The Geography of Malnutrition: Seemingly worlds apart, but not really

On 11 July 2017, Lawrence Haddad, GAIN’s Executive Director, attended the UK Nutrition Society meetings in London. His presentation focused on challenges and opportunities for urban nutrition in low and middle income countries.

Most of the conference was focused on high-income country issues.  I went because it was a new audience for me and for GAIN.

The presentations in my session were on (a) the nutrition case for and against the consumption of artificially sweetened drinks (Professor Peter Rogers), (b) demand creation for water consumption (Dr. Emma Derbyshire) and (c) how public policy can shape food landscapes (Dr. Amelia Lake). I spoke about the challenges and solutions in urban areas in low and middle income countries.

The first presentation was interesting as it tried to separate perceptions from evidence about the consumption of artificially sweetened soft drinks. Based on the evidence presented, do they reduce overall calorie intake? (yes, although we don’t know enough about long term effects on weight management) and do they develop an increased demand for sweetened foods? (the evidence suggests no). What was somewhat reassuring about the presentation was the use of systematic reviews and the citing of Barry Popkin’s work (the guru: see “The World is Fat”). What was less reassuring was that some of the research was funded by the soft drink industry (as declared by Prof. Rogers at the start of his talk).  The work would have presented much more powerfully if it had been more independently funded.

Our BADUTA project with the Government of Indonesia, has a strong behaviour change component, and the project is showing good signs of changing behaviour and increasing diet diversity (I have seen the first draft of the independent evaluation by the University of Sydney—I will share it when it becomes publicly available). The second presentation focused on how to increase water consumption.  Most people are below the daily recommended levels.  The session included a couple of innovative demand creation campaigns for water and for activity (Drink Up Drink Water in the US and the JOGG “free movement” campaign in the Netherlands)—the videos were fun and engaging.  We need more of this in nutrition in the lower and middle-income countries.  Of course the question is what impact do the campaigns have, especially after they end.

The third presentation was all about “foodscapes” (i.e. how does the built environment shape the availability and affordability of healthy and unhealthy foods?).  Work was highlighted from an EU funded research programme called “Transforming the Foodscape: development and feasibility testing of interventions to promote healthier take-away, pub or restaurant food”.

Interventions piloted in the North East of England included (a) Take Away Masterclass (working with staff from 18 takeaways–180 were invited–on how to improve the healthiness of cooking practices), (b) reducing portion size in fish and chip shops (working with wholesalers to create smaller portion options with half the calories of regular portions—there has been significant demand from customers for smaller portion options) and (c) a desk evaluation of the offerings of “healthier” flagship sit down/take away restaurants such as NOSH Healthy Kitchen (work not completed yet). All very interesting and all very disconnected from similar work that is happening in Africa, Asia and Latin America–which is a major missed opportunity for all countries.

In the Q & A session, Dr. Alison Tedstone, the Director of Public Health England—the nation’s lead government agency for ensuring the health of the English population—asked me about my presentation: how do we avoid “tinkering around the edges” and zero in on the really big levers that can change food consumption?  She highlighted the effect the soft drinks levy on food manufacturers is having: they are changing their product formulation to avoid paying the levy, and more importantly the dialogue has changed completely, from foot dragging on voluntary codes to having to deal with the implications of legislation.  My answer was that every context is different and some preliminary work has to be done to find that lever—work which factors in technical, political and capacity considerations. In other words there are bound to be lots of promising options to effect change, but we need to look hard in a given context to find the best.

Other questions in the panel discussion related to (a) what is the role of researchers in lobbying for change based on balanced high quality evidence? (my answer: senior researchers should be active in advocating for change, as long as they are faithful to the evidence), (b) how do we persuade research funders to be more inclusive in their acceptance of a range of evaluation methods that are driven by the issue and context rather than a familiarity with and preference for a particular method? (my answer: again, use the evidence to show that other methods can work and engage with funders to show them the wealth of credible evaluative tools that are available), and (c) do we focus on demand or supply to change food environments? (my answer: both).

I enjoyed the conference session. It was good to see the experiences from the high income countries and to think about how they may read across to countries that are trying to avoid their fate. But it was a bit disappointing to see so few people present working on these issues in low and middle-income countries.  The continental boundaries are really very hard to cross, it seems.

The convergence in malnutrition problems between the high, middle and low-income countries continues at rapid pace (GNR 2016). We better make sure the convergence in problem solving can keep up. In the Sustainable Development Goals era, all countries have malnutrition problems and all need to share the solutions.

Download Lawrence Haddad’s presentation

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Published 14 July 2017