MonitoringofFoodAffordabilityandDietQuality

AnnaHerforth,Ph.D.UCDavisWorldFoodCenter

June3,2017

Problems

• Dietaryrisksarethenumberoneriskfactorwithintheglobalburdenofdisease,andincludingwithin“developing”countries.

• By2020,itisestimatedthatnearly75%ofdeathsand60%ofDALYswillbeattributedtoNCDs,mostlyduetodietaryordiet-relatedcauses(Limetal.,2012).

• Itispossibleforeveryonetoeatenoughcalories,butimpossibleforeveryonetoeathealthydiets.

3

Source:KeatsandWiggins2014;2009datafromFAOSTAT

Affordability

Non-Stapleplants

FishandMeat

EnergySource FoodBudget

Staplefoods

Slide Source: Howdy Bouis; FNB 2011; rural Bangladesh

Topdietaryproblemsglobally

Source:GlobalBurdenofDiseaseStudy,GBD-comparetool

Foodenvironment

HerforthandAhmed,June2015.FoodSecurity

Theinterfacebetweenfoodsystemsanddiets,encompassingtherangeoffoodsavailable,affordable,convenient,anddesirabletopeople.

ANHAcademyFoodEnvironmentWorkingGroup,May2017

South Texas, USA. Washington Post 11/9/2013

Howrah, Calcutta - A Herforth

Roma Ostiense - A Herforth

CFSvision

Aworldfreefrommalnutritioninallitsforms,whereallpeopleatallstagesoflifeandatalltimeshave

accesstoadequatefoodandenjoydiversified,balancedandhealthydietsforanactiveandhealthylife.

Needstobereflectedinfoodmetrics

Measurethechangeyouwishtoseeintheworld.

-notGandhi

Existingmetricsareinadequate

Agriculture Food*Access

DietQuality Nutrition

*Nutritiousfoodtomeetdietaryneeds

Ag2NutCommunityofPractice&FAO

“FoodPrices”

• Usuallyreflecteitherstarchystaples,orabasketoffoodsmostoftenpurchased

• Doesnotmeanthepriceoffoodsthathumanbeingsneedtohaveadequatenutritionorthrive.

Needed:Foodpricesthatreflectnutritiousdiets

• Agricultureandfoodsystemscanmakenutritiousdietsmoreavailableandaffordable.

• But,governmentsandprojectshavenoinformationsystemthattrackspricesofnutritiousfoods.

• Countriescanuseexistingfoodpricemonitoringsystemsbettertounderstandavailabilityandpricesofnutritiousfoods.

• Internationalagenciescouldmonitortheseacrosscountries.

Indicators of Affordability of Nutritious Diets in Africa (IANDA)

� Tufts University, University of Ghana, Sokoine University (Tanzania), Johns Hopkins University

� Funded by an IMMANA grant (DFID)

� Goal: To use existing food price data systems to monitor the affordability of nutritious diets

MoFA in Ghana� Has a mandate to monitor and ensure food security

� Agreed: This mandate extends to nutritious food.� Tracks food prices regularly in 164 markets in all districts

� Missing: several important nutritious foods in Ghanaian diets

� Piloted an expanded food list� Decision: scale up nationwide, to enable tracking of

prices of nutritious diets.

Visiting markets with Ghana Ministry of Food and Agriculture staff

Photos: Anna Herforth

MoFA enumerator collecting food price data

Ghana as a pioneer� This process could be replicated in other countries, based

on existing data collection systems.

� Relevance: The price of nutritious food can be used to inform programs and policy. � Most expensive (limiting) food groups, and foods most

important to nutrient adequacy, can be prioritized in programs and policies.

Indicators Developed� Indexes:

� Cost of a Diverse Diet (CoDD)� Nutritious Food Price Index (NFPI)

� Absolute cost:� Cost of Nutrient Adequacy (CoNA)� Cost of a Recommended Diet (CoRD)

Whatisa“RecommendedDiet”?

