Recently, the Global Nutrition Report (2014-16) describes a new norm of malnutrition in Asian emerging markets: obesity and non-communicable diseases are on the rise, while a substantial proportion of people still suffer from undernutrition. People living in cities now outnumber those living in rural areas and research suggests a convergence in urban and rural consumer demand for packaged or processed foods within low- and middle-income Asian countries. Both how economics favors the production of cheap, energy-dense but nutrient-poor foods and their growing contributions to modern diets in low- and medium-income populations are important factors in the growing double-burden of malnutrition and disease. All sectors involved in the food and nutrition value-chain need to work together to achieve the research-driven incremental improvements and disruptive innovations that shift the factors of food production and consumption towards improved nutritional and health-related outcomes.

1. 1
Diets in Transition:
Urbanisation & Processed Food at the
Heart of Malnutrition Crisis in Emerging
Asia’s Countries?
Presenter
Regina Moench-Pfanner, PhD
ibn360 Pte Ltd, Singapore
Presentation for
HKUST
18 November 2016, Hong Kong

2. OUTLINE OF PRESENTATION
 New ‘Norm of Malnutrition’ in Asian context
 Asia’s Nutrition Transition
 The BoP Market
 Key Players & Strategies in Nutrition Improvement
 The Way Forward
 Key Takeaways

3. GLOBAL NUTRITION REPORT
The New Norm of Malnutrition:
Obesity and NCDs are on the
rise alongside undernutrition
Every country has a nutrition
problem
- Overnutrition
- Undernutrition
- Micronutrient deficiencies
- Non-communicable diseases

4. SCALE OF MALNUTRITION IN 2016
4
Source: IFPR. 2016. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington, DC.

5. DOUBLE BURDEN OF MALNUTRITION -
PREVALENCE OF WASTING AND OVERWEIGHT
IN CHILDREN UNDER FIVE IN ASEAN
Source: ASEAN/UNICEF/WHO (2016). Regional Report on Nutrition Security in ASEAN,
Volume 2. Bangkok; UNICEF

6. DIABETES
1 in 12 people have diabetes
 1 in 2 people with diabetes do not know they have it
Source: International Diabetes Federation. http://www.idf.org/sites/default/files/Atlas-poster-2014_EN.pdf

7. PREVALENCE OF DIABETES AT A GLANCE
SEASEA:
Bangladesh, Bhutan, India,
Maldives, Mauritius, Nepal, Sri
Lanka
Source: International Diabetes Federation, IDF Diabetes Atlas. http://www.idf.org/sites/default/files/Atlas-poster-2014_EN.pdf

8. GLOBAL HIDDEN HUNGER: FACTS AND
FIGURES
Source:
World: Global Hidden Hunger Map (as of 28 Jan 2010) [Internet]. Sight and Life; 28 Jan 2010. Available from: http://reliefweb.int/map/world/world-
global-hidden-hunger-map-28-jan-2010

9. ASIA’S TWO FACES (1)
“Asia and the Pacific’s
drive for food security
has focused too narrowly
on quantity, with a surge
in obesity and still high
levels of malnutrition in
some countries
highlighting the need for
a new approach”
Asian Development Bank,
Food Security in Asia and the
Pacific, Asian Development
Bank, Manila, 2013
Source: Asian Development Bank (2013). Food Security in Asia and the Pacific

10. ASIA’S TWO FACES
Source: Asian Development Bank (2013). Food Security in Asia and the Pacific
ASIA’S TWO FACES (2)

11. TACKLING MALNUTRITION AND
MICRONUTRIENT DEFICIENCIES – THE
BENEFITS IT WILL BRING
• Prevent 35% of child deaths – that’s
approximately 3 million deaths!
• Prevent GDP losses of about 11%
(estimated figures for Asia & Africa)
• Reduce disability burden for children
<4y by half
• Better performance in school
• ↑ grade attainment of 1.2 years
• Improve labour market returns to
nutrition
• 33% less likely to remain in
poverty by adulthood
• 1 SD ↑in height-for-age → ↑ per
capita consumption level of the
household that they live in by
almost 20%
Source: Ending Undernutrition: Our Legacy to the Post 2015 Generation
Lawrence Haddad, IDS in partnership with the Children’s Investment Fund Foundation
http://www.scribd.com/doc/139698432/Ending-Undernutrition-Our-Legacy-to-the-Post-2015-Generation-Lawrence-Haddad-
Institute-of-Development-Studies-in-partnership-with-the-Childr#scribd

