by Marion Nestle

Currently browsing posts about: Malnutrition

Aug 24 2022

Task force on Hunger, Nutrition, Health report: a missed opportunity?

The Task Force on Hunger, Nutrition, and Health released its comprehensive report yesterday.

The report’s purpose is to inform the upcoming White House Conference on Hunger, Nutrition, and Health.  If so, it’s going to leave the White House in a quandary.

The report has lots of useful information, beautifully presented, and does all it should on adddressing hunger.

But as I read it, the report, titled Ambitious, Actionable Recommendations to End Hunger, Advance Nutrition, and Improve Health in the United States,” is not nearly ambitious enough when it comes to nutrition and health.

It makes far too many recommendations—30.  That’s always a bad sign (too many to do).  .

Really, only 2 recommendations are needed.  These should establish or expand federal agriculture, food, and nutrition policies to ensure:

  1.  Adequate, affordable food and nutrition for everyone.
  2.  Healthy diets for everyone, meaning those that follow Dietary Guidelines and are largely plant-based, balanced in calories, and low in undesirable fats, sugars, and salt (i.e., ultra-processed foods).

The hunger recommendations do the job: they call for ensuring benefits sufficient to meet households’ basic needs.

But the second?  A mess.

Here is the most obvious example [my comments follow] .

Recommendation #9: “Reduce the marketing of foods that do not align with the latest DGA and increase the marketing of foods that align with the latest DGA to children and populations with disproportionate rates of diet-related chronic conditions” [Good! But not through the recommended voluntary methods by industry.  That won’t work; it requires legislation]

But here’s Recommendation #25: “Increase the ability of food companies to communicate with consumers about the evidence for healthfulness of certain food products and nutrients.”  [Uh oh]

This comes with three action items:

  1. FDA should expeditiously update its definition of the word “healthy” [good] and incentivize food companies to use the terminology and/or associated symbol in their food packaging and marketing [Yikes!] and increase the proportion of products on the market that meet the “healthy” definition [OK, as long as they are not gaming the system].
  2. Congress and/or FDA should improve and streamline the process for application, review, approval, and use of health claims and qualified health claims on food packages. [No!  If it’s one thing we don’t need, it’s more misleading health claims]. 
  3. Congress and/or FDA should create a new process for communicating about foods, nutrients, and other bioactive ingredients that may prevent or treat disease through label claims. [No!  We do not need more claims for the benefits of ultra-processed food products].

What’s missing from this report?

  • Anything about ultra-processed foods and their effects on calorie intake and overall health.  The term is mentioned once, but only in the context of ‘more research needed’ (Recommendation #19).
  • A clear statement of the benefits of soda taxes in reducing consumption of sugar-sweetened beverages.  Why isn’t there one?  A box explains: “Task Force members voiced diverse perspectives on this topic.”
  • A clear statement about making SNAP align with Dietary Guidelines.  This is mentioned, but only in the context of pilot research (recommendation #2), and therefore contradicts recommendations #3 and #5.  #3:  Increase nutrition security by promoting dietary patterns that align with the latest Dietary Guidelines for Americans (DGA) through federal nutrition programs.  #5:  Leverage the federal nutrition programs’ power in economic stimulus to support food systems that promote foods that align with the latest DGA.”
  • Firm calls on Congress to pass legislation to do what is needed.

What happened?  One member of the committee explained to me that its membership included everyone from anti-hunger advocates to food industry representatives, and too many vested interests were at stake.  Members could not agree on anything that would make a real difference to policy.  Anything substantive met strong resistance.

When it comes to public health policy, which this most definitely is, the food industry has no business being at the table.

This was a recommendation of the 2019 Lancet Commission on the Global Syndemic of Obesity, Undernutrition, and Climate Change.  Read that report.  It explains why including the food industry in policy recommendations that might reduce sales is not a good idea.

If I had been a member of this Task Force, I would have called for a minority report on policies for reducing consumption of sugary drinks and ultra-processed foods.  But that, of course, is why I’m no longer appointed to such committees.

Aug 2 2022

USAID’s Framework for assessing the interaction between Covid-19 and nutritional health

I’m getting caught up on reports this week.  Here’s one from the US Agency for International Development:  COVID-19 and Nutrition Analytical Framework

The purpose of the Framework:

  • Allow policymakers and implementers to better track the interaction of the COVID-19 pandemic and nutrition
  • Provide a tool for planning policies, programs, and interventions
  • Help identify data gaps
  • Support a systems approach to addressing problems “caused, increased, or intensified by the COVID-19 pandemic”

The Framework:

What I like about this Framework is how it so clearly identifies the upstream system levels of intervention: food, health, social, education, and infrastructure.

