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Diets in Transition: Urbanisation & Processed Food at the
Heart of Malnutrition Crisis in Emerging Asia’s Countries?
PresenterRegina Moench-Pfanner, PhDibn360 Pte Ltd, Singapore
Presentation forHKUST 18 November 2016, Hong Kong
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
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
SCALE OF MALNUTRITION IN 2016
4Source: IFPR. 2016. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington, DC.
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
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
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
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
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
ASIA’S TWO FACES
Source: Asian Development Bank (2013). Food Security in Asia and the Pacific
ASIA’S TWO FACES (2)
TACKLING MALNUTRITION AND MICRONUTRIENT DEFICIENCIES – THE BENEFITS IT WILL BRING
Malnutrition &
micronutrient
deficiencies
• 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 Foundationhttp://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
A FINANCIAL BURDEN TO THE ECONOMYThe 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 addressingMalnutrition (1.7% GDP)
Eating choices
Do we eat the wrong foods?
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
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
DEMOGRAPHIC TRENDS 1950 - 2050
1950 1970 2011 2030 20500
2
4
6
8
10
Total population - worldTotal population - more developed regionsTotal population - less developed regionsRural population - less developed regionsUrban population - less developed regionsPo
pula
tion
(bill
ion)
Source: United Nations, World Urbanization Prospects, The 2011 Revisionhttp://esa.un.org/unup/pdf/WUP2011_Highlights.pdf
SHARES IN TOTAL FOOD EXPENDITURE, BY RURAL/URBAN & COUNTRY
Bangladesh Indonesia Vietnam
19% 19%28%
22% 17%7%
46%41% 47%
13%23% 18%
RuralOwn Production UnprocessedLow Processed High Processed
Bangladesh Indonesia Vietnam4%
12%4%
26% 16%
10%
52%
38%54%
18%34% 32%
UrbanOwn Production UnprocessedLow Processed High Processed
Source: Reardon et al., 2014, Urbanization, Diet Change, and Transformation of Food Supply Chains in Asia
CRITERIA USED TO DEFINE LEVELS OF FOOD PROCESSING
Number of ingredients Degree of processing Packaging
Unprocessed One ingredientConsumed unprocessed (e.g. fruit, vegetables, eggs, fluid milk)
Processed lowOne 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
POTATO – UNPROCESSEDPOTATO PROCESSED AT HOME
FROM LOW TO ULTRA-PROCESSED FOOD
HIGH PROCESSED FOODS – SAUSAGES OR INSTANT NOODLES
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
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
OBJECTIONS TOPROCESSED 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.”
Is nutritious food expensive?
nutrient-dense versus energy-dense
COSTS OF FOODS
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
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?
PEOPLE LIVING ON LESS THAN $2 A DAY…
World Development Indicators, World Bank 2012
World Development Indicators, World Bank 2012
ANNUAL INCOME SPENT ON FOOD AND MALNUTRITION RATE
BOP SPENDS US$ 2.3 TRILLION A YEAR ON FOOD & BEVERAGES
Source: Time Magazine, February 28, 2011
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
KEY PLAYERS IN THE FOOD AND NUTRITION VALUE CHAIN
Food & Nutrition
Environment
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
Grow
th
(bon
e &
mus
cle)
Cognitive
developmen
t
Bolsters
immune
response
Repairs cellular damage
Energy metabolism Good health
Healthy aging
Good
performance
STRATEGIES ADDRESSING THE PROBLEM OF VITAMIN AND MINERAL DEFICIENCIES – HIDDEN HUNGER
► Targeted health interventions
► Supplementation
► Home fortification
► Biofortification
► Food fortification
► Dietary diversification
Mar
ket
Pub
lic
Hea
lth
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;
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)
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”
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.
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.”
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.”
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.)
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
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
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.
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
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
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.
Q & A
49
Information & correspondence:
Regina Moench-Pfanner, PhDChief Executive Officer, Ibn 360 Pte Ltd3 Pickering Street, #02-36 Nankin Row, China Square Central, Singapore 048660m +65 8387 2535 • t +65 6327 8824 • f +65 6223 [email protected] • www.ibn-360.com • @Moenchpfanner
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.
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