Regional overview of diets and nutrition in South Asia
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From Global Panel and Brac roundtable on improving nutrition. More on: glopan.org/news/regional-approaches-delivering-healthy-diets-all-south-asia
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Regional overview of diets and nutrition in South Asia
- 1. Click to edit Master title style Click to edit Master subtitle style Food, Diets and Nutrition in South Asia: A Regional Overview of Challenges and Opportunities Patrick Webb Dhaka, Bangladesh November 21, 2016
- 2. 1990 2015 Poverty Mortality Illiteracy Malnutrition Communicable diseases Famine deaths Many improvements in human well-being
- 3. Global trends in child stunting 3Source: World Bank (2015) Investment Case for Nutrition
- 4. Child stunting prevalence (2015 est.) 4Source: World Bank (2017) Investment Framework for Nutrition
- 5. Child wasting prevalence (2017 est.) Source: Development Alternatives (2017) Global Nutrition Report
- 6. Click to edit Master title style Click to edit Master subtitle style 6 Distribution of stunting, wasting (and both) across South Asia Source: UNICEF 2017 (forthcoming)
- 7. Click to edit Master title style Click to edit Master subtitle style 7Source: UNICEF 2018 (forthcoming)
- 8. 8 Prevalence of anemia (among adult women) Source: Development Alternatives (2017) Global Nutrition Report
- 9. Most global burden of disease risk factors are linked to diet and malnutrition Source: Lancet Sept 2017
- 10. Diets do not automatically improve over time Source: Masters (2016), Global Dietary Database grams per day changes 1990-2013changes 1990-2013
- 11. Diets do not automatically improve over time Source: Masters (2016), Global Dietary Database grams per day changes 1990-2013
- 12. Consumption of Fruits and Veg and Salt relative to WHO min/max
- 13. 13Source: Lancet (Nov 15, 2017) 1990 2016 All-age DALYs in epi transition: lower ratio (bluer) = >NCDs. Ratio between NCDs and non-NCDs
- 14. Risk factors for DALYs, adult women in India 14Source: Lancet (Nov 15, 2017)
- 15. Click to edit Master title style Click to edit Master subtitle style 15Source: UNICEF 2018 (forthcoming) Prevalence metabolic risk factors for diet-related non-communicable diseases among adults in South Asia, by country (2008) Raised blood glucose Raised blood pressure Raised blood cholesterol Overweight Sri Lanka
- 16. Mean intake of sodium (relative to WHO threshold) Source: Development Alternatives (2017) Global Nutrition Report
- 17. Source: Development Alternatives (2017) Global Nutrition Report Diabetes/Raised Blood Glucose
- 18. Business as usual will generate catastrophic health burdens in the future Globally, overweight and obese adults: 1.33 in 2005 3.28 billion in 2030 China: overweight & obese adults: 32.3% in 2012 51.2% by 2030. Bangladesh: more adults with diabetes by 2030 than in Mexico or Indonesia.