It’s also interactive, but for that you have to go to its source and click on each section.

Dec 1 2021

Should stunting be reconsidered as an indicator of intervention success?

The US Agency for International Development (USAID) has issued two reports arguing that reduction of the prevalence of child stunting should no longer be used as the sole measure of success of nutrition intervention programs.

Background: Stunting is defined as low height-for-age.  It has long been used as a measure of nutritional deficiency due to inadequate diet in the presence of poor sanitation and other conditions.  Interventions focused on improving dietary intake rarely prevent stunting or affect it to only a small extent.

The first report: Stunting: Considerations for Use as an Indicator in Nutrition Projects

Emerging evidence supports the need to reexamine stunting as the primary indicatorof the success or failure of nutrition interventions.  Stunting should be interpreted not as an indicator of short-term programmatic success, but rather of the overall well-being of populations.  Not all nutrition programs, projects, or activities should be expected to reduce the prevalence of stunting… Failure to reduce the prevalence of stunting should not be interpreted as the failure of a nutrition program or project.  Nutrition programs should consider—and measure—a broader range of the many benefits that programs can achieve.

The second report:  Beyond Stunting: Complementary Indicators for Monitoring and Evaluating USAID Nutrition Activities

this guide shows how accurate and meaningful results, beyond stunting, can be captured through the use of more comprehensive and responsive indicators that directly link to an activity’s logical pathway…Measuring different types of indicators across the program’s impact pathway helps to understand how well programs are implemented and how results are achieved. Most important, measures like these allow for learning about what the program has, or has not achieved,
and why.

This second report provides a useful Table listing possible non-stunting indicators such as rates of breastfeeding, nutrient supplementation, home food production, participation in food assistance programs, and the like.

These are all downstream (personal) interventions.  I’d like to see USAID fund some more upstream (policy-based) interventions and see if those might do greater good for greater numbers of people.

Jan 28 2019

New Lancet report: The Global Syndemic: Uniting Actions to Address Obesity, Undernutrition, and Climate Change

The Lancet has been busy.  Last week, it published a blockbuster report on the need for worldwide dietary changes to improve human health and that of the environment.  I posted about this EAT-Forum report on Friday.

Now, The Lancet releases yet another report, this one taking a unified approach to dealing with the three most important nutrition issues facing the world: Malnutrition (undernutrition), obesity, and the effects of our food production and consumption system on the environment and climate change—for which this report coins a new term: The Global Syndemic.

This report breaks new ground in identifying the food industry as one of three main barriers to ending this “Syndemic.”  I’ve added the numbers for emphasis.

  • Powerful opposition by [1] commercial vested interests, [2] lack of political leadership, and [3] insufficient societal demand for change are preventing action on The Global Syndemic, with rising rates of obesity and greenhouse gas emissions, and stagnating rates of undernutrition.
  • New social movement for change and radical rethink of the relationship between policymakers, business, governance and civil society is urgently needed.
  • The Commission calls for a global treaty to limit the political influence of Big Food (a proposed Framework Convention on Food Systems – modelled on global conventions on tobacco and climate change); redirection of US$5 trillion in government subsidies away from harmful products and towards sustainable alternatives; and advocacy from civil society to break decades of policy inertia.

Wow.  This is telling it like it is—at long last.  From the press release:

  • A key recommendation from the Commission is the call to establish a new global treaty on food systems to limit the political influence of Big Food.
  • The food industry’s obstructive power is further enhanced by governance arrangements that legitimise industry participation in public policy development, and the power that big corporations have to punish or reward governments by relocating investment and jobs.
  • Regulatory approaches to product reformulation (eg. salt and sugar reduction), labelling and marketing to children are needed because industry-led, voluntary approaches have not been effective.

Yes!

The documents

The press

▪ The Guardian
The Times (London)
Irish Farmers Journal

Additional press, posted January 30

Newswires (syndicated in international outlets):

UK:

US:

Rest of world:

Dec 7 2018

Weekend reading: the 2018 Global Nutrition Report

If you want an overview of the current status of nutrition problems in the world, what is being done about them, and what needs to be done about them, this report is required reading (to get to the download button for the entire report, scroll to the end of the page).

The report is chock full of useful facts, figures, case studies, and recommendations.  A massive undertaking, it

was produced by the Independent Expert Group of the Global Nutrition Report, supported by the Global Nutrition Report Stakeholder Group and the Secretariat at Development Initiatives. The writing was led by the co-chairs Jessica Fanzo and Corinna Hawkes, supported by group members and supplemented by additional analysts and contributors.

For a quick overview, go right to the slide deck and then to the graphics in the executive summary.

The report deals both with problems of malnutrition (undernutrition) and obesity (overnutrition), especially in children.

