approaches can benefit the whole population from cradle to grave, spanning the food insecurity-malnutrition spectrum and addressing other dimensions also relevant to nutrition outcomes. With these two wings in tandem, we will be able rise faster towards a better-nourished, healthier, fairer, and more sustainable world.

For additional pictures from ASN visit here and for ANH visit here

[i] Willet et al., “Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems”. Lancet 2019; 393: 447–92.

The IV World Public Health Nutrition Congress in Madrid

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The IV World Public Health Nutrition Congress held within NUTRIMAD in Madrid from October 24 – 27, 2018 at the Melia Castilla Hotel. As with its predecessors in Barcelona (2006), Oporto (2010), and Las Palmas in the Canary Islands (2014), an Iberian setting hosted the event. Sponsored by the Spanish Society of Community Nutrition (SENC), the meeting was organized by CEU San Pablo University of Madrid, with Prof. Gregorio Varela-Moraias presiding. Some 450 speakers, professionals and students were registered; the majority was from Spain, along with attendees from Austria, Belgium, France, Finland, Greece, Iran, Ireland, Israel, Italy, Portugal, the Netherlands, and the UK. Additionally, Argentina, Brazil, Canada, Guatemala, Mexico and the USA from the Western Hemisphere had attendance at the WPHNC. African and Asian nations were not represented.

Packed into a diverse and dense Program over the four days were a total of 51 sessions: 4 plenary lectures; 4 lectures; 21 symposia; 12 conferences; 5 round tables; 4 presentations; and 1 workshop. Fifty-four free papers were distributed among 6 topical oral-presentation sessions and 196 posters were scheduled over the course of two of the congress days. A plurality of sessions was devoted directly or tangentially to the issues of overweight/obesity and metabolic disorders. This report focuses primarily on micronutrient aspects, but the Mediterranean diet science and policy is a cross-cutting linkage between the two domains. 

Notable Lectures

The opening night’s inaugural sessions were highlighted by the Keynote Plenary lecture “What have we learned from Nutrigenomics?” by Prof José Ordovás of Tufts University and the Nutrition and Genomics Laboratory at the Jean Mayer USDA Human Nutrition Research Center on Aging in Boston. His discipline examines the interaction between genetic traits and nutritional exposures. He began by taking a 3-decade tour of advances in both domains. On the genetics side, the human genome was sequenced allowing precise and exact localization of genes both by single-nucleotide polymorphisms (SNP) and genome-wide association studies (GWAS). By contrast, the exactness of quantifying dietary intake is lacking. This can vitiate the stability of associations between the domains, limiting achievements in nutrigenetics. His laboratory is working on sensors aimed at quantifying the foods and beverages (and their nutrients) as they pass from the diet to the host.

Ordovás’ nutrigenetics approach has shown interactions between the fat content of the diet and HDL cholesterol and triglycerides in relation to the genetic polymorphism of the hepatic lipase (LIPC) gene. The dominant allele is CC or CT, whereas the TT is the minor form. In the Boston Puerto Rican Health Study, an unfavorable association between dietary saturated fat intake and lipid status was found in those with the TT modification. To confirm causality in an intervention study, Hispanic subjects were randomized to a Western (high-fat) or Caribbean (low-fat) for 4 weeks; those with the major allele showed a protective effect against HDL elevation on the higher fat exposure.

Dr. Ordovás also mentioned the advent of methylomics (methylation omics), which is the subdivision of epigenomics that assesses the degree of methylation of DNA in the nuclear material of cells. Epigenetics is the alteration of the original genetically-determined transcription for proteins due to acquired changes along the structure of the DNA helices. Insofar as DNA methylation is influenced by the dietary intake of specific constituents (folate, vitamin B12, betaine, choline and others), its relevance to micronutrient nutrition is obvious.

Another important plenary lecture was that of Dr. Mario Arevlo, Chairman of the FAO’s Committee on World Food Security entitled ”Food and Nutrition Security in a Globalised World.” In a historical context, the concept of food as a human right is a precept dating to 1947, two years after the founding of the United Nations and the Food and Agriculture Organization. 

The second goal of the Sustainable Development Goals (SDGs) is touted as the embodiment of the food and nutrition agenda; the speaker asserted that elements related to food security could be identified across all 17 SDGs. Three major threats to food security and barriers to its resolution are extraordinarily menacing.  The first is conflicts, notably the confrontations in the Middle East as in Yemen, Syria and Palestine. Climate change offers a host threats soil and waters, the natural flora and fauna, the abundance of food harvested from the sea, and the yield of crops and other edible plants across the world. Mass migrations, occurring all over the world in both visible and less obvious manners, displace people from agricultural pursuits, while creating a tenuous relationship between food stocks and people. 

Food policy has a small – and largely reactive – role to play in the face of the aforementioned obstacles of conflict and migration. A food systems approach, which links agriculture, food production and trade with the nutritional needs of the human and non-human population, is currently being developed and refined.  It is fundamental to assuring food security despite the paradoxical situations that pre-harvest, post-harvest and in-home losses affect up to 50% of all edible items grown, raised or captured and that over half of the adult population in the world suffers from overweight or obesity.

The Symposia

The symposium entitled “Coping with Vitamin D Deficiency: Benefits and Safety of Additional Vitamin D Intakes” first provided an overview on vitamin D nutrition, function, dietary sources, intake recommendations, safety and tolerable limits. It then provided a case history on contemporary research and policy in Iran. Because their traditional garments exclude solar exposure in schoolgirls, the Iranian government has begun a school-level intervention providing a monthly mega-dose of 50,000 IU in each of the 10 months of the school year to female students. The efficacy and safety of this measure had not been evaluated before his became national policy. A presenter outlined a nested placebo-controlled intervention in adolescent boys conducted to determine the efficacy among males. Over a 6 month period, the rate of low vitamin D levels fell from greater than 30% to less than 10% in the treatment group, whereas the no-treatment group of boys had a persistent low-status rate in three in ten subjects. Meanwhile, the Iranian government is exploring the feasibility of fortifying wheat flour universally with the vitamin; this is based on poor status and buoyed by a trial in which 25 µg of vitamin D3 (1000 IU) within 50 g of bread raised circulating 25 hydroxy-vitamin D by 30 nmol/L over 8 weeks in healthy adults. A final fortificant dose has yet to be assigned. 

A series of issues arose in the discussion. It was suggested that the lifestyle conditions of boys are distinct from those of girls, such that the response documented in the male cohort may not represent how girls would respond – or have responded. Analyzing a random sample among the girls already enrolled in the periodic supplementation would indicate if the current dosage is sufficient for them. A second point of contention was whether or not there was any rationale plan to transition from the school-based supplementation to reliance on the forthcoming programs of fortification of flour and bread. The current plan was to suspend school intervention when fortification is implemented, but no research to assure desirable outcomes has been planned. 

The symposium on “Dietary Surveys: An Overview” combined a researcher from France, from the United Kingdom and from Spain considering the social determinants and quantitative findings in relation to dietary surveys. On the quantitative side, an array of national surveys across the European Union – and in particular, a survey of Spanish consumers – outlined the adequate and deficient intakes of macro- and micronutrients through combined food records and 24-hour recall. Common to all, to a greater or lesser degree, however, was a lower than expected average, daily energy intake. This is attributed to systematic underreporting of food and beverage intake by the participants. This is paradoxical in light of the ascending prevalence of overweight and obesity. The presenters readily accepted the suggestions from the audience that inclusion of the doubly-labeled water method in a subgroup of the surveyed could allow a proportional energy adjustment to the nutrient intakes, and expression of nutrient density would be a better standpoint for comparison across international surveys.

The symposium on “Activating Nutrition Recommendations by Understanding Breakfast Habits” summarized a comparative, multi-centric study including the standardized analysis of national nutrition surveys from Canada, Denmark, France, Spain, UK and the US. It looked to establish normative values for the energy and macronutrient contribution of the morning meal to the total daily energy, finding a range of 16 to 21%. Using the make-up of the top tertiles for nutrient-richness and healthful pattern, a set of recommendations for breakfast composition was advanced. It was lamented that the hydration implications for the liquids consumed as breakfast was not included in the agenda. A cautionary note for the extrapolation and generalization to a wider geography was expressed insofar as breakfast habits in countries like Brazil and Guatemala diverged greatly from this Western pattern.

The Mediterranean Diet as a traditional cuisine has been declared a World Cultural Heritage by the UNESCO in Paris. The Mediterranean diet is based around fish and seafood, whole grains, fruits, vegetables and legumes with wine and ultra-virgin olive oil being the essential – albeit processed – items at the center  of the cuisine. Two symposia dealt with this as their central topic: “Mediterranean Diet in the 21st Century: A Holistic View” and “The Mediterranean Diet and Cardiovascular Prevention: The PREDIMED Trial.” Described in the first symposium was the geographic extent and variation within the general cuisine, and the ecological advantages for a sustainable environment as compared to other European and industrialized-nation cuisines. Both the anti-oxidant and anti-inflammatory properties and the various applications of omic techniques being applied to the study of consumers of the Mediterranean diet were reviewed. The PREDIMED trial compared cardiovascular mortality across three study groups.  Participants were randomly assigned to education on a low-fat diet (control group) or to one of two MedDiets, supplemented with either free virgin olive oil (1 liter/week) or nuts (30 g/day). With the trial results, published in, retracted from and republished in the New England Journal of Medicine, it can now reasonably concluded that both of the treatment diets equally reduced the risk of cardiovascular death. For those of us focused on micronutrients, these symposia underscore the obligation to broaden the focus to patterns of dietary selection.

Insights from the Free Papers

Of the 240 free-papers programmed, some 20 (9%) were directly or indirectly endowed with the name of a micronutrient (vitamin D, vitamin E, folate; omega-3 fatty acid, calcium, iron, zinc and selenium) or the implication of multiple micronutrients in the title. The most noteworthy and newsworthy free-paper came from the oral-papers series; it had the self-explanatory title of “Betaine homocysteine S-methyltransferase deficiency increases susceptibility to noise-induced hearing loss correlating with plasma homocysteinemia.” Since human deficiency of this enzyme had not been associated with altered homocysteine levels, this may represent a landmark observation. It has a provisional functional consequence (auditory acuity), and has theoretical implications for choline intake by persons with this polymorphism.

The Workshop

Photo Credit: Noel Solomons

The sole workshop of the Congress was relevant to nutritional quality and micronutrient intakes. It was sponsored by Nestlé and the Sant Joan de Deu Hospital in Barcelona, and presented a tool for fostering healthful dietary consumption in children. Called the NUTRIPLATO (Nutritious Plate), it is the latest generation of an idea pioneered by the American Institute for Cancer Research (the New American Plate) and the US Dietary Guidelines(MyPlate), which conceptualized the relative selection of food groups. The Spanish initiative involves the distribution of actual, reusable dinner plates with the partition of food groups and their proportion in meals depicted on the surface as shown in the Figure. About 350 of a targeted 1000 Catalan children have so far been enrolled; the primary outcome is the maintenance or achievement of a normal body weight with guidance form the NUTRIPLATO.

Mexico Hosts the XXII Latin American Congress of Nutrition

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The XVIII Latin American Congress on Nutrition was held in Guadalajara in the state of Jalisco in Mexico from November 11 – 16, 2018. Since 2016, the Presidency of the Latin American Society of Nutrition (SLAN) has been in the hands of Dr. Juan Rivera-Domarco, a graduate of Cornell University and currently the Director of the National Institute of Public Health (INSP) in Cuernavaca, Mexico. On January 1, 2019, the Presidency of SLAN will have passed from Juan Rivera and Mexico to Rafael Figueredo-Grijalba and Paraguay, for the following triennial congress in Asuncion in 2021. Meanwhile, Dr. Wilma Freire of Ecuador was installed as President-Elect of SLAN, such that her Andean nation will host of the 2024 meeting of SLAN.

The theme of the 22nd SLAN Congress was “Healthful Eating for a Sustainable Planet.” The watchword of the Organizers was the limitation of “Conflict of Interest,” interpreted as undisclosed involvement with the food and beverage manufacturers who constitute the commercial marketplace. None of these foods, drinks and snacks, deemed as unhealthy, were permitted as part of the Congress in sponsorship or on the premises; the boast was made that the congress was financed without industry support, relying on registrations, membership fees, and a major contribution from UNICEF as well as other NHOs, with some in-kind support by the local Jalisco authorities. In symbolic manner, the coffee break snacks were fresh fruits, accompanied by plain drinking water and coffee without sugar, creamer or artificial sweeteners. With limited funding, austerity was the watchword. Not a single performance by the Mariachimusical genre of Jalisco was seen in the Congress and the gala dinner was a bring-your-own-bottle affair.

Themes of the Congress were brought forward to its 1800 attendees, who brought 1280 free-papers as oral presentations or posters to the spacious confines of the Expo Guadalajara conference center. These were joined by 77 invited or arranged events, of which 55 were 1.5-hour Symposia, Thematic Panels or Discussion Forums.  An additional four were Plenary Lectures in the main auditorium. They included:

1) Brent Loken, Science Liaison Officer of EAT-Commission, with the topic directly crafted verbatim after the Congress’ title theme;
2) Barry Popkin of the University of North Carolina, with “Policies for the Prevention of Obesity and Chronic Disease in Latin America”;
3) Dr. Francesco Branca, Director of the Department of Nutrition for Health Development of the World Health Organization, with “the Double Burden of Malnutrition”; and
4) Cesar Victora, Professor Emeritus at the University of Pelotas in Brazil, with “the First 1000 Days and the Sustainable Development Goals.” 

