2012 June blog

Reggie Annan

Kumasi, Ghana. Now back home again, this month I review our Rio2012 congress held in Rio de Janeiro. And here above for the first time, is a view of water not from Africa, as is my custom in these columns. It is a view just before dawn from a window in the Novo Mundo hotel by Rio's Flamengo beach, where we congress speakers were housed. Also inspiring!

Rio2012: What next. Public health and nutrition crises

Policies, civil society, integration

The spiral theme images for Rio2012 signified the conference theme: knowledge – policy – action, and how these are linked. Here are some of the spirals that have been used on our website, from many parts of the world. The one of the staircase third from the left I found myself! We aim to be more action oriented. However, policies and actions are informed by knowledge and evidence and these three are interlinked. The goal of the conference has been to apply our current knowledge and evidence of the science of nutrition to influence rational policies and effective actions.

The programme was structured to enable us to achieve this. After the opening ceremony, we had an unusual opening plenary. Association president Barrie Margetts invited four people briefly to set the scene, and then right at the end of the conference, again briefly, to sum up what had been achieved and to look forward. I had the privilege of being one of the four speakers for these sessions. Indeed it was challenging, for our task was first to say what we wanted the conference to achieve, and then – even more challenging – on the final day to take into account the presentations, experiences shared, deliberations, debates discussions and conclusions reached, over the four conference days. It was a task I enjoyed immensely.

The two crises

Marion Nestle, an Association founder member, from New York University, was the first to speak. She said that two words summarise the public health nutrition crisis: undernutrition and obesity. Lack of food is only one of the causes of undernutrition, she said. The major causes are deeper. These include lack of education, lack of policy, and lack of action addressed to enable communities and families to get enough food. Inequities, violence and conflict, are some of the reasons undernutrition still prevails. At the same time, hundreds of millions of people are now obese. 'As public health professionals we know that it is not enough just to tell people to eat less, education is not going to do it. Instead we must confront the food environment. Industry will do whatever they can to make people eat more, not less. As public health professionals we are dealing with a very powerful political and economic force' she stated.

Here at left I am speaking, next to Marion Nestle, and in the picture at right, you see fellow plenary speakers Philip James and Renato Maluf listening

Needed: understanding and competence

I was next on. I said that while both undernutrition and overnutrition are major problems globally, Africa is hit the hardest by these epidemics. One challenge is that there are very few policies; and so policy-makers in Africa do not hold people accountable for what is being done and not done. Nutrition is not a high priority in Africa, lack of respect for nutrition as a science is still an issue. Other health professionals often do not see why they need training in nutrition, for instance in how to manage children with severe malnutrition. When we professionals talk about nutrition, people just think we are talking about catering or else make comments like 'just give them food'.

Another problem is funding. There are now so many opportunities for funding in nutrition with the Millennium Development Goals and the Scaling Up Nutrition initiative, but when Africa depends on external funding we all know this is dangerous. There are always strings attached, and external funding is not sustainable. Simple solutions and programmes to increase exclusive breastfeeding and improving complementary feeding will have significant impact, and are not expensive.

Governments need to generate internal funding for programmes. Leadership and building capacity for nutritionists is crucial. Lack of capacity means that we cannot scale up programme implementation. Presently we in Africa have very few public health nutritionists with competencies. [Ed: Hélène Delisle writes about this in her commentary in World Nutrition this month] It is also a challenge to involve young people in these programmes. They need to be mentored and kept engaged in the process, they are leaders of the future, but the future starts now.

The invisible hand of marketing

Philip James was the next to speak. He also is a founder member of the Association. He said that the issue of maternal and child nutrition is locked into the issue of non-communicable chronic diseases. He roused the 1,800 participants in the great room. 'Historically there has been an incredible change in the food industry, and not just agriculture. There's marketing: you are unconscious of the manipulation, and how do you cope with that? Globalisation and free trade – we have not yet confronted some of those challenges. Climate change is with us now and moving fast. There's water deprivation; unfair social policies; increasing inequities. How do we find the power to start a major revolution? These things are complicated. How do we put all these complicated things together?'

Connections and variety

Renato Maluf has just stepped down from his eminent position as president of CONSEA, Brazil's national nutrition and food security council, which reports directly to the president of the republic of Brazil. He said we have to grasp that food crises are interconnected with the climate crisis and the energy crisis, and require interconnected responses. The second issue we need to grasp is that sustainability needs good understanding of the great variety of different cultures and ways of life. The third issue for him was the need to go beyond conventional partnerships. He added that hunger is still a scourge in our world now, and this is absolutely unacceptable.

