Theme III. Nutrition
and Health
Peter R. Berti
Eating is an agricultural act:
On the Edge of Understanding Nutrition-
Sens...
Agriculture – Sensitive
Nutrition
Attig et al., 1993
Kidala et al., 2000
Smitasiri et al., 1999.
Ahmed et al., 2000
Alderman, 1987
Ayalew et al. , 1999
Begu...
Attig et al., 1993
Kidala et al., 2000
Smitasiri et al., 1999.
Ahmed et al., 2000
Alderman, 1987
Ayalew et al. , 1999
Begu...
Attig et al., 1993
Kidala et al., 2000
Smitasiri et al., 1999.
Ahmed et al., 2000
Alderman, 1987
Ayalew et al. , 1999
Begu...
•… investing broadly in five types of capital, especially
human capital, increases the prospects for nutrition
improvement...
•[positive] nutrition outcomes when
they involve diverse and
complementary processes…
•Future programs should be
carefully...
… we concluded that the absence
of … significant impact of
agricultural interventions on
children’s nutritional status sho...
Food and Nutrition Bulletin (2014) 35:126-132
Food and Nutrition Bulletin (2013) 34:369-377
Turner et al. Food and Nutrition Bulletin (2013) 34:369-377
0
10
20
30
40
50
60
70
80
Ag production of
nutritious foods
Va...
Turner et al. Food and Nutrition Bulletin (2013) 34:369-377
0
20
40
60
80
100
Children Women Other
Agriculture for improve...
What we know
What we don’t know, but need to
know
What we don’t know, but it
doesn’t matter
• Home gardening with focus on vitamin A rich crops can
improve vitamin A status
What we know:
• For agriculture intervent...
What we don’t know, but need to know:
• What are the characteristics of self-replicating (or, at
least, scalable) nutritio...
What we don’t know, but it doesn’t matter:
• What are the nutrient-specific benefits of various types of
nutrition-sensiti...
We have a lot to learn… how can we
work together?
• Dietary diversity and ultra-processing
• The relationship between biod...
•Grains, roots or tubers
•Vitamin A-rich plant foods
•Other fruits or vegetables
•Meat, poultry, fish, seafood
•Eggs
•Puls...
Monteiro C (2010) The big issue is ultra-processing. [Commentary] World
Nutrition:16: 237- 269
Potato Wh grain bread Wonder bread
Milk Sw. Yogurt Cheez Whiz
Olive oil Butter Veg Lard
Lesson 1: ‘Interdisciplinarity’ is tough
I had no idea that working across disciplines
[….]was this painful, but it might ...
Peter R. Berti
Nutrition Advisor/Deputy Director
pberti@healthbridge.ca
www.healthbridge.ca
Peter Berti
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  •  
    Wendell Berry famously wrote “…eating is an agricultural act. Eating ends the annual drama of the food economy that begins with planting and birth.” This simple truth underlies the direct links between the world of nutrition and the world of agriculture. Despite the direct links, agriculture and nutrition scientists and development specialists have had difficulty communicating, working together and learning from each other.
    So start with: What is “Nutrition-sensitive agriculture” ? It is agriculture that is aware of the consumer at the other end of the chain, that includes the consumer’s health and dietary needs in the calculus of what and how to farm.

  • Now let me propose another version, and that is agriculture-sensitive nutrition. It needn’t all be on the aggies to be sensitive to the nutritionists.
    So what is agriculture-sensitive nutrition?
    Nutrition that is aware there is a farmer at the other end of the chain, that considers the needs and capacities of the farm in the calculus of what to eat. Nutrition that is aware of the seasons, the costs, the risks of farming.

    Where does this “sensitivity” get us? Maybe nowhere, or maybe it is the start of mutual understanding between nutritionists, consumers, agriculture scientists and farmers.