The first three were based primarily on the excesses in nutrition whereas the last focused on stunting, which was attributed more to poverty, poor sanitation and inequality than to dietary factors.

The Congress wrapped up with a final plenary session in the format of an interactive panel discussion on the topic of “Nutrition Priorities on the Horizon of the Sustainable Development Goals (SDG).” It was moderated by Lynnette Neufeld of GAIN, President-Elect of the International Union of Nutritional Sciences, and including as panelists, Marc-André Prost of the World Food Program, Victor Aguayo of UNICEF, and Dr. Rafael Flores-Ayala of the Center for Disease Control and Prevention in Atlanta. The general consensus was sage and modest, with emphasis on harmonizing new policy initiatives with both the underlying evidence and the population needs in transparent focus.

The Dominant Thematic Thread of the Congress

The mantra for the global nutrition community has been malnutrition in all of its forms. The Program of the SLAN Congress covered a broad front of themes and topics. The most dominant, however, were aspects of quality, selection and provision of food and the adverse consequences from exposures to sugars, sodium, saturated and transfat, packaging and environmental toxins, as well as the issue of excess calories. Of 55 major, non-plenary sessions, 34 were in this domain. Nine had the terms obese or obesity in the titles. Four involved front or back nutritional labeling of commercial food.  So-called ultra-processing of commercial food was woven into this thematic area as well. The integration of the entire food system in terms of the social, cultural and environmental impact aspects of satisfying the foodstuff needs of populations at local, regional and global bases. The qualifying principle of “sustainable” accompanied many of these sessions, in line with the Congress title and the corresponding SDGs for 2030.

Outside of the major focus on dietary pattern, food- and ingredient-avoidance, and sustainability and food-system domains, there were assorted other topics treated in the major sessions. Across the life-cycle from infants, to pregnancy to aging, nutritional health issues were treated, as was nutritional and gastrointestinal health and the importance of phytonutrients. Certain sessions addressed methodological issues such as food security assessment, bioelectrical impedance and body composition and nutritional modeling.

The Micronutrient Agenda

Sessions dedicated to micronutrients were scarce, counted as one pre-congress event and five major sessions within the Congress Program. The Symposium and Workshop on “Lipid-soluble Nutrients in Human Milk: Pathway to International Collaboration” was a collaborative, pre-congress effort of the Fundacion Iberoamericana de Nutrición (FINUT) of Granada, Spain, the DSM Nutritional Products of Basel, Switzerland, and the Center for Studies of Sensory Impairment, Aging and Metabolism (CeSSIAM) in Guatemala. The nutrients of interest were vitamin D, vitamin E and omega-3 fatty acids. The morning session was dedicated to the symposium aspects, with biological functions of the nutrients and the epidemiological and quantitative-analysis issues regarding human milk. The presenters were Angel Gil (Spain), Noel W. Solomons (Guatemala), Alfonso Valenzuela (Chile) and Doug Bibus (USA). The afternoon session provided practical instruction on field investigation of these nutrients in breast milk including protocol development, bioethics, and milk collection, processing and handling, based on the experience of the CeSSIAM staff members who conducted the workshop. The goal of the effort was to enroll up to 20 diverse sites in Spain and the Americas to obtain dried milk samples for fatty-acid profile assays and up to 10 of these with analyses of vitamin D vitamers and alpha-tocopherol from liquid milk samples in addition.
 
The four symposia and single thematic panel focused on micronurient malnutrition are outlined in the Insert Box, with the session title, moderator and speakers. Within the five dedicated sessions were 22 individual presentations. The consensus findings from a global inquiry on selected micronutrients via the New York Academy of Sciences with funding from the Bill and Melinda Gates Foundation were presented with a regional focus. A strong realization is that, at least for the micronutrients of conventional public health interest, the situation in Latin America has improved and the task ahead consists of dedicated refinements and improvements in the implementation of programs to close the remaining gaps. This was true for folate and thiamine in the region, in which the situation is superior to that on other developing continents. Vitamin D nutriture was identified as a problematic area in this conclave. Elsewhere in the congress Program, data from Mexico and other sunny countries, confirm that customary solar exposures are not sufficient for prevention of the deficiency and insufficiency of this vitamin. From another session focusing on traditional nutrients, attention to the fortification of salt with iodine was identified as an enduring need due to on-going variation. Anemia prevalence has declined progressively across the region, but focus in under-five children and elderly over 60 years old is still warranted. The reminder was made that reliance on the validity of commonly-used biomarkers of micronutrient status must be tempered by the endemic nature of infectious and inflammatory states, and the distortion this exerts on interpretation of diagnostic findings for vitamin A and iron.  

A micronutrient that is not a vitamin or a mineral was the subject  of a symposium relenvant to the region. Presented by DSM Nutritional Products, four international experts were featured, covering the combined theme of the basic biology and region-wide epidemiology of the omega-3 fatty acid, docosahexaenoic acid (DHA). The relationship between adequate intakes of this essential fatty acid and neuronal development and cognitive function was reviewed and explained.

Interventions to prevent micronutrient malnutrition were the subject of two sessions with involvement of international agencies or non-governmental organizations. Food fortification with conventional (folic acid, iron) and emerging (vitamins D and E, choline and omega-3 fatty acids) nutrients was addressed in a session sponsored by the Fundación Iberoamericana de Nutrición(FINUT) of Granada, Spain. A corollary was that the meticulous efforts in monitoring and surveillance required to determine the state of fortification coverage and potential needs for adjustments in levels or changes in food vehicles. The Global Alliance for Improved Nutrition (GAIN) and the World Food Program (WFP) updated the status for home-fortification of complementary food with micronutrient powders (MNP). Efficacy studies have shown robust capacity of MNPs to reduce iron deficiency anemia, but there effectiveness at the public health level has been problematic in their implementation. A series of qualitative and mixed-methods research findings examined the underlying social and household barriers in MNPs and proposed corrective solutions.

Notable Special Events

The V Rainer Gross Prize was awarded in Guadalajara. This prize recognizes the expression of the spirit of the late Dr. Rainer Gross, leader in scientific discovery and capacity building first in Brazil, Indonesia and Peru in his career with the German Gesellschaft für Technische Zusammenarbeit (GTZ) and later at UNICEF Headquarters in New York. The award is sponsored by the Hildegard Grunow Foundation of Munich, Germany. Dr. Sun-Eun Lee, an Assistant Scientist in the Department of International Health of the Johns Hopkins Bloomberg School of Health in its Center for Human Nutrition in Baltimore was the winner of the fifth prize. The innovative direction that her research takes is in the proteomic profiles of micronutrient populations of Nepal and Bangladesh. Her research has provided alternative biomarkers for nutritional status and strengthened the associations of functional aspects of immune and cognitive function with specific micronutrients.  Dr. Lee was unable to travel to Mexico as her first child had been born four days earlier, but she presented an awards lecture by pre-recorded video presentation. Dr. Rebecca Kanter, who received her doctoral degree from the same Center of the JHSPH received the certificate plaque on behalf of Dr. Lee.

Summary Comments

The distribution of the themes featured in Guadalajara at the 22nd SLAN Congress is a reflection of how far ahead of the African and Asia continents is the Latin American and Caribbean region in terms of the alleviation of macro- and micronutrient deficiency states at the population level. It was announced that, even at UNICEF, historically a bastion to address problems of undernutrition in the context of social and economic deprivation, initiatives to combat childhood obesity have recently been initiated, specifically for the Western Hemisphere. A poignant and troubling exception is the public health nutrition situation of a humanitarian crisis in contemporary Venezuela; this was brought to the attention of the gathering with a Symposium and numerous free papers. 
 
Nonetheless, emphasis on feeding patterns that would eliminate overweight, chronic degeneration and metabolic condition was clearly expressed in the SLAN Congress Program. It is in the emerging micronutrients, vitamins D, E, K, choline and essential fatty acids, which justify research investment in the region. It is to be hoped that ongoing investigation in these areas can sustain an increased representation of micronutrient themes in Paraguay and Ecuador in the coming congresses of the Latin American Nutrition Society.

Changing the Standard

Why Multiple Micronutrient Supplements in Pregnancy Are an Ethical Issue

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On 9 July 1999, the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the United Nations University (UNU) held a technical workshop at the UNICEF headquarters in New York to address widespread micronutrient deficiencies and high rates of anemia among pregnant women. Looking beyond iron and folic acid (IFA), the workshop designed a comprehensive prenatal supplement – or multiple micronutrient supplement (MMS) –that would be tested in effectiveness trials among pregnant women in low- and middle-income countries (LMICs). Thus, the United Nations International Multiple Micronutrient Antenatal Preparation – now commonly known by its acronym, UNIMMAP – was born.

Women, Family, children

The group at the workshop was, in many ways, before its time. They identified access to MMS as an inequity issue as stated in a report the group published after the workshop: “The high [micronutrient] needs of pregnancy are almost impossible to cover through dietary intake [alone] – in most industrialized countries, it is common for women to take multiple micronutrient supplements during pregnancy and lactation.” And the group discussed how MMS could impact other at-risk groups, particularly adolescent girls.
 
They also considered the needs of the women most in need – and reflected on the information at their fingertips. The UNIMMAP formulation consisted of1 RDA (Recommended Dietary Allowance for women 19-50 years during pregnancy and lactation) for 15 essential vitamins and minerals. But they correctly predicted that 1 RDA underestimated the requirements for populations in LMICs because they were based on dietary reference intakes from populations in the US and Canada, where nutritional statuses are stronger. In April, results from the JiVitA-3 study in rural Bangladesh (the largest ever trial comparing prenatal MMS to IFA) showed that 1 RDA, while reducing risks of preterm birth, low birth weight and still birth, and while improving micronutrient status, failed to eliminate deficiencies. Might 2 RDAs have had a greater effect on birth outcomes in an environment where poverty, poor diets and frequent infections prevail?

The bigger picture

Malnutrition – undernutrition, overweight, obesity, and micronutrient deficiencies – is a driver of intergenerational inequity, poverty, and poor health. It represents a significant barrier to equitable and sustainable social and economic development, in high- and low-income countries alike. However, many women and girls lack access to essential antenatal and postnatal care services, including micronutrient supplementation. This is especially true for women living in LMICs. While 62% of pregnant women globally receive at least four antenatal care visits, in regions with the highest rates of maternal mortality – such as sub-Saharan Africa and South Asia – only 52% and 46% of women in the respective regions receive the same services. Further coverage disparities exist between poor and rich, and rural and urban households. In South Asia and sub-Saharan Africa, the urban-rural gap in coverage of antenatal care visits exceeds 20 percentage points in favor of urban areas, and the richest 20% of the population are more likely to receive antenatal care than poorer women. Good nutrition and equitable rights for all women are mutually reinforcing, and with improved gender equality leading in turn to improved nutrition.

We see this uneven and sub-optimal maternal care reflected in infant birthweight. A new study by the London School of Hygiene & Tropical Medicine (LSHTM), the WHO, and UNICEF finds that there has been minimal progress on reducing the number of babies born low birthweight (LBW), meaning they weigh less than 2,500 grams (5.5 pounds) at birth – a cause for alarm given that LBW increases the risk of newborn death, stunted growth, developmental delays, and conditions such as heart disease and diabetes later in life. As the mother’s micronutrient requirement increases during pregnancy in order to support the growth of the fetus, maternal undernutrition during pregnancy is closely linked with LBW.In 2015, 14.6% of all births worldwide, or 20.5 million babies, were born with LBW, the majority in sub-Saharan Africa and South Asia. Urgent action is needed to get the world on track to meet global goals on LBW, and maternal nutrition must be at the center of this effort.

Time for a change

To help meet women’s increased nutritional demands during pregnancy, the WHO recommends IFA as the current standard of care for pregnant women – but the policy has not changed in 50 years. The most recent 2016 WHO Antenatal Care (ANC) Guidelines, however, opened a window for MMS. The guidelines counsel against the use of MMS due to “some evidence of risk, and some important gaps in evidence,” but stipulate that “policymakers in populations with a high prevalence of nutritional deficiencies might consider the benefits to outweigh the disadvantages [such as cost], and may choose to give multiple micronutrient supplements that include iron and folic acid.”
 
Since 2016, the scientific community has met all the WHO’s concerns regarding risk and evidence. Compelling scientific evidence shows that taking MMS during pregnancy reduces the risk of maternal anemia and reduces the likelihood of a child being born LBW and too small. Anemic and underweight women benefit even more from MMS and have reduced risk of infant mortality and preterm births compared with mothers taking only IFA. Furthermore, recent research shows that MMS can reduce the gender imbalance in terms of the survival of female neonates compared with IFA supplementation alone, and that it represents an opportunity to invigorate maternal nutrition by putting women at the center of antenatal care.