The biggest issues

Plenary presentations are usually given by one person, and at the end the audience applauds, and that is that. Not at Rio2012! As well as the five of us, including our host Barrie Margetts, there were questions and interventions after we spoke. We were each asked, what are the most critical challenges that we face? The answers were: lack of income and inequity; inadequate transparency and accountability, and the multi-sectoral and multi-faceted nature of nutrition itself.

We agreed that we cannot overcome undernutrition and obesity unless we overcome inequity. Renato said: 'In Brazil there is no relevant social question that can be discussed without having inequities as the basis for the discussion. It is the determinant of these major social issues. No analysis can be made without it as a determinant'. On transparency and accountability we agreed that these are essential to any sort of good governance. Civil society organisations must demand these.

Philip said that in government, the health department is typically not strong. Above all, the finance ministry is the one to go for. We need to deal at the highest possible level with politicians and officials responsible for planning, justice and even foreign affairs.

We all stressed that the most vulnerable communities need to gain the capacity and opportunity to represent themselves. The invisible must become visible. The 'top-down' approach is not sustainable and should be discouraged.

Marion said 'Think about what you personally can do'. Philip said 'Let's become educated about politics, social policy and economics'. 'Nutrition is usually related from a bad perspective – the disease. It is important to develop a different approach, based on values and ethics' said Renato.. Let's have more action, I said.

Rio 2012: What next. Ultra-processed products

Why obesity and NCDs increase

Ultra-processed products penetrated Africa a long time ago, but production, advertising and consumption are now rocketing throughout the continent

After the opening plenary, other plenary and parallel sessions, debates and discussions, and workshops, were held during the four conference days. I report here on just two major sessions. On the Sunday, a plenary session on 'From traditional foods to ultra-processing: Policies for healthy eating' was hosted by Philip James. The speakers were Association founder members Walter Willett and Carlos Monteiro. All of us who have been following Carlos Monteiro's World Nutrition series on ultra-processing [Ed: which continues this month] looked forward to this session.

The menace of ultra-processing

Carlos explained the nature of ultra-processed products. These are assembled from ingredients extracted from whole foods or minimally processed foods, preserved and made to look and taste like real food with additives. They contain little or no whole foods, have extremely long shelf lives, are ready-to-consume, and are unhealthy if only because of being high in fat, sugar, or salt, and energy. They are formulated to be hyper-palatable, and are often served in super-sizes. They are aggressively marketed. They have disrupted eating patterns, and are in the amounts now typically consumed in so many countries, a major cause of the obesity pandemic.

Most are made with very cheap ingredients and are often preferred by impoverished people, making their negative health impact worse in lower-income countries. Public policies are needed to stop the dominance of ultra-processed products in food systems. These need to include marketing regulation, taxation and support for the production and supply of whole or minimally processed foods.

As an African, I have to say that while the negative health effects of these products are well known and commonly discussed in rich countries, in many poorer countries like my own country of Ghana, they are very prestigious. Fast food joints are springing up fast, and many people think it is modern and stylish to buy such products. No wonder that non-communicable diseases are increasing so fast.

Confronting industry

In his presentation, Walter Willett said that many scientists naively think that scientific evidence alone is enough to cause policy change. This is rarely the case. Public health nutritionists have a lot to learn from other public health issues and how these were dealt with: for example, the campaigns against smoking, that required inter-sectoral collaboration, patience, persistence, fierce energetic advocacy, and as well as education, legislation. If we want to get serious about reducing trans fats and sodium in processed products we have to go the same route.

In the discussions that followed it became clear that industry has a major responsibility for what has gone wrong. There is a need to correct industry-driven misinformation and abuse of evidence. The scientific and professional community has to get active and to write about, publish and expose industry wrong-doing. Involving the media is essential but transnational corporations have hundreds of millions of dollars they can spend. The academic, professional and scientific community can though influence policy-makers in government and the UN system.

Also the public if mobilised can then press governments to make laws and policies to protect the public. These sorts of interventions take time, but will show positive results eventually. Participants also agreed on the need for guidelines to address global and local ultra-processing and public health nutrition issues. Definitions and messages need to be universal so that we are all saying the same thing, but at the same time need to be appropriate for local cultures and local foods available in different countries.