12. A FINANCIAL BURDEN TO THE
ECONOMY
The annual magnitude of malnutrition in nine low-
income Asian countries:
• 2.8 million child deaths
• 65,000 maternal deaths
• At least 2-3% GDP loss
Source: Horton, S. Opportunities for investments in
nutrition in low-income Asia. Asian Development Review;
17(1,2):246-73
Chronic malnutrition incurs a
3% loss in GDP annually which
is worse than energy crisis (2%
GDP loss)
266 million USD loss by not addressing
Malnutrition (1.7% GDP)

13. Eating choices
Do we eat the wrong foods?

14. Source: Bloem MW, de Pee S, Le TH, Nguyen CK, Laillou A, Minarto, Moench-Pfanner R, Soekarjo D, Soekirman J, Solon A, Theary C,
Wasantwisut E. Key strategies to further reduce stunting in Southeast Asia: Lessons from the ASEAN countries workshop. Food and Nutrition
Bulletin. Volume 34, Supplement 1, June 2013 , pp. 8S-16S(9)
Quantity and quality
of dietary intake
Nutrient-dense food

15. NUTRITION IN TRANSITION
A holistic understanding of
how people get and
consume food and nutrients
in the present environment
must inform solutions to
improve nutrition and health

16. DEMOGRAPHIC TRENDS 1950 - 2050
0
2
4
6
8
10
1950 1970 2011 2030 2050
Population(billion)
Total population - world
Total population - more developed
regions
Total population - less developed
regions
Rural population - less developed
regions
Urban population - less developed
regions
Source: United Nations, World Urbanization Prospects, The 2011 Revision
http://esa.un.org/unup/pdf/WUP2011_Highlights.pdf

17. SHARES IN TOTAL FOOD EXPENDITURE,
BY RURAL/URBAN & COUNTRY
19% 19%
28%
22% 17%
7%
46%
41% 47%
13%
23% 18%
BANGLADESH INDONESIA VIETNAM
RURAL
Own Production Unprocessed
Low Processed High Processed
4%
12%
4%
26%
16%
10%
52%
38%
54%
18%
34% 32%
BANGLADESH INDONESIA VIETNAM
URBAN
Own Production Unprocessed
Low Processed High Processed
Source: Reardon et al., 2014, Urbanization, Diet Change, and Transformation of Food Supply Chains in Asia

18. CRITERIA USED TO DEFINE LEVELS OF
FOOD PROCESSING
Number of ingredients Degree of processing Packaging
Unprocessed One ingredient
Consumed unprocessed (e.g.
fruit, vegetables, eggs, fluid
milk)
Processed low
One ingredient (e.g.
husked and polished
rice)
Alteration of the form (e.g.
paddy milled into rice)
Paper, plastic bag
or wrap
Processed high
Multiple ingredients
(e.g. cookies)
Additional processing steps
(e.g. cooking, extruding,
freezing, added chemicals,
flavours)
Bottle or can
• Any item with 2-3 of the above variables meeting the high processed category is categorized as
“Processed high”
• Any item with 0-1 of the variables meeting high processed category is categorized as
“Processed low”.
Source: Reardon et al., 2014, Urbanization, Diet Change, and Transformation of Food Supply Chains in Asia

19. POTATO – UNPROCESSED
POTATO PROCESSED AT HOME

20. FROM LOW TO ULTRA-PROCESSED FOOD

21. HIGH PROCESSED FOODS –
SAUSAGES OR INSTANT NOODLES

22. HIGH PROCESSED FOODS –
SUGAR-SWEETENED BEVERAGES
Source: Public Health Law Center (William Mitchell College of Law, Minnesota). Healthy Beverage Policies: Key
Definitions and Sample Standards. http://www.publichealthlawcenter.org

23. PROCESSED FOODS – BRIEF HISTORY
• Industrialization:
 efficient formulation
 mass manufacture
 distribution and sale of processed
foods
• Declines in food insecurity and nutrient
deficiencies of public health concern in
early 20th century
• Cheap surplus grain + food
science/technology advances →
processed products made from cheap
ingredients and additives
• Rapid increases in NCDs at first in
high-income countries, then globally

24. OBJECTIONS TO
PROCESSED PRODUCTS
• “Ultra-processed products are made
from processed substances extracted
or refined from whole foods – e.g. oils,
hydrogenated oils and fats, flours and
starches, variants of sugar, and cheap
parts or remnants of animal foods –
with little or no whole foods.“
• “[They] are typically energy dense;
have a high glycaemic load; are low in
dietary fibre, micronutrients, and
phytochemicals; and are high in
unhealthy types of dietary fat, free
sugars, and sodium.”

