A Global Research Agenda for Nutrition Science

Websites

1000 Days
Advocacy organization that emphasizes nutrition work in the first one thousand days of life, from conception through age two years.

Agriculture Research Service
Human nutrition research to build the scientific evidence base for food policy and nutrition programming in the U.S.

Alive and Thrive
Program to improve infant and young child feeding by reaching over 16 million children under two years old in Bangladesh, Ethiopia, and Vietnam.

Bill & Melinda Gates Foundation: Nutrition Overview
Overview of nutrition research supported by the Gates Foundation.

CCMCentral
Centralized resource for information on integrated community case management of childhood illness.

Economic Research Service
Performs research linking food choices and economics; evaluates food policies.

Global Alliance for Improved Nutrition (GAIN)
Program to reduce malnutrition through sustainable strategies aimed at improving the health and nutrition of populations at risk.

Global Database on the Implementation of Nutrition Actions (GINA)
Collects key data on worldwide nutrition policy and action in a standard format.

McGill World Platform for Health and Economic Convergence (MWP)
Organization dedicated to effecting changes needed to help people make healthier choices in what they eat in order to ease the global obesity epidemic.

National Institutes of Food and Agriculture
Extramural research arm of the USDA that administers competitive grant programs and funding for training of future scientists.

Scaling Up Nutrition (SUN)
Global collaboration for action and investment to improve maternal and child nutrition on a large scale.

SecureNutrition
Platform to bridge knowledge gaps between agriculture, food security, and nutrition.

The Vitality Group
Actuarial based wellness program intended to reduce healthcare costs for participating companies.

WHO e-Library of Evidence for Nutrition Actions (eLENA)
Library of WHO nutrition guidelines and supporting documents.

WHO Evidence Informed Policy Network
Promotes the systematic use of health research evidence in policy-making, focusing on low and middle-income countries.

Journal Articles

Ahmed AM, Ahmed T, Roy SK, Alam N, Hossain MI. Determinants of undernutrition in children under 2 years of age from rural Bangladesh. Indian Pediatr. 2012;49(10):821-824.

Ahmed T, Mahfuz M, Ireen S, et al. Nutrition of children and women in Bangladesh: trends and directions for the future. J Health Popul Nutr. 2012;30(1):1-11.

Black RE, El Arifeen S. Community-based treatment of severe childhood pneumonia. Lancet. 2012;379(9817):692-694.

Cecchini M, Sassi F. Tackling obesity requires efficient government policies. Isr J Health Policy Res. 2012;1(1):18.

Christian P, Black RE. Food, micronutrients, and birth outcomes. JAMA. 2012;307(19):2094-2096.

Deckelbaum RJ, Ntambi JM, Wolgemuth DJ. Basic science research and education: a priority for training and capacity building in developing countries. Infect Dis Clin North Am. 2011;25(3):669-676.

Dube L, Pingali P, Webb P. Paths of convergence for agriculture, health, and wealth. Proc Natl Acad Sci U S A. 2012;109(31):12294-12301.

Habicht JP, Pelto GH. Multiple micronutrient interventions are efficacious, but research on adequacy, plausibility, and implementation needs attention. J Nutr. 2012;142(1):205S-209S.

Hammond RA, Ornstein JT, Fellows LK, Dube L, Levitan R, Dagher A. A model of food reward learning with dynamic reward exposure. Front Comput Neurosci. 2012;6:82.

Paul KH, Muti M, Chasekwa B, et al. Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe. Matern Child Nutr. 2012;8(2):225-238.

Paul KH, Muti M, Khalfan SS, Humphrey JH, Caffarella R, Stoltzfus RJ. Beyond food insecurity: how context can improve complementary feeding interventions. Food Nutr Bull. 2011;32(3):244-253.

Rasmussen KM, Habicht JP. Maternal supplementation differentially affects the mother and newborn. J Nutr. 2010;140(2):402-406.

Seale AC, Berkley JA. Managing severe infection in infancy in resource poor settings. Early Hum Dev. 2012;88(12):957-960.

Talbert A, Thuo N, Karisa J, et al. Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome. PLoS One. 2012;7(6):e38321.

Van de Pas NC, Woutersen RA, van Ommen B, Rietjens IM, de Graaf AA. A physiologically based in silico kinetic model predicting plasma cholesterol concentrations in humans. J Lipid Res. 2012;53(12):2734-2746.

Verschuren L, Radonjic M, Wielinga PY, et al. Systems biology analysis unravels the complementary action of combined rosuvastatin and ezetimibe therapy. Pharmacogenet Genomics. 2012;22(12):837-845.

Wasantwisut E. Moving towards evidence-based policy and program planning in multiple micronutrient interventions for children: symposium summary. J Nutr. 2011;141(11):2092-2094.

Wasantwisut E, Neufeld L. Use of nutritional biomarkers in program evaluation in the context of developing countries. J Nutr. 2012;142(1):186S-190S.

Presented by

Speaker:
David Nabarro, Special Representative of the UN Secretary General for Food Security and Nutrition

Nutrition scientists have made considerable progress identifying the components of a healthy diet, particularly with regard to needed levels of micronutrients (vitamins and minerals). Successful nutrition interventions have alleviated deficiencies in some countries; for example, through fortification of cereals with folate and of salt with iodine. Researchers have also made significant progress in determining the levels of macronutrients (protein, carbohydrates, and fat) that are needed for healthy growth and development and to promote a full lifespan. The problems of undernutrition, which leads to stunted growth and underweight, are well documented in many countries, as is the growing prevalence of overnutrition, which leads to overweight, obesity, and increased risks of noncommunicable diseases such as diabetes and cancer.

Despite this progress, translating knowledge into interventions that improve health outcomes on a population level remains a challenge. Many low- and middle-income countries lack the resources to deliver proper nutrition, while high-income countries are faced with a nutrition environment that encourages overeating and with the need to change people's behavior to stem the tide of obesity. Some countries where undernutrition has been chronic are now facing rising levels of overnutrition, a situation nutrition researchers call the "double burden." In addition, basic questions about human physiology remain to be answered; for example, appropriate dietary levels of previously neglected nutrients such as fatty acids. Other questions must be revisited, such as the effects of calcium and beta-carotene supplementation.

The double burden of undernutrition and overnutrition. (Images courtesy of Francesco Branca)

In a two-day conference organized by the Sackler Institute, researchers, policy makers, and leaders from the public and private sectors discussed how to utilize limited resources to address nutrition challenges around the world. Led by Mandana Arabi, executive director of the Sackler Institute, researchers have been working to identify critical questions that will bridge the gap between nutrition science and the actions needed to improve global nutrition. Anna Herforth described Focus Area 1, environmental and societal trends affecting food and nutrition; Tahmeed Ahmed described Focus Area 2, unresolved issues of nutrition in the lifecycle; and Purnima Menon described Focus Area 3, program theory and impact measures to support effective delivery of nutrition interventions.

