Food for a healthy and active life: New indicators to guide action in the agriculture and food sector - Anna Herforth, Ph.D.
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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 1974 World Food Summit: 1996 World Food Summit:
food security “availability at all “physical and economic
times of adequate world food access to sufficient, safe,
supplies” nutritious food to meet
dietary needs…for a
healthy and active life”
Nature of main Hunger and protein Stunting, obesity,
nutrition problems deficiency; micronutrient micronutrient deficiencies
deficiencies
Data on malnutrition Estimates made using per Collected in nearly all
prevalence capita food supplies countries regularly since
mid-1990s (DHS, MICS)
Main cause of Considered to be lack of Inadequate food, health,
malnutrition calories (and protein) and care
Data on apparent Dietary energy supply (DES) Next slide…
causes of malnutrition and protein supply
Why have global indicators of “food” not
evolved with understanding of the problem?
Food Health Care
1970s Dietary Energy Supply
Protein supply
1980s- Dietary Energy Supply Access to safe water Breastfeeding to 3 mos
Undernourishment Access to health services Breastfeeding to 6 mos
mid-90s Supply of iron and vitamin A * Immunization Breastfeeding to 12 mos
1998 Dietary Energy Supply Access to safe water Exclusive BF 0-3 mos
Undernourishment Access to adequate sanitation BF & comp food 6-12mos
Immunization Breastfeeding 20-23mos
ORT use
2013 Dietary Energy Supply Access to safe water Early initiation of BF
Undernourishment Access to adequate sanitation Exclusive BF to 6 mos
Protein supply Immunization Intro of solid/semi-solid/soft
% calories from starches ORS use foods 6-8mos
VAS coverage 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%
%
80
70
60
50
40
30
20
10
0
Overweight + Obesity (all age 15-100 yrs) Stunting (age
165 million under 5 are stunted
Projected increases in diabetes to 2030 Source: International Diabetes Federation, Diabetes Atlas 5th Ed. 2011
Top 10 causes of years of life lost
All developing countries, 2010
Source: Institute for Health Metrics and EvaluationTop contributors to “Dietary risks”
All developing countries, 2010
Source: Institute for Health Metrics and EvaluationCauses 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 2014Low 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
Fish and Meat
Non-Staple
plants
Energy Source Food Budget
Staple foods
Slide Source: Howdy Bouis; FNB Mar 2011Photo: Anna Herforth
McDonald’s Outlets, 1987-2002
8000
7000
6000
5000
1987
4000
1997
3000
2001
2000 2002
1000
0
Latin Asia/Pacific Europe Global other
America (excludes
US)
Pingali, Food Policy 2006Habits and norms change over time
Washington Post 11/9/2013Demand 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 undernutritionGiven 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.pdfFAO 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 2013Share 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 2013Is 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 thatExamples 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 1994Addressing 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 LSMSThank you
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