Reaching Last-Mile Communities in South Africa with Fortified Food

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

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

Impact of nutrition

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

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

Bambanani

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

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

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

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

Savanna Lodge

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

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

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

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

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

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

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

The Convergence of COVID-19, Climate Change and Malnutrition

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

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

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

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

The potential for a new global food and nutrition crisis

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

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

‘Nutrition in the Perfect Storm’

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

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

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

The compounding effect of climate change

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

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

The time to act was yesterday

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

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

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

Changing the Standard

Why Multiple Micronutrient Supplements in Pregnancy Are an Ethical Issue

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

Women, Family, children

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

The bigger picture

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

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

Time for a change

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

The push for progress

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

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

Email: klaus.kraemer@sightandlife.org
 
 
 
 

The Role of Demand Creation in Addressing the Double Burden

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

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

What motivates consumers to buy and consume more nutritious foods?

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

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

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

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

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

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

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

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

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

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

Obaasima, demand generation, Ghana, women, nutrition

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

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

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

nutrition, biodiversity, chefs, 2020FOR2020

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

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

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

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

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

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

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

Fueling the Dilemma

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

Beverage Industry, energy drinks

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

Unraveling the Issue

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

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

obaasima, food fortification, quality seal

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

Evolving Over Time 

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

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

Sources

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

Announcing the NEW sightandlife.org

Check out the features & information now available

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We are proud to reveal the NEW sightandlife.org!

Our redesigned website is now equipped with enhanced navigation and functionality for an improved user experience and a robust blog full of engaging posts. 

The design and large visual elements of the website are visually pleasing while the original content is valuable for the audiences within the nutrition sector. Created with the user experience in mind, the site boasts many new features to help users quickly and easily navigate the site to find relevant information.

We invite you to explore the new attributes highlighted below:

About Us: Learn more about Sight and Life and our dedication to eradicating all forms of malnutrition in this section through our vision and strategy that is being carried out by our talented leadership team and board members. Additionally, this page tells the story of our history starting in 1986, with an original goal to be at the forefront of global efforts to improve vitamin A nutrition, to today serving as a nutrition think tank.

Our Work: Take a look at Sight and Life’s projects around the world and more specifically in Africa, Asia, and South America. This interactive page shares each of our projects which are divided into categories including research, advocacy, public health, humanitarian, or social business. We have established a distinguished alliance consisting of academia, research partners, and funders working collectively to eliminate all forms of malnutrition. Together, we discover and implement sustainable solutions, grounded on solid scientific evidence, to improve the lives of those in most need. 

News: The latest happenings in the nutrition atmosphere, from newly released reports and guidelines to important announcements, will be posted and keep our readers up-to-date.

Blog: Visit the blog to find insightful and scientific posts relating to nutrition. Keep tabs on this page as we will continue rolling out new and original posts including interesting perspectives from nutrition thought leaders and interviews with select authors fromm the latest issue of the Sight and Life magazine.

Resources: Sight and Life provides a range of educational materials on malnutrition issues. This section is filled with the current, and past editions dating back to 2005, of the Sight and Life magazine and supplements along with our highly sought after infographics. In addition, we have books, brochures, and documentaries to support the information needs of health workers, scientists, representatives of governmental/non-governmental agencies, and the media.

Newsletter: Sign-up to receive the latest news from Sight and Life in your inbox. We are also active on social media. Follow us on FacebookTwitterLinkedInYouTube and Instagram.

We hope you enjoy our new, user-friendly website! A BIG thank you to the eyeloveyou.ch team for outfitting Sight and Life with a fantastic new website. 

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The Double Burden of Malnutrition

Impacts of obesity and undernutrition

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Increasingly those in the global nutrition arena are discussing challenges presented by the double burden of malnutrition (DBM), a concept first discussed in 1992 at the International Conference on Nutrition (ICN) held by the Food and Agriculture Organization (FAO) and the World Health Organization (WHO). The concept refers to the coexistence of undernutrition and overnutrition in the same population across the life course.