  • So what do we know about nutrition-sensitive agriculture? Not as much as we would like.
    In 2004 we conducted a review of the literature documenting the impact of agriculture interventions on nutrition outcomes in participating households. There were 34 studies in the review (listed by first authors last name and year – not necessary that you are able to read the authors’ names)
  • A World Bank review in 2007 added an additional 23 studies, while also including many of the studies from the 2004 review.
  • The Masset review of 2011 added four more studies (but had much stricter inclusion criteria and only included a handful of the studies that were included in the earlier reviews), for a total of 61 agriculture and nutrition studies that between them had to cover all aspects of nutrition, all types of agriculture, in every geoclimatic zone and culture…
  • What did the three reviews conclude?
  • 8
  • Masset concluded “the absence of … significant impact of agricultural interventions on children’s nutritional status should not be attributed to the inefficacy of these interventions. Rather it is the lack of[statistical] power of the studies

    So the three reviews reached some common conclusions:
    -broad based interventions are required to achieve nutrition impact (not shared by Masset et al)
    -but we really don’t know enough to make firm conclusions.
  • There have actually been seven additional reviews, for a total of 10 reviews on the impacts of agriculture on nutrition in the last 15 years. In February 2014 a review of these 10 reviews was published in the Food and Nutrition Bulletin. Their conclusion, to simplify, is that we still do not know very much and much more research is still needed.
  • Fortunately, there is a lot of research being carried out now. In this paper from late 2013, the authors identified 151 ongoing research projects that will be yielding their results in the coming years. About two-thirds of the studies are in Africa, and one-quarter in Asia.
  • But “agriculture for improved nutrition” is a very broad theme, and there are many areas to be covered. In this graph, I plotted the number of studies being carried out in six different categories, as described in the Turner review. Within each column the different colours represent different sub-themes. For example, within “Agricultural production of nutritious foods” there are studies on agrobiodiversity, aquaculture, home gardens, biofortification and more.

  • Also there are various target groups or populations of central interest in the study. There are studies on children (different colours for different age groups), on women (women of reproductive age, pregnant women, breastfeeding women), and on “Other” groups (including men, urban/rural populations, the extremely poor).

    So while there have been many studies conducted and many more are underway, we obviously won’t have studies for every possible agricultural intervention, in every age group, in every cultural/ethnic group. What are the broad lessons we have learned and still need to learn?
  • While some may call this “what we wish were true”, I think the balance of the evidence supports it and we can call it “what we know” (while still holding out for further details to improve our understanding).

    This first item is the central conclusion from our 2004 review.

    The impact of home gardening on vitamin A rich status is perhaps the most well studied theme in nutrition-sensitive agriculture, and the conclusion is that vitamin A status can be improved through home gardening. One of the earlier speakers at the conference stated that “Golden Rice” is the food-based solution for vitamin A deficiency, but it is clearly unnecessary. Carrots, mangos, papayas, eggs, and liver are all documented to be effective at improving vitamin A status.
    [[is there anywhere in the world where you can grow rice, but you can not grow at least one of carrots, mangos, papayas, or other vitamin-A rich fruits, or raise chickens?]]

    In the past few months a number of studies have been published documenting that animal husbandry focused projects can increase the consumption of Animal source foods – and increased ASF consumption in malnourished populations has been clearly linked to improved nutrition.
    See: http://www.sciencedirect.com/science/article/pii/S0306919213001814
    http://www.fao.org/docrep/018/i3396e/i3396e.pdf
    http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9146134&fulltextType=RA&fileId=S1368980012005010


  • We know of some nutrition-sensitive agriculture interventions that have scaled up with minimal additional input from the outside. What are the characteristics of these interventions? Is it simply that the benefits of the interventions are clear to neighbouring farmers and so they adopt the technology or practice themselves using their own resources? We need to know because we usually work in the scale of dozens, hundreds or thousands, but we really need to reach many millions.

    [THIS IS THE MOST IMPORTANT POINT OF THE ENTIRE PRESENTATION]:
    For an intervention to be nutrition-sensitive it has to carefully consider how it will impact women’s work loads. We must protect a mother’s time and energy for breastfeeding her children. If the intervention somehow changes a mother’s schedule and thereby decreases the amount that she breastfeeds her children, it is a great loss, and there is nothing that the intervention can do that could make up for this, no matter how effective it is otherwise. Exclusive breastfeeding* for six months is the “silver bullet” for starting children off well, and then continued breastfeeding (not exclusive) for two years is critical for continuing to nourish a child well. If an intervention, for example, requires that a mother spends more time a a field distant from her home, and the child is left at home with an older sibling, then the intervention is a nutritional failure.

