Srujith Lingala, Kalpana Beesabathuni, Klaus Kraemer and Rebecca Olson
Most Recent, Perspectives
On a quiet morning in rural Mchinji, a small district in Malawi, Grace wakes up and walks over to the house she constructed just a year ago. She inspects her 1,200 chickens carefully – they are all hale and healthy! It will soon be time for their breakfast – a specially formulated meal with the right mix of carbohydrates, protein, vitamins and minerals so they can lay healthy and fresh eggs. All of this is thanks to the egg hub – a Maeve, Lenziemill and Sight and Life project that aims to increase the income of farmers like Grace by providing high quality and affordable inputs, credit, training, and access to markets; as well as increase availability and affordability of eggs in Malawi.
Challenges to improving egg consumption in Malawi
As a source of high-quality protein, vitamins and minerals and fatty acids, eggs have the potential to dramatically improve nutrition outcomes for vulnerable populations. Yet, in many parts of the world eggs remain inaccessible to those who need it the most. At the same time, the poultry industry is growing exponentially in many low- and middle-income countries (LMICs), making it an important source of income for poor households.
In Malawi, 37% of children under five are chronically malnourished (stunted), and about 86% of the population lives in rural areas, where most people practice smallholder subsistence farming. The rural poor are particularly affected by malnutrition despite increases in caloric consumption across all socioeconomic quintiles. Although eggs have proven nutrition benefits, eggs continue to be scarce and costly in Malawi – the average per capita annual consumption is only 27 eggs, compared to 180 globally.
This is due to multiple demand and supply side challenges, notably disease and mortality among chickens, cost and quality of production inputs, and access to credit and markets leading to high egg cost (8-11x the price of cereals, compared to 1.6x in the US and 3.4x in Europe) and low availability. Cultural beliefs and taboos also undermine egg consumption. For example, in some Malawian communities, eating eggs is associated with stomach pains, or even with babies becoming bald.
Increasing egg production using the Egg Hub model
In Malawi, there is a huge unmet domestic demand for chicken meat and eggs; and the Government of Malawi is committing to improving food security and nutrition through progressive national livestock strategies.
Against this background, interventions and innovations across the poultry value chain that consider the role of poultry for society and the prevailing farming systems are increasingly being implemented. The Maeve/Lenziemill/ Sight and Life egg hub projectwas launched in 12 villages in central Malawi to set up and develop bird poultry farms with 3-year break even period.This project has brought together various partners to support poultry farmers, who are organized into groups of five. In addition to receiving specialized feed, the groups also receive all important vaccinations for the birds, which are ready to lay when they arrive at the farms, training, and continuous supervision.
Since the project was initiated in September 2018, 60 farmers have been registered, received training, established farms and started egg production; and a total of 12,000 birds were placed in these farms to start egg production. The program aims to produce 3.5 million eggs annually. Sight and Life has also built a digital platform for the farmers to track progress, program outcomes and biosecurity protocols.
Not only has the project led to increased egg production and consumption among participants like Grace and their families, but it has also increased their incomes as the eggs are also being sold in local markets.
“There has been a surge of excitement and interest in the villages to the point where we have had current farmers also asking for more chickens to meet their local demand. It is very exciting to see the overall demand and drive the farmers.” – Maya Stewart, fund recipient & Director of the Maeve project
The way forward
In addition to addressing supply side concerns, Sight and Life will also create demand through a targeted social marketing campaign, making eggs aspirational and desirable for caregivers of young children, pregnant and lactating women. Sight and Life is on a quest to end malnutrition, and we believe in the power of eggs to improve health and nutrition for all.
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
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.
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!
Sight and Life Nutrition Kiosk: Reaching the Last Mile in India
The Nutrition Kiosk, a Sight and Life innovation, was conceived as a simple and effective solution to the problem of last mile nutrition in India. It aims to drive both the demand and supply of affordable nutritious foods and services for vulnerable populations.
As a new and innovative solution for low-resource settings, the Nutrition Kiosk has the potential to create demand for good nutrition and supply essential, nutritious products. Additionally, it is customizable allowing the user to adapt the stand to various contexts, conditions, lifestyles, and landscapes. There are two essential components of the Nutrition Kiosk- products and services. The Nutrition Kiosk can be equipped with products such as whole foods, fortified foods, supplements, accompaniments/condiments, and nuts while concurrently offering nutrition counseling services.
To operationalize this idea, Sight and Life used a human-centered design approach to bring the kiosk to life and piloted in Mumbai, India at the 19th IUFOST World Food Science and Technology Conference in October 2018. Those who experienced the Nutrition Kiosk confirmed the potential this idea has to improve the nutritional status of the vulnerable populations in India.
The first step in the design process for the Nutrition Kiosk began with a simple question: What if healthy food was as affordable, appetizing and more importantly as accessible as fried foods?
The Nutrition Kiosk was imagined as the ultimate one-stop shop for all the nutrition needs of the target consumer, in our case women and children, would include a complete portfolio of products, information, and services; with the ultimate aim to create demand for good nutrition within low and middle-income groups.
In the next step, we looked at the urban landscape around us to decide on the physical design of the kiosk.