These presentations were followed by a series of sessions addressing the dissemination, implementation, and evaluation of nutrition research findings. One session focused on communicating results to other scientists, policy makers, and the general public, and included a presentation by Robert E. Black on The Lancet's 2008 Maternal and Child Undernutrition series, a seminal publication in the field. A panel discussed traditional and non-traditional means of disseminating research findings, including online channels such as Twitter and Facebook.

The next session showcased work intended to fill nutrition research gaps and translate new knowledge into interventions. Rebecca Stoltzfus described fieldwork on the effects of improved hygiene on infant nutrition in Zimbabwe. Laurette Dube discussed computer simulation work intended to uncover and test solutions for nutrition gaps, food insecurity, and poor food choices in whole populations. A panel discussed how research agendas should be set and how they can be aligned with funding capacity. The final session included two panel discussions with representatives from advocacy organizations, such as 1000 Days and Save the Children, and policy makers from government agencies in the U.S., China, Malaysia, and South Africa. These discussions focused on how research can inform and promote evidence-based nutrition policies.

"Nutrition science is no longer a backwater ... but instead is obviously one of the most important areas that need to be addressed in today's society," said Ellis Rubinstein, president and CEO of the New York Academy of Sciences, who opened the conference. David Nabarro, special representative of the UN Secretary General for Food Security and Nutrition, also made introductory remarks by video link. Nabarro emphasized the importance of research on best practices, as the evidence base is a "crucial foundation" for delivering interventions. He said that today's nutrition scientists have "an opportunity to make sure that the efforts that are being conducted now make a real difference" in countries across the world facing the challenges of undernutrition and overnutrition.

Keynote Speakers:
Francesco Branca, World Health Organization
Jean-Pierre Habicht, Cornell University

Speaker:
Mandana Arabi, The Sackler Institute for Nutrition Science

Highlights

• The World Health Organization (WHO) has adopted aggressive targets for reducing undernutrition and overnutrition, which despite some progress represent significant challenges in most parts of the world.
• Over 80% of child deaths could be prevented by more efficient delivery of nutrition interventions, but this topic receives only 3% of research funding.
• A carefully prioritized global research agenda is needed to utilize resources effectively, particularly as nutrition interventions are scaled up for delivery at population levels.
• The Sackler Institute has initiated a global collaboration to identify critical topics and knowledge gaps in nutrition research.

Global nutrition challenges

In his keynote address, Francesco Branca from the World Health Organization (WHO) described global challenges that require focused nutrition research. Recent data show that 165 million children under the age of five suffer from stunting, defined as a height below two standard deviations from median height for age in a given population; and 52 million children are wasted, defined as a weight below two standard deviations from median weight for height in a given population. Most live in sub-Saharan Africa and South Asia (India and Southeast Asia). In addition, over 500 million women of reproductive age are affected by anemia. Paradoxically, 43 million children under the age of five are overweight, while 500 million adults are obese, predominantly in upper-middle- and high-income areas of the world.

In May 2012 the World Health Assembly (WHA), the decision-making body of the WHO, endorsed ambitious nutrition targets as benchmarks for a global reduction of both undernutrition and overnutrition. These targets are to reduce stunting by 40%, reduce wasting to less than 5%, reduce overweight to zero, increase breastfeeding to over 50% of mothers, reduce anemia by 50%, and reduce low birth weight to 30% of newborns.

Branca noted that nutrition is a complex science. An individual's nutritional status lies at the center of an interrelated web of individual and societal factors, including eating behaviors, energy and activity levels, food production and consumption, cultural factors, and others. This web changes as the world population grows and ages, as the climate changes, and as urbanization becomes more prevalent. This complexity greatly increases the difficulty in reaching these targets and drives the need for further research.

Societal and individual factors that impact nutrition outcomes. (Image courtesy of Francesco Branca)

Branca described the WHO's efforts to assist member states in addressing these challenges. The WHO has developed an e-Library of Evidence for Nutrition Actions (eLENA) that includes evidence-based guidelines and supporting documents. In another initiative, known as the Global Database on the Implementation of Nutrition Actions (GINA), the WHO is collecting information on nutrition policies and actions worldwide. GINA currently contains over 1000 policy documents and 2000 action reports. These efforts will support the growing Scaling Up Nutrition (SUN) movement, an organization of 33 countries supported by over 100 agencies and institutions that is dedicated to improving nutrition rapidly and efficiently.

Traditionally, nutrition science has focused on individual nutrition in relation to the surrounding environment. Much less attention has been paid to best practices for delivering interventions, the topic of the second keynote by Jean-Pierre Habicht of Cornell University. He noted that improving nutrition delivery could prevent 80% of child deaths, yet this topic receives only 3% of nutrition research funding.

Nutrition delivery research studies how food reaches the intended recipient of an intervention with the minimum loss of nutrients. The delivery process can be improved by addressing safe food preparation, by ensuring food accessibility and affordability, and by understanding consumers' knowledge of nutrition and the factors that motivate behavior. Research can identify bottlenecks and solutions that could greatly improve a given intervention. Habicht explained the use of Program Impact Pathways (PIP) analyses to plan interventions, identify potential obstacles, and map delivery processes from intervention through outcomes.

Habicht noted that research is particularly scarce on methods to measure the outcomes of large-scale, population-level interventions, even for efforts like food fortification, a major accomplishment of the field. He called for increased funding to train researchers in implementation and delivery science and to develop an evidence base for population-scale delivery. "Research for research's sake is good," he said, "but will not deliver better nutrition on a population level."

Methodology: identifying key research topics

Research has made significant contributions to our understanding of nutrition: linking undernutrition to increased infection and mortality, defining overnutrition as a key risk factor for chronic diseases like diabetes, characterizing the physiological roles of various single nutrients, and identifying effective interventions to address nutrient deficiencies and excesses. This progress has opened many new avenues of research, but because resources are limited strategic choices must be made to maximize the worldwide impact of new findings.

Mandana Arabi, executive director of the Sackler Institute, described the institute's work to facilitate global nutrition research by identifying strategic focus areas, building research partnerships, and ensuring that findings are disseminated to a broad audience. The Sackler Institute's advisory board began developing the global research agenda by identifying three major focus areas: (1) environmental and societal trends affecting food and nutrition, such as climate change and urbanization, (2) unresolved questions about the role of nutrition in the human lifecycle, particularly in the first thousand days of life from conception through age two years, and (3) gaps in and barriers to the delivery of nutrition interventions.

Three working groups of nutrition scientists have been formed to address these areas, using a methodology designed to be both holistic and non-traditional. Each working group generated research topics, which, after evaluation and feedback from the research community, were refined to a few key areas for further analysis. The results were reported at this conference and will be published in a special issue of the Annals of the New York Academy of Sciences.

Working group (WG) methodology. (Image courtesy of Mandana Arabi)

Once the agenda is complete, the institute will facilitate its research objectives by organizing meetings and workshops, disseminating evidence-based outcomes and best practices, developing and promoting funding mechanisms, and developing monitoring and evaluation tools to assess impacts. The project is intended to mobilize the nutrition community to address problems through more rigorous research and with an increased focus on implementation science.