    We recognize that agriculture interventions are often most effective at improving family well being when they are directed at the women. Women more often tend to use the proceeds from interventions in ways that benefit their children. But it can’t be done at the expense of reducing breastfeeding. Alternative approaches (eg engaging men in child care and support of mothers) are required.


    *that is a child consumes nothing other than mother’s milk
  • We can resist the spread of “nutritionism”, and instead of considering specific nutrient benefits (e.g. vitamin A or iron), we should focus on whole diet and food-system level benefits.
    Nutrient-specific benefits are important – such as the improvement in vitamin A status discussed earlier – but for the point we are at now, we (in the agriculture-nutrition research community) do not need to work on those specific benefits, but rather we need to focus on how our activities can lead to improvements in the food system and not to worry, for now, about the specific benefits at the nutrient level.
  • Here are three possibilities for considering how agriculture and nutrition scientists and practitioners may begin to work together.

    First, the technical side of nutrition that we need to work in is not complicated. We do not need to measure nutrient content of foods through complex lab work, we do not need to understand the biochemistry of all the nutrients, or nutrient-nutrient interactions. The nutrition that is needed is quite simple in ag-nutrition work: eat good food. Eat the eggs, the carrots, the meat, the beans, the whole grain bread, etc. The challenging and difficult part is behaviour change. But at least that is a common challenge to numerous fields, including agriculture. If in your agriculture projects you have been promoting intercropping or seed saving or improved animal husbandry etc etc you have been working in behaviour change. Now we just need to channel that experience into figuring out how to promote change in the diet. It is a tremendous challenge, but it is not a “technical nutrition issue” per se.
    Dietary diversity is associated with better quality diets (more later) and on farm biodiversity is often of interest and promoted. Study of the relationship between these two types of diversity can be a mutually interesting starting point. Is biodiversity needed for dietary diversity?
    And thirdly the issue of dietary diversity and ultra-processing…
  • There are numerous ways to define and measure dietary diversity, but in general, more diverse diets are more likely to be nutritionally adequate. The FANTA system divides all foods into 8 categories (other systems use 7 or 9 or 10 or more categories) and the number of different food groups consumed in a day is counted, yielding a score from 0 to 8 (or 7, 9 or 10). It is a tool both for measuring dietary quality and for promoting improved dietary quality.
    But there has been a weakness to the system that bothers me… Do we count “fruit rollups” as fruit? Is “Wonder Bread” a grain? Do we credit a diet when it includes unhealthy but highly variable food choices?
  • Carlos Monteiro has developed a system for thinking of food processing and evaluating it within food systems. Very briefly, foods may be considered minimally processed, moderately processed or ultra-processed. (he has since developed this classification further, but this basic understanding still holds).
    Monteiro hypothesized, and there is now accumulating evidence supporting this hypothesis, that many of the diseases of the epidemiological transition* can be accounted for by the level of “ultra-processed” food in the diet.

    But in countries in transition there is still a need to promote dietary diversity. We need to be able to promote diversity, while at the same time not increasing the consumption of ultra-processed foods – a difficult task.


    *As countries move out of low income to middle income status there is an increase in the rates of overweight, heart disease cancer, and a decrease in malnutrition, and infectious disease.
  • Perhaps this system will help. It is an integration of dietary diversity score with Monteiro’s level of processing to produce a diversity-processing matrix.
    For example, in the grains group, potatoes would be minimally processed, whole grain bread is moderately processed and “Wonder Bread” is ultra-processed. Other categorizations can be made at each food group level. It is somewhat arbitrary (how processed does a food have to be to move from yellow to red?) But the concept may be clear to consumers, where we can use the traffic light system to promote a diverse selection of the green column foods, and restrict the use of the red column foods.
    We have just started trying this out in Ecuador and we look forward to seeing if the system makes sense to the people we are working with.
  • To end, I would like to quote from a recent posting on the “From poverty to power” blog by Duncan Green of Oxfam.
    http://oxfamblogs.org/fp2p/

    He was not writing about working across agriculture and nutrition, but some of his lessons on interdisciplinarity apply to us.

