Food for a healthy and active life:

New indicators to guide action in the agriculture

and food sector

Anna Herforth, Ph.D. Independent Consultant

Visiting Fellow, Cornell University

Festschrift, Dec 13, 2013

What is access to adequate food?

And what is the agriculture and food sector supposed to do about it?

1960s-1970s: The “food shortage era”

• Green Revolution; formation of CGIAR

• “Although deficiency of vitamins and minerals may cause serious health problems, especially among children, the therapy is now well known and relatively easy to apply so that the magnitude of this problem is almost negligible in relation to the one created by lack of calories and proteins.”

World Bank, 1972 Possible Actions on Malnutrition Problems

1960s-1970s Today

Concept of food security

1974 World Food Summit: “availability at all times of adequate world food supplies”

1996 World Food Summit: “physical and economic access to sufficient, safe, nutritious food to meet dietary needs…for a healthy and active life”

Nature of main nutrition problems

Hunger and protein deficiency; micronutrient deficiencies

Stunting, obesity, micronutrient deficiencies

Data on malnutrition prevalence

Estimates made using per capita food supplies

Collected in nearly all countries regularly since mid-1990s (DHS, MICS)

Main cause of malnutrition

Considered to be lack of calories (and protein)

Inadequate food, health, and care

Data on apparent causes of malnutrition

Dietary energy supply (DES) and protein supply

Next slide…

Why have global indicators of “food” not evolved with understanding of the problem?

Food Health Care

1970s Dietary Energy Supply Protein supply

1980s-mid-90s

Dietary Energy Supply Undernourishment Supply of iron and vitamin A *

Access to safe water Access to health services Immunization

Breastfeeding to 3 mos Breastfeeding to 6 mos Breastfeeding to 12 mos

1998 Dietary Energy Supply Undernourishment

Access to safe water Access to adequate sanitation Immunization ORT use

Exclusive BF 0-3 mos BF & comp food 6-12mos Breastfeeding 20-23mos

2013 Dietary Energy Supply Undernourishment Protein supply % calories from starches

Access to safe water Access to adequate sanitation Immunization ORS use VAS coverage

Early initiation of BF Exclusive BF to 6 mos Intro of solid/semi-solid/soft foods 6-8mos Breastfeeding at age 2yrs

Sources: UNICEF SOWC, SCN Reports on the World Nutrition Situation, FAO SOFA and SOFI reports

Nutrition isolationism (1980s-2008)

• “The major lesson of the last 20 years is that reductions in malnutrition cannot be achieved only by increases in food production.” – UNICEF first flagship “State of the World’s Children” report, 1980

• Attention went elsewhere for a long time…

nutrition science incubated its story, data, and priorities

Long tradition of “personal responsibility” in nutrition science

• Nutrition education is and has been the main intervention to address diet quality

• Historical: – Since deficiencies were discovered,

response has been supplementation, fortification, and nutrition education

– Gender division: women in home economics; men in agricultural economics

• Arguably, for political/pragmatic reasons – Allows nutrition to continue to work

by itself, without getting into the messy business of food policy

Politically easier to avoid food

• “[Micronutrient programs could] reduce human suffering yet do not threaten the existing economic and political structures.” – S Reutlinger, 1993

• Echoed in Per’s Lancet 2013 commentary

Nearly 1/3 of “high stunting-burden” countries have overweight + obesity rates >40%

0

10

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30

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50

60

70

80

%

Overweight + Obesity (all age 15-100 yrs) Stunting (age <5 yrs)

Data source: WHO Global Infobase Global Obesity Comparison Tool

165 million under 5 are stunted

Source: International Diabetes Federation, Diabetes Atlas 5th Ed. 2011

Projected increases in diabetes to 2030

Top 10 causes of years of life lost All developing countries, 2010

Source: Institute for Health Metrics and Evaluation

Top contributors to “Dietary risks” All developing countries, 2010

Source: Institute for Health Metrics and Evaluation

Causes of poor diets?

“Consumers ultimately determine what they eat and therefore what the food system produces.”