Speakers:
Anna Herforth, Independent consultant
Shiriki Kumanyika, University of Pennsylvania

Highlights

• More research is needed on environmental and societal trends that impact nutrition, such as climate change, globalization, urbanization, and demographic shifts.
• New multidisciplinary research methods and models must be used to address these questions.

Trends affecting food and nutrition

After the keynote addresses and Arabi's introduction, each focus group presented their findings. Anna Herforth, an independent consultant, spoke on behalf of the Focus Area 1 working group. This group identified environmental and societal trends affecting food and nutrition, including complex pathways to delivering high-quality nutrition and the trade-offs associated with particular pathways. They examined trends like globalization, climate change, and energy availability, as well as demographic factors like urbanization, poverty, and vulnerable populations.

Group 1 identified five main research topics, each of which encompasses multiple research gaps. (1) An analytical toolbox of methods is needed to examine the impact of environmental, societal, and other large-scale trends on nutrition. This work will necessitate involvement by scientists outside the nutrition arena, such as economists, climate change researchers, and urban and environmental engineers. (2) Research is needed on the economic and environmental trade-offs of government policies. Little is known about the impacts of foreign investment, rural development and food production policies, and efforts to improve socioeconomic status. (3) More research is needed on the production, processing, and distribution of food, and how changes in these systems affect nutrition status. (4) A better understanding is needed of the individual and household factors that underlie economic vulnerability and food insecurity; in particular, the role of women's economic empowerment in improving health and nutrition status. (5) Global trends, such as climate change, population growth, and environmental sustainability, must be linked to desired improvements in nutrition.

An ecological framework for the interactions of nutrition with social and environmental factors. (Image source: Dufour DL, Goodman AH, Pelto GH. Nutritional Anthropology: Biocultural Perspectives on Food and Nutrition. 2nd ed. Oxford University Press; 2012)

Each focus area presentation was followed by an expert commenter. Shiriki Kumanyika of the University of Pennsylvania commented on Focus Area 1. Kumanyika noted that addressing undernutrition and overnutrition in countries experiencing the double burden is a key challenge in meeting the research agenda, particularly as the strategies and politics involved are likely to be different for each of these problems.

Speakers:
Tahmeed Ahmed, International Centre for Diarrhoeal Disease Research, Bangladesh
Jay Berkley, KEMRI-Wellcome Trust Research Programme, Kenya

Highlights

• Research on the effects of nutrition over the lifecycle will help to identify critical periods of development during which interventions have the greatest impact.
• Research must move from a single-nutrient focus to a systems-biology, food-based focus.

Unresolved issues of nutrition in the lifecycle

Tahmeed Ahmed of the International Centre for Diarrhoeal Disease Research in Bangladesh spoke on behalf of the Focus Area 2 group, which developed research topics for unresolved issues of nutrition in the lifecycle. The group identified four research themes: (1) determine optimal nutrition during pregnancy and understand its effects on child growth, early childhood development, and long-term health; (2) develop a food-based systems biology approach to nutrition and mother and child health; (3) develop an integrated approach to mother and child health over the lifespan and within different contexts, considering in particular social and environmental factors associated with the double burden; and (4) address methodological challenges involved in studying biological processes, behavior, genetics, economics, and agricultural production.

Developing nations that were unable to meet UN Millennium Development Goals for reducing underweight in children in 2010. (Image courtesy of Tahmeed Ahmed)

Ahmed began with an assessment of recent progress. He reported that many developing countries in Asia and Africa did not reach United Nations (UN) Millennium Development Goals for lowering the proportion of underweight children by 2010. Moreover, many developing countries face the double burden; in Guinea-Bissau and Malawi, for example, 10% of children are overweight while another 50% are stunted.

Ahmed said that early approaches to these problems focused on one nutrient at a time, but growing evidence demonstrates the importance of a systems biology, food-based approach that considers the interactions between nutrients, the individual's physiology, and the environment.

The working group identified a number of inter-related areas for future research, including missing knowledge of biological mechanisms, such as fetal growth and nutrient exchange between mother and fetus, and the influence of context on nutritional status and development, such as the relationships between maternal nutrition, mental health, women's empowerment, and care giving. Other areas for research include the roles of fatty acids and other previously neglected nutrients, development of prevention strategies throughout the lifecycle, and best practices for interpreting nutrition studies when there is unexpected heterogeneity due to genetic variation.

Jay Berkley of the KEMRI-Wellcome Trust Research Programme in Kenya described his work as an example of the first theme in this focus area. Berkley and his colleagues are working in rural Kenya, an impoverished setting where dietary diversity is low. They are researching ways to reduce the susceptibility of children to infection, to reduce susceptibility of the general population to noncommunicable diseases, and to ensure that health improvements are passed to the next generation. They are studying the influence of epigenetics and the microbiome on nutritional status, neurodevelopment, and infection susceptibility, and how these factors are affected by external conditions such as nurturing and stress.

Speakers:
Ben van Ommen, TNO, The Netherlands
Tahmeed Ahmed, International Centre for Diarrhoeal Disease Research, Bangladesh
John G. Kral, SUNY Downstate Medical Center

Highlights

• Systems biology can elucidate the physiologic mechanisms that allow the body to cope with metabolic perturbations and environmental stresses and can define the roles of nutrients in these processes.
• Microbiomics, genomics, epigenetics, and other new approaches are important to understanding the interactions between human development, nutrition, and infection.

A systems approach to understanding nutrition

Ben van Ommen of TNO, the Netherlands Organization for Applied Scientific Research, discussed work that exemplifies the second theme of Focus Area 2: a systems-biology, food-based approach to nutrition research. Van Ommen noted that the purpose of nutrition is to provide energy for body systems as well as nutrients for maintaining optimal physiology, allowing the body to adapt to environmental fluctuations like a changing diet, oscillating temperatures, exposure to infections, and mental and physical stress.

Many processes that regulate the body's responses to environmental stress use the same essential nutrients as co-factors, so it makes sense to study these processes together, van Ommen said. Systems biology tools can be used to model the interactions between micronutrients as they work to maintain homeostasis in specific states, such as inflammation. These tools can also be used to build biological networks that model health and disease phenotypes; for example, comparing the physiologic processes of a healthy adult with those of an insulin-resistant adult or a child with impaired gastrointestinal function.

Van Ommen is involved in a research consortium called ENOUGH, Essential Nutrients for Optimal Underpinning of Growth and Health, which aims to apply a systems approach to global nutrition data, connecting projects from different groups and building analytical tools to advance research. The project intends to develop essential nutrient recommendations for impaired health situations in many different subpopulations. Their first goal is to recommend interventions to promote optimal intestinal health in the first thousand days of life.

Role of nutrients for maintaining homeostasis in the presence of pathological conditions. (Image courtesy of Ben van Ommen)

Tahmeed Ahmed described research exemplifying the third theme of Focus Area 2: interactions between nutrition, infection, and functional and developmental outcomes. He described research designed to understand the causes and find remedies for stunting, including research that shows differences between the microbiomes of adequately and undernourished children in Bangladesh. Other research aims to understand environmental enteropathy, a subclinical condition that occurs in areas of poor sanitation and hygiene. This syndrome, which includes impaired gut function, malabsorption, and oral vaccine failure in children without symptoms of diarrhea, appears to be closely linked to poor growth and may affect cognitive development. Understanding the underlying mechanisms of this condition may uncover potential targets for intervention.

