1

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 7314regina@ibn-360.com • 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