    ‘Interdisciplinarity’ is tough’ You will be working with a new language a new way of thinking, and a whole new field you know nothing about.

    ‘Beware geeks bearing gifts.’ “Choose on the basis of emotional intelligence as well as the more academic kind. “


    I hope that this has been useful to you and encourages you as you continue in your work in nutrition-sensitive agriculture and agriculture-sensitive nutrition.
  • Peter Berti

    1. 1. Theme III. Nutrition and Health Peter R. Berti Eating is an agricultural act: On the Edge of Understanding Nutrition- Sensitive Agriculture
    2. 2. Agriculture – Sensitive Nutrition
    3. 3. Attig et al., 1993 Kidala et al., 2000 Smitasiri et al., 1999. Ahmed et al., 2000 Alderman, 1987 Ayalew et al. , 1999 Begum,1994 Brun et al. , 1989 Brun et al., 1991 CARE Nepal,1995. DeWalt et al., 1990 English & Badcock,1998 English et al., 1997 Galal et al., 1987 Hagenimana et al., 1999. HKI/AVRDC, 1993. Ngu et al. , 1994. Niemeijer, 1988 Phillips et al.,1996 Popkin et al.,1980 Smitasiri et al., 1999 Solon et al., 1996. Solon et a., 1979 Greiner & Mitra, 1995 Hoorweg et al., 1996 Marsh,1998 Bouis et al., 1990. Hernandez & Hidalgo, 1974 Kennedy, 1989. Kennedy & Oniang’o, 1993 Kurth, 1989 Morris et al., 1999 Rajasekaran, 2001 Sornmani et al.,1981
    4. 4. Attig et al., 1993 Kidala et al., 2000 Smitasiri et al., 1999. Ahmed et al., 2000 Alderman, 1987 Ayalew et al. , 1999 Begum,1994 Brun et al. , 1989 Brun et al., 1991 CARE Nepal,1995. DeWalt et al., 1990 English & Badcock,1998 English et al., 1997 Galal et al., 1987 Hagenimana et al., 1999. HKI/AVRDC, 1993. Ngu et al. , 1994. Niemeijer, 1988 Phillips et al.,1996 Popkin et al.,1980 Smitasiri et al., 1999 Solon et al., 1996. Solon et a., 1979 Greiner & Mitra, 1995 Hoorweg et al., 1996 Marsh,1998 Bouis et al., 1990. Hernandez & Hidalgo, 1974 Kennedy, 1989. Kennedy & Oniang’o, 1993 Kurth, 1989 Morris et al., 1999 Rajasekaran, 2001 Sornmani et al.,1981 De Pee et al., 1998 Nielsen et al. , 2003 Roos et al., 2003 Blanken, 1994 Bouis et al., 1998. Carrasco Sanez et al., 1998 Chakravarty, 2000 Habtemariam et al., 2003 HKI, 2003 HKI, 2004 HKI, 2004 HKI, 2006 IFPRI, 1998. Kumar & Siandwazi, 1994 Mullins et al. , 1996 Mulokozi, 2000 Niemeijer & Hoorweg, 1994. Parlato & Gottert, 1996 Tangka et al., 1999. Thompson et al., 2000 von Braun, 1988 von Braun & Kennedy, 1994 von Braun et al., 1991.
    5. 5. Attig et al., 1993 Kidala et al., 2000 Smitasiri et al., 1999. Ahmed et al., 2000 Alderman, 1987 Ayalew et al. , 1999 Begum,1994 Brun et al. , 1989 Brun et al., 1991 CARE Nepal,1995. DeWalt et al., 1990 English & Badcock,1998 English et al., 1997 Galal et al., 1987 Hagenimana et al., 1999. HKI/AVRDC, 1993. Ngu et al. , 1994. Niemeijer, 1988 Phillips et al.,1996 Popkin et al.,1980 Smitasiri et al., 1999 Solon et al., 1996. Solon et a., 1979 Greiner & Mitra, 1995 Hoorweg et al., 1996 Marsh,1998 Bouis et al., 1990. Hernandez & Hidalgo, 1974 Kennedy, 1989. Kennedy & Oniang’o, 1993 Kurth, 1989 Morris et al., 1999 Rajasekaran, 2001 Sornmani et al.,1981 De Pee et al., 1998 Nielsen et al. , 2003 Roos et al., 2003 Blanken, 1994 Bouis et al., 1998. Carrasco Sanez et al., 1998 Chakravarty, 2000 Habtemariam et al., 2003 HKI, 2003 HKI, 2004 HKI, 2004 HKI, 2006 IFPRI, 1998. Kumar & Siandwazi, 1994 Mullins et al. , 1996 Mulokozi, 2000 Niemeijer & Hoorweg, 1994. Parlato & Gottert, 1996 Tangka et al., 1999. Thompson et al., 2000 von Braun, 1988 von Braun & Kennedy, 1994 von Braun et al., 1991. Aiga et al. , 2009 Bushamuka et al., 2005 Faber et al., 2002 Gunaratna et al. 2010