John G. Kral of SUNY Downstate Medical Center commented on Focus Area 2. Kral highlighted challenges for implementing any global nutrition agenda, foremost changing male attitudes towards women with reproductive capacity, given their roles as custodians of nutrition and food security for the next generation. Research needs to address mechanisms by which people acquire attitudes, customs, and beliefs to develop methods that lead to behavior change. He also noted a need to adapt novel disciplines, such as epigenetics and microbiomics to large-scale, population-based research.

Speakers:
Purnima Menon, IFPRI, India
Gretel Pelto, Cornell University

Highlights

• Research on effective delivery of nutrition interventions is a nascent field that will benefit from a unified approach intended to fill specific knowledge gaps.
• Nutrition implementation research needs a more consistent, theory-driven approach that measures multiple intermediate outcomes in addition to final outcomes and includes the development of well-publicized consensus statements or guidelines.

Implementing and evaluating nutrition programs

Focus Area 3 identified research priorities in program theory and impact pathways to support the design of more effective nutrition delivery systems. Impact pathways are causal chains of activities, outputs, and outcomes through which a project is expected to achieve its goals. These network maps show how participants in the chain work together, influence each other, and influence the general environment for the new knowledge or technology under development. Purnima Menon of the International Food Policy Research Institute (IFPRI) in India said that although randomized controlled trials have created an evidence base for some interventions, there is a dearth of research on large-scale applications. In addition, recent reviews suggest that the same interventions can have highly variable effects when applied in different contexts. The group identified four high-priority topics in this area: (1) determine optimal infant and young-child food delivery systems, (2) develop new impact pathways to better understand agriculture-based nutrition programs, (3) identify innovative methods for measuring and validating behavior and behavior change, and (4) determine why delivery systems sometimes fail to reach enough people and do not lead to desired outcomes.

Because there is so little published research in these areas, the group focused on developing a conceptual framework that describes the pathway from intervention planning to the development of implementation processes to scaling up delivery of the intervention to evaluating outcomes and impacts. This framework identifies numerous areas where further research is needed.

Conceptual framework for nutrition intervention planning and implementation. (Image courtesy of Purnima Menon)

Menon said that intervention trials should include more detailed descriptions of specific inputs and processes for later use by implementation scientists. Nutrition implementation research needs a more consistent, theory-driven approach that measures multiple intermediate outcomes in addition to final outcomes and includes the development of well-publicized consensus statements or guidelines. A database should be created for documenting nutrition implementations and their results, linked to the WHO eLENA and GINA databases, to foster links between projects in different countries and among researchers from different disciplines, and to garner additional support.

Gretel Pelto of Cornell University commented on Focus Area 3. She emphasized the importance of large-scale testing and recommended embedding implementation studies within interventional studies, although she noted that this approach can lead to conflict when the aims of nutrition scientists and implementation specialists diverge. She discussed Program Impact Pathways as means to identify bottlenecks, noting that bottlenecks can differ considerably even within one project, requiring the knowledge and skill sets of different types of specialists to solve. Large-scale implementation also requires the cooperation and resources of social organizations, government agencies, businesses, and others to be successful.

Keynote Speaker:
Robert E. Black, Johns Hopkins University

Moderator:
Sera Young, Cornell University

Panelists:
Dennis Bier, The American Journal of Clinical Nutrition
Lou Woodley, Nature
Douglas M. Braaten, The New York Academy of Sciences

Highlights

• Advocacy plays a critical role in securing new resources for nutrition science research and implementation.
• Journal editors can take steps to ensure that nutrition science research meets high standards of evidence.
• Social media platforms can be useful for disseminating nutrition research and for advocacy if appropriate platforms are chosen for specific communications goals.

The importance of advocacy

Results of The Lancet's 2008 Maternal and Child Undernutrition series. (Image courtesy of Robert E. Black)

Next, the focus shifted to strategies for communicating and advocating for nutrition research. In his keynote address, Robert E. Black of Johns Hopkins University defined advocacy as the act of strategically supporting a cause, idea, or policy; that is, convincing the right people of its importance and of the need to take action. Advocacy can be used to change or defend practices or policies, secure resources, and overcome barriers and challenges. The science of advocacy draws from social science, political theory, human psychology, organizational and international development studies, public health, and other disciplines.

Black said that scientists can contribute to nutrition advocacy by providing compelling evidence for change and by ensuring that this evidence is accessible and understandable for important audiences. Scientists make good advocates because they are knowledgeable and passionate about their fields of research.

Black participated in The Lancet's 2008 Maternal and Child Undernutrition series, the goal of which was to disseminate key nutrition findings, develop clear messages about undernutrition, engage and activate crucial stakeholders, and expand support for maternal and child nutrition programs. The creators of the series convened leaders, created tools, planned events and media strategies, and linked the series to existing programs to foster partnerships and build coalitions. Their efforts helped to establish nutrition on the global policy agenda, creating an environment that has allowed movements like SUN to grow and expanding opportunities for nutrition research. A second edition is planned for 2013.

Channels of communication

The focus on communication continued with a panel discussion moderated by Sera Young of Cornell University on how to disseminate research results to the scientific community and the public, featuring the editor of a traditional print journal, a social media expert from the journal Nature, and the editor-in-chief of the Annals of the New York Academy of Sciences.

Dennis Bier, editor of the American Journal of Clinical Nutrition, discussed current trends in print dissemination of scientific results as peer-reviewed journal articles. He said that the journal selects papers for publication that provide answers to compelling, previously unanswered research questions. Scientific standards should be the same in nutrition science as in other fields: the research process should include an explicit question, pre-specified and concrete outcomes measures, and a well-defined intervention, leading to potentially replicable results. Journal editors can help to uphold high ethical standards by insisting on a priori study registration, by publishing only studies that adhere to accepted reporting standards, by demanding access to primary data if an independent re-analysis is warranted, and by promoting the establishment of a single, global registry for conflict-of-interest information.

Bier said that scientists tend to want research results to be available "now, at my desk, and free." Accomplishing these goals necessitates replacing the current print journal revenue stream with other funding sources. There is also a trend toward multidisciplinary journals, which requires raising the level of what constitutes evidence in some disciplines. He said that much of the controversy in nutrition is caused by researchers' reluctance to be realistic about the level of evidence their work represents, as well as a failure to adequately analyze and describe caveats that contribute to uncertainty. Although different fields have different standards of evidence, the increasingly multidisciplinary nature of nutrition research will require increased attention to standards of evidence.

Standards of evidence for nutrition research. (Image courtesy of Dennis Bier)

Lou Woodley, who directs social media activities for the journal Nature, described options for disseminating scientific work through online platforms. In general, audience engagement activities, whether live or online, should have well-defined goals; for example, news dissemination, opinion gathering, or publicity. Social media tools should be chosen with specific goals and audiences in mind and with an awareness that social media has a different time scale compared to traditional publishing.