- 19. Children overweight, global trend Source: Development Alternatives (2017) Global Nutrition Report
- 20. Click to edit Master title style Click to edit Master subtitle style 20Source: UNICEF 2018 (forthcoming)
- 21. Click to edit Master title style Click to edit Master subtitle style 21 1996 (3% overw8t) 2007 (15% overw8t) 2014 (26% overw8t) * p<0.05; ** p<0.01 for the corresponding adjusted odds ratio for given risk factor Similar results for women in India (1999 and 2006) and Nepal (1996, 2006 and 2011) Source: UNICEF 2018 (forthcoming)
- 22. What are food systems? Food systems go well BEYOND Agriculture production: to storage, transport, trade, transformation, provisioning, retail Policy actions needed across these systems to achieve goals
- 23. Food systems and diets
- 24. Meeting “5-a-day” fruit and vegetable intake would cost low income households in Bangladesh, India, Pakistan 52% of their household income! Miller et al. Lancet August 2016
- 25. Consumer prices 1990-2010 (UK, Mexico, Brazil, South Korea & China)
- 26. Low diet diversity – problem for producers and consumers Composition of food expenditure in India, 2009–10 Est. 55% percent of calories still come from cereals in India Composition of food expenditure Rural Urban Cereals 29.2 22.3 Grains 0.3 0.2 Cereal substitutes 0.1 0.1 Pulses and products 6.9 6.5 Milk and products 16.1 19.1 Edible oil 6.9 6.3 Egg, fish and meat 6.5 6.6 Vegetables 11.5 10.5 Fruits, fresh and dried 3.0 5.1 Sugar 4.6 3.8 Salt and spices 4.5 3.8 Beverage and the like 10.5 15.5 26
- 27. 0 10 20 30 40 50 Bangladesh 2014 India 2005-06 Nepal 2011 Pakistan 2012-13 Diversity of diet is critical to improved nutrition, health and human development Child 6-23m fed WHO/UNICEF minimum dietary diversity (%) *Minimum dietary diversity is 4+ food groups from: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c. vitamin A-rich fruits and vegetables (and red palm oil); d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts. 27
- 28. • Economic returns from investments in nutrition: – Up to 10% of global GDP gained by eliminating stunting – Investments to nutrition programs = benefit-cost ratio 16:1 • Low and middle income countries should not have to take same damaging path towards recommended diets as high income countries did. • SDGs, UN Decade of Action on Nutrition. Why now?
- 29. Returns on $1 invested in reducing multiple forms of undernutrition 29Source: World Bank (2017) Investment Framework for Nutrition
- 30. 0 10 20 30 40 Nepal Burma Bangladesh Pakistan India Benefit-cost ratio/child of reducing stunting 30 Myanmar
- 31. Estimated gap in funding for nutrition-specific actions to meet MIYCN targets, 2017 31 Source: Development Alternatives (2017) Global Nutrition Report
- 32. 10 types of nutrition-sensitive programmes, by share of funding (37 countries, 2017) 32 Source: Development Alternatives (2017) Global Nutrition Report
- 33. A systems perspective can help guide effective policies for agriculture, food and nutrition 33 Food supply Food marketing Food transformation and retail Food demandFood choices
- 34. The factors behind Bangladesh’s impressive reduction of stunting were multi-sectoral4 Prevalence stunting <5y in Bangladesh (%) 0 10 20 30 40 50 60 1997 2000 2004 2007 2011 2014 0 10 20 30 40 50 60 70 80 90 100 Factors Unexplained Maternal height Birth interval Birth order Extent of open defecation Born in medical facility Prenatal doctor visit Improvement in parental education Increase in household assets Factors contributing towards fall, 1997-2011 (%) 34 • 1997 to 2011 % stunting fell by 2.7%/year (AARR), almost twice as fast as India. • Factors included: parental education (14%), fall in open defecation (7%), health care use (10%).