Rio 2012: What next. UN and other high level policies

How to become effective

Francesco Branca of WHO (left) and Denise Coitinho Delmuè formerly of WHO, Enrique Jacoby of PAHO, and government advisor Carlos Monteiro

This plenary session was followed by a discussion and debate on 'How to make structural and high level policies and actions effective'. I chose this because it addressed one of the challenges I myself spoke about: that in Africa, there is lack of nutrition policies or, where there are policies, these lack implementation. The session host was Francesco Branca, director of the nutrition department at WHO Geneva. Speakers included Denise Coitinho Delmuè, a former WHO head of nutrition and also former executive secretary of the UN Standing Committee on Nutrition. The other speakers were Enrique Jacoby, who has just returned to the Pan American Health Organization in Washington from a secondment as deputy Minister of Health in his native Peru, and Carlos Monteiro in his role as a Brazilian federal government advisor.

Agreeing to work together

Denise discussed a study undertaken to identify the lessons from successful global movements that could be applied to nutrition. A large number of key informants from donors, governments, policy makers, opinion formers, catalysts and advocates were interviewed.

The study found that the key strategies for the success of global campaigns such as those addressing HIV/AIDS, tuberculosis, malaria, education for all, climate change and landmines included the following. Consensus on do-able solutions; effective global leadership; working in partnership; effective advocacy targeted at decision makers; and making a universal case. Barriers were the reverse – lack of global leadership, lack of unity or collaboration between players, and public disagreement on what to do. With nutrition, the Scaling Up Nutrition movement is moving in the right direction.

Enrique Jacoby stressed that in order for policies to be effective we need to understand the interconnectedness of agriculture, food systems, human health and education. Systems thinking is the new and right way of thinking. The infrastructure of consumption needs to be changed to an infrastructure of well-being. Legislative and regulatory powers of governments need to be strengthened. Public health nutritionists need to engage in agricultural, environmental and other issues. Plus there is an urgent need for global agreement on the conflicts of interest issue.

The Brazilian experience

Carlos spoke about how Brazil has dealt with childhood stunting, which has been reduced from 37 per cent in 1975 to 6.8 per cent in 2008. Reasons why, have included income redistribution, families strongly reduced in number, maternal schooling, access to basic health care, and water and sanitation improvements. These were all made possible by public policies, including a federal fund to support primary education, support for family agriculture, conditional income transfer programmes, and the creation and empowerment of CONSEA.

In closing, Francesco said that social action and policies are needed to address inequities, and structural policies are needed to reorganise society. A whole social movement is needed. He encouraged the women among the audience to see how important their role is in achieving change, using Brazil's experience, where maternal schooling and antenatal care have been successfully reformed. As citizens in our respective countries, we need to make our democracies work well.

Rio2012: What next. Up the Association!

Public health and nutrition action

So I come to the final session, and we plenary speakers again. Barrie Margetts invited Marion, me, Philip and Renato to address key actions that now need to be taken. Marion said that we all need to do what can, both personally and politically. There needs to be universal agreement on food marketing to children. We need strong community action which nutritionists should champion.

I mentioned three actions that can make a difference. One: a strong civil society movement. Two: we need to work with others. Three: we must build capacity, especially in less resourced countries and in Africa.

Renato said we need to continue to establish the connection between biodiversity and adequate and healthy diets. We need to realise the human right to food. We need to know to which extent strategies to combat poverty can solve the food problem. Regulation of the private sector, including the regulation of marketing, is crucial. We should continue to build capacity, and the Association has a responsibility here.

Philip said we should stop moaning and start moving. We should not get angry in general but be specific and focused. Take the 2014 World Cup and the 2016 Olympics. The Olympic committee has a contract with companies such as Coca-Cola and McDonalds until 2020. Beginning in Brazil we should establish a set of principles so that no Olympics from then on can engage on such activities. Brazil can also take a lead in development of agriculture policy. ABRASCO should be congratulated for 1ts achievements in Brazil, but it now has ten more jobs, and the Association has another dozen!

Here I am again in the centre after the final plenary session of Rio2012
with Marion (left) and Renato (right). Philip has walked out of the picture!

Up with the Association!

During the whole conference, the Association was itself seen as a major player. Our website and our journal World Nutrition should continue to be a platform for sharing our experiences and evidence, and our ideas about how to deal with the issues and challenges that face us all. We are an independent global body, with no vested interests. We also can be a combined think-tank and campaigning organisation. Internationally, nationally and at local and family levels, we need to help to build alliances with other organisations working for example on food security and other social, political and environmental issues.

How well did we all do, in Rio? Pretty well, I reckon. So now it is Rio2012: What next. Let's move our knowledge and our proposed policies into action, and then we will have a lot of progress to report at Delhi2016.

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: Annan R [Column]. Rio2012: What next Website of the World Public Health Nutrition Association, June 2012. Obtainable at www.wphna.org.

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

This column is reviewed by Geoffrey Cannon.

2012 June blog: Reggie Annan

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