Woodley discussed effective uses of social media platforms. Twitter is a microblogging platform where communications must be succinct and precise. It has the advantage of speed, generating almost instant feedback. Twitter can be useful for addressing customer service issues, generating user feedback, and real-time blogging at live events. Facebook, while in some ways similar, allows for longer posts and the addition of video and other types of media.

Blogs are another type of online platform. Nature has editorial blogs as well as third-party blogs written by external scientists. Blogs can be longer than other types of posts and provide multiple links to related content. Nature also sponsors live engagement events that allow readers to meet and talk with scientific leaders. These events can reach a wide audience built up using social media and can be recorded and posted online to expand this audience further. In addition to engaging lay audiences, online platforms could be used within the scientific community to foster collaboration and facilitate multidisciplinary projects.

Douglas M. Braaten, editor-in-chief of the Annals of the New York Academy of Sciences, which has been in print since 1823, discussed the selection process at this publication. In the current format, each Annals volume consists of a collection of invited reviews on specific topics. Braaten noted that editorial input may have changed the standards of research published in the Annals, but the content and research areas covered depend largely on researchers' input.

Speaker:
Michael I. McBurney, DSM Nutritional Products

Moderator:
Mandana Arabi, The Sackler Institute for Nutrition Science

Panelists:
Emorn Wasantwisut, Mahidol University, Thailand
Raoul Bino, Wageningen University and Research Center, The Netherlands
Richard J. Deckelbaum, Columbia University

Highlights

• Academia, industry, and government should work together to solve current nutrition challenges because philanthropy alone is unlikely to be sufficient.
• Nutritional needs are a moving target, demanding flexibility on the part of nutrition research programs.
• Basic science nutrition research should be performed in the countries where nutrition challenges exist, but low-income areas such as sub-Saharan Africa lack research infrastructure and trained personnel.

Working together

The second day of the conference was organized as a series of panel discussions on translating research gaps into research projects and new knowledge into action. Michael I. McBurney of DSM Nutritional Products introduced the day with his perspective on the global nutrition agenda. As someone who has worked in both industry and academia, McBurney said that while barriers to creating public–private partnerships can sometimes lead to compartmentalization, it is also true that good fences make good neighbors. He emphasized the importance of mutual respect, agreement on responsibilities, and honoring commitments as academia, industry, government, and other sectors work together to solve nutrition challenges. "Philanthropy is not a sustainable solution," he said.

McBurney noted that many successful nutrition interventions have been launched based on plausible rather than probable evidence, including vitamin D fortification of milk, iodization of salt, folate fortification of cereal grains, and others. The success of these interventions suggests that improved leadership might be more useful than more interventional research. Nutrition could be improved substantially by putting more money into nutrition and health education and into infrastructure to deliver food where it is needed.

Aligning research capabilities with current needs

The first panel discussion of the second day looked at how to align research needs with capacity. Three panelists from academia described their nutrition research institutes in a discussion moderated by Mandana Arabi.

Emorn Wasantwisut of the Institute of Nutrition at Mahidol University in Thailand described how her organization supports the activities of the Thailand National Food and Nutrition Committee. In addition to performing research on food and nutrition, the university provides education and training for nutrition professionals and technical services such as laboratory food analysis. The university also performs research and provides training in areas related to nutrition, such as epidemiology, chronic disease prevention, sustainable development, food safety, and other areas important to national food and nutrition policy makers.

Wasantwisut described the history of nutrition issues in Thailand, which in the 1960's centered on malnutrition and micronutrient deficiencies but now includes obesity and related noncommunicable diseases such as diabetes and heart disease. She said that both the national nutrition policy and the university's research agenda have changed with these developing trends. Thailand considers itself a leader in food as "a kitchen of the world," she said, and intends to be a leader in nutrition research as well.

Different stakeholders have different perspectives on nutrition issues. (Image courtesy of Raoul Bino)

Raoul Bino of Wageningen University and Research Center in the Netherlands is a metabolomics researcher studying the biochemical processes underlying individual dietary choices. Bino is the managing director of the Division of Human Nutrition, which conducts multidisciplinary research in food science at the cellular, individual, and population levels.

Bino echoed Wasantwisut's emphasis on flexibility, describing the nutrition research agenda as a "living strategy" that should respond to changing nutrition challenges. It should also be forward-looking and aim to build coalitions. An effective strategy will consider actions that can be taken now as well as capabilities that should be built to meet future needs. Bino emphasized the need for public–private partnerships to disseminate innovative nutrition products and ideas.

Richard J. Deckelbaum of the Institute of Human Nutrition at Columbia University described the institute's PhD training model, which it is working to export to countries in Africa where increased basic research capacity is needed. The institute has a multidisciplinary research faculty drawn from over 20 departments at Columbia, allowing for highly synergistic results.

The institute is setting up the Multi-institutional African PhD Consortium in Basic Nutritional Sciences, which is funded by the African Development Bank and includes partnerships with academic institutions in Kenya, Uganda, Tanzania, and Rwanda. The consortium will train researchers in their home country, who will then be able to train others, reducing "brain drain" from African countries and improving the status of African universities as training institutions. Research will focus on local public health problems, including undernutrition and overnutrition, prevention of noncommunicable diseases, and reproductive health. After an 18-month planning period, the consortium will be handed over to African leaders and cease to be run remotely from the U.S. Although it is progressing, Deckelbaum said that the program still faces challenges to meet its needs for physical infrastructure, equipment, staffing, and economic resources.

Moderator:
Mandana Arabi, The Sackler Institute for Nutrition Science

Panelists:
Ellen Piwoz, The Bill & Melinda Gates Foundation
Dominic Schofield, The Global Alliance for Improved Nutrition (GAIN)
Alan Dangour, Department for International Development UK (DIFD)

Highlights

• Organizations such as the Gates Foundation and the Global Alliance for Improved Nutrition (GAIN) are working to maximize the impact of available nutrition funding.
• The Research and Evidence Division of the British government's Department for International Development (DFID) has identified research gaps through a strategic mapping analysis of current research on agriculture and nutrition.

Strategic prioritization

The next panel discussion centered on strategic funding of nutrition research and implementation programs. Three panelists from research funding agencies described their funding portfolios and how funding priorities are set in a discussion moderated by Mandana Arabi.

Ellen Piwoz of the Bill & Melinda Gates Foundation described how the foundation develops its funding priorities. The Gates Foundation has a $50 million per year budget for nutrition projects, augmented by another $50 million per year for programs focused on agriculture. Piwoz described the rigorous process of developing funding strategies, which includes gap analysis, systems analysis, expert consultations, and development of collaborations with other groups already working in a given area.

The foundation's strategy, developed in 2010, includes three research initiatives and one translational initiative. Research initiatives focus on human growth and development in the first thousand days, basic research on micronutrient deficiencies, the development of scalable model interventions, and new interventions for improving breastfeeding rates. The translational initiative includes analytics and advocacy programs designed to prompt decision makers to convert research results into action more quickly.