- 35. 0 10 20 30 40 50 60 70 80 1993 2000 2006-07 Lessons from improved in infant/young child feeding practices in Sri Lanka Rate of exclusive breastfeeding (%) WHA TARGET 2025 Sri Lanka provides ‘continuum of care’ through lifecycle: • >95% of women get antenatal care and deliver in health facilities • Community outreach by public health midwives - 2 home visits in first 10 days • Supportive culture for breastfeeding; high literacy rate among women 35
- 36. 0 10 20 30 40 50 60 70 80 Afghanistan Bangladesh Bhutan India Nepal Pakistan Sri Lanka Nepal shows anaemia reduction is possible Women of reproductive age with anaemia (%), 2011 *WHA TARGET IS A 50% REDUCTION OF ANEMIA IN WOMEN OF REPRODUCTIVE AGE BY 2025 FROM A BASE YEAR OF 2011 In 2004, Nepal launched Iron Intensification Project (IIP) in 5 districts. Over 7 years, scaled up to 70 districts. Success factors include: • Community-based platform using female volunteers (“near peers”) • Increased awareness driving demand • Strengthened logistics system to expand access to supplies • Addressing preventable causes, particularly deworming 75% in 1998 36 Children Women
- 37. Pathway from agriculture growth to better nutrition is not assured 0 10 20 30 40 50 60 70 0 5 10 15 In India, agriculture-nutrition link still relatively weak: • Small and marginal farmers find difficulty in accessing inputs, credit, extension, and markets for perishables (nutrient-rich foods) • Higher and volatile food prices challenge both producers (net- buyers) and consumers • Gender inequity impinges on agricultural productivity and diets Annual agricultural productivity growth Children under 5 underweight 37
- 38. • Many opportunities to focus on 1000 days agenda – but also beyond • This requires focus on: – Prevention (as well as treatment) – Adolescent girls’ nutrition and health (healthy pregnancies) – In utero services (incl. maternal supplementation) – Quality infant and young child feeding (IYCF) – Child care (disease-free environment, sanitation) • But also focus on high quality diets for all, reduced time burden of mothers (esp. in agriculture), knowledge (not just education) Focus on the first 1,000 Days 38
- 39. • No country in the world has ‘no nutrition problem’ • South Asia should leverage gains in economic (and agricultural) growth to achieve sustained gains on malnutrition in all its forms: • Stunting • Wasting • Low birth weight • Micronutrient (vitamin/mineral) deficiencies • Levels of exclusive breastfeeding • Overweight and obesity Tackle multiple faces of malnutrition 39
- 40. countries with multiple burdens of malnutrition Source: Development Alternatives (2017) Global Nutrition Report Progress, but still much to be done… South Asia
- 41. • High quality diets require attention across the food system. • South Asia has many innovators and strong commercial momentum. How to harness this for sustainable agriculture, more diverse foods in markets, more informed consumer choice, strong effective (informed) demand? • It’s not just about input prices, food trade, supermarket agendas or lack of purchasing power; it’s all of these! Adopt a food system-wide lens 41
- 42. • Essential, often neglected. Requires good co-ordination across sectors, leadership at highest levels, understanding of incentives to work differently. • A unified all-of-society vision of what needs to be done – governance happens at mayoral level, in states, in business sectors. • How can public and private sectors work in tandem to achieve population-wide public health goals? Nutrition governance 42
- 43. Thank- you 43
- 44. Call to (Region-Wide) Action 1. Focus on diet quality not just ‘food’ to meet the SDGs. 2. Ensure that food-based dietary guidelines guide policy decisions to reshape food systems (not only consumer-focus). 3. Make fruits, vegetables, pulses, nuts and seeds, fish, dairy more available, affordable and safe. 4. Focus on improved diets for infants, adolescent girls and women. 5. Adopt a food system lens to policies aimed at triple burden of malnutrition. 6. Promote evidence-based actions – ensure good data on cost-effective impacts of policies, trends in diet quality, scaling of best practice.
- 45. 1. Think diet quality (not just food supply or individual nutrients). 2. Think food systems not just sectors. 3. Think policy/program innovation to support choice of nutritious diets.
- 46. 47
- 47. 48 Coverage of clean water and good sanitation - poorest 40% households by district Source: World Bank (2017) Precarious Progress
- 48. World Economic Forum –Shaping the Future of Global Systems: A Scenarios Analysis
Editor's Notes
- Business as usual will generate Catastrophic health burdens Globally, if current trends continue, the combined number of overweight and obese adults will increase from 1.33 billion in 2005 to 3.28 billion in 2030 In China, the combined rate of overweight and obese adults has gone from 14.6% in 1992 to 32.3% in 2012 and is projected to rise to 51.2% by 2030 In Nigeria, the number of adults with diabetes is estimated to double between 2011 and 2030: from 3.1 million to 6.1 million In 2030, Bangladesh will have more adults with diabetes than Mexico or Indonesia
- Meeting “5 a day” consumption recommendations of 3 vegetable and 2 fruit servings per day for each household member would cost low income households in Bangladesh, India, Pakistan and Zimbabwe 52% of their household income. Miller et al. Lancet August 2016.