The push for progress

The Women Deliver Conference (Vancouver, 3–6 June 2019) will be the world’s largest conference on gender equality, so Sight and Life and other leading organizations are working to elevate MMS. At Women Deliver, Sight and Life has partnered with the Children Investment Fund Foundation (CIFF), Kirk Humanitarian, 1,000 Days, Vitamin Angels, and the Multiple Micronutrient Supplement Technical Advisory Group (MMS TAG) – to host a side-event to make the case for MMS and build support behind the movement to update the global recommendations on MMS. This event, named Power for Mothers, will capitalize on the gathering of global leaders, key influencers, decision-makers, civil society and donors as part of the Women Deliver conference.

I firmly believe that, after 20 years of research and some 20 studies and meta-analyses comparing IFA and MMS on birth outcomes, it is unethical to further withhold MMS from pregnant women in low-resource settings. The MMS TAG (to which I belong) has documented the clear scientific advantage of MMS over IFA and the safety of MMS for mothers and their children, and has shown that the provision of prenatal MMS is a cost-effective intervention. Not only is MMS cost-effective, but it has also achieved cost parity.
 
It is no wonder why some early-riser countries with widespread micronutrient deficiencies have requested implementation research and donations of MMS for the successful replacement of IFA in their health sector. The time is now to adapt global and national guidelines to the overwhelming evidence. Disparities in antenatal care including the provision of MMS are no longer acceptable.

Email: klaus.kraemer@sightandlife.org
 
 
 
 

Pavithra Balasubramanian

Executive Assistant for Sight and Life

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I believe working for a cause that resonates with me, even though I hold a degree in computer science and engineering, my career thus far has been primarily in the social sector. In my role, I support the team in reaching their day-to-day milestones and ensure a smooth administration throughout the organization.

Being a part of this passion-driven team striving to make a positive difference, inspires, and motivates me to be the best at what I do.

I hope to be a valuable addition to the team by applying my managerial experience and contribute the utmost possible to Sight and Life’s work in eliminating all forms of malnutrition.

Puja Peyden Tshering

Consumer Insight Specialist for Sight and Life

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During my childhood, I moved every one or two years with my family. Moving often ensures one stays in a state of constant learning. My experiences left an impression and created my enthusiastic and curious outlook about new cultures, new places, and new people. I have always been obsessed with asking questions, finding answers and solutions and I work hard at keeping my mind and heart as curious as it was when I was 5. I find that learning is the easiest way to challenge oneself. It bursts bubbles, encourages stepping out of your comfort zone and makes you appreciate the world more.  
 
As I grew older, it made sense to assimilate what I was learning, and compile the skills I was building, to give back to the world I had taken so much from. I wanted to work toward making the world better, safer and more wholesome, whichever way I could, as long as I could and because I must. My experience in consumer research has been a revelation in the study of people and their psyche, teaching me most importantly, that no problem is unidimensional – not in a city, not in a forest, not in a field.
 
Sight and Life articulates a vision of a world free from all forms of malnutrition and understands the complexity of that vision. Joining Sight and Life feels like a convergence of various sorts – my passion for solving multifaceted problems, meeting new people and learning about new cultures, working with an experienced team that helps me learn and laugh more each day. Solving for malnutrition is such a layered learning process, I could not think of a better team to be part of, to continue to be curious and apply my learnings to positively change the lives of others.

Harnessing Public and Private Sector Engagement for Improved Nutrition

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“Why are things not better when we know so much more than before?” is the uncomfortable question the 2018 Global Nutrition Report leaves us with. In this blog post, we argue that part of this slow progress in improved nutrition is due to the elephant in the room which can no longer be ignored – the private sector.
 
The private sector has long been engaged in initiatives aimed at preventing and treating malnutrition, producing products to treat severely malnourished children and manufacturing nutrient-rich and fortified foods. At the same time, some private sector actors have engaged and are still engaging in harmful practices.[i] Consequently, public-private engagement remains difficult due to a lack of trust, differing goals, objectives, working cultures and timeline expectations.

 

Engaging the private sector – positive developments

There is a growing recognition that complex and multi-dimensional issues such as the double burden of malnutrition require cross-sectoral and holistic approaches. Governments must remain in the driver’s seat as the legislative and standard setting body, whilst convening and pooling together the resources, knowledge and expertise of different stakeholders. Multiple actors have varying roles in providing solutions to the burden of malnutrition and the private sector is one key player. A number of initiatives involving the private sector have made valuable contributions to improving nutrition outcomes through product reformulation, improved labeling standards, restrictions on marketing and distribution to vulnerable groups. In low and middle income countries (LMIC), these efforts have concentrated on food safety or fortification of staple foods (flour, rice, oil) and condiments with micronutrients.


Several initiatives such as Sizanani Manzi (social business originally founded by Sight and Life & DSM South Africa) and OBAASIMA (PPP), have used consumer insights and a demand driven approach to develop nutritious products for vulnerable populations. Sizanani Manzi conducted consumer research in the economically disadvantaged townships of Ivory Park and Soweto in South Africa: through food diaries, shopping tours and in-depth interviews it aimed to understand purchasing and consumption habits for instant porridge and juice concentrate, which revealed to be the most frequently consumed convenience foods and thus the easiest vehicles through which the required nutrients could be delivered to low-income consumers on a regular basis. The OBAASIMA (PPP) in Ghana applied a demand-driven approach, with the use of a ‘quality seal’ logo to distinguish products meeting nutrient profile (sugar, salt, saturated fat) and fortification standards for women of reproductive age.
 
Mobilization of the private-sector is increasingly viewed as essential to creating change in food systems and global, national and local food environments. Moreover, international agencies have repeatedly called for increased engagement with the private sector to address the double burden of malnutrition in LMICs. Sustainable Development Goal 17 in particular, encourages “global partnership for sustainable development, complemented by the use of multi-stakeholder partnerships” as a means of implementing the 2030 Agenda. It also invites states and other stakeholders to “encourage and promote effective public, public-private and civil society partnerships” that “mobilize and share knowledge, expertise, technology and financial resources, to support the achievement of the Sustainable Development Goals in all countries, in particular developing countries.”

Still…what is missing?

At present, little has happened in measuring the impact of public private engagement and their impact on nutrition outcomes. Independent impact evaluations are scarce and as reviewed by Hoddinott et al., “considerable caution is thus warranted when assessing PPPs in nutrition.[ii]” Simply put – we are uncertain as to whether or not, and to what extent nutrition PPPs actually work. Assembling the missing data, developing appropriate indicators, screening for quality and publishing it in peer-reviewed journals will better align business efforts to investments in positive nutrition actions (e.g., marketing, packaging, labeling), and boost efforts to hold businesses and governments accountable and inform on what makes for a successful PPP in nutrition.[iii] Independent evaluation mechanisms such as the Access to Nutrition Index (ATNI) are commendable initiatives that can serve as useful private sector accountability tools. Not only do we need more of these tools to help create transparent environments and initiate dialogue between both parties, but these tools also need to be more relevant to small and medium sized companies  in LMICs, who play a vital role in meeting consumers’ needs and who make up the bulk of the food system. The time has come to move from talk and advocacy to action. Being able to show the impact of PPPs on nutrition is a first step in that direction.



Additionally, there is an urgent need for evidence-based dialogue between governments, civil society and the private sector. Governance and organizational structures need to be looked at more closely – how do existing and should future PPPs manage conflict of interest? How do they manage power imbalances? Differing language and jargon? Values? Monitoring and evaluation? Is there a recipe for success? If captured in a systematic way, these learnings can support the development of a framework to enable jurisdictions to undertake an evidence-informed approach to assess partnership development opportunities with the food industry.[iv]

How do we go about filling the gap?

At Sight and Life, one of our core strategic areas is to build and support PPPs in nutrition. Through consumer insights, market research and private sector expertise, we design, test and innovate viable (business) models that will increase supply and demand for nutritious foods for the reduction of malnutrition in all its forms.

In light of this challenge and our engagement in multisectoral partnerships for nutrition, Sight and Life was invited to organize a working group) on “Harnessing public-private partnerships to improve nutrition outcomes” at the 2018 International Symposium on Understanding the Double Burden of Malnutritionin Vienna (Austria). The session served as a knowledge sharing and learning session amongst different stakeholders on better understanding the levers and the blockers for public-private engagement for nutrition. The group attempted to answer the following questions:

– How do we learn and share our knowledge on what makes public private engagement work?
– What currently exists in this regard? What is missing? How can we fill the gap?
– How do we measure the impact of public private engagement and public-private partnerships more specifically?
– What is stopping public private engagement?
– What tools can we use to evaluate the work – to understand why they worked or not?
– How can we put people at the center?
 
The meeting started with a presentation by Breda Gavin-Smith (SAL) on the OBAASIMA PPP, a partnership between Sight and Life, Royal DSM, the German Federal Ministry for Economic Cooperation and Development, the Children’s Investment Fund Foundation (CIFF), Bill and Melinda Gates Foundation (BMGF), Association of Ghanaian Industries (AGI) and Ghana Standards Authority (GSA), that is driven by the common objective of improving micronutrient intakes of women of reproductive age in Ghana. Breda shared on the challenges and learnings when engaging diverse partners in a project that demands an entrepreneurial mindset to meet shifting project requirements. For more information on OBAASIMA, take a look at the infographic.

Obaasima, demand generation, Ghana, women, nutrition 
Saskia Osendarp (Micronutrient Forum) shared about the Tswaka study, a multi-sectoral partnership between Sight and Life, the North West University of South Africa, the Global Alliance for Improved Nutrition (GAIN), DSM and Unilever, which examined the effects of two lipid-based complementary food supplements on older infants’ growth, iron status and psychomotor development among children living in an underprivileged community in South Africa. Saskia revealed that the journey the partners embarked on in 2010 was not always an easy one, with many challenges, and eventually a successful completion after more than eight years! You can read the peer-reviewed publication of the study here; the infographic here; and don’t miss the soon to be published article “The Tswaka study: a journey into an innovative public-private research partnership” in the next edition of the Sight and Life magazine due in June of 2019.
 
Stineke Oenema (UNSCN) shared about the 2018 High Level Panel of Experts’ (HLPE) report on “Multi-stakeholder partnerships to finance and improve food security and nutrition in the framework of the 2030 Agenda” which provides an excellent starting point to frame the challenge at hand. The report suggests relevant criteria to enable governments and non-state actors to perform their own assessments of partnerships and identify pathways for improvements by means of a questionnaire. The proposed common methodology has the potential to strengthen transparency and accountability by improving the learning process through knowledge generation and sharing. Two key recommendations of the report and relevant to this blog’s topic are to (1) increase the impact of multi-stakeholder partnerships through effective monitoring, evaluation and experience sharing and (2) integrate different forms of knowledge and explore further areas of research on multi-stakeholder partnerships to finance and improve nutrition in all its forms.
 
In the context of these examples and in light of the PPP debate, we see three elements which we believe will help us move forward in building and supporting effective PPPs for nutrition and will ultimately accelerate our progress towards the reduction of malnutrition in all its forms.

1.Understand and share information on existing partnerships

To support further effective partnering for nutrition we must understand what makes PPPs successful, challenging, and what makes them fail. Before doing that, we first need to gather information on them. At present, it is difficult to find detailed and publicly available information on existing PPPs. A great part of the available data is self-reported with no guarantee of independent verification. An online register of PPPs[v] would enhance transparency and could serve as an excellent starting point. It is important to note that simple registration will have limited value add without clear guidance on the adequate level of information to be reported. In particular, partnerships should disclose appropriate information on goals and commitments, members and their contributions, governance and financial arrangements.

2.Translate the collected information into knowledge and learnings

Once the information has been collected, it needs to be curated and screened for quality, with the aim of establishing a research agenda that will enable us to measure the impact of these partnerships on nutrition outcomes. A curated online hub that would look to (1) increase the impact of public-private engagement through effective monitoring, evaluation and experience sharing and (2) integrate the different forms of knowledge and explore further areas of research on public-private engagement in order to finance and improve them.

3. A framework on innovative methodologies and metrics to assess the impact of PPPs

Further research could use the readily available criteria on what makes PPPs work, to develop innovative methodologies and metrics to assess the short- and long-term impacts of PPPs on food security and nutrition. For instance, the High Level Panel of Experts for Food Security and Nutrition (HLPE) Multi-stakeholder partnerships to finance and improve food security and nutrition in the framework of the 2030 Agenda report provides a potential framework to start developing metrics in the areas of transparency, accountability, trust, the partnering process and on when and how to engage.
 
Sight and Life is interested in hearing from anyone keen to invest or partner with us on PPPs for nutrition. To contact us regarding this endeavor, please send an email to breda.gavin-smith@sightandlife.org
 
Learn more about our projects/partnerships:
OBAASIMA
Partners in preventing micronutrient deficiencies – Sight and Life, DSM and JHU Case Study
DSM – SAL – WFP: A Partnership to Advance the Global Nutrition Agenda
Sizanani Mzanzi series: Part 1,Part 2,Part 3, Part 4, Part 5

References 
[i] Global Health Advocates. 2018. Ending malnutrition: what role for the private sector? From prevention to treatment.Paris: GHA.
[ii] Hoddinott, John F.; Gillespie, Stuart; and Yosef, Sivan. 2015. Public-private partnerships and the reduction of undernutrition in developing countries. IFPRI Discussion Paper 1487. Washington, D.C.: IFPRI.
[iii] GAIN & USCIB. 2018. No more missed opportunities. Advancing public-private partnerships to achieve the Global Nutrition Goals.
[iv] Multi-sectoral Partnerships Task Group. 2013. Discussion Paper: Public-private partnerships with the Food Industry. Washington DC: PAHO.
[v] https://www.gainhealth.org/wp-content/uploads/2017/10/Why-isn%E2%80%99t-there-more-research-on-public-private-engagements-in-nutrition_Lawrence-Haddad-Presentation_October-2017.pdf

The Role of Demand Creation in Addressing the Double Burden

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With most food consumed across the world being obtained from the marketplace, from large, multinational companies to small street vendors, businesses have a significant influence on the food people eat. However, we know that businesses are interested in promoting their own products, thus there is a need for wide ranging market development for more affordable, accessible, and nutritious food.