The foundation funds programs like the Grand Challenges in Global Health program, which addresses bio-fortification and healthy growth, as well as a number of multi-sectoral interventions on topics like hygienic water sanitation and nutrition-sensitive agriculture. It also develops new nutrition products, such as lipid-based nutritional supplements, bio-fortified crops, and fortified salt, for distribution in sub-Saharan Africa and South Asia.

Addressing maternal and child nutrition

The Global Alliance for Improved Nutrition (GAIN) was created in 2002 as part of the UN General Assembly's Special Session on Children and became a Swiss Foundation in 2005. Dominic Schofield, director of the Multinutrients Supplements Initiative at GAIN, explained that GAIN aims to reduce global malnutrition using sustainable strategies, with an emphasis on at-risk populations such as women and children. GAIN's programs currently reach over 600 million people, but its goal is to reach over 1.5 billion.

GAIN also focuses on the first thousand days of life as a high-impact period for nutrition interventions, as recommended by the WHO and UNICEF. It has developed nutrition products for maternal/infant and young-child feeding, produced and distributed using a range of business models, including commercial, private–public partnerships, and private–non-governmental organization (NGO) partnerships. Their portfolio reflects the complexity of nutritional needs, reaching communities in Latin America, Eastern Europe, Africa, and Asia. Each project is tracked against defined performance measures, such as production volume, costs, and how many individuals are reached, to ensure maximum impact.

GAIN supports nutrition research that looks for large-scale impacts rather than isolated interventions; for example, changing government policies, prevention rather than treatment of diseases, and effective nutrition delivery.

Targeting the thousand day window. (Image courtesy of Dominic Schofield)

Assessing nutrition and agriculture

Alan Dangour, seconded to the Research and Evidence Division of the British government's Department for International Development (DFID), described a mapping analysis of current research on the relationship between agriculture and nutrition. DFID administers UKaid, the British fund designated to combat global poverty, which has an agricultural research portfolio that includes topics such as crops, zoonotic diseases, digital technologies in agriculture, and animal vaccination.

The mapping analysis identified research gaps based on a conceptual framework relating nutritional status to agricultural practices, food consumption, health care, education, and economics. It identified 151 current or planned studies, mostly led by CGIAR (the international agricultural research system), universities, and NGOs, about 60% of which focus on sub-Saharan Africa and 20% of which focus on South Asia. Many projects involve active agricultural interventions.

The project uncovered a dearth of research on the links between agriculture and nutrition, the effects of agricultural policy on nutrition, the economics of agricultural projects intended to promote better nutrition, and other areas. DFID is designing new programs to support large-scale experimental studies in nutrition-sensitive agriculture, research on the links between food and agricultural policies and nutrition outcomes, and the development of innovative research tools, metrics, and networks on agriculture and nutrition. DFID is also developing multi-partner research consortia to facilitate the conduct of high-quality research, to promote partnerships, and to strengthen research capacity.

Speakers:
Rebecca Stoltzfus, Cornell University
Laurette Dubé, McGill World Platform for Health and Economic Convergence

Highlights

• The multidisciplinary SHINE trial will investigate whether protecting babies from fecal ingestion improves their nutritional status and overall health.
• Systems science can model the complex interactions between environment, economics, and human behavior to uncover synergistic, whole-of-society solutions to nutrition challenges.

Nutrition and hygiene

The next presentations illustrated the types of multidisciplinary projects that will be needed to answer the questions posed by the global nutrition research agenda. Rebecca Stoltzfus of Cornell University described her work on the Zimbabwe SHINE (Sanitation Hygiene Infant Nutrition Efficacy Safety) project, which is testing whether babies who are protected from fecal ingestion have healthier guts, leading to better nutrition and improved growth. The project is studying whether the WASH intervention, which includes integrated water, sanitation, and hygiene interventions, reduces the likelihood of stunting and wasting. Some households will receive the WASH intervention only; some will receive an infant-feeding intervention; some will receive both; and some will receive neither. Outcomes will include stunting and anemia in infants at 18 months, intervention uptake, and behaviors relevant to the success of the intervention.

The SHINE study will be conducted in rural Zimbabwe, an area where food insecurity is highly prevalent. The researchers have identified 212 clusters of households that will participate, and a target population of 4800 women will be enrolled at 10 to 12 weeks gestation. A subgroup of 1600 infants will be assessed for causal factors associated with environmental enteritis at 3, 6, 12, and 18 months.

Potential mechanisms for the influence of fecal contamination on infant health. (Image courtesy of Rebecca Stoltzfus)

Stoltzfus said that there are many potential sources of fecal ingestion by babies in the target population. Although hygiene is important to adults in Zimbabwe, economic factors mean that many households do not have a latrine, soap is seldom available, and babies are frequently fed leftover food that has not been heated. Infants also spend considerable time on the ground where they ingest chicken feces, stones, and dirt, and are often fed in the yard or on the kitchen floor, both of which are frequently contaminated with Escherichia coli. The experimental protocol will encourage the use of a protected play space, infant and caregiver hand washing with soap, water treatment, safe disposal of feces, and other interventions.The project is a multidisciplinary effort between experts in nutrition, epidemiology, statistics, social work, medicine, economics, environmental health, and other disciplines. It uses an unconventional research design that is designed to work through and strengthen community systems while tapping into local knowledge.

A systems-science approach

Laurette Dubé of the McGill World Platform for Health and Economic Convergence described her work on the impact of economic factors on food security, which uses systems science to explore whole-of-society solutions to nutrition problems. Dubé said that between food access and nutrition is the "act of eating," which is an agricultural and industrial act, as well as a personal act and a neurobehavioral phenomenon. She emphasized that the nutritional needs of the developing world are converging with those of the Western world as income, urbanization, diet, lifestyle, and other aspects of everyday life become more similar. These points of convergence can be leveraged to design innovative solutions to food insecurity that capitalize on a multicultural perspective.

The developing discipline of complexity science can be used to create systems-level models of food access, eating, and nutrition. Dubé and her colleagues have a developed an agent-based computational model of reward learning to investigate the complex interactions between individuals and their environment that contribute to healthy or unhealthy food choices. Their results suggest that early exposures may shape food preferences more strongly than recent experiences, which may help explain the importance of early childhood experiences in adult obesity.

Dubé described another model that uses a systems-dynamic-computational approach to investigate how market and social dynamics affect changes in food access and in the overall food market. The model traces interactions between the food supply, consumer food choices, population health, and government interventions, with simulations run over a long time horizon during which many interactions will take place.

She and her colleagues are also developing metrics and integrated models to support the convergence between nutrition science, policy, and innovation. The food environment is monitored using indicators such as food marketing, product quality, availability, and affordability. This information is combined with longitudinal and geospatially localized biological, socio-environmental, and economic population data to monitor and analyze the food-consumption system, simulate its dynamics, and design interventions. The objective is to develop a whole-of-society knowledge architecture that will allow for a whole-of-society transformation agenda.