25. Is nutritious food expensive?
nutrient-dense versus energy-dense
COSTS OF FOODS

26. Energy dense foods:
- oils, pastries, animal fat, cheese, deli meat, salt
snacks, grains
- Energy dense foods are normally in dried form
Nutrient-dense foods:
- vegetables, fruits, dairy products, fish, eggs,
meat, poultry
- Nutrient-dense foods are normally in fresh form
COSTS OF FOODS

27. COSTS OF FOODS
Energy-dense foods less
expensive than nutrient-dense
foods
- 1 USD of energy-dense foods
buys more calories than 1 USD
of nutrient-dense foods
- Cheap foods fuelling obesity?

28. PEOPLE LIVING ON LESS THAN $2 A DAY…
World Development Indicators, World Bank 2012
World Development Indicators, World Bank 2012

29. ANNUAL INCOME SPENT ON FOOD AND
MALNUTRITION RATE

30. BOP SPENDS US$ 2.3 TRILLION A YEAR ON
FOOD & BEVERAGES
Source: Time Magazine, February 28, 2011

31. 1 Billion
>$60/day
2 Billion
$10-60/day
3 Billion
$1-10/day
1 Billion
<$1/day
Purchasing
Power:
$12.5 Trillion
$5 Trillion
Humanitarian
Fairly urban, extremely
competitive, well-served
Changing
food
consumption,
under-served,
informal
economy,
inefficient and
little
competition
Base of
Pyramid
(BoP)
BASE OF THE PYRAMID MARKET POTENTIAL

32. KEY PLAYERS IN THE FOOD AND
NUTRITION VALUE CHAIN
Food &
Nutrition
Environment

33. THE HEALTH SIGNIFICANCE OF
VITAMINS AND MINERALS
(MICRONUTRIENTS)
Micro • needed in small amounts
Nutrients
• vitamins and minerals are needed by the body to perform hundreds of roles
• body cannot manufacture on its own in sufficient amounts
• must be consumed
Some of the roles of micronutrients

34. STRATEGIES ADDRESSING THE PROBLEM OF
VITAMIN AND MINERAL DEFICIENCIES – HIDDEN
HUNGER
► Targeted health interventions
► Supplementation
► Home fortification
► Biofortification
► Food fortification
► Dietary diversification
Market
Public
Health

35. USE OF PROCESSED FOODS IN PUBLIC HEALTH
Food Fortification
Addressing wide-spread deficiencies in vitamins and minerals
by enriching commonly consumed and accessible staple foods
in a cost efficient way
Over 80 countries have mandatory law in place to fortify wheat
flour; most countries have universal salt iodization; rice
fortification efforts underway in several countries;

36. FORTIFICATION HISTORY
1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
Early 1920s programs –
Elimination of single
endemic nutrient
deficiency, ex. Goiter in
Switzerland
In 1940s – 50s: Elimination of
multiple nutrient
deficiencies, e.g. B-vitamin
deficiencies in USA, Canada
In 1960-90s: Early
industry voluntary
fortification
In 2000s: Emphasis on
effectiveness to show health
impacts, with high cost-benefit ratio
(MDGs, Copenhagen Consensus)

37. THE USE OF ULTRA – PROCESSED FOODS IN
HUMANITARIAN FOOD AID
Targeted Food Fortification
Preferred approach when fortified foods are used for
specific population groups with specific nutritional needs
https://www.wfp.org/nutrition/special-nutritional-products
Ready to Use Foods (RUFs)
High Energy Biscuits (HEBs)
Micronutrient Powders or “Sprinkles”

38. EVIDENCE BASE FOR FORTIFICATION (1)
“Integration of fortification and
supplementation strategies
together with other mother and
child health and prevention
programs may be the answer to
address the widespread global
under-nutrition and to ensure
sustainable benefits.
“Community education and
promotion campaigns should also
be implemented to increase
awareness, acceptability and
equity.

39. EVIDENCE BASE FOR FORTIFICATION (2)
“Fortification is potentially an
effective strategy but evidence
from the developing world is
scarce and future programs also
need to assess the direct impact
of fortification on morbidity and
mortality.”

40. EVIDENCE BASE FOR FORTIFICATION (3)
“The future of functional
beverages depends on the
unequivocal demonstration of
their efficacy in promoting health.
“Thus, a joint venture between
food producers and researchers
is advisable, as a tool to provide
scientific evidence of many
health claims, as well as a way to
find successful strategies to
improve the appeal of functional
beverages.”

41. EVIDENCE BASE FOR FORTIFICATION (4)
• Multi-micronutrient fortified
beverage interventions highly
effective at reducing anemia
and iron deficiency
• Strong public health rationale
for use in countries with high
prevalence
• Further research needed on
impact of fortified beverages
with other nutrients or on
other outcomes (i.e. other
nutrients, physical
performance, etc.)