– Key Message of FAO SOFA 2013 (on homepage)

• Most nutritionists and agricultural economists have agreed with this for the last century (in deed if not in word)

Ecological model for diets

Image source: Pelto, Dufour and Goodman. Nutritional Anthropology: Biocultural Perspectives on Food and Nutrition. Oxford University Press

Concept of food environment

• Constrains and signals consumers what to purchase – What foods are available; their nutritional quality and

safety – What foods are most affordable, based on relative prices – What foods are most convenient to obtain and prepare – What foods consumers have information about – What foods are most strongly marketed, including

advertising or strategic placement to encourage purchase

Source: Herforth, forthcoming 2014

Low availability and high prices of diverse diets

Source: Herforth 2010 (in Pinstrup-Andersen, Ed.), based on FAO data. Note: analysis redone with 2009 data, same results

Share of Energy Source & Food Budget in Rural Bangladesh

Non-Staple plants

Fish and Meat

Energy Source Food Budget

Staple foods

Slide Source: Howdy Bouis; FNB Mar 2011

Photo: Anna Herforth

McDonald’s Outlets, 1987-2002

010002000300040005000600070008000

LatinAmerica

Asia/Pacific Europe Global other(excludes

US)

1987199720012002

Pingali, Food Policy 2006

Habits and norms change over time

Washington Post 11/9/2013

Demand from individuals, or from food industry?

• “In high-income and rapidly growing low-

income countries, the agricultural sector has become or is rapidly becoming a supplier of raw materials for the food processing industry, rather than a provider of food for direct consumption.”

-Pinstrup-Andersen 2013, Lancet series on maternal and child undernutrition

Given the advances in the food security conversation and the nature of nutrition problems today… Does it make sense to measure “access to adequate food” with a 1960s-era calorie availability indicator?

Key Recommendations for Improving Nutrition through Agriculture

• Food and agriculture policies can have a better

impact on nutrition if they: – Monitor dietary consumption and access to safe,

diverse, and nutritious foods. The data could include food prices of diverse foods, and dietary consumption indicators for vulnerable groups.

http://unscn.org/files/Agriculture-Nutrition-CoP/Agriculture-Nutrition_Key_recommendations.pdf

FAO SOFI 2013 lists 30 indicators Still, few shed light on availability of and access to healthy diets.

Undernourishment and undernutrition

• Of the 21 countries that have already met the MDG1 target of halving the proportion of the population below the minimum level of dietary energy consumption, only six are on track to meet the underweight target.

Source: World Bank 2013

FAO SOFI 2013

Share of energy supply from starches has potential

• Diversity of national food supply is a predictor of child undernutrition outcomes, independent of national income, calories available per capita and other socio-economic variables. – Remans et al. 2013

(presented at IUNS ICN)

FAO SOFI 2013

Is it sufficient?

• Maybe for correlations with stunting… probably not for chronic disease. – Not significantly correlated with obesity rates

(Remans et al., presented at IUNS ICN 2013)

• What is the appropriate policy response?

• It is not an indicator of diet quality; need

household survey data for that

Examples of food indicators • National-level food availability: what does the picture of food availability look like?

– % non-starches – Fruit and vegetable availability falls below need in most countries in the world (Siegel et al,

forthcoming) – Sugar availability (sig. assoc. with diabetes prevalence – Basu et al. 2013) – Others…possibly legume and nut availability, or Plant:Animal source protein supply ratio

• Local-level food environments:

– Percent households who cannot afford a balanced diet (e.g. Save UK Cost of Diet tool) – Cost of healthy diets: on average, $21/week more than unhealthy alternatives (Rao et al. 2013) – Relative prices of different food groups – “Food deserts”-type indicators – Community-level production diversity in Kenya associated with household dietary diversity (Remans

et al. 2011)

• Household-level food security: – Household dietary diversity (HDDS) – access to diverse foods – Food Insecurity Experience Scale (FAO Voices of the Hungry) – being piloted in Gallup World Poll

• Individual-level diet quality:

– Women’s dietary diversity (WDDS) – cut-off being developed for early 2014 – Fruit and vegetable dietary variety – In Brazil, the proportion of ultra-processed foods in household food increased from 20% to 28%

from 2003-2008 (Monteiro 2010)

Problem identification and advocacy

• “In addition to identifying the problems and measuring the number of people affected, information from [food security and nutrition monitoring] is also used for sensitizing the public and the decision makers in the government and donor community.”

Babu and Pinstrup-Andersen 1994

Addressing Nutrition through Agriculture is now high on agendas

• Agriculture’s main contribution to better nutrition is food.

• But, how are planners to weigh potential policy options without any indicators of how the food environment looks, and what diets are like?

Conclusion • Current global measurement of food access was made for a different

world, 50 years ago. – Then “food shortage” – Now “healthy food shortage” (World Bank 2014)

• Available data make it possible to analyze core health and care causes of

nutritional problems at national level, but not food causes

• Lesson from history: Core data collected and published can change.

• Post-MDGs: time to align understanding of “food” causes of malnutrition with globally-collected indicators

• Global institutions need to monitor “food for a healthy and active life” with data on healthy food access and dietary quality – FAO (SOFI) – DHS, UNICEF MICS, World Bank LSMS

Thank you