The Convergent Innovation Coalition, spearheaded by the McGill World Platform, is developing Convergent Innovation Roadmaps. These projects will foster novel collaborations and convene expert panels to generate policy direction and set short, achievable one-to-three-year objectives. Roadmap projects have been established for micronutrient and macronutrient insufficiencies; safe, affordable, and sustainable dietary diversity; home health, addressing education and sanitation issues; and obesity and noncommunicable-disease prevention and control. These projects promote innovative convergent solutions to nutritional challenges across the world.

Speakers:
Derek Yach, The Vitality Group
Stuart A. S. Craig, DuPont Nutrition and Health

Moderator:
Nabeeha Kazi, Humanitas Global Development

Panelists:
Francesco Branca, World Health Organization
Jennifer Rigg, 1000 Days
Eric Swedberg, Save the Children
Michele Cecchini, Organization for Economic Cooperation and Development

Highlights

• The Vitality program is a work-based wellness program that aims to reduce health care costs by promoting healthier diets and lifestyles.
• Integrated Community Case Management (iCCM) trains community-based health workers to provide care for critical childhood illnesses such as pneumonia and malaria.
• Health economics can provide population-level insights into overnutrition and obesity.

Nutrition in the workplace

Vitality is a comprehensive actuarial-based wellness program that assists, educates, and motivates people to live healthier lifestyles. Companies use the program to improve employee health while reducing medical costs. Derek Yach of the Vitality Group explained how the Vitality program uses behavioral economics to understand how people perceive personal risks and decide to pursue lifestyle changes like weight loss. Studies show that people are more likely to change if change is made easy, and that incentives are critical. Individuals participating in the program complete a health assessment to identify health goals and specific steps to follow based on evidence-based recommendations.

The program started in South Africa, where a study of over 350 000 Vitality members found that a discount program for healthy food purchases was associated with increased consumption of fruits and vegetables and increased likelihood of consuming three or more servings of whole-grain foods daily. The Vitality workplace program is also associated with increases in healthy food purchases and health awareness. Yach said that as the program develops, research will draw on advances in areas such as genomics to elucidate the role of other factors in healthy behavior.

Stuart A. S. Craig of DuPont Nutrition and Health described DuPont’s vision to create sustainable solutions for global nutrition challenges, reduce dependence on fossil fuels, and protect the environment. He discussed DuPont Global Collaboratory, a program intended to strengthen food and agricultural systems through collaboration with local farmers and communities. Craig highlighted the trend towards natural, clean label products and the need to increase the food supply significantly, address rising raw material prices, and produce affordable and sustainable food. DuPont research programs include food safety, probiotics, dietary fiber, and agriculture. DuPont develops specialty food ingredients, which are ingredients that maintain freshness, provide texture, assist with processing, and add nutritional value to foods. Craig provided an example of a supplement produced in Malawi from local food sources (soy protein and ground nuts) to help address malnutrition. He also described the Global Food Security Index, designed and constructed by the Economist Intelligence Unit and sponsored by DuPont, which measures risks and factors that drive food security, like affordability, availability, quality, and safety. Craig closed by observing that solutions to global nutrition challenges can best be accomplished through collaboration between all stakeholders.

Advocating for science

Nutrition research, while interesting as an end in itself, is also intended to confront nutrition challenges. The next panel discussion, moderated by Nabeeha Kazi of Humanitas Global Development, examined how science can be used to motivate policy makers, with presentations on advocacy, implementation, and evaluation of nutrition interventions.

Francesco Branca began by discussing the WHO process for developing guidelines, which is available as a published handbook. Requests for new guidelines are made by WHO member states, the WHA, or WHO sister agencies. New guidelines are developed under the aegis of the Guideline Steering Committee and the Guideline Development Group, which includes outside experts and stakeholders. The process includes comprehensive and transparent examination of conflicts of interest and guidelines are multi-supported, so that no specific guideline is sponsored by a single funding source.

Each guideline is supported by a systematic review of a research question, conducted according to the principles in the Cochrane Collaboration's Handbook for Systematic Reviews. The systematic review is then used to grade the quality of evidence for the recommendations made in the guideline, but Branca emphasized that expert opinion is also considered. The library of evidence collected for the review is posted online together with the guideline for use by policy makers. The WHO's Evidence-Informed Policy Network assists countries with adapting and implementing new guidelines and promotes the systematic of use of health research evidence in policy making, particularly in low- and middle-income countries.

Jennifer Rigg is the director of policy and partnerships at 1000 Days, an advocacy organization promoting partnerships, investment, and action on projects to improve nutrition among women and young children. This organization is committed to the thousand days concept as a critical window in development when proper nutrition is likely to reduce illness, improve school performance, and reduce adult poverty. Rigg said that advocacy is effective when it provides a clear, consistent message with focused policy recommendations and case studies demonstrating successful interventions. She recommended that advocacy groups use a variety of publishing options, participate in policy maker meetings, and partner with other organizations including universities.

Eric Swedberg of Save the Children turned the topic to interventions rather than advocacy. His organization promotes and studies Integrated Community Case Management (iCCM), a specialized program that trains, supports, and supplies community health workers to diagnose and treat childhood diseases in places without adequate access to such treatment. The training curriculum is a simplified version of the Integrated Management of Childhood Illness approach originally developed by the WHO and UNICEF to improve case management of childhood diseases within fixed health facilities.

The iCCM program is under testing in Ethiopia, Nicaragua, Bangladesh, Zambia, and other countries. Studies in Ethiopia began in 1997. At baseline, 17% of children with pneumonia and malaria received facility-based care for their illnesses. After an initial focus on strengthening facility-based services, treated cases rose to 42%; addition of community case management increased this proportion to 84% by 2006. Ethiopia has implemented iCCM through an existing cadre of over 30 000 health extension workers.

Impact of community case management on treatment of children with pneumonia symptoms in Ethiopia. (Image courtesy of Eric Swedberg)

The WHO, UNICEF, and major donors are promoting iCCM as a key strategy to meet the UN's Millennium Development Goal 4, to reduce mortality in children under 5 years old to two-thirds of 1990 levels by 2015. Other countries are incorporating iCCM into their national child health programs and research continues to uncover the best ways to implement and evaluate these programs in a range of settings. iCCM is supported by a unified community, including a global task force and expert working groups who set research priorities and ensure that outcomes research is integrated into the intervention programs.

Michele Cecchini is a health economist and policy analyst with the Organization for Economic Cooperation and Development (OECD), an international group of 34 member countries that works to promote policies to improve economic and social well-being. Cecchini and his colleagues study chronic diseases like obesity and diabetes. He said that classic epidemiological approaches involving small study populations and short time periods are inadequate for studying these diseases because interventions and policies can take a long time to show results.

He is working on a micro-simulation model for chronic disease prevention that uses individual-level data to investigate population effects over the long term and the costs of interventions intended to reduce unhealthy behaviors. Employing a causal web of interrelated lifestyle risk factors that would be difficult to study using empirical methods, the model is intended to identify interventions that will generate the greatest public health gains while also paying for themselves by reducing health care spending.