    6. 6. •… investing broadly in five types of capital, especially human capital, increases the prospects for nutrition improvement. •Our analysis … was often hampered by the projects using study designs that were not suitable to assess this relationship. •The agriculture–nutrition link must be studied in a large variety of projects and settings, in order to build a body of knowledge
    7. 7. •[positive] nutrition outcomes when they involve diverse and complementary processes… •Future programs should be carefully monitored and rigorously evaluated to ensure that performance can be continually tracked and improved.
    8. 8. … we concluded that the absence of … significant impact of agricultural interventions on children’s nutritional status should not be attributed to the inefficacy of these interventions. Rather it is the lack of[statistical] power of the studies.
    9. 9. Food and Nutrition Bulletin (2014) 35:126-132
    10. 10. Food and Nutrition Bulletin (2013) 34:369-377
    11. 11. Turner et al. Food and Nutrition Bulletin (2013) 34:369-377 0 10 20 30 40 50 60 70 80 Ag production of nutritious foods Value chains Ag-based development Multisectoral Aflatoxin Policy / methodology Agriculture for improved nutrition: The current research landscape Research theme N studies
    12. 12. Turner et al. Food and Nutrition Bulletin (2013) 34:369-377 0 20 40 60 80 100 Children Women Other Agriculture for improved nutrition: The current research landscape: Populations of interest N studies
    13. 13. What we know What we don’t know, but need to know What we don’t know, but it doesn’t matter
    14. 14. • Home gardening with focus on vitamin A rich crops can improve vitamin A status What we know: • For agriculture interventions to have a positive impact on nutrition of the participating households they should invest in multiple areas of the farmers’ lives, including, but not limited to, nutrition education. • Animal husbandry focused projects can lead to increases in ASF consumption
    15. 15. What we don’t know, but need to know: • What are the characteristics of self-replicating (or, at least, scalable) nutrition-sensitive agriculture? • How do nutrition-sensitive agriculture interventions impact women’s work loads?
    16. 16. What we don’t know, but it doesn’t matter: • What are the nutrient-specific benefits of various types of nutrition-sensitive agriculture interventions?
    17. 17. We have a lot to learn… how can we work together? • Dietary diversity and ultra-processing • The relationship between biodiversity and dietary diversity can be a mutually interesting starting point •The key issue in nutrition: is NOT “nutrition”, but behaviour change
    18. 18. •Grains, roots or tubers •Vitamin A-rich plant foods •Other fruits or vegetables •Meat, poultry, fish, seafood •Eggs •Pulses/legumes/nuts •Milk and milk products •Oils/fats Dietary Diversity – more diverse=better
    19. 19. Monteiro C (2010) The big issue is ultra-processing. [Commentary] World Nutrition:16: 237- 269
    20. 20. Potato Wh grain bread Wonder bread Milk Sw. Yogurt Cheez Whiz Olive oil Butter Veg Lard
    21. 21. Lesson 1: ‘Interdisciplinarity’ is tough I had no idea that working across disciplines [….]was this painful, but it might be worth it Lesson 2: Beware geeks bearing gifts. What kinds of people do you want in the room? … the ability to empathise is probably more essential than being top of the field.
    22. 22. Peter R. Berti Nutrition Advisor/Deputy Director pberti@healthbridge.ca www.healthbridge.ca
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