• Noglobaldietaryguidelines.

• Scalingup:UsingnationalFBDGswouldtakesignificanttimetocreateadifferentindicatorforeachcountry/region,andwouldlimitinternationalcomparability.

• Arethereanyuniversalrecommendationswecoulduse?

• Diet:the#1riskfactorwithintheglobalburdenofdisease• Yetnoindicatorsofdietqualityaretrackedacrosscountries.

• Norwithinmostcountries.

Existingsourcesofdietarydata?

• DHSandMICS• Onlyyoungchildrenage6-23months,&onlyin60countries

• HouseholdConsumptionandExpenditureSurveys(HCES)• Noindividual-leveldata• Highlyvariable

• Nationaldietaryintakesurveys• Bestcasescenario:NHANES,collectedeveryyear,nationallyrepresentativesample• ExistingdatabeingcompiledbyGIFTandGDD

• WHOSTEPSsurvey• Maynotberepresentativeorconsistentlycarriedoutbycountries• Countriesdonotalwayssharedata

• Noneareimmediatelyfeasibleorsatisfactorytofillthedatagap!

ProposaltodevelopanewDietQualitymoduleintheGallupWorldPoll• In2005,GalluplaunchedtheWorldPolltocollecthigh-qualitydataworldwidewithaconsistentmethodologythatallowsGalluptoannuallycoveratleast98%ofthepopulationoverage15.

• Nationallyrepresentativesurveysin>160countries• Allowsforcomparisonsacrosscountries,trendsovertime,andunderstandingdifferencesbygender,age,andincomelevel

• GallupWorldPollsuccessfullyimplementedFIESforthelasttwoyears

• Team• AndrewRzepa,PabloDiego-Rosell,AnnaHerforth,TerriBallard,PatrickWebb• Advisoryboard

Desiredcharacteristicsofadietqualitymodule• Reflectiveofthemostcriticalpiecesofdietqualityacrosscountries• Coversbothadequacyandprotectionagainstdiet-relateddisease• Standardizedandcomparableacrosscultures• Simpletoadministerandscore

• doesn’trequireintensiveanalysissuchasconversionoffoodstonutrientcontent

• Easilyinterpretable

Goal/Premise

• Wearenotseekingtomeasuredietqualitycomprehensively.• Rather,weseekindicatorsthatgiveastrongindicationofdietquality.

Whatarehealthydiets- review• Whatshouldcross-culturallyvaliddietqualityindicatorsmeasure?

• Internationaldietaryguidance• Nationalfood-baseddietaryguidelines• Dietpatternsusedfrequentlyinliterature

• e.g.DASH,Mediterranean• GlobalBurdenofDiseasestudy

2016

WHO:HealthyDietFactSheet

• Ahealthydietprotectsagainstmalnutritioninallitsforms• Includesadequacy,andprotectionagainstdiet-relatedNCDs.

• Fruits,vegetables,legumes(e.g.lentils,beans),nutsandwholegrains(e.g.unprocessedmaize,millet,oats,wheat,brownrice).

• Atleast400g(5portions)offruitsandvegetablesaday.• Limitsonfreesugars,fats(especiallytransfatsandsaturatedfats),andsalt.

• Theseareoftenfoundinultra-processedfoods-->Lowinhealthydiets.

WHOHealthyDietFactSheet

FBDGs

• 88countries• Europe33• NorthAmerica2• NearEast4• LatinAmericaandtheCaribbeanregion27

• AsiaandthePacific16• Africa6

Mostcommonmessagesacrosscountries

• Consumefruitsandvegetables(95%ofcountriesinkeymessages;100%ofcountriesingraphicimages)

• Limitconsumptionof:• salt(70%)• variousfats/fattyfoods(63%)• sugars(51%)

• Fewcountriesspecifiedrecommendedamountsof“proteinfoods”ornecessarytypes(substitutable)