It also deals with adult obesity:

It identifies measurable nutrition indicators that can be used to track progress:

It recommends actions to reduce the prevalence of malnutrition and obesity.

What stands in the way of implementing these steps?  Political will, alas.

These reports have come out annually since 2014.  Let’s hope this one gets the attention it deserves.

Oct 6 2017

Weekend reading: Nutrition and Food Systems

HLPE [High Level Panel of Experts on Food Security and Nutrition]. Nutrition and food systems. A report by the High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security, Rome, 2017.

This report takes a food systems approach to recommendations for reducing the double burden of malnutrition—obesity in the presence of widespread hunger and its consequences.

This report aims to analyse how food systems influence diets and nutrition. It offers three significant additions to previous frameworks. First, it emphasizes the role of diets as a core link between food systems and their health and nutrition outcomes. Second, it highlights the central role of the food environment in facilitating healthy and sustainable consumer food choices. Third, it takes into account the impacts of agriculture and food systems on sustainability in its three dimensions (economic, social and environmental). 2. A food system gathers all the elements (environment, people, inputs, processes, infrastructures, institutions, etc.) and activities that relate to the production, processing, distribution, preparation and consumption of food, and the outputs of these activities, including socio-economic and environmental outcomes. This report pays specific attention to nutrition and health outcomes of food systems. It identifies three constituent elements of food systems, as entry and exit points for nutrition: food supply chains; food environments; and consumer behaviour.

May 22 2017

WHO resources for ending the double burden of malnutrition (under- and overnutrition)

The World Health Organization (WHO) has just published a series of papers on “double-duty” actions needed to end world malnutrition.  By this, it means addressing not only classic undernutrition and its consequences (stunting and wasting of children, nutrient deficiencies and starvation in adults) but also obesity and its risks for chronic disease.

In a commentary on the WHO site and in The Lancet, Fracesco Branca, Alessandro Demaio, and Corinna Hawkes say:

This is the potential of “double-duty actions”—interventions, programmes, and policies that have the ability to simultaneously reduce the risk or burden of both undernutrition and overweight, obesity, or diet-related NCDs (noncommunicable diseases). Double-duty actions offer an integrated approach to addressing malnutrition. WHO proposes three levels for increasing the efficiency of nutrition actions through a double-duty approach.

The three levels are:

  1.  Ensure that current interventions, policies, and programmes designed to address one form of malnutrition do not inadvertently increase the risk of another.
  2. Leverage existing actions designed to address one type of malnutrition to simultaneously reduce other types.
  3. identify the shared drivers between different forms of malnutrition to proactively identify de novo actions for reducing all forms of malnutrition.

 

The WHO expands on these ideas in a policy brief.

They describe the interventions that can and should be taken in an action policy brief.

These are useful resources for anyone interested in and concerned about doing something about the double burden of malnutrition.

Oct 24 2016

Rethinking nutrition policy in developing countries

I recently coauthored an editorial on international development.  It appeared first in French, and now in English in Ideas for Development, a blog coordinated by the French Agency for Development.

Rethinking nutritional policies in developing countries taking into account the double burden of malnutrition

By , Marion Nestle, and

The world now experiences two forms of malnutrition which may seem contradictory: “undernutrition” (which includes micronutrient deficiencies) and “overnutrition” (obesity and its health consequences).The problem of malnutrition in developing countries is approached by most aid bodies (donors, international organisations and NGOs) and governments solely from the angle of undernutrition. And yet in these countries, the complex and multi-faceted challenge which malnutrition now presents can justifiably be called the double burden of malnutrition. In addition to the continuing problem of undernutrition there are now major issues linked to overnutrition and its associated illnesses.

Rapid nutrition transition

The stereotyped image of skeletal young children with protruding bellies saved by souls of goodwill in sub-Saharan Africa is still too widespread. Severe acute malnutrition still persists of course, especially among the victims of extreme poverty, natural catastrophes and wars. Naturally, this deadly disease must continue to be addressed and treated, as numerous NGOs are doing.

The treatment of malnutrition should focus not only on severe malnutrition in children. Less severe malnutrition, going back to life in the foetus and resulting from malnutrition in women even prior to their pregnancy, continues to contribute to stunting, which affects 23.8% of all children under the age of 5 throughout the world.

In parallel with acute and chronic undernutrition, the “nutrition transition” in low-income countries, driven by globalisation, urbanisation and technological progress and linked to “overnutrition,” leads to a swift increase in obesity and other chronic diseases – mainly diabetes and cardiovascular diseases. Nutrition transition is the term used to describe the progressive Westernisation of eating patterns, typified by a sharp increase in the consumption of animal fats and processed foods all over the world, combined with an increasingly sedentary lifestyle. It is easy to see how this transition encourages the increase in overweight and obesity.