There is increasing recognition on the role of demand creation for improving consumption of nutritious foods. Food purchase drivers, and subsequent purchase decisions, need to be addressed to adopt healthy eating behavior and improve diets. Yet, for that – fundamental questions have yet to be addressed:

What motivates consumers to buy and consume more nutritious foods?

How can we make nutritious diets and foods more desirable to consumers?

On March 2019, during the 4th Hidden Hunger Congress in Stuttgart, Germany, Breda Gavin-Smith, Sight and Life’s Global Public Health Nutrition Manager, co-chaired a session with Alessandro Demaio, CEO of EAT on “The role of demand creation in addressing the double burden of malnutrition”. The session brought together four visionaries in order to further understand the significant role of demand creation in improving the consumption of healthy nutritious foods.

The role of demand creation across the food system in addressing the double burden of malnutrition – setting the scene

Rowena Merritt, Head of Research at the National Social Marketing Centre, examined the principles underpinning demand creation and provided an overview on how it can address the double burden of malnutrition. Knowledge is not enough to change the behavior of beneficiaries and target consumers because rational decisions are overrated when it comes to food. When creating demand for nutritious foods, it is therefore imperative to link desired behavior change with something the consumer cares about. What is it that they value? What moves them? What motivates them? There is much the public sector can learn from the private sector when it comes to communicating promises and benefits (as opposed to facts, figures or product features as is often does) and there are successful examples showcasing this. The key and challenge is to offer consumers/beneficiaries immediate benefits that outweigh the barriers of changing their behavior. When this is done, we can start seeing a change in behavior.

hidden Hunger. double burden, demand generation, food, healthy
Rowena Merritt presents at the 4th Hidden Hunger Conference in Stuttgart, Germany.

“It would be easy to give the public information and hope they change behavior, but we know that doesn’t work very satisfactorily. [If it did] none of us would be obese, none of us would smoke and none of us would drive like lunatics.”
– Ian Potter, Director New Zealand Health Sponsorship Council

Identifying opportunities to increase supply and demand for nutritious foods – the Fill the Nutrient Gap

Natalie West, Nutrition Consultant at Fill the Nutrient Gap (FNG), looked at how the FNG assessment identifies opportunities to increase the demand for nutritious foods. The FNG situation analysis for decision making identifies context-specific barriers and entry points for food, health and social protection systems to improve nutrition through increasing availability, access, affordability and choice of healthy, safe, nutritious foods. It does so through the review and analysis of secondary sources of information on access to and availability of nutritious foods, and Cost of the Diet analyses and modeling that assess affordability of a nutritious diet, and possible improvements thereof. Stakeholders from multiple sectors (food system, health, agriculture, food processing, marketing, retail, and social and behavior change communication) are engaged throughout the process. Based on the FNG results, they formulate recommendations around improving nutrient intake, and supply and demand stimulation for nutritious foods. Demand creation is not only about consumer demand, but also about awareness and push by policy makers, to ‘enable’ or ‘allow’ consumers to have demand (i.e. making nutritious choices available and affordable).

An example of a double duty in action – incorporating demand creation as a key component in improving micronutrient intake in Ghana – the case of OBAASIMA

Daniel Amanquah, Food Fortification Specialist for Sight and Life, reviewed OBAASIMA which is a demand driven approach to address micronutrient deficiencies in Ghana. Consumer demand for nutrient-dense foods has a greater chance of success if foods fit the underlying consumer values that inform and guide consumption decisions and purchasing choices. Factors that drive demand for nutritious foods are convenience, affordability, and the aspirational value of nutritious foods. OBAASIMA recognizes the importance of consumer values and conducts insight research to help understand the target population. The OBAASIMA demand creation strategy draws on deep consumer insights and deploys above and below-the-line marketing to ensure continued consumer awareness and affinity for the OBAASIMA seal. The seal trademark is awarded to products that adhere to the minimum fortification content, as well as nutrition criteria on maximum allowable levels of sugar, salt, fat, and trans-fat. This helps inspire healthy food choices by making products easily identifiable and recognizable.

Obaasima, demand generation, Ghana, women, nutrition

Chef’s Manifesto – leveraging chefs to create demand for healthier foods

Paul Newnham, Director at the SDG2 Advocacy Hub, spoke on the importance of engaging diverse actors in creating demand for healthier foods. New voices must be brought into nutrition conversations that are struggling to reach their target audience. As food influencers and the bridge between farm and fork, chefs have an important role to play in helping us to rethink food– what we eat and how its produced – with conversations that prioritize taste and language that inspires action. Present in our schools, neighborhood gardens, community projects and businesses, chefs can speak to farmers, consumers, politicians and communities alike with a message of sustainable, nutritious food for all to deliver the Sustainable Development Goals by 2030. Adding greater food diversity to our plates is a first step in making Agenda 2030 a reality, as biodiversity not only adds nutritional value to our diets but also strengthens food systems and builds climate resilience. The Chefs’ Manifestois an initiative that works to bring new voices into the food system debate, raise awareness about key challenges and solutions, and bridges the gap between high-level UN debates and the general public.

Food Forever and the Chefs’ Manifesto are joining forces to launch the 2020FOR2020 campaign whose aim is to inspire 2,020+ chefs from across the world to champion biodiversity by 2020. Chef actions will be showcased online and at global food events throughout the year to demonstrate how chefs can inspire better ways of cooking, eating and advocating for biodiversity conservation. 

nutrition, biodiversity, chefs, 2020FOR2020

Find out more about demand generation and this Sight and Life session by checking out the presentations of each speaker:

Rowena Merritt | The role of demand creation across the food system in addressing the double burden of malnutrition – setting the scene

Natalie West | Identifying opportunities to increase supply and demand for nutritious foods – the Fill the Nutrient Gap

Daniel Amanquah | An example of a double duty in action – incorporating demand creation as a key component in improving micronutrient intake in Ghana – the case of OBAASIMA

Paul Newnham | Chef’s Manifesto – leveraging chefs to create demand for healthier foods

The Beginnings of The Society for Implementation Science in Nutrition

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The Outset

The Society for Implementation Science in Nutrition (SISN) began on a wintery, New York evening in February, 2014. Eva Monterrosa, formerly Sight and Life’s Senior Scientific Manager, and Klaus Kraemer, Director of Sight and Life, together with Jessica Johnston and Rolf Klemm, met at Jean-Pierre Habicht and Gretel H. Pelto’s home to discuss a presentation by Eva on the role of context in fostering, developing and implementing nutrition interventions. Based on their previous experiences, they were concerned there was not a venue where the important ideas in the presentation could be published. The conversations began with the idea of creating a working group focused on implementation science, but quickly moved to consider a more formal, long-term institution, such as a scientific society.

The group appointed itself as a six member Secretariat. The first goal of the Secretariat was to identify a group of founding members for a meeting in Addis, Ethiopia during the Micronutrient Forum in June 2014. The enthusiasm and broad support from the nutrition community for SISN and its role in convening and shaping the discussion for implementation research in nutrition was an exciting moment and positive affirmation we were headed in the right direction,” described Eva Monterrosa, who led the Secretariat. SISN was gaining momentum. Commitments came quickly from thirty-one experts with diverse experiences and the first meeting with the founding members in Ethiopia was a success.

Founding Members

The founding members all had years of experience in nutrition implementation and research and encompassed a range of organizational experiences, national perspectives, academic and cultural backgrounds, and program experiences. The list, in alphabetical order, consisted of:  Mandana Arabi, Jean Baker, Gilles Bergeron, Martin Bloem, Howarth Bouis, Namukolo Covic, Luz Maria De-Regil, Stephan German, Stuart Gillespie, Jean-Pierre Habicht, CJ Jones, Klaus Kraemer, Karin Lapping, Rolf Klemm, Anna Lartey, Robert Mwadime, Banda Ndiaya, Lynnette Neufeld, Eva Monterrosa, Juan Pablo Pena Rosa, Gretel Pelto, David Peters, Juan Rivera, Marie Ruel, Werner Schultink, Meera Skear, Rebecca Stoltzfus, Emorn Udomkesmalee, Cesar Victora, Patrick Webb, and Stan Zotklin.

Understanding the Ambition 

Implementation science was not in Sight and Life’s wheelhouse until Klaus Kraemer, Managing Director of Sight and Life, reviewed and was mystified by the data in the 2013 DEVTA trial, which was published in The Lancet. Previously, randomized controlled trials conclusively demonstrated that high-dose vitamin A supplementation of children under five years of age reduces mortality by 24%. However, the DEVTA trial in India showed a non-significant 4% reduction in child mortality. Jean-Pierre Habicht observed that “This randomized controlled trial, as is typical of such trials, was carefully designed to interpret positive effects as due to the supplementation. However, it was not designed to interpret lack of effect”. In particular, it did not have plausible evidence of wide spread effective implementation.

The massive study had bare bone supervision of the intervention with only 18 monitors overseeing the work of over 8,300 Anganwadi workers and the participation of a million children. It also remained unclear how well mothers were counseled, how many and how often children received the intervention, how much of the supplement was wasted or shared, and what other socio-biological factors could have affected program utilization. Gretel Pelto pointed out that “understanding the behavior of implementing staff is as important as understanding household behavior” neither of which were studied by the DEVTA trial. The disconnect between the DEVTA trial and disconnect between all of the previous work, which had established the importance of Vitamin A supplementation for child survival and child health was the tipping point and motivation for Sight and Life’s commitment to implementation science. As Klaus Kraemer explains, “This drastic fluctuation in understanding the results of field trials clearly demonstrates the importance of implementation science and was a significant driver behind Sight and Life’s push to further implementation science.

Momentous Journey

With a mission to convene, advocate, disseminate and promote dialogue among scientists, policy leaders, government officials, funders and practitioners to advance the science and practice of nutrition implementation world-wide, SISN headed into its first operational year (2015) with a full agenda. Following a two-day meeting in Castel Gandolfo, Italy, SISN was officially established with the proclamation of the Lazio Declaration. By the end of 2015, the inaugural board was nominated, elected and set to meet that December.

Lazio, gandolfo, SISN, implementation science, sight and life
SISN was officially established with the proclamation of the Lazio Declaration after a two-day meeting in Castel Gandolfo, Italy.

Meanwhile, the Lazio declaration served as a culmination of the efforts of many people, and highlighted  the importance of implementation science. Read more on this important milestone here.

In 2016, Sight and Life committed to continue supporting financially by funding the Secretariat activities and advocating for implementation science. Creating a new institution was a challenge,” explains Eva Monterrosa. Recently she said, “We are incredibly grateful for the generous support of Sight and Life funding the Secretariat and operations for SISN over the last three years.” The 2016 calendar year featured a strategic plan for SISN to increase awareness, build membership, and continue to build a solid foundation. Putting the plan into action began with a symposium on implementation science during the Experimental Biology conference in Chicago, and the Micronutrient Forum in Cancun where SISN developed the following symposia:

Plenary session – Implementation Science in nutrition: purposes, forms, functions, and country examples.

Symposium session sponsored by Sight and Life – Implementation research to improve implementation outcomes (coverage, adherence, quality, and equity) of micronutrient/nutrition programs and policies.

The interest in the topics was apparent as the sessions drew crowds with an overflow of people listening from outside the room. The especially keen interest of students, seeing the value of implementation science and hungry to learn how to do it,” describes David Pelletier, Past President of SISN.

Behind the scenes the SISN team had been diligently working to develop a robust website, implementnutrition.org. The site launched in the spring of 2017, activating new members and providing a wealth of information about implementation science. At the same time, the final paperwork was also approved and SISN became incorporated in the USA as a non-for-profit education corporation. While internally several working groups including methods, membership, and communications, as well as a finance committee were formed.

As the structure of SISN builds, so does its exposure. On November 7th, 2017, SISN along with the International Food Policy Research Institute (IFPRI), and the Scaling Up Nutrition (SUN) secretariat co-hosted a workshop session at the SUN Global Gathering in Abidjan, Côte de Ivoire, on “Sharing Knowledge, Methods, and Experiences on Implementation: How can SUN Countries Better Implement Priority Actions?” The workshop was organized as part of the ongoing Knowledge for Implementation and Impact Initiative (KI3). An initiative jointly implemented by these three organizations, with the overarching goal of closing the knowledge and communication gap among nutrition knowledge generators, policy planners, and implementers in SUN countries.

Also in 2017, at the International Union of Nutritional Sciences – International Congress of Nutrition (IUNS-ICN) in Argentina, a SISN and Nutrition International (NI) co-sponsored symposium entitled “Evidence-based integration of nutrition across multiple sector programs: how can this be done?” was presented and very well attended. Additionally, outreach to the CDC, USAID, the USG Interagency Working Group on Implementation Science was established and SISN received a sub-award for implementation research in Kenya and Uganda in partnership with 3ie.