Pushcarts in various forms have become an integral part of the urban landscape in India. Around every corner, pushcarts are seen transporting goods in, out and around the city. They connect the last mile and are compact while in South Asia there is a strong street vending culture.
Street vending not only provides goods and services at convenient locations and affordable prices but also self-employment to a large number of people. It links vendors to the formal sector, and keeps streets busy and safe as pushcart vendors often become the “eyes on the street”. Food and beverages companies are also adapting to this market and culture by using pop-up architecture, including using pushcarts, with new innovations to reach the target consumers.
Applying the pushcart design to the Nutrition Kiosk allows for a significant degree of adaptability, which is key in addressing the last mile nutrition in India. For example, the kiosk can be customized for a “mom and pop” store or be placed in community health centers, leveraging the already established public health systems. The opportunities are endless and critical to ensuring good nutrition for all, all over India.
Both the products services components of the Nutrition Kiosk was developed with the ideal user in mind, the mother.
We closely examined the needs of a mother. She is, more often than not, the person responsible for buying the food and cooking meals for the family, therefore, the Nutrition Kiosk needs to provide healthy and nutritious food options for herself and her family. Supporting her personal needs, it is also a place where she can talk to a counselor and receive actionable feedback or join a mothers’ group to share her concerns among other things. These ideas influenced the final design of the cart.
We also spoke with street vendors who identified the following key components and challenges of pushcarts: they have four wheels on a frame, making it difficult to navigate in an urban landscape; the carts are mostly flat and do not offer variations in level so vendors have to creatively display their goods; and street conditions and crowds determine the locations and times they are active as well as their offerings.
The final design of the kiosk took all of these challenges into account. We considered the need to offer a variety of products through important life stages allowing a mother, or the customer, to easily identify the products fitting the specific needs of her household. From a design perspective, this led us to the display surface having various levels making the offerings easy to be seen and visually self-explanatory in order for the mother to shop in the correct category. Optimizing the design, a table surface can be folded down when the cart is not moving and the ideal space to provide nutrition counseling directly at the Nutrition Kiosk.
Piloting the Nutrition Kiosk at IUFoST 2018 gave us the opportunity to gather feedback from many different groups of attendees, ranging from students and technical experts to field workers and industry. As a next step, we will be improving the prototype by incorporating the actionable feedback. We will then create a business model for the Nutrition Kiosk focusing primarily on hospitals and other healthcare facilities. Once a sustainable business model is established, we will pilot the Nutrition Kiosk.
Stay tuned for more information on the Nutrition Kiosk, including videos and a presentation from IUFoST on the Sight and Life website!
Below is a gallery of pictures from the conference where we tested out a prototype of the Nutrition Kiosk:
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.
Take a look through the picture gallery from ASN:
Global Public Health Nutrition Manager for Sight and Life
As a child growing up in rural Ireland, you are continually reminded of the impacts of the great famine. This instilled the importance of food availability, diversity, and politics in determining food security and in turn a country’s ability to prosper economically. These factors certainly influenced my decision to study public health nutrition.
My chosen career path allows me to utilize my knowledge in nutrition to support and implement programs that have a real impact in the lives of millions of malnourished children. Having access to a diverse, safe, secure, and healthy food supply is a basic human right. We need to put politics aside and work together to end malnutrition in all its forms. It is one of the greatest challenges of our generation.
“Poor nutrition has devastating impacts on a child’s ability to grow, learn, and thrive while also having a lasting impact on a country’s growth and development. We know the first 1,000 days are critical to reversing this trend. We now need to focus our approaches more on the ‘how’ than ‘what’.” – Breda Gavin-Smith
Throughout my career, I have worked within both the public and private sectors, a non-governmental organization (NGO), and multi-stakeholder platform; providing me with a diverse foundation of experiences in the nutrition field. Now at Sight and Life, I am able to bring my nutritional science background together with my expertise in engaging partners across sectors to improve nutritional outcomes. Sight and Life is unique in the nutrition sphere in its ambition to link science with implementation know how to support a broader understanding on the dynamics of successful nutrition interventions. This truly lies at the heart of achieving real impact in nutrition.
Growing up I spent the summers at my grandmother’s home in India and fondly remember a daily ritual of picking vegetables from the garden, eggs from the henhouse and picking up fresh coconuts from the storeroom. Even as a child I was cognizant to only take what is needed from the garden – two eggplants, four chilies, and the ripe tomatoes. The feeling of fullness not only came from the meal but also from the fact that the whole meal – from farm to the plate – was a series of mindful actions.
My family was lucky to a have a well-rounded meal every day, from the fresh cow’s milk and a clean source of spring water to a garden providing nutritious fruits and vegetables. Compared to the hardships face by Durga and Apu, characters from the moving tale of Pather Panchali, my life was a dream. In the story the mother, Sarbajaya, would struggle every day to feed her children Durga and Apu by rationing meals of puffed rice and a few vegetables. This hardship has forever been etched in my mind and is an unfortunate reality for many.
Working for Sight and Life, I am honored to be applying my skills as an architect and designer to bring stories, concepts, experiences and voices to life and help improve lives of children like Durga and Apu!