Today, undernutrition alone is not the major issue; the greatest problem is the double burden of undernutrition and overnutrition. According to estimates from 129 countries with available data, 57 experience serious problems of both undernutrition in children and overweight in adults[i]. And Africa is not exempt from this double burden where undernutrition and overweight are undeniably linked. In West Africa, 50% of women of child-bearing age are anemic while at the same time 38% are overweight and 15% are obese. For the whole of sub-Saharan Africa, 40% of children have stunted growth characteristic of chronic undernutrition, while 7.5% of adults suffer from obesity. Malnutrition early in life increases the subsequent risk of chronic diseases in places where obesity is encouraged by the environment. Obesity is now on the increase among children in all developing countries. The World Health Organization (WHO) reports that between 1990 and 2015 the number of overweight or obese African children doubled from 5 to 10 million. 

The responsibilities of the industrial food system

It is often said that communication aimed at changing food habits is the best way to prevent obesity, a problem reserved for rich people in low-income countries. This cliché contains three errors:

  • The first is the claim that preventing nutrition-related chronic relies entirely on the capacity of individuals to make appropriate choices regarding food, physical activity or lifestyle. This claim ignores the well-documented effects of the food system and the socio-cultural factors which play a determining role and which influence the choice of individuals.
  • The second error is to believe that significant changes cannot be made to the eating practices of limited-income groups in the absence of an increase in resources. Yet several studies show the opposite, whether they are about exclusive breastfeeding for the first six months of life and improved complementary feeding, or else hygiene measures and supplies of drinking water.
  • The third error is to consider that obesity continues to be only a problem of the rich in low-income countries. Obesity is escalating and affecting growing numbers of not so well-off people, particularly in cities.

When analysing the impact of the food system, it is necessary to account for the agri-food industry (Big Food). On a world-wide scale Big Food is primarily responsible for the nutrition transition” towards processed food. “Globalised” industrial food is gradually replacing traditional cooking and locally produced foods, with ultra-processed foods’ (food-like substances as Michael Pollan calls some of them) undeniable appeal for city-dwellers and young people as these products are strongly associated with Western-style fast food and heavily promoted by the media. This appeal is reflected in profound changes in consumption trends in developing countries. Global sales of highly processed foods increased by 44% from 2000 to 2013, but only by 2% in North America as opposed to 48% in Latin America and 71% in Africa and the Middle East.

So what is the problem? Industrial food products (and drinks) are often a nutritional disaster: rich in calories, sugar, fat and salt, but low in essential nutrients and fiber. Even more, these products are relatively inexpensive, often less expensive than more nourishing local food products.

Changing the food environment

What is the explanation for the popularity of these “globalized” food products? Part of the answer lies in extremely effective advertising. Anyone travelling in Africa, for example, will see campaigns to promote salty stock cubes to replace traditional spices and vegetables. “Social marketing” efforts to change eating behaviour must be as forceful as these adverts, with commensurate budgets.

One idea is to impose a tax on soft drinks or other highly processed foods and use the revenues to finance cutting-edge nutrition education campaigns. This is what the United Kingdom has recently decided to do by taxing soft drinks.

It is especially important to rethink the nutrition programs created by NGOs and financed by international aid. Correcting the nutrition of malnourished mothers or children is only part of the problem.

A wider vision is needed to recognize the threat to world health posed by nutrition-related chronic diseases.

To cope with this new challenge, it will be important to address many determinants of health – education, social disparities, housing, and culture – as well as the food environment. The latest report on global nutrition1 points out the excellent return on investment of nutrition interventions (16 for 1), and challenges governments and decision-makers to identify and implement strategies that target the double burden of malnutrition. If this is not done, it will be difficult to reach the nutrition objectives set by the WHO for 2025 (see below). Solutions do exist, however, as can be seen from places such as Ghana, Brazil, or the state of Maharashtra in India, which have had encouraging results in fighting malnutrition in all its forms.

Global nutrition targets for 2025

  • Reduce the number of children with stunted growth by 40%
  • Reduce and keep the prevalence of acute malnutrition in under-five children (low weight) under 5%
  • Avoid any increase of overweight in children
  • Reduce the prevalence of anemia in women of child-bearing age by 50%
  • Increase exclusive breastfeeding for babies less than 6 months old by 50%
  • Reduce low birth weights by 30%
  • Avoid any increase in the prevalence of overweight, obesity and diabetes in adults.

The opinions expressed on this blog are those of the authors and do not necessarily reflect the official position of their institutions or of AFD.

[i] Global Nutrition Report 2016 www.globalnutritionreport.org