Moderator:
David Pelletier, Cornell University

Panelists:
Guansheng Ma, CDC China
Molly Kretsch, USDA
Rokiah Don, Ministry of Health Malaysia
Barbara Dennison, New York State Department of Health
Marjanne Senekal, University of Cape Town, South Africa

Highlights

• Developing countries such as China, Malaysia, and South Africa now face the double burden of undernutrition and overnutrition, complicating the development of nutrition policies.
• In the U.S., agencies such as the U.S. Department of Agriculture and the New York State Department of Health devote considerable resources to the development of evidence-based nutrition policies.
• Other countries, like South Africa, have very limited resources, which are largely used to alleviate undernutrition.

From evidence to policies

The final panel discussion, moderated by David Pelletier of Cornell University, consisted of state- and national-level policy makers charged with implementing evidence-based nutrition policies.

Guansheng Ma of the National Institute for Nutrition and Food Safety at the Centers for Disease Control, China, described the institute's nutrition research and work to support the formulation of policies, regulations, and standards for nutrition. The institute monitors the nutritional status of the population, measures the nutrient content of food, and administers national nutrition programs, including a school meal program that feeds 26 million students and a supplementation program that reaches 274 000 children across China.

Ma said that the double burden is increasingly prevalent in China. Cereal grain consumption has decreased while animal food, fast food, and sweetened beverage consumption has increased; and fewer jobs require high levels of physical activity, resulting in increasing rates of overweight, obesity, and hypertension. Yet malnutrition is still a problem in rural and poorer areas. Additional challenges include low nutrition literacy and wide circulation of nutrition misinformation. Ma stated that China needs new laws and policies to address these issues.

Changes in the prevalence of overweight and obesity in China, 1992–2002. (Image courtesy of Guansheng Ma)

Molly Kretsch, senior advisor for nutrition, food safety and health in the Office of the Chief Scientist at the U.S. Department of Agriculture (USDA), provided an overview of research capacity and translational activities in support of USDA nutrition policy and programs. These activities are primarily carried out by two USDA divisions, the Research, Education, and Economics mission area (REE) and the Food and Nutrition Consumer Services mission area (FNCS). Priorities include finding ways to prevent childhood obesity, to link food systems to beneficial human health outcomes, and to build an evidence base for federal dietary guidance policy and nutrition programs.

The USDA also monitors the nutritional status of the U.S. population and evaluates food and nutrition policies. It maintains a database of the standard nutrient composition of foods that is considered the “gold standard” worldwide. Action agencies such as the Center for Nutrition Policy Promotion formulate and disseminate federal dietary guidelines in partnership with the U.S. Department of Health and Human Services. The majority of the USDA’s budget is devoted to the FNCS division, which administers food assistance programs and health education programs for at-risk children and families. The REE division provides research to ensure those programs are science based. The USDA also participates with other federal departments in developing U.S. policy. A recent example in which USDA played an important role is the U.S. National Prevention, Health Promotion, and Public Health Council chaired by the U.S. Surgeon General. This council developed national prevention and health promotion strategies and an action plan to help move the focus of U.S. health care towards disease prevention.

The double burden: Malaysia, the U.S., and South Africa

Rokiah Don of the Ministry of Health Malaysia described the country's comprehensive health care delivery system, which includes government and private hospitals, regional health clinics, and local community clinics. Don reported on the impact of first-thousand-day programs in Malaysia, which have reduced anemia among pregnant women at 36 weeks gestation, increased the proportion of babies who are still exclusively breastfeeding at six months of age, and rapidly reduced the percentage of children under five years old who are underweight.

Malaysia also faces the double burden, with a large increase in overweight or obese adults in the past two decades. Noncommunicable diseases and risk factors have become more prevalent: diabetes in adults over 30 years and blood cholesterol levels in adults over 18 years have both increased. Data suggest that many cases of diabetes and hypertension are undiagnosed.

The Malaysian government has developed a National Plan of Action for Nutrition of Malaysia 2006–2015 (NPANM) and a National Strategic Plan for Non-Communicable Diseases (NSP-NCD). These plans are intended to develop structures to implement evidence-based policies and to build collaborations with research and academic institutions that can provide research support as well as nutritional and population data.

Barbara Dennison of the New York State Department of Health reiterated that nutritional issues differ by country and change with time, adding to the challenge of developing evidence-based policies. In the U.S., she said, nutritional issues once revolved around micronutrient deficiencies, which were improved by fortifying milk, cereals, and salt. However, cereal and milk consumption have decreased. Undernutrition has traditionally been addressed with programs such as the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP, or food stamps), but these have also been forced to change over time to meet evolving challenges.

In the U.S., obesity and obesity-related chronic disease are particularly pressing problems. Obesity has been attributed to excess calorie, sugar, and fat consumption. Dennison said that sugar consumption in particular has increased, largely in the form of sugar-sweetened beverages. Calories consumed in this form have tripled since the 1970s and account for half of all added-sugar consumption. New York State and 40 other states and localities have proposed taxes on sugar-sweetened beverages but none have passed, largely due to strong lobbying efforts by the beverage industry.

Increases in beverage industry lobbying in recent years. (Image courtesy of Barbara Dennison)

More successful efforts have been made by the Alliance for a Healthier Generation, a public–private partnership between the American Heart Association, the William J. Clinton Foundation, and the American Beverage Association, whose members include Pepsico, Coca-Cola, and Snapple. Because of the Alliance, these manufacturers agreed to adhere to voluntary guidelines intended to change the beverage mix in schools by removing full-calorie sugar-sweetened beverages and reducing portion sizes. These efforts have led to a 97% reduction in full-calorie soft drinks and a 90% reduction in beverage calories shipped to schools.

Increased public awareness of the health effects of saturated fats and trans fats has prompted industry to reduce these fats in processed foods, and dietary consumption has dropped. These changes coincide with a recent reduction in high blood cholesterol and cardiovascular disease in the U.S. In New York City, lawmakers have successfully legislated a ban on trans fats in restaurant foods.

Dennison said that further challenges include improving nutritional standards for the National School Lunch and Breakfast programs. Thus far, these attempts have met with limited success because school lunch programs are generally run at a loss and are often undermined by the sale of more profitable competitive foods that meet limited or no nutritional standards. Tougher standards are also opposed by strong, active food-industry lobbies.

Marjanne Senekal of the Division of Human Nutrition at the University of Cape Town, South Africa, discussed challenges in that country, where nutrition programs have had only modest success against stunting, wasting, and undernutrition. Anemia and vitamin A deficiencies have actually increased in recent years, while overweight, obesity, and noncommunicable diseases are also increasing. Senekal said that her country has a very small budget to address nutrition challenges, most of which is spent on supplemental feeding.

In closing remarks, Branca noted that this last session of the meeting showed "the concreteness of the problems we are facing." He emphasized the need for multidisciplinary approaches and the importance of ensuring that research results inform and generate actions. It will be critical to generate further dialogue with scientists in low- and middle-income countries, where many of these problems are the most pressing. And because resources are limited, careful prioritization of research topics and policy actions continues to be a necessity.