So, thank you so very much to the BMJ and
to Swiss Re Institute for your kind invitation to this amazingly interesting and thought
provoking meeting. My task is to present the BMJ series article
on Nutrition Disparities in Global Malnutrition. The authors of this paper do not have any
conflicts of interest to declare, however, I do want to share with the audience that
I am currently funded by the NIH, the CDC, by the US Agency for International Development,
by the Gates Foundation, and by the Family Larsson-Rosenquist Foundation. I have also and still am a senior nutrition
and food security advisor to UNICEF, the World Health Organization, and FAO. And speaking about the authors, I was probably
the luckiest man in the world when the BMJ helped me assemble this amazing team of co-authors,
each of which contributed very, very substantially to the debates that we had and to the multiple
versions that were written of these manuscripts. My special recognition to Odilia Bermudez,
Gabriela Santos Buccini, Shiriki Kumanyika, Chessa K Lutter, Pablo Monsivais, and Cesar
Victora. So when we first look at the data on anemia,
presumably the majority of which is due to iron deficiency, we found, as we had expected,
that the prevalence of this condition among children under five in low- and middle- income
countries was strongly inversely associated with wealth. When we then looked at stunting prevalence
in the same target group in low- and middle- income countries we re-confirmed what had
already previously been reported that stunting is strongly inversely associated with wealth,
with household wealth. However, when we looked at the data on childhood
overweight in low- and middle-income countries, or the regions where they are located, the
analysis had to be a little more complex, because at face value, it would appear as
if still the children that live in the wealthiest households are the ones that have the higher
prevalence of overweight. However, this cross sectional picture has
to be interpreted in the context of an understanding that the speed at which childhood obesity
is increasing is much more rapidly now in low- and middle-income countries in the most
socioeconomically vulnerable groups. So these are data that Juan Rivera shared
with me from Mexico, because it is one of the best analysis that I have seen to be able
to demonstrate this principle. What you can see is that, in a period of seven
years, the childhood obesity rates increased by 15% in indigenous households versus 8.3%
in non-indigenous households. By the same token, there was a much higher
increase in the rate of childhood obesity in the poorest households, that is 27.3% compared
with children living in the wealthiest households, which was only 2%. So it is correct to state that even though
the absolute prevalence of childhood obesity in low- and middle-income countries is still
higher among better off children, the speed of increase at which this is happening strongly
indicates that the obesity epidemic, as time goes by, is concentrating and more and more
among the poor. When we looked at data from high income countries
represented here by the US and England, what we found, if you can see the graph on the
left, these are NHANES data, across age groups 2-5 year olds, 6-11 year olds, or 12-19 year
olds, those who lived in households whose mothers had higher levels of education had
significantly lower rates of obesity. So you can see, for example, among youth it’s
26% if they had high school compared to 18% if the mom had more than high school. And this finding cuts across the age groups. When we looked at the NHANES data by racial
or ethnic group, we can see that across the age groups, the prevalence of obesity is significantly
higher among African-American children and youth and Hispanic children and youth compared
with their white counterparts which are represented by the orange bars. And as we know, the ethnic racial group attribution
in the US has nothing to do with genetics but it has all to do with social class. With regards to England, very recent data
from the National Child Measurement Program shows a fairly strong correlation between
the index of neighborhood deprivation on the x-axis and a higher rate of obesity. So, in both the US and England, poverty is
associated with higher risk of childhood obesity. Now in this diagram, what we did was to summarize
the knowledge with regards to the development of the double burden of malnutrition through
the life cycle and highlighting the fact that it is transmitted from one generation to the
next and that there are shared drivers that really have to be taken into account to try
to address the double burden of malnutrition to prevent it from happening through more