- Youngest children age 6-23 months living with their mother who are fed based on WHO/UNICEF guidelines for minimum dietary diversity during the day or night preceding the survey (%)
- *Conservatively assumes that individuals work only until the age of 36 or that the benefits of improved nutrition stop at age 36; discount rate of 5% “The variations depend on the country’s current level of income, projected growth rate, the current rate of stunting, and other parameters. Countries which are growing faster and/or have higher incomes have higher benefit-cost ratios, because the absolute dollar value of the benefits (due to higher wages) are greater, while there is less variation in costs of the nutrition intervention.”
- These priorities focus on Bangladesh, India and Nepal and rely heavily on FANTA ‘Overview of the Nutrition Situation in Four Countries In South and Central Asia’
- These priorities focus on Bangladesh, India and Nepal and rely heavily on FANTA ‘Overview of the Nutrition Situation in Four Countries In South and Central Asia’
- These priorities focus on Bangladesh, India and Nepal and rely heavily on FANTA ‘Overview of the Nutrition Situation in Four Countries In South and Central Asia’
- These priorities focus on Bangladesh, India and Nepal and rely heavily on FANTA ‘Overview of the Nutrition Situation in Four Countries In South and Central Asia’
- Policymakers need to demand more of their food systems. Need to go beyond simply delivering food and incentivize delivery of food that promotes health and nutrition. Start with nutrition and diet problems and work back to look for opportunities to change things in the food system—there are many opportunities. Many opportunities for change involve engaging with private sector. Nutrition community cannot afford to stick our head in the sand any longer. But proceed with eyes open. Factor in tradeoffs between nutrition, greenhouse gas emission and natural resource use. They are not as straightforward as they may seem.
- The global panel’s foresight recommendations are summarised in a call to action with 10 recommendation:
- It is a choice that is well within policymakers grasp. It is a choice that will help achieve the SDG goal of ending malnutrition in all its forms by 2030. It is a choice that will reap benefits for decades to come, for all people, in all countries.
- Make policies which regulate product formulation, labelling, advertising, promotion and taxes a high priority. These are needed to create disincentives for companies to allocate resources to forms of processing that undermine diet quality. Policies to educate consumers of the adverse health effects of consuming these products more than occasionally are also needed. 7 Improve accountability at all levels. Governments committed to reshaping food systems toward healthy diets need to set targets and publish transparent scorecards of their results. Private sector actors should acknowledge their far-reaching roles in defining food environments – and the nutritional quality of foods and other products that they promote to consumers. Civil society organizations need to monitor the performance of others. 8 Break down barriers associated with the longstanding division of jurisdictional responsibilities within many governments – between agriculture, health, social protection and commerce. These can fundamentally impede integrated action across food systems, inhibit the effective allocation of resources and create barriers that inhibit access to data. 9 Institutionalize high-quality diets through public sector purchasing power. Food provided in schools, hospitals, across the armed forces and in the prison system should be of the highest dietary benefit to the consumer. This approach has the potential to shape the norms around foods that contribute to high-quality diets and incentivize suppliers and contractors to align their value chains accordingly. 10 Refocus agriculture research investments globally to support healthy diets and good nutrition. Global and national public research organizations (and their funders) must rebalance their priorities to reflect a priority focus on high-quality diets. Much more investment in research on fruits and vegetables, animal source foods, legumes, nuts and seeds is urgently required. Better national-level and subnational data are needed on diet, consumer food prices, food safety, food loss and waste. The Access to Nutrition Index that assesses the conduct and performance of companies should be strengthened at the country level.