There are over two billion people worldwide who are overweight or obese while at the same time undernutrition persists, sometimes within the same country, city or household.” 
– Shauna Downs, Institute of Human Nutrition & Earth Institute, Columbia University

Many governments are now challenged with having populations that are subject to both nutrient “excesses” and “deficiencies”. Undernutrition is not only a phenomenon of low- and middle-income countries (LMICS), and overnutrition is not just a rich country’s problem (Kolčić, 2012).

Currently, two billion people are overweight or obese, one-third of the population still suffers from iodine deficiency, 40 percent of women of reproductive age have anemia, and 17 percent of preschool children are underweight (UNSCN 2010). Increasingly these conditions occur at the same time in the same population, in the same household, and even in the same individual (FAO 2006). The below graphic was featured in the article, “The Multiple Burdens of Malnutrition“, from the Sight and Life magazine focused on Food Systems and highlights these coexisting dynamics.

There is gathering evidence that when economic conditions improve, obesity and diet related non-communicable diseases may escalate in countries with high levels of undernutrition. There is also evidence to indicate that undernutrition in utero and early childhood may predispose individuals to greater susceptibility to some chronic diseases (Shrimpton and Rokx, 2012).

The scale of the global problem continues to increase, with few examples of the trend reversing or even reducing. This will be further challenged in coming years by an increasingly urban population. In just two decades, two-thirds of the global population will reside in the urban areas of the current LMICs. People in urban environments are becoming increasingly exposed to relatively cheap energy dense processed foods, access to healthier foods, especially fruits and vegetables, is increasingly difficult and there is reduced energy expenditures due to sedentary occupations and lifestyles, with less opportunity and areas to get adequate exercise (Shrimpton and Rokx, 2012).

The Solution?

The double burden of malnutrition certainly has shared drivers and solutions giving a unique opportunity for combined nutrition responses. The WHO recently launched a policy brief drawing attention to the issue with the aim of encouraging action for cost-effective interventions and policies within the United Nations Decade of Action on Nutrition – and, through this, to contribute to achieving the Sustainable Development Goals of ending all forms of malnutrition (SDG2) and ensuring healthy lives and well-being for all at all ages (SDG3) (WHO, 2017)

Referred to as double-duty actions, these may be interventions, programmes and/or policies, that have the possibility to reduce the risk or burden of both undernutrition (including wasting, stunting and micronutrient deficiency or insufficiency) and overweight, obesity or diet-related NCDs (WHO, 2017)

Double duty can be achieved at three levels: through doing no harm with regard to existing actions on malnutrition; by retrofitting existing nutrition actions to address or improve new or other forms of malnutrition; and through the development of de-novo, integrated actions aimed at the double burden of malnutrition (WHO, 2017)

The challenge for many countries is the absence of positive experiences, evidence and success stories in dealing with the double burden of malnutrition. Convincing governments of the win-win scenario that can be gained by viewing malnutrition more broadly rather than the previous silo approach is a real test for the global nutrition community as realities, constraints and limitations of the country context unfold.

References

FAO (2006) The double burden of malnutrition, Case studies from six developing countries (Accessed on 17th June 2017)

Kolčić, I (2012) Double burden of malnutrition: A silent driver of double burden of disease in low– and middle–income countries. J Glob Health. Vol 2(2). Online. (Accessed on 17th June 2017)

Shrimpton, R and Rokx, C (2012) The double burden of malnutrition – A Review of Global Evidence (Accessed on 17th June 2017)

WHO (2017) The double burden of malnutrition -Policy brief (Accessed on 17th June 2017)

UNSCN (2010) This Sixth report on the world nutrition situation (Accessed on 17th June 2017)

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Eggciting Innovation

Eggs for Improved Maternal, Infant and Young Child Nutrition

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The statistics show the continued, and sadly in some cases growing, prevalence of malnutrition in a number of countries. The 2015 Global Nutrition Report (GNR) had as one of its key messages, “Although a great deal of progress is being made in reducing malnutrition, it is still too slow and too uneven.” And the 2016 GNR just launched this month, states that “Malnutrition and diet are by far the biggest risk factors for the global burden of disease: every country is facing a serious public health challenge from malnutrition.” Addressing nutrient (macro and micro) deficiencies amongst the most vulnerable, usually women and children is proving to be a ‘hard egg to crack’ and requires disruptive ideas and real innovation.