It’s been a journey from a small group of highly committed founding members to 200 global members. And we are still growing and establishing our organization,” described Eva Monterrosa as the year came to an end, “The ideas, and dedication of inaugural Board and members has positioned SISN an institution leading the implementation research space.”

Importance of SISN

SISN’s vision is a world where actions to improve nutrition are designed and implemented with the best available scientific knowledge and practical experience that promotes effective actions. Policy makers, funders, and community members will benefit when scientists and practitioners work together to answer ‘how to implement effective nutrition actions’. “We are currently enjoying an unprecedented window of opportunity to address nutrition through national policies and large scale programs,” states David Pelletier, Past President of SISN, “Now we must deliver the goods by showing results, or the window may close and remain closed for another generation. Implementation science and research is vital for showing those results.”

SISN looks to support and positively impact global nutrition outcomes. “Achieving 2025 global target set by the World Health Assembly (WHO), will require a concerted effort,” explains Eva Monterrosa. “SISN, as a convener, can bring together various stakeholders and assemble and organize different types of knowledge, methods, and approaches that are required to advance how we implement effective nutrition actions to meet our targets for anemia reduction, low birth weight, exclusive breastfeeding, and wasting.”

At SISN, diversity is valued and there is a strong belief that scientists and practitioners are co-producers of implementation knowledge, and both play incredibly important roles in shaping the field of implementation science in nutrition. David Pelletier explains, “The world is awash with evidence and knowledge to improve implementation and impact but facing a major non-utilization crisis; SISN is dedicated to enhancing utilization of existing knowledge in addition to generating new knowledge that is useful at local, national and global levels.

SISN Members

Everyone is welcome! As SISN continues to forge ahead, the members need to include visionaries, doers, and people who are undaunted by the task ahead, which is to create a new institution that will benefit millions of people around the world as well as our scientific and practitioner communities. Being a member-based organization, SISN is as strong, innovative, and creative, as its membership.

SISN provides a global platform for members to learn, share, and network with like-minded people while paveing the way for professional development opportunities. Becoming a member is a great way to be a part of shaping the future of implementation!

Delivering Quality and Nutritious Foods in Ghana

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OBAASIMA is a trusted trademark for fortified foods aiming to increase the availability of and access to affordable, safe andnutritious food products for Ghanaian women. This engaging initiative has been making waves when it comes to developing fortified food products in Ghana.

Gladys M. T. Sampson, General Manager of Premium Foods Limited

Recently, OBAASIMA has collaborated with Premium Foods Limited, an agro-processing company with a focus on breweries, poultry farmers, and food distributors. Over the past 20 years they have worked with smallholder farmers, addressing nutritional needs through local food staple fortification for industries, including rice, cassava, maize, soya beans, millet, and sorghum to meet the micronutrient requirements of Ghanaian’s. Premium Foods has a strong focus on nutrition, making sure nutritious and affordable foods are available to everyone, especially for their target market. Here at Sight and Life, we had an opportunity to speak with Gladys M. T. Sampson, General Manager of Premium Foods Limited, about malnutrition in Ghana and their collaboration with OBAASIMA.

GS: Gladys M.T. Sampson
SAL: Sight and Life

SAL: What is the key reason Premium Foods has decided to align its products with the strict nutrient profile required for the OBAASIMA seal?

GS: In the past, Premium Foods has been a business-to-business company adding nutritional value to grains and other staple foods in order to meet micronutrient deficiencies in Ghana. The OBAASIMA label is authentic; it shares the same mandate and supports our target consumers to meet their micronutrient requirements. To the Premium Foods brand authenticity is important, so when we have an authentic label, like OBAASIMA, associated with the brand it is ideal. This is what convinced us to collaborate with OBAASIMA.

Package Foods, Obaasima, Fortified
Finished goods at Premium Foods warehouse stacked and ready for delivery

SAL: What was the biggest issue you faced when signing on with OBAASIMA?

GS: Initially, we had a different micronutrient formulation in our product than the nutritional requirements of OBAASIMA. This was the only thing that we were discussing and we decided to include the whole spectrum of the micronutrient requirement in our product. It was a positive discussion leading us to change our micronutrients composition to adapt to the OBAASIMA label.

SAL: What are some of the biggest challenges you face in providing nutritious products to consumers? Moreover, how does the OBAASIMA seal help resolve those issues?

GS: The only challenge on my end is that being a business-to-business company, we need to learn the most effective ways to market and distribute our new consumer products. However, working with OBAASIMA, which focuses on consumer products, enabled us to tap into their experience and ensure we can move into this area.

Fortify, fortified foods, obaasima, ghana
Extrusion machine working to fortify grains at Premium Foods

SAL: Can you share any details about your first product for OBAASIMA?

GS: It is a porridge. The product is called “LOVIT,” a blend of maize and soya beans fortified with minerals and vitamins meeting the requirements of the OBAASIMA seal.

SAL: In your opinion, what makes the OBAASIMA seal stand out from other options?

GS: There are various products on the market and OBAASIMA, in our language, stands for the perfect woman, a holistic woman. So the label itself sends a positive message and is appealing to consumers, well that is what I think. It is something positive.

SAL: What has exceeded your expectations by using or working with OBAASIMA?

GS: Looking back at the product development process with Daniel and Jonson from OBAASIMA, we received a lot of technical inputs from them. Their willingness to contribute and ability to advise on technical issues is something that is a plus and a benefit I cannot quantify.

SAL: What is the main reason you would recommend to others to use the OBAASIMA seal with their products?

GS: I think as a nation (in Ghana), we have a problem with hidden hunger, which means a low intake of many important micronutrients. I think that if we are looking to fight hidden hunger together as a nation, then we need to create more of these products with the OBAASIMA label. To consumers this authentic label guarantees your food product can help meet your micronutrient requirements. Although, Premium Foods cannot do it alone.

SAL: Well, this sounds like a fantastic partnership. Thank you for doing wonderful work and collaborating with OBAASIMA.

Obaasima, demand generation, Ghana, women, nutrition

Can the Food and Beverage Sector Contribute to a Healthier Society?

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Despite the progress made over the past few decades, malnutrition remains a leading global challenge and a major obstacle to achieving the Sustainable Development Goals. 88 percent of all countries face a serious burden of at least two of the three forms of malnutrition – undernutrition, micronutrient deficiencies, and overweight/obesity1. Worldwide, stunting still affects 155 million children, and 52 million children are wasted. 2 billion people are micronutrient-deficient, while another 2 billion adults and 41 million children are overweight or obese. The global community is off-course to meet the agreed-upon global nutrition targets.

Fueling the Dilemma

Central to the challenges of malnutrition in its three modalities, as well as to the approaches to address them, are food systems. Food systems – the set of processes of production, processing, marketing, distribution, purchasing, and consumption of food, together with the consumer practices, resources, and institutions in these processes – are major determinants of food quality and choices and consequently nutritional status and health. The private sector – from multinationals to smallholder farmers – is the engine that drives food systems, with the food and beverage (F&B) industry playing a unique and powerful role. The F&B sector has a disproportional impact on nutrition and health outcomes as the “nutrition transition” in low and middle-income countries (LMICs) has shown, with increased consumption of sugar, fats, refined grains, and highly processed foods2. In LMICs, F&B industry products represent a growing share of local diets, driven by urbanization, rising incomes, maturing supply chains, and increasing demand for processed foods due to their convenience and extended shelf life. Though taking place at a faster pace in cities, this transition is increasingly reaching rural areas.

Beverage Industry, energy drinks

The associated global obesity epidemic3, which has engulfed developed countries and LMICs alike, is costing the world an estimated US$ 2 trillion annually. Noncommunicable diseases (NCDs) now account for 68 percent of all deaths worldwide, with three of the four most prevalent ones – cardiovascular diseases, cancers, and diabetes – being associated with diets4. The global community may well have reached a tipping point with the accumulating evidence on the global and serious nature of overweight and obesity and their major contribution to the increasing burden of NCDs and premature death. Urgent, comprehensive, and systematic action is called for now to reverse this tide.

Unraveling the Issue

Together with consumer choices and lifestyles, the F&B sector’s influence on these trends and burden is undeniable. Moreover, the industry’s contribution to reducing undernutrition and micronutrient deficiencies has been insufficient, with numerous missed opportunities to help address these burdens across countries and markets.

Five key levers can be employed by society to improve the F&B sector’s contribution to improved nutrition and health: incentives, a favorable enabling environment, consumer education and demand, safety net procurement, and direct pressure and accountability from consumers, grassroots organizations, high-value employees, and investors. Incentives through various policies can be strong inducers of positive action by private sector actors. Tax policy, for example, can both incentivize increased availability of affordable nutritious foods and discourage production and consumption of poor quality foods. A favorable enabling environment, primarily instituted by the public sector, can reward F&B players which contribute to public health and discourage or penalize those that don’t. Consumer education and demand can pull the whole food value chain towards sustainable diets and compel companies to offer a nutritious, sustainable, and ethical product portfolio. The recent clean label movement in high-income countries5 illustrates the power of consumers to catalyze major industry shifts. As institutional buyers such as national governments and multilateral agencies step in to ensure the poorest of the poor are covered, they contribute to the viability and sustainability of nutrition-minded companies. Last but not least, the voice of society through various actors and channels can both inhibit the most egregious corporate actions in the short term and promote long-term steering and investment in a nutrition-positive direction. An auspiciously growing trend are right-minded nudges on firms from large individual and institutional investors, including asset managers and pension funds, as highlighted by the recent letter from the CEO of BlackRock, the world’s largest asset manager, to his fellow executives.

obaasima, food fortification, quality seal

A number of industry initiatives and public-private partnerships have made valuable contributions to improving nutrition outcomes through product reformulation, improved labeling standards, restrictions on marketing and distribution to vulnerable groups, and disincentives to consumption of poor nutritional value products of such as sugar-sweetened beverages through taxation. In LMICs, these efforts have concentrated on food safety or fortification of staple foods (flour, rice, oil), and condiments with micronutrients. Some of them, including the OBAASIMA program in Ghana, have applied a category branding approach, with the use of a “quality seal” logo to distinguish products meeting nutrient profile (sugar, salt, saturated fat) and fortification standards.

Evolving Over Time 

Today, LMICs grapple with the full spectrum of malnutrition challenges, with a persistent burden of undernutrition and micronutrient deficiencies combined with a rising tide of overweight and obesity. The aforementioned tipping point of awareness may well represent a leapfrogging opportunity for LMICs as their food systems develop and their F&B sectors mature and can better align their strategy and investments with societal needs, thus avoiding the enormous burden this misalignment has imposed elsewhere. Key to this alignment is a systemic approach that encompasses all three modalities of malnutrition, includes actions that both promote the consumption of nutritious foods and reduce that of poor quality products, and addresses the critical areas in which F&B companies can make the greatest difference to nutrition outcomes: product portfolio and labeling, marketing communications and practices, and availability and affordability for low-income consumers. 

Aligning the F&B sector with societal needs is a long, winding, and overdue journey, which will ultimately benefit all individuals in all countries, as consumers, suppliers, employees, or shareholders, as well as the planet. Let’s embark on this likely bumpy ride and step on the gas – a healthier, happier and more productive world awaits us and our descendants.

Sources

1Global Nutrition Report 2017.
2Hawkes, Corinna; Harris, Jody; and Gillespie, Stuart. 2017. Changing diets: Urbanization and the nutrition transition. In 2017 Global Food Policy Report. Chapter 4. Pp 34-41. Washington, DC: International Food Policy Research Institute (IFPRI). https://doi.org/10.2499/9780896292529_04.
3WHO, Controlling the global obesity epidemic. Available at http://www.who.int/nutrition/topics/obesity/en/.
4World Bank, An Overview of Links between Obesity and Food Systems; Implications for the Food and Agriculture Global Practice Agenda. June 2017.
5Kerry, Beyond the Label: The Clean Food Revolution. Available at https://go.kerrycleanlabel.com/cleanlabelwhitepaper/?.

Driving Change in Nutrition

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An engaging initiative called OBAASIMA has been making waves when it comes to developing fortified food products in Ghana. OBAASIMA is a trusted trademark aiming to increase the availability of and access to new affordable nutritious fortified food products for Ghanaian women. 

The inspiring team behind the OBAASIMA seal is dedicated to changing the food environment in Ghana by creating healthy food options for women. At Sight and Life we are passionate and supportive of OBAASIMA’s pursuit and wanted to learn more about what drives the group behind the OBAASIMA seal. Therefore, we sat down for an interview with Daniel Amanquah, OBAASIMA’s fortification specialist, to find out what makes him tick and much more.
 
SAL: Sight and Life
DA: Daniel Amanquah

Daniel, Sight Life, Obaasima, food fortificationSAL: Tell me a little bit about your background in nutrition.

DA: I attended the University of Ghana in Legon and graduated with a Master of Philosophy in food science and a Bachelor of Science in nutrition and food science. During university, I had an internship in a factory working with a couple of companies to help  introduce new products to the market. Following school, I worked with a colleague to develop our own food product in which we wrote, “Development of a Tigernut Based Ready–to-Use Therapeutic Spread” which was published in the International Journal of Agricultural Policy and Research.

SAL: Describe your current role at OBAASIMA.

DA: My current role at OBAASIMA is as the food fortification specialist working on behalf of Sight and Life in Ghana. One of my key focus areas is supporting companies who sign onto the OBAASIMA seal. This work involves modifying the product to include the vitamin and mineral premix and examining the nutrition profile to ensure it fills the criteria developed in the OBAASIMA seal code of conduct. This stipulates acceptable levels of sugar, fat and salt level for products to carry the OBASSIMA seal. We then test the premix with a scientific analysis to make sure we are on track to develop quality food products.

What I love about my role is visiting the factories, sitting down with the key players, and working through the product development phase. 

SAL: How did you hear about OBAASIMA?

DA: My first job was with the GIZ in 2014 and I was part of the inception team for OBAASIMA when the project was called “Affordable Nutritious Foods for Women (ANF4W)”. I was the technical officer for the project and collaborated with Sight and Life, Children’s Investment Fund Foundation (CIFF) and colleagues at GIZ to get the pilot phase of the project up and running. 

SAL: In two words how would you describe OBAASIMA?

DA: One word is innovative. The second, I would say, is complex. OBAASIMA is a very good model for a lot of companies in low- to middle-income countries to alleviate micronutrient deficiencies and encourage healthy eating.

SAL: What do you like most about working for OBAASIMA?

DA: What I like most is the team, teamwork, and authenticity.

obaasima, food fortification, quality seal

SAL: What is the biggest challenge for OBAASIMA?

DA: Acquisition of companies to join the OBAASIMA seal has been quite tough especially with the  level of sugar required as part of the seal. Sugar is a driving factor for companies, particularly juice and beverage companies that have a lot of sugar in their products. We have not been able to engage any of them yet, but we are still working hard to get them on board. The OBAASIMA seal has quite stringent qualifications, so it is quite difficult for a company that is not nutrition sensitive to join the seal.
 
I mean you speak to people about nutrition and they know about good nutrition. However, the industry tells you, “But, this is what is on the market, this is what people are buying. So why do you want me to change the formulation? Why do you want me to make it more healthier?” Therefore, it is interesting and complex to convince companies to include the OBAASIMA seal on their products. They know it is beneficial to reduce sugar and fat while including micronutrients, they know it is going to help reduce malnutrition and the double burden of malnutrition, specifically in Ghana where you have high obesity rates. So they know this and they appreciate it but they tell you, “the market is not like that, and the customers want this.” Albeit, we do have successes and the momentum is growing.

SAL: In your opinion, what makes the OBAASIMA seal stand out?

DA: The innovation that comes with the OBAASIMA seal has not been done or piloted anywhere in the world, at least not that I know of. Currently, Zambia, through the SUN Business Network, has a similar seal, however, it is a general seal for good nutrition not for a specific target group. OBAASIMA is unique. It is only for processed and package foods, which are ready to eat and includes 18 essential vitamins and minerals for women of childbearing age. We believe the focus on the first 1,000-days is crucial to addressing malnutrition in women and children. This is the first time we are doing something like this in Ghana, and I am proud to be a part of it. The results that will emerge will be a good model to demonstrate what can be done and replicated in other places as well.

SAL: What does the future look like for OBAASIMA?

DA: To broaden it, not just for women of child-bearing age, but for all segments of the populations and to go beyond Ghana. I see in a few years several multi-national companies signing on to the OBAASIMA seal and a global movement of eating healthy and getting healthy processed foods onto the market. We have a lot of work on our hands.
 
The landscape is changing and we will get to a time when people will demand healthier foods for their children and themselves and enforcement of healthier product profiles will being to happen. Companies will be forced to cut out the less desirable ingredients such as sugar. Once we get multi-national companies to come on board, adaption will follow, every other company will follow, and the OBAASIMA seal will become big. So I believe there is a future for this seal, it needs more advocates! We will get there.

SAL: Well, you have a mighty large task ahead of you to recruit many of these companies to join the OBAASIMA seal. Sight and Life supports and applauds your efforts to make these changes and wishes you much success on furthering this great, great initiative.
 
 

A Jump-Start into the World of Nutrition

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On June 7th, 2018, only three-days after starting my summer internship with Sight and Life, I found myself on a long-haul flight traveling to Boston, Massachusetts, from Switzerland. I was invited to join the Sight and Life team at the American Society for Nutrition’s (ASN) Nutrition 2018 conference – what an incredible opportunity! I could not have been more excited for this perfect introduction into the world of nutrition, particularly since I am interested in applying my current academic background in economics and law to the field of nutrition.

Initiation as an Intern

On the first day, I participated in a team workshop where I met the global team of Sight and Life – such an interesting mix of people! As a complete newbie, I quickly observed that the team is held together by their passion for nutrition, as their backgrounds are quite diverse. Besides nutritionists and scientists, I was stunned to discover there is an assortment of business, communications, marketing, and architecture degrees amongst the group. Additionally, I gained insight on how Sight and Life operates. The team of twelve is spread across four different continents – India, Egypt, Switzerland, South Africa, and USA – completing the majority of their work remotely and therefore making team retreats of great importance.  


The workshop focused on ‘design thinking’ and was a great opportunity for everyone to learn a new method of problem solving. Additionally, having a team with a wide variety of knowledge and experiences presented interesting and rich discussions the during group exercises. The most valuable take aways, for me, were learning the importance of a broad stakeholder analysis, defining a high potential but underdeveloped stakeholder, and how you can engage with an assortment of stakeholders within a complex interdependent system. This mirrors the importance of a multi-sector and multi-stakeholder approach to solving the complicated malnutrition puzzle. The day culminated at Fenway Park cheering on the Boston Red Sox’s as they played the Chicago White Sox for a Sight and Life team outing. 

A Peek into Nutrition

For the next three days, I participated in ASN’s Nutrition 2018 at the Hynes Convention Center. As I have never been to a conference, let alone one focused on nutrition, and I was eager to see how it all worked. With over 3,500 participants registered, it was shaping up to be the largest ASN conference so far. When I walked through the main entrance for the first time, I thought something probably quite typical of a European in America, “Oh my god, this is so big!” Sight and Life showcased a booth in the gigantic exhibitors hall, but there was also several floors of meeting rooms where I would spend the coming days in listening to interesting presentations. 

ASN, Sight Life, Nutrition2018, conference, malnutrition

Eager to learn, I attended as many sessions as I could possibly fit into my schedule covering a wide variety of nutritional topics. I didn’t know what to expect when I saw the list of speakers for each session, naively I thought they would all sit in front and have a panel discussion. However, they were mostly individual presentations sharing the results from their recent research. I learned about behavior change communication, nutrition education, heard about different nutrition strategies and their implementation, and community health interventions that were completed in India and one in a refugee camp in Beirut.
 
For me, the most interesting session was “Demographics, Diversity and Disparities in Nutrition Science”. A few speakers presented research that was focused on a specific region in Hawaii, USA, and an ethnic group of American indigenous people while others presented nutrition issues and development on the global level. The most shocking session I attended was, without doubt, about the nutrition situation of Native Americans by Dr. Donald Warne, a member of the Oglala Dakota tribe from South Dakota, USA. He provided extensive evidence that one does not have to travel far to find health issues as they exist in native communities in the United States of America. He argued that it is almost perverse that in America you are automatically eligible for dialysis in the case of kidney failure; yet, a child is not automatically eligible for healthy food. An anecdote that resonated with me was a story Warne shared of three sisters illustrating the importance of targeting health problems at their roots.

As three sisters walk along a river, they see there are children in the river who cannot swim and are about to drown. One of the sisters says, “Something needs to be done.” She jumps into the river and tries to save the children. The second sister disagrees with the first one saying, “We just need to teach them how to swim!” The third sister has not said or done anything, and the other two are furious with her. “Why aren’t you helping us?” they exclaim, “These children need to be saved!” The third one turns away and starts to walk up the river saying, “I will find and stop the person who is throwing these children into the water.”

Experiencing the Conference

During the three days, my time spent at the Sight and Life booth was both busy and truly engaging. I found it most interesting to talk to students, researchers, journalists, and scientists from all over the world and explain what Sight and Life stands for. It was intriguing to visit the other exhibitors at the conference presenting a variety of nutrition topics from non-profit organizations fighting malnutrition to private corporations offering vitamin supplements. One booth representing a company called Allulite Rare offered samples of chocolate and gummys made with a new kind of sweetener that tastes just like sugar, but without all the disadvantages such as calories, glycemic effect or digestive upset. At the InBody exhibit, I had a body measurement analysis done free. This machine provides individual results for weight and body fat percentage as well as the distribution of lean muscle mass in less than a minute. 

Sight Life, Elevator Pitch Contest, EPC, Finalists 
A highlight for Sight and Life was the Elevator Pitch Contest, where selected students and young researchers presented their innovative ideas on nutrition assessment to a panel of experts. It was fascinating to hear about these cutting edge concepts and that many people my age share the passion for nutrition. Many of the presentations introduced fascinating new mobile applications for measuring food intake. One of my favorite pitches was from Andrea Spray of INATU, standing for ICT’s for Nutrition Agriculture and Time Use. By attaching a tiny camera to women’s clothing, the device provided in-depth research for nutrition assessment as the device automatically takes a picture every minute. Her project in Africa proved that the gadget was generally well received in communities and proved to be a good option for measuring nutrition behavior remotely without much paperwork – this was an interesting idea. It is impressive to see the tremendous progress that can be made in a relatively short time when one is focused on a goal and teams up with the right people.
 
After spending a sunny day sightseeing in Boston, I once again found myself onboard a flight back to Zurich. It was an incredible experience. I learned so much about nutrition, the broadness of the worldwide nutrition issues currently at hand and the importance of bringing all stakeholders to the table. I would like to thank the Sight and Life team and my boss, Klaus Kraemer, for making this possible and for welcoming me into the Sight and Life family.

Take a look through the picture gallery from ASN: 

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Where are they now?

Sight and Life Elevator Pitch Contest Finalists

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Ever wonder what happened to the first Sight and Life Elevator Pitch Contest finalists from 2016? Sight and Life had the privilege of catching up with four of the ten finalists from Elevator Pitch Contest to find out what they are up to now and reflect on their experience.

EPC, Elevator Pitch Contest

 
During this competition, graduate and post-doctoral students were invited to submit their ideas on the theme ‘The Future of Micronutrient Innovation’ across diverse categories in nutrition-related products, services and technologies. We received over 90 submissions from students in 18 different countries. With the support of a distinguished jury, we narrowed the selection to ten bold ideas for presentation. The finalists were sponsored by Sight and Life and Tata Trusts, who mentored them as they prepared to present their ideas to a panel of experts, in front of an audience of conference participants during the Micronutrient Forum in Cancun, Mexico. Read more about the 2016 Sight and Life Elevator Pitch Contest here

The first and second place winners, Muzi Na and Nicholas Myers, share their status and weigh in on the Elevator Pitch Contest along with finalists Nicholas Myers and Sambri Bromage. 
 
Uzi Na, Elevator Pitch Contest FinalistMuzi Na
Location: China
Concept: Empower Grandparents – A mobile application using SMART feeding messages that empower senior caregivers, such as grandparents, to better feed their grandkids in rural China.
 
Na was the first place winner of the 2016 Elevator Pitch Contest with her innovative mobile phone application and persuasive pitch. Today, the idea is on paper with plans to write grant allowing her to collect data about acceptability regarding the idea among the target population. Currently, Na is on faculty at Penn State University as an Assistant Professor in Nutritional Epidemiology.

EPC, Elevator Pitch Contest, Philip James

Philip James
Location Gambia
Concept: Next Generation Supplement Design – A novel nutritional supplement to optimize the mother’s micronutrient status in early pregnancy to better regulate infant epigenetics and decrease future disease risk.
 
A future full of potential, James caught the attention of the jury panels with his inventiveness in 2016. The nutritional supplement has now been designed and is currently in the process of setting up a clinical trial in Gambia to test its effectiveness in correcting micronutrient deficiencies. James and histeam is also looking at how nutrition in pregnancy, particularly at the time of conception, has the potential to influence the way an infant’s genes are expressed, and the implication this may have for the health of that child over his or her life.
 
EPC, Sight and Life, Elevator Pitch Contest Nicholas Myers
Concept: Paper Analytical Devices – A lab-on-paper that measuresiodine levels in salt and urine samples to monitor iodized salt programs at a low cost in real time. 
 
Myers has found support through The Black Lion Hospital, in conjunction with the Ethiopian Food, Medicine, and Health Care Administration and Control Authority, and is performing an implementation study in Ethiopia. If the study is successful, health agencies and governments may use the test card to monitor the quality of iodized salt in marketplaces.
 
With a shift from the nutrition field to public health, Myers has adapted the chemistry of his iodine test card to instead quantify the amount of penicillin-class antibiotics present in finished pharmaceutical pills with greater than 95% accuracy. His hopes are that the test card becomes a field-friendly technology that governments use to detect breaches in medicine compliance.

EPC, Elevator Pitch, Sabri BromageSabri Bromage
Location: Mongolia
Concept: Leveraging Academic Networks for Dietary Survey (LANDS) – A global student-centered network for collecting, analyzing, sharing, and applying dietary data from populations in low-and middle-income countries.
 
Today LANDS is used in Mongolia with interest to expend it internationally. Bromage is currently finishing his dissertation on “Epidemiology of dietary and micronutrient deficiencies in Mongolia” and beginning the search for a post-doc position or job. In tandem, he is working on new and interesting projects that he will be able to share in the future.

1. What did participating in the Sight and Life Elevator Pitch Contest mean to you personally and your innovation?

Na – The Sight and Life Elevator Pitch Contest meant a lot to me! Personally, the contest provided an opportunity for me to meet and know manyyoung innovators working in diverse fields all over the world. From the innovation’s perspective, the elevator pitch style is very different from writing a proposal or a manuscript, as there is a short window of time to articulate an idea, including the rationale behind the idea and the potential impact. I really want to thank Sight and Life for organizing this fantastic event, in which I discovered new possibilities to share and sell novel ideas that aim to tackle nutrition problems. 
 
James – It was a privilege to be short-listed for the contest. Being able to attend the contest at the Micronutrient Forum enabled me to meet so many people from different fields in nutrition, to network with people who were interested in my team’s project and to be able to benefit from everything else happening at the Forum.
 
Myers – As an inventor, I welcome any chance to disseminate information about my invention. At the competition, I pitched an idea about an inexpensive paper test card that quantifies iodine levels in fortified salt with greater than 90% accuracy and how it can be used in low- and middle-income countries. At the time of the contest, my invention was making its way through the “Valley of Death,” which is a relatively low funding period between R&D and commercialization. The contest provided a platform on which I, a chemist, reached hundreds of experts in the micronutrient sector, and these multi-disciplinary connections are critical to push an invention through the “Valley of Death” and to commercialization.
 
Bromage – Participating in the Sight and Life Elevator Pitch Contest helped me realize the international potential of my innovation. Personally, it exposed me to nutrition innovation, a part of nutrition I have not had much experience with as I mostly work in research.

2. What was the biggest challenge you experienced through the creation process of your innovation?

Na – I guess there were many challenges but the biggest one for me probably was to identify the ‘big’ problem that maybe solved by a ‘small’technology, which I understood. Once a niche target population was identified, the process to identify and design an intervention, applying feasible technology to serve the population was straightforward.
 
James – The field of nutritional epigenetics is still rapidly developing, so consolidating the evidence base to design a supplement was an interesting but challenging piece of work. 
 
Myers – The biggest challenge for me was overcoming small but daily setbacks. I had to rapidly prototype dozens of devices with relatively minor changes, most of which did not work. I came to term this ‘Edisoning’ as Thomas Edison had to follow a similar process as he trialed 2000+ materials to develop the light bulb. My technology and I survived the research and development phase because I saw the benefits of the final product outweighing the emotional, physical, and monetary costs to create it.
 
Bromage – My biggest challenge is getting other people interested in my innovation because I am not really a natural born salesperson.

3. What was the most memorable moment from the Sight and Life Elevator Pitch Contest?

Na – It was the moment I decided to stay among the audience and not to give the pitch behind the podium. It was a completely random thought, mostly because I was very nervous. Once I started my pitch right next to the first row of listeners, I immediately felt a connection with the audience. It was an amazing feeling and my nerves immediately disappeared.
 
James – The session when we delivered our presentations was a great experience. It was so good to hear everyone’s pitches, get inspired by the creativity in the room, and to have the support of a room full of interested people. It was also encouraging afterwards to network with people who had further questions and advice.  
 
Myers – The moments I enjoyed the most happened behind the scenes when all the innovators had the opportunity to get to know each other personally. We are not just a bunch of mad scientists- we are a group of seemingly ordinary people with a shared desire to improve health, and with the motivation to do so.
 
Bromage – Getting to meet the other contestants and the Sight and Life team including Kalpana Beesabathuni, Kesso Gabrielle van Zutphen, and of course Klaus Kraemer.

4. What lesson(s) did you learn from your experience?

Na – Be bold, be confident. No idea is too small to share. Lastly, but not least, it is important for any speech-based contest to practice, practice, and practice. 
 
James – It was a great opportunity to learn how to explain an idea succinctly and avoiding technical jargon. An elevator pitch is a very different style of communication than I was previously used to and this was the ideal setting to learn more about how to develop those skills.
 
Myers – Even though I was one of the winners, investors and buyers are not knocking down my door to advance the technology. The lesson I learned is that perseverance is needed at all steps of product development and that I will have to keep pushing just as hard as I did through the research and development stage to survive the commercialization phase of my invention. It took a lot of hard work and gumption to achieve what I have so far, and it will take at least as much to reach the next level.
 
Bromage – Some of the greatest innovations are not devices but rather new ways of thinking about the world.

5. Where do you see the future of nutrition?

Na – I see a lot of potential for the future of nutrition is from the interdisciplinary perspective, where technology, engineering, biology, and other disciplines interact with nutrition making groundbreaking discoveries as well as solving critical nutrition and health problems.
 
James – I see a future where nutrition continues to be integrated with other sectors and disciplines. In my field that means analyzing nutritional biomarkers together with metabolomics, genomic, and epigenomic data to broaden our understanding of the complexities of human metabolism. 
 
Myers – The future of nutrition relies on all of us being citizen scientists making information-based health decisions. Ordinary people need to be provided easy-to-use and robust technologies to help them with these choices. We saw this at the competition, especially with the technologies presented by the three winners.
 
Bromage – Dealing with the effects of climate change.

Interested in learning more? Read the about the next group of EPC alumni here

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International Society for the Study of Fatty Acids and Lipids (ISSFAL) 

Congress Report 

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ISSFAL

The International Society for the Study of Fatty Acids and Lipids (ISSFAL) was established in 1991, with the main objective of providing a better understanding of the role of dietary fatty acids and lipids in health and disease through research and education. The 13th congress of ISSFAL was held at the MGM grand hotel and casino in Las Vegas, Nevada, USA. This congress provided a very unique opportunity for me to learn from the seasoned researchers and experts in my area of interest. Approximately 500 scientists, health professionals, administrators and educators with an interest in the health effects of dietary fats attended the congress. 

The ISSFAL program was well organised and comprised different satellite symposia, plenary and parallel break-out sessions. ISSFAL hosted two satellite symposia on Sunday, May 27. On this day, the registration desk was open and accessible through out the whole day. I attended the satellite symposium on arachidonic acid (AA) and docosahexaenoic acid (DHA) in infant and development. An international panel of thought leaders in this area were assembled specifically for these presentations and the symposium highlighted the biological functions of AA and DHA in early human and animal development.

In the evening, there was an opening reception at the Tropicana Hotel where the congress chair Hee-yong Kim from National Institutes of Health welcomed the attendees to Las Vegas and the congress. Kim encouraged all young investigators and junior scientists to take advantage of the many events within the program to interact with the seasoned researchers and experts in the field of fatty acids and lipids and foster interaction among all participants. These included the ‘meet the Professors breakfast’ and ‘young investigator social’ providing networking opportunities with people from different parts of the world. At that moment I realized that there is more to research than collecting data and writing articles, it’s all about being part of something, socializing with people who share similar interests and coming together to help improve the world we live in. 

The program for the congress covered three major topics: Biochemistry and Metabolism of Fatty Acids; Lipids in Health and Disease; and Lipids in Nutrition. These major themes encompassed all other aspects of lipids including but not limited to lipidomics and metabolomics, which are all important for understanding human physiology and pathophysiology. The actual scientific congress started on Monday, May 28 and ended on Thursday, May 31. Each day began with one plenary session in the morning, followed by three parallel break-out sessions, another plenary session soon after the lunch break and three parallel break-out sessions after the afternoon coffee break. All in all, there were six plenary sessions and 24 parallel break-out sessions. Presentations ranged from translational research to clinical studies. Most presentations provided evidence about the impact of lipids in different clinical diseases and a clear understanding of the role that dietary lipids play at all ages in preventing diseases related to lifestyle. 

Below are a few key learnings from my experience at ISSFAL:

Maternal and Infant Nutrition 

– Results from a randomized controlled trial showed that enteral DHA supplementation with 60mg per kilogram of DHA resulted in a greater risk of lung inflammation in very preterm infants. Therefore, these results did not support supplementing very preterm infants with DHA above levels currently available in breast milk and recommended in infant formula. 

– Other analyses highlighted the importance of controlling for environmental factors when evaluating nutritional interventions. Furthermore, differences in brain function and behavior were observed in children more than 5 years after in utero DHA supplementation. However, boys may be more vulnerable and tend to benefit more from early supplementation.

– The importance of long chain polyunsaturated fatty acids (LCPUFAs) in infant formula is still evolving. Polymorphisms add an entirely new dimension, particularly, the FADS status of the mother and infant should be considered when designing future studies. In addition, fortified infant formula milk should contain both DHA and AA, because there is insufficient clinical trial evidence for the safe removal of AA in infant formula milk containing DHA. 

Clinical Trial Methodology 

–  It is important to optimize the differences between the treatment and control groups to ensure that effects are detected, if any. The interpretation of results solely depends on the background diet, dose of fatty acid intervention and use of appropriate control diets or supplements. Research is important for assessing different trial outcomes, therefore, it is important to have realistic expectations and outcomes. 

– At the beginning of a trial, it is important to consider the design of tools to enable effective organisation of the study protocol with the aim of improving compliance. Of importance is a communication plan, study timeline, data management and monitoring plan as well as the establishment of appropriate committees. The full lifespan of the project must be examined, giving special attention to defining roles, training a skilled research team and creating a comprehensive manual of standard operating procedures. 

– Also critical is further refining relationships with institutional support sectors including institutional review boards, research institutes, and clinical stake holders. When conducting clinical trials, it is important to be vigilant and focus on the goal as well as to keep contact on the ground on the project’s routine needs thus allowing your team to not only keep momentum but also to anticipate a variety of road blocks at any stage of the trial. 

Dietary Fatty Acid Intake 

– In Canada, healthy toddlers are not meeting the recommended dietary intakes of DHA and AA. 

– Moreover, in the United States of America, the current recommendation of 2 servings of fish per week in adults is unlikely to result in a desirable omega 3 index. Thus, at least 3 servings of fish per week plus an EPA+DHA supplement appears to be necessary to achieve this target level. 

I also attended the Alexander Leaf award ceremony and had the privilege to listen to Maria Makrides’ (South Australian Health and Medical Research Institute & School of Medicine, University of Adelaide, Australia) lecture titled, “Standing on the shoulders on giants: Great women role models of my career”. From this speech I learnt that: 

– It is important to keep your eye on the horizon. Be clear about your destination and how you want to get there. Keep trying out new things, adjust and modify your journey accordingly. Sometimes you want to think that your career will be linear, always a step forward, but along the way you will find a lot of sharp turns. Even then, do not cut too many corners in the process because the value of the outcomes is strongly linked to the quality of the research process. 

– It’s all about creating opportunities and preparation. Learn from as many people as you can along the way. Be open to new possibilities and by so doing you will always have a runway for continuing to explore new areas of research and stretching yourself beyond limits. Also, remember to be kind to yourself and to others. Have fun and enjoy the journey. 

Congress report, DHA
Linda P. Siziba standing by her poster at the ISSFAL congress

Poster presentations were done every day during lunch and coffee breaks. I had the privilege of presenting my poster entitled “Associations of plasma total phospholipid fatty acid patterns with feeding practices, growth and psychomotor development in six-month old South African infants.”

Furthermore, some activities were organised to enable everyone to meet and socialize with other delegates at the congress. In addition to the welcome reception, I also had the privilege to attend the ‘DSM 1000 days award breakfast’, DSM Science and Technology Award reception, young investigator social and ‘meet the Professors breakfast’. Wednesday, May 30 was an ‘off-day’ and this was an opportunity for everyone to explore Las Vegas and surrounding areas. There was a variety of tours and activities to choose from which included but were not limited to a helicopter ride or a drive to the Grand Canyon. The congress officially ended on Thursday, May 31 with a gala dinner, where we had an amazing ‘German’ experience, while in Las Vegas, at the Hofbräuhaus. 

I would like to express my utmost gratitude to Sight and Life, DSM, Centre of Excellence for Nutrition and my promoters (Prof Marius Smuts and Prof Jeannine Baumgartner) for generously contributing towards making my ISSFAL congress attendance possible. It was indeed a unique opportunity for me as a budding researcher for personal branding, networking and learning even more about fatty acids from leading scientists in the field. 

Correspondence: Linda P. Siziba, PhD student at Centre of Excellence for Nutrition, North West University, South Africa. Email: sizibalinda@gmail.com

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Expand your Knowledge

Recommended Reading on Behavior Change Communication

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At Sight and Life, we are pleased to share knowledge and recommend resources that we find useful in our work. This is certainly the case with behavior change communication (BCC).

To expand your knowledge about the steps in the Sight and Life BCC Process we shared during the webinar “Assessing the Situation: What you need to know” in our BCC webinar series, we have collated an array of books, websites, and papers that are valuable resources. This is just our opinion but we hope these recommendations can deepen your knowledge on BCC and provide though-provoking ideas and inspiration as it did for us.

During this second webinar in the series, we discussed Step 2 and Step 3 in the Sight and Life BCC Process; the desk review and client research.

Bcc Process Cycle, behavior change, nutrition

The key takeaways from this webinar are:
– The BCC principle ‘know your audience’ lies at the core of developing successful nutrition communication campaigns. 
– Defining your knowledge needs, or simply what you need to know, is the first critical consideration.
– Step 2 in the BCC process isabout assessment, analysis, and synthesis of information to effectively answer questions on the broader context, thedrivers and constraints for the target behavior and communication efforts previously employed to change the desired behavior.
– Client research, step 3 in the BCC process,involves gaining valuable insights from the target audience and communities that you seek to change. 

Watch the video of webinar 2 below and find the complete slide deck from the second Sight and Life webinar HERE.

Our Recommended Resources on BCC from Webinar 2

 

Research Paper
1.
Download the paper by Population Services International (PSI). A Qualitative Research for Consumer Insights: One Organization’s Journey to Improved Consumer Insight HERE

In this paper, PSI, a leading social marketing and behavioral change communication NGO describe how they improved the use of research to gain better consumer insights and plan better interventions. It offers a practical perspective through the lens of an organization where research is core of the business.

Why do we like this?
We think this paper is insightful for any organization wishing to strengthen their qualitative research capacity for improved target audience insight generation. The paper lays out how an organization focusing on behavioral change, has sophisticated their approach to qualitative research to improve their programmes over time.

Useful Websites
2.
The Health COMpass
The Health COMpass is a platform offering a wealth of useful resources from different proven sources, for researchers, from specific guides on data collection methods for the field to more comprehensive guides on how to conduct formative research. It is funded by USAID and managed by Johns Hopkins University Bloomberg School of Public Health.
 
Why do we like this?
The Health COMpass provides evidence-based, easy to understand tools – ready to take and apply to a real-life context for beginner and specialists in behavioral change alike.
 
3. The UK National Social Marketing Center
This former non-profit and now agency offers a comprehensive step-by-step guide on developing a behavioral change intervention. Of specific interest is the section on generating insights, in their planning guide as well as the real-life examples of behavioral change interventions, in the showcase section, you can learn how insights were derived from research to development. 

Blog
4.
Innovative Research Methods – Roleplay
As we often conduct research on topics that can be sensitive such as personal health or child feeding practices, creating an environment where the interviewee feels comfortable and at ease, enough to open up to the interviewer is often a challenge. The choice of a research method that best fits the environment is key. Using roleplay for research is an innovative way to allow the interviewees to ‘act-out’ their behaviors, concerns, beliefs, and barriers with others rather than be interviewed. IDEO, a social innovation consultancy, uses this method successfully and provides free tools to download.

Another interesting blog post about the use of role-play in research is “Candy Wrappers and Stethoscopes: Role-play in the user testing environment” written by Estee Liebenberg, a service design consultant.
 
Why do we like this?
Innovative research methods to tailor how we approach our audience and adhere to their needs and contexts is an important part of ‘knowing your audience’. Roleplay provides an applicable research method and in this blog post the author and practitioner of roleplay provide great insight into how this methodology works in practice.

Book
5.
Thinking Fast and Slow by Daniel Kahneman
 Drawing on decades of research in psychology that resulted in a Nobel Prize in Economic Sciences, Daniel Kahneman takes readers on an exploration of what influences thought example by example. System 1 and System 2, the fast and slow types of thinking, become characters that illustrate the psychology behind things we think we understand but really don’t, such as intuition.
 
Why do we like it?
In webinar 2 we talked a lot about the BCC principle ‘know your audience’ and this book is an interesting examination of human behavior and how we think. It is a comprehensive explanation of why we make decisions the way we do and how the decision-making process can be improved. An interesting tidbit is our decisions are strongly colored by how we frame questions in our minds. Simply re-framing a question can easily cause people to reverse decisions. We need to understand these framing issues in order to avoid bad decisions. This provides useful insights for BCC interventions aiming to influence the decision-making process.

Webinar 2 Sources
And lastly check out these great sources our experts referred to during webinar 2! 

6. Merritt, RK. Bsc, D.Phil  (2011). Developing your  Behaviour Change Strategy ‘How To’ Guide.  On behalf o f NHS East London & the city.  Tower Hamlets PCT. 
 
7. Dickin, Kate and Marcia Griffiths, The Manoff Group, and Ellen Piwoz, SARA/AED. Designing by Dialogue. Consultative Research to Improve Young Child Feeding. Support for Analysis and Research in Africa: Washington, D.C.: AED for the Health and Human Resources Analysis (HHRAA) Project, June 1997 
 
8. Focused Ethnographic Study of Infants and Young Children Feeding Manual

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Assessing the Situation

What you Need to Know 

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Recently listening to TEDxCSU Talk on behavior change led by Professor Jeni Cross from Colorado University, I was immediately struck by how we routinely rush the planning stage of a behavior change communication (BCC) intervention. Taking time to understand where we are, where we want to go, and what will enable us to reach our goal is essential in devising a successful nutrition communication campaign. Resonating with this topic is the second webinar in Sight and Life’s Webinar Series “Assessing the Situation: What you Need to Know.” It is a valuable and timely reminder on the importance of understanding your target audience during the BCC planning process. 

During this enlightening dialogue Professor Cross spoke candidly about the existing myths regarding behavior change. For example, does education change behavior? What we know about education is how the information is presented, rather than the information itself, creates behavior change. Making learning tangible, personalized, and incorporating social interaction provides the greatest impact in behavior change.  

Another misconception is that one needs to change attitudes to change behaviors. Attitudes do not predict behavior! A more effective strategy is to connect to people’s values to set behavior expectations. The last myth is that people know the triggers that motivate them. Professor Cross argues this is not the case, as social norms have, by far, the greatest influence on human behavior. For instance, if you see someone select a healthy option at lunch, then you are more likely to follow suit. Understanding these constructs in human behavior is important because they are the core of developing successful nutrition communication campaigns.  Watch the TEDxCSU Talk below: 

Keep this principle thought in mind as you embark on the next steps in the BCC process presented in Sight and Life’s second webinar in the BCC Webinar Series. 

The Journey to Understanding your Audience 

Here are the questions to ask as you embark on step 2 and 3 in the BCC process:   
– What is it that I really need to know about my audience and the environment in which they live? 
– What works and does not? 
– How do I get to the core of what matters to my target audience? 

Webinar 2 walks through the typical knowledge needs required for a BCC intervention in nutrition, examines how to get the most out of each knowledge source and suggests approaches that enable a deep understanding of the target audience.  

BCC Process Step 2. The Desk Review 

Before beginning the desk review, be sure to answer the question, what is the purpose of this information and how do you plan to use it?  

The desk review encompasses three elements: 
– Exploring the broader context
– Reviewing the effectiveness of past experiences
– Understanding program context (reaching your target audience) 

In summary, elements 1 through 3 of the desk review help define the scope of your communication strategy. These identify the broad parameters and constraints to use when designing and delivering the intervention while also supporting the critical decisions when creating a communication strategy.  

BCC Process Step 3. Client Research 

The next step in the BCC process involves acquiring valuable insights from the target audience and communities you seek to change. We are again reminded of the BCC principle; know your audience!  

BCC, Nutritional Status, conceptual Model, behavior communicationDuring webinar 2 we share three key components in client research which support the gathering of comprehensive information on the target audience and factors that influence behaviors and practices; the inquiry framework (what do you need to know about the behaviors), applicable research methods (how to extract that information), and insight generation (moving from understanding behavior to finding deep, shared truths). 
BCC, Nutritional Status, conceptual Model, behavior communication
Consider the questions posed at the start of this blog: what do I need to know about my audience and the environment in which they live, what works or does not, and how do I get to the core of what matters to my target audience? Steps 2 and 3 help you answer these questions.  

Key Takeaways from Webinar 2 

– The BCC principle ‘know your audience’ lies at the core of developing successful nutrition communication campaigns.  
– Defining your knowledge needs, or simply what you need to know, is the first critical consideration.  
– Step 2 in the BCC process is about assessment, analysis, and synthesis of information to effectively answer questions on the broader context, the drivers and constraints for the target behavior and communication efforts previously employed to change the desired behavior.
– Client research, step 3 in the BCC process, involves gaining valuable insights from the target audience and communities that you seek to change. 

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Essential Reading on Behavior Change Communication (BCC)

Back to Overview

At Sight and Life, we are pleased to share knowledge and recommend resources that we find useful in our work. This is certainly the case with behavior change communication (BCC)! To continue learning about BCC while waiting for the upcoming webinar, we have collated an array of books, websites, and e-learning modules that are valuable resources. This is just our opinion but we hope theses recommendations can deepen your knowledge on BCC and provide though-provoking ideas and inspiration as it did for us. 

During the first webinar in the Sight and Life Webinar Series focusing on behavior change communication (BCC), we examine integrating BCC into nutrition programs. The key learnings are:

– BCC is a communication approach with distinct underlying principles, which make it a valuable part of nutrition programming.
– It is complicated but can be managed by taking a systematic approach.
– Consider the Sight and Life BBC process cycle as a tool to support planning your nutrition communication campaign.

Find the video and the complete slide deck here from the first Sight and Life webinar People eat food not nutrition: Integrating BCC into nutrition programs HERE.
Behavior change communications, BCC, SBCC 
On May 15th we will be hosting our second webinar Assessing the situation: What you need to know (please register HERE). In this webinar we will identify the typical knowledge needs for BCC intervention in nutrition. We will discuss how to get the most out of the knowledge sources, including written material (program reports, scientific papers), experienced program stakeholders, knowledgeable service providers, and of course, your target audience. Additionally, learn tips for tailoring formative research to generate insights on the factors driving eating behaviors.

Our Recommendations on BCC

E- learning:

1. This interactive course by Strengthening Partnerships, Results, and Innovations in Nutrition Globally project (SPRING) will guide you through narrated slides, quizzes, exercises, handouts, videos, and links to helpful resources. This course will help you understand agriculture’s role in improving nutrition, learn how to use behavior change methods to prioritize and promote nutrition-sensitive agriculture practices, and develop a behavior change strategy for current and future agriculture projects. Find it HERE.

Reading

2. Read this work SPRING; Evidence of Effective Approaches to Social and Behavior Change for Preventing and Reducing Stunting and Anemia to learn the findings from a systematic literature review. 

Lamstein, S.,T. Stillman, P. Koniz-Booher, A.Aakesson, B. Collaiezzi,T.Williams, K. Beall, and M.Anson. 2014. Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and Anemia: Report from a Systematic Literature Review. Arlington,VA: USAID/ Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

Toolkit

3. Behavior Change Toolkit  – for International Development Practitioners
This behavior change toolkit is a useful, well written and simple introduction to BCC. A great resource for those starting their learning journey on BCC. The toolkit can be downloaded HERE.

Books

4. Nudge: Improving Decisions about Health, Wealth, and Happiness, Richard H. Thaler, and Cass R. Sunstein.
A book from the winner of the 2017 Nobel Prize in Economics, Richard H. Thaler, and Cass R. Sunstein: it is a revelatory look at how we make decisions. The authors examine the process of how people think and suggest that we can use sensible “choice architecture” to nudge people toward the best decisions for ourselves, our families, and our society, without restricting our freedom of choice. Nudge is really about the small, subtle pushes that our modern-day world makes to sway one’s opinion or real-world choices.

Why it’s on our Kindle’s
To succeed in behavioral change we must be able to offer people better, more favorable and less costly choices to what they are currently doing. To reduce the consumption of junk food in teenagers for example, we must be able to design alternatives that are equally desirable. Therefore, we must build an architecture that will encourage people to change their habits and follow our behavioral goals. We loved reading the real-life examples in this book and learning how simple, thoughtful ‘nudges’ can help people change a variety of behaviors. Find it HERE
 
5. The Power of HabitWhy We Do What We Do in Life and Business, Charles Duhigg 
In The Power of Habit, award-winning New York Times business reporter Charles Duhigg takes us to the edge of scientific discoveries that explain why habits exist and how they can be changed. It uses research to explain how habits are formed and changed. At its core, The Power of Habit contains an exhilarating argument: The key to exercising regularly, losing weight, raising exceptional children, becoming more productive, building revolutionary companies and social movements, and achieving success is understanding how habits work. 

Why we think it’s an essential read for BCC
We recommend The Power of Habit as an easy and fun to read introduction into the science of habit formation and the art of attempting to change them. As nutrition program managers, most of the time, our challenges go beyond changing people’s behaviors. Changing what and how people eat requires us to understanding people’s daily habits and then help them to adopt new routines. This book an excellent foundation to understand the particulars of habits. Buy your copy HERE.  

6. The Tipping Point, Malcolm Gladwell
The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire. The Tipping Point explains the phenomenon of why some products, businesses, authors, etc. become hugely successful (tip) while others never seem to break apart from the masses as anything special. Buy your copy HERE.

Why we think it’s relevant to BCC
We think The Tipping Point is a great read to understand how change happens and what makes a behavior tip. Successful interventions and campaigns aimed at changing people’s routines have certain critical characteristics in common: They manage to gain followers, naturally mobilize the audience, and make the behavior contagious instead of imposing it. These initiatives succeed in making the behavior desirable, the message exciting and memorable – like a jingle that naturally ‘sticks’ – and they understand that ‘little things’ in people’s lives matter.

Happy reading!

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