unified and cohesive approaches. So, the four main shared drivers are behavioral,
environmental, mostly related to the food supply and the food systems, and for our paper
we paid a lot of attention to the poverty and food insecurity related determinants of
both stunting, obesity, and also we can think about micronutrient in malnutrition. However, we fully acknowledge that these three
dimensions interact very powerfully with biology and specifically with the genome of individuals
in many ways through complex epigenetic mechanisms. The life course framework, which is now very
strongly supported by the scientific evidence available strongly highlights the key importance
pregnancy, the first two years of life, what we call the first 1000 days, because we know
that birth weight, if it’s either low birth weight or very high birth weight, then becomes
a powerful risk factor to subsequent development of stunting, obesity and even a number of
chronic diseases. In the rest of the diagram, when you see in
the salmon color boxes and blue color boxes are risk factors and consequences for stunting
in the case of the salmon squares and obesity in the case of the blue squares across the
life course. Even though we did have a good number of debates
about the role of what we call nutrition-specific interventions, there was zero evidence that
the reductionist approach of expecting that we are going to prevent stunting through food
fortification programs, specifically in low- and middle-income countries the use of micronutrient
powders or lipid nutrient supplements the evidence is zero that that is ever going to
work. There is also zero evidence that, in spite
of billions of dollars in research bonds, we have been able to find any magic silver
bullets to address the problem of childhood obesity. What there is a lot of evidence coming from
countries that have become case studies is that to actually prevent both the development
of under nutrition and over nutrition, what we need is to empower households, and specifically
the low-income households that are suffering the most social injustice and the most serious
socioeconomic inequities, empower them to be household food, health and nutrition secure
first of all through the development of reasonable health, economic, and social policies that
will be able to provide the protection systems to actually have the families have the access,
not only to the knowledge, but to actually what is needed to consume healthy foods, to
have relaxation, to have fun in leisure spaces in safe neighborhoods, to have access to sanitation
and healthcare. This is nothing else but a simplification
of the social ecological model and the evidence is very clear that there are no shortcuts,
this is not easy to do, but if we’re serious about addressing effectively the double burden
of nutrition this is what it’s going to take. Now, why do we say that when thankfully we
have a beautifully well documented natural experiment, a massive case study from the
country of Brazil, where there have been impressive improvements in stunting levels and breastfeeding
practices since the mid 1970s? You may wonder why I am bringing up breastfeeding
when, first of all, I have been a breastfeeding researcher for over 30 years, I should have
this disclosed that conflict of interest since the very beginning, but most importantly because
it’s an example of a behavior that happens during the first 1000 days of life that has
been strongly linked with issues related to prevention of both under nutrition, over nutrition
and corresponding infectious and non-communicable diseases. Stunting prevalence in Brazil among children
younger than five years dropped from 37% in 1975 to 19% in 1999 and to 7% in 2007. Exclusive breastfeeding in kids under six
months of age improved from 4.7% in 1996 to 37 in 2006 and it has remained at that level
since. The medium breastfeeding duration increased
from 2.5 months in the ’70s to around 14 months now. How did this happen in Brazil? It’s because first and foremost there was
the strong political commitment to deal with problem of malnutrition following a social
ecological approach. What they did was to achieve a more equitable
wealth distribution, especially during the periods when the country was experiencing
very, very strong economic growth. They improved social protection programs and
invested heavily in public health programs. The Bolsa Familia Program, the largest cash
conditional transfer program in the world, is not an accident that it is in Brazil, where
there were also these major improvements in water and sanitation investments and also
in legislations to protect employed women. Brazil also restructured and strengthened
the health sector, shifting a lot of resources from tertiary care to primary health, i.e.