Eggs

Enter the humble egg

Eaten since the beginning of time; eaten almost everywhere in the world; relatively easy to obtain; adaptable to many different types of cooking techniques and; an affordable source of highly digestible protein, we believe that the time has come to re-think and innovate around the humble egg!

We are not alone in our thinking, and Iannotti et al. have written an excellent review article that eloquently positions the egg as offering real potential to improve maternal and child nutrition in developing countries. Studies promoting egg consumption for women and children as part of wider dietary improvements show that, child growth indicators are significantly improved in the intervention group compared to controls and a recent breakthrough research study shows that all nine essential amino acids were significantly lower in stunted children compared with non-stunted children. This is important because it tells us that stunted children are not receiving sufficient quality protein from their diets.

Did we put all our eggs in one basket?

Could this research point to the fact that in nutrition’s zeal, over the last four decades, to focus on ensuring that children received sufficient micronutrients (particularly vitamin A, iodine, iron, zinc, and folate), that protein fell off the agenda? It would seem that the widespread assumption that children were receiving enough protein from their basic diet was incorrect. Now is the time to realise that it is not ‘either/or’ but rather that optimal child growth and thus development, depends on addressing deficits of both protein and micronutrients. This calls for ensuring adequate micronutrient and protein in the diet especially during critical life stages – pregnancy, lactation, infancy and adolescence. We need to take a holistic approach and embrace the farm to flush approach anchored in food systems (take a look at this Sight and Life magazine focusing on food systems), so as not to neglect any of the nutrients as we look to future solutions that can be scaled up in order to have the impact that the 2016 GNR rightly puts under the spotlight.

Don’t count your chickens before they hatch

While eggs are a highly nutritious food source, both the productivity of laying hens and the nutritional content of their eggs are, to a certain extent, a function of the hen’s dietary intake. The reality is that for laying hens, an optimally micronutrient fortified diet improves egg production in numerous ways – increased egg numbers, improved egg weights, percentage lay and increased feed efficiency. Interestingly, for many micronutrients, egg content responds rapidly (within a few weeks) to dietary changes; transfer efficiency, from feed to egg, does depend on the micronutrient – high for vitamin A, selenium, iodine, and DHA; medium for vitamin D and E and; low for folic acid, niacin, and iron. This points, to a real opportunity to improve the nutritional value of eggs with only limited input in the feed and in egg eating populations requires no need for dietary behaviour change communication, which we know to be both costly and not always highly successful.

Projections from FAO suggest significant growth in egg consumption in developing countries. Even in countries considered to have largely vegetarian population, such as India, data shows that the diet of many Indian households is diversifying to include more animal source foods, a trend that has been particularly notable in rural populations. This makes the idea of tapping into the potential of eggs extremely eggciting. A ‘powdered’ micronutrient feed supplement for chickens could contribute to solutions for farmer through improved egg production and, for consumer by providing added nutritional value. An additional advantage of eggs is their environmentally friendly packaging. 

The proof of the pudding is in the eating

There is research to show the benefits of consuming fortified eggs. A 2009 study showed that feeding DHA-fortified eggs to infants and pregnant mothers improved infant visual acuity and attention and other studies have found that DHA fortified eggs were associated with increased gestational duration and infant birth size. In addition to DHA, there is literature to support the role of eggs in reducing deficiencies of iodine and vitamin A and even decreased anemia.

“Leaders don’t wait for problems to lay eggs before they attempt dealing with them.” 
– Israelmore Ayivor

A range of nutrients delivering various levels of their recommended daily allowance could relatively easily be added to eggs through the chicken feed. There are many avenues to explore, such as supplying micronutrient feed supplement directly to existing farmer networks or to women running poultry programs. Simultaneous social marketing campaigns could encourage egg consumption and an assessment over time could be undertaken to provide the evidence of impact…

Sight and Life is actively exploring these eggciting opportunities and would be interested in hearing from anyone keen to invest or partner with us, as we believe the egg just can’t be beaten.

To contact us regarding this project send an email to Kalpana.Beesabathuni@sightandlife.org

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