Guidanceonfruitandvegetableconsumption

0102030405060708090

100

FruitsandVeg

Amount Variety Colors Fresh Local

Source:Arimond etal.,inpreparation

GDDandGBD

• TheGlobalDietaryDatabase(GDD)• compilesover1,000dietaryintakesurveysfrom178countries• Providesthedietarydatafor:

• GlobalBurdenofDisease(GBD)study• startedin1990• aimstodeterminecomparablecross-country,regionalandglobalestimatesoftheburdenofdiseases,injuriesandriskfactors

Dietaryriskfactorsglobally,allages

Source:GBD-comparetool

Numberofregionswhereeachglobaldietaryriskfactorisoneofthetopthreedietaryriskfactorsin-region

Source:Herforth2016,Gallup.

Hopeforcross-culturalvalidity

• “Theexactmake-upofadiversified,balancedandhealthydietwillvarydependingonindividualneeds(e.g.age,gender,lifestyle,degreeofphysicalactivity),culturalcontext,locallyavailablefoodsanddietarycustoms.Butbasicprinciplesofwhatconstituteahealthydietremainthesame.”

• WHOHealthyDietsFactSheet

Summaryofdietaryguidancearoundtheworld• Emphatic:

• Eatanabundantvarietyoffruitandvegetables.• Donoteatultra-processedfoods,includingSSBs,processedmeatsandsaltyandsugarysnacks.

• Donoteatindustrially-producedtransfats(inmargarineorprocessedfoods).

• Advicethatcomesupinmostguidanceandevidenceincludes:• Eatwholegrains.• Forfatsandoils,useunsaturatedvegetableoils.

• Whattodoaboutprotein:• Legumesandnutsarehighlyrecommended;fishishighlyrecommendednutritionallybutnotenvironmentallyfeasibleforall;milk/yogurtisgenerallypositivedependingonlactosetoleranceandfoodculture;littletosayabouteggsandunprocessedpoultry;unprocessedredmeatisgenerallynegative;andprocessedmeatsarenotadvisable.

Source:Herforth2016,Gallup.

Source:InDefenseofFood,MPollan

Principlesofsustainablediets• Diversity• Basedonminimallyprocessedtubersandwholegrains,legumes,fruitsandvegetables,seedsandnuts

• Meat,ifeaten,inmoderatequantitiesandallanimalpartsconsumed

• Dairyproductsoralternativeseateninmoderation• Smallquantitiesoffishandaquaticproductssourcedfromcertifiedfisheries

• Verylimitedconsumptionoffoodshighinfat,sugarorsaltandlowinmicronutrients(i.e.ultra-processedfoods)

• Tapwaterinpreferencetootherbeverages

Proposeddietaryelementstomeasure

• Health-ProtectiveDiet• Indicatortobedevelopedbasedon:• Consumptionoffruitsandvegetables

• AND/OR plantfoodsingeneral,includingfruits,vegetables,wholegrains,legumesandnuts

• Consumptionofultra-processedfoods

• Adequacy• Useestablishedindicator:MDD-W

MinimumDietaryDiversity– Women(MDD-W)

Darkgreenleafyvegetables

OthervitaminArichfruitsandvegetables

Otherfruits Othervegetables

Dairy Eggs Meat,poultryandfish

Starchystaples

NutsandseedsPulses

Slide:AnnaHerforth

Summary:DietQualitymonitoring• ProposalforadietqualitymoduletoimplementinGallupWorldPoll

• Wouldmonitordietqualityin160countries

• Proposedelementsofthemodule• Adequacy(throughtheMDD-Windicator)• Dietpatternsthatprotecthealth

• Needsupport– SDCisfundinghalfthecost2016

Updatesneededtocurrentglobalfoodmetrics

1. Foodpricesshouldreflectthepriceofwhatpeopleneedtoeat2. Weneedtostartmeasuringdietsacrosscountries.

• Accessto andconsumptionofhealthydietsarecoretosharedvisionforfood• Withoutinformation,theseareasarepolicy-invisible