public health programs, which included breastfeeding, oral rehydration, immunizations, and universal
healthcare. The authors, we also identified a number of
food systems levels, or behavioral economics interventions, for which there is some degree
of evidence that they could make a difference in a much less reductionist approach than
what has been used before in the field of nutrition. First is the use of fiscal incentives, or
the production of a variety of foods, vegetables, and sustainable protein sources. Most countries are still figuring out how
to do it, but there is a super important paper on an analysis on what not to do, which is
the natural experiment that has happened in the US for decades through the Farm Bill,
where what it has been subsidized is pushing, nudging people to consume very high starchy
diets that no one in this room thinks anybody should be consuming in these days and times. There are also interesting randomized controlled
trials that have looked from the demand side, fiscal incentives that issuing of vouchers
or discounts for fruits and vegetables. The study by Waterlander in the Netherlands
and by Le in Australia, provided 20-50% discounts among consumers in supermarkets to purchase
fruits and vegetables and they were able to demonstrate that they purchased more fruits
and vegetables and one of the studies also that they consumed more of those fruits and
vegetables. The study by Klerman and colleagues is an
RCT based on SNAP or food stamp program recipients in the US and they provided 30% discount and
they show an increase in purchase and consumption of fruits and vegetables and the study by
Ni and colleagues that was conducted in New Zealand only offered a 12.5% discount and
they report a higher purchase of healthier foods. We also have interesting evidence from conditional
cash transfer programs like Prospera in Mexico, like Bolsa Familia in Brazil, and it is very
interesting because, on one hand, they do show that there is an increasing household
food security, especially with this cash grants, they get families out of extreme poverty. But on the the other hand, some of this food
is going to buy ultra processed foods and sugar sweetened beverages and there are contradictory
findings in regards to the the double burden of malnutrition with some of the studies showing
that stunting in children gets prevented but obesity among their mothers gets promoted. So there is more work to do, but clearly it
is a mechanism that is getting to millions and millions of people. And last, but not least, the sugar sweetened
beverages and junk food taxes are gaining a lot of popularity and especially because
of the work that the former mayor of New York City funded in Mexico City. So recently, the NIH Poverty Center asked
me to lead a development of a paper on explaining how Latin America has taken the lead globally
on the implementation of systems, changes, policies, also behavioral economics policies. We looked at the cases of excise taxes on
sugars in Mexico, Front-of-package legislation in Chile and Ecuador, trans fatty acid removals
in Argentina, and ciclovias recreativas or “open streets” throughout Latin America and
I know that our next speaker will talk a lot about policy issues, so I’ll just summarize
the lessons that we learned on this paper. First of all, the implementation of evidence-formed
anti-obesity policies is gaining momentum in Latin America. We think that countries globally should know
what is happening there because they are evaluating a lot of the work that is being done. Translating science into policy is a high
complex multi-directional non linear process. There is a need for multi sectoral coordination
of evidence-based policies that enable the environments so that households can have access
to healthy lifestyles. In other words, we need to change the default
systems and stop blaming the low-income individuals for not following the healthy lifestyles that
we are recommending. And last, but not least, complex adaptive
systems frameworks are needed to objectively assess how to effectively scale up and implement
these policies. So to conclude in my paper presentation, I
hope I did justice to the enormous work that we did collectively, all the co-authors. There are common drivers of the food and nutritional
components of the double burden of malnutrition and the obesity epidemic, in that case in
both low- and high- income countries. We believe that a single preventive approach
multi sectoral can be taken to prevent those conditions. Once it happens it’s another story, but we’re
talking about public health, about prevention. We need to heavily take into account, policy
makers need to understand, that when it comes to national development we are talking about
the inter-generational transmission of this problem. They are not going to go away over night. There are environmental and socio economical
influences that need to be addressed and there is a lack of coordination across sectors. The Brazil case study is a prime example as
to why and how it is possible to apply the socio-ecological approach to deal with the
double burden of malnutrition. And Brazil is not the only country that has
done it. We also cite the papers from Chile and Peru. There are now more and more countries that
have been able to be successful, at the very least, with the under nutrition and of the
equation. We have acknowledged that is is challenging
to improve access to social determinants of health in different context. The countries need to have robust economic
growth and they need to make a social decision, society needs to make a decision, on how to
re-invest in a more equitable way those resources. There is a need for implementation science
research based on complex systems frameworks and to conclude wanted to share how my team
at Yale was able to develop the AIDED complex adaptive systems framework that then got translated
into the pragmatic breastfeeding year model that is now guiding the scaling of breastfeeding
programs at the national level in eight low-, middle-, and high-income countries, including
Great Britain and Germany. It is also very important to acknowledge that
the experience from Mexico has garnered a lot of attention globally. It is very, very rapidly expanding; lots and
lots of countries are introducing sugar-sweetened beverages taxes. But it is important to try to find some order
out of this chaos because we know that you can’t transplant one policy approach or one
programmatic approach without any adaptation from one context to another. The same with the octagons from Chile, the
food label octagons, the Front-of-package that now even Canada is considering a similar
approach. All of these initiatives are spreading very
rapidly and needless to say, ciclovias has spread like fire all over Latin America. So it is very important that we conduct the
complex adaptive systems implementation science research so that the next country that tries
it out takes much less time making the right decisions. So there is the need for global visionary
leadership to address nutrition disparities in the context of the double burden of malnutrition. The strategies have to be based on some policy
and program evaluation frameworks that take heavily into account the first 1000 days of
life, the Lancet early childhood development nurture repair framework strongly recommended
in the context of the social ecological model. Thank you very much.