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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