42. THE WAY FORWARD
1. Given the central role of food in the double burden of
malnutrition, a food-based strategy to redress the energy-
nutrient balance in the food system is needed
2. A food-based strategy modelled on the stealthy nutrition
improvement approach of governments in the early 20th century,
when mass fortification helped eradicate major public health
problems in industrialized countries
3. But updated for the 21st century – not staple foods fortified with
single nutrients but processed foods re-engineered to
promote health and help close the nutrient gaps in modern
diets

43. KEY PLAYERS AND THEIR ROLES IN
NUTRITION IMPROVEMENT
Consensus
to provide
nutritious
foods
 Labelling
 Enforcement
 Regulations
 Incentives
 Education
 Innovation
 Social marketing
 Financial
sustainability
 Holding
industry &
government
accountable
 Research
 Knowledge
 Advocacy
 Education
 Nutrition awareness
 Participation

44. STRATEGIC THRUSTS
1. (Incremental Improvement) Encourage sharing of research and best
practices in support of health-promoting processed food products:
 looking at value chain opportunities (farm, post-farm, processing,
logistics, retail) to improve inputs, processes and outputs with a
view to increased nutrient density
2. (Disruptive Innovation) Encourage entrepreneurship in innovating
inputs, processes and outputs in the food and nutrition value chain:
 Encouraging ‘startups’ taking risks that big companies cannot and
testing new products/processes with the goal of increased nutrient
density
 Organizing ‘food hackathons’ with food scientists, chemists,
packagers, technologists and marketers come together to address
current challenges.

45. RESEARCH PRIORITIES
- Scientific research to increase evidence base for fortification
beyond iron/anemia, and in developing countries
- Product R&D to determine optimal vehicle(s) and nutrient
formulations to achieve health-promoting functional food
and beverage profiles, while reducing undesirable
ingredients, such as sugar, salt, unhealthy fats, etc.
- Market research to identify most suitable products to reach
nutritionally-underserved population groups and define
affordable price points to encourage uptake
- Packaging R&D to develop innovative and intuitive visual
cues on serving/portion sizes as well as
nutrition/educational information

46. KEY TAKEAWAYS (1)
1. Despite increasingly robust food security in Asia, the
double burden of malnutrition (undernutrition and
obesity/NCDs) has become the new normal
2. Cheap, energy-dense, nutrient-poor processed products
are increasingly becoming a larger share of the modern
diet in low- and medium-income Asian countries
3. Access to low-cost excess calories and increasingly
more sedentary lifestyles in urban environments drive
the double burden of malnutrition in LMIC populations
4. Malnutrition has measurable impacts on GDP as well as
individual and social development

47. KEY TAKEAWAYS (2)
5. One part of the solution is to harness the increasing
consumption of processed foods and beverages, and
reformulating them to promote health with the help of
micronutrient fortification
6. This can be achieved through incremental improvements
to existing processes or through disruptive innovation that
replaces conventional but outdated processes
7. Ultimate goal is to make health-promoting, easily
accessible and suitably affordable processed food and
beverage products so ubiquitous in the food environment
that nutrition improvement happens as a matter of course.

48. Q & A

49. 49
Information & correspondence:
Regina Moench-Pfanner, PhD
Chief Executive Officer, Ibn 360 Pte Ltd
3 Pickering Street, #02-36 Nankin Row,
China Square Central, Singapore 048660
m +65 8387 2535 • t +65 6327 8824 • f +65 6223 7314
regina@ibn-360.com • www.ibn-360.com •
@Moenchpfanner

50. WHAT WOULD AN IDEAL FOOD-BASED
SOLUTION LOOK LIKE? (1)
Fortified Food/Beverage – hybrid of dietary diversity and
supplementation approaches
Besides being affordable, ideal products would:
- Provide adequate quantities of nutrient-dense calories
- Contain limited or non-existent amounts of unhealthy
ingredients, i.e. sugar, salt, trans/saturated fats, etc.
- Maintain/deliver an appealing sensory experience
(sight, smell, taste, texture/viscosity)
- Possess reasonably good handling and storage
characteristics, i.e. shelf life, packaging, etc.

51. WHAT WOULD AN IDEAL FOOD-BASED
SOLUTION LOOK LIKE? (2)
- Provide easy-to-understand visual cues on
serving/portion sizes (if containing more than 1
serving/portion) – packaging innovation needed
- Provide adequate information/education on the
nutritional content, particularly key macro- and
micronutrients – meet or exceed labeling requirements
- (Bonus) Include labeling that enables consumers,
regulators, NGOs or industry watchdogs to verify
origin and other supply chain characteristics – for
traceability/transparency and proof of sustainability