In this column, the author critiques the approach of only focusing on nutrition and health sector-related solutions for achieving food security. She calls for more holistic approaches that take into account the various contextual factors that influence food and nutrition outcomes for the majority of the undernourished, such as food production and systems, agricultural policies, food and beverage industry, sanitation, and the extent of social inclusion in government programmes and in the society at large.
The food and nutrition challenge
A set of articles in The Lancet in 2013
has had unusual influence in putting nutrition on top of the food security agenda. Although the articles describe a comprehensive set of factors that determine nutritional outcomes, their solutions are nutrition-specific, largely emanating from the health sector. These solutions have received the most attention. This is unfortunate.
Nutritional outcomes are profoundly influenced by food production systems, food and agriculture policies, and the food and beverage industry. Nutritional outcomes occur through numerous location-specific pathways of production and distribution, which depend on the stages of economic development. They are determined by patterns of agricultural and overall economic growth, with the distribution of benefits varying by socioeconomic class, economic sector and gender. As an example, the majority of the world’s poor live in rural areas, make a living from agriculture, and yet tend to be undernourished.
Even a cursory look at these processes highlights some of these pathways, along with many puzzles, some of which are discussed below. Their exploration requires going beyond methodologically sophisticated randomised control trials. The latter provide apparent precision to results and comfort to journals such as The Lancet, but do not explain the reasons underlying nutritional outcomes. An outcome orientation calls for eclectic approaches to research, which are interdisciplinary, intersectoral and multilevel. But first comes the need to clarify concepts.
Distinguishing between hunger and under-nutrition
The terms hunger and undernutrition are often used, at times interchangeably, which can cause confusion. Hunger means empty stomachs, an absence of calories (te Lintelo et al. 2013). Undernutrition means absence of critical nutrients, including energy. