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.
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.
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)
Anne-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.
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.
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
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.
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
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.
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.
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
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.
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 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 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
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.
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
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.
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.
Breda Gavin-Smith, Global Public Health Nutrition Manager & Kesso Gabrielle van Zutphen, Knowledge and Research Manager
Most Recent, Perspectives
“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?
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 email@example.com
Breda Gavin-Smith, Global Public Health Nutrition Manager & Kesso Gabrielle van Zutphen, Knowledge and Research Manager
Most Recent, Demand Creation
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.
“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.
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.
Find out more about demand generation and this Sight and Life session by checking out the presentations of each speaker:
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.
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 a 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.”
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.
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:
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.”
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!
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.
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.
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.
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.
Can the Food and Beverage Sector Contribute to a Healthier Society?
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.
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.
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.
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/?.
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: 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
International Society for the Study of Fatty Acids and Lipids (ISSFAL)
Linda P Siziba, PhD student at Centre of Excellence for Nutrition, North West University, South Africa
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.
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: firstname.lastname@example.org
Expand your Knowledge
Recommended Reading on Behavior Change Communication
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.
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.
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.
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 show case section, you can learn how insights were derived from research to development.
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 which 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.
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 provides great insight into how this methodology works in practice.
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
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!
During 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). 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.
Essential Reading on Behavior Change Communication (BCC)
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.
– 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 programsHERE.
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.
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.
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.
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 Habit, Why 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 characteristic 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.
A recent report and podcast from the British Medical Journal1 has revived the controversy on when to scale back high-dose vitamin A supplementation (VAS) to reduce child mortality.2 We believe only compelling evidence can justify scaling back this intervention for the reasons pointed out below.
VAS is a Safe and Cost-effective Strategy for Reducing Child Mortality
Estimates from the World Health Organization (WHO) indicate that still 190 million children aged under five (U5) are vitamin A deficient (VAD).3 VAD increases the risk of disease and death from severe infections, and is the leading cause of preventable blindness in children U5. Well-controlled randomized trials in different regions with a high prevalence of VAD have conclusively demonstrated that high-dose vitamin A supplementation (VAS) given every four to six months to children U5 is an efficient and cost-effective strategy for reducing child mortality. VAS programs have largely contributed to the reduction in U5 mortality rates over the last decades.
A 2011 Cochrane review of 17 randomized controlled trials (RCTs) in 9 countries concluded that VAS results in a 24% reduction in U5 child mortality rate.4 This reduction in all-cause mortality confirmed an earlier meta-analysis from 1993, in which WHO’s5 original VAS guidelines were based upon and adopted by over 80 countries. There is also strong evidence, from both community and clinical trials, that VA prophylaxis and treatment can reduce the severity and fatality from measles, diarrhoea, and reduce the risk of hearing loss following middle ear infections. The most recent 2017 Cochrane reviewof 47 RCTs conducted in 19 countries concluded that vitamin A supplementation to U5 results in a significant 12% reduction for both all-cause mortality and mortality due to diarrhoea.6
DEVTA Contradicts the Evidence of VAS on Child Mortality
Cutting in half VAS effect on mortality between the 2011 and 2017 Cochrane reviews differ due to the latter’s inclusion of the DEVTA (Deworming and Enhanced Vitamin A) study,7 a large-scale program evaluation in the state of Uttar Pradesh, India. The ‘DEVTA study’ was an attempt to evaluate a large supplementation program providing VAS every six months through routine services. Approximately two million preschool children were reportedly enrolled through the Anganwadi Centres of the Integrated Child Development Scheme (ICDS) for the study and comparisons were made between usual care, 6-monthly VAS, 6-monthly albendazole (for deworming), or both. The intervention continued for 5 years and concluded that VAS did not reduce child mortality, although there was a 4% non-significant decline.
The DEVTA Study Had Limitations in the Program Design, Implementation, and Evaluation
Certain elements in the program design may shed light on the lack of effect in DEVTA. The research activity was vastly under-staffed with only 18 monitors overseeing the work of over 8,300 Anganwadi workers and the participation of two million children. This lack of human resources required the number of children and their levels of compliance to be determined only from a mid-study census using anon-random opportunistic sample of 2,106 children out of two million, therefore leaving the estimate open to bias. Thus, this number represented ‘compliers’ at the time of the census, rather than the numbers of children and capsules taken throughout the intervention. The authors reported an overall compliance of 86%, raising questions about accuracy of record keeping. Finally,the DEVTA evaluation also did not include younger children between 6-12 months, who normally account for one-third of the deaths in children U5 and would have benefited most from VAS.
The DEVTA Results Should Not Be Combined with Other Trials
Delivering VA to children every six months is a well-established intervention to reduce child mortality. The DEVTA study represented an earnest attempt to assess a large VAS program run by the Government of India with only a non-significant reduction in child mortality. The evaluation was expected to have revealed a greater program impact. The reasons for this ineffective program were due to how it was run and evaluated, problems that commonly afflict most large intervention strategies. There are many lessons to be learned from this undertaking, both with respect to VA delivery and program design, implementation, and resources needed for running and evaluating programs. We encourage the global scientific community to resist combining the DEVTA findings (as done in the 2017 Cochrane review) with those of previous, rigorously conducted trials to reset the overall “efficacy” of VA in reducing child mortality. Doing so could send the wrong message that mixing program evaluation results with those of well-controlled randomized human trials is an acceptable strategy, when it is not, especially when millions of children lives are potentially at stake.
Scaling Back of VAS Requires Compelling Evidence
As VAS saves lives, eyesight, and hearing of children only irrefutable evidence can justify scaling back this intervention. While continuing VAS programs, it is also critical to address the direct and underlying causes of VAD through effective interventions (e.g., dietary diversity, breastfeeding, fortification, hygiene, etc.). According to the Global Alliance for Vitamin A (GAVA),9it would only be justifiable to scale back VAS if VAD were no longer a public health issue (<5% biochemical VAD at population level). Only evidence from regular data collection in countries (at least every 10 years for VA intake and status data in children), or other data indicating a reduction in VAD, shall inform decisions to phase out of VAS.10
In settings where VAD is a public health problem (prevalence of night blindness is 1% or higher in children 24–59 months of age or where the prevalence of biochemical VAD (serum retinol 0.70 µmol/L or lower) is 20% or higher in infants and children 6–59 months of age), high-dose VAS (200,000 IU) is recommended for children 12–59 months of age (with a single half-dose for infants 6-11 months of age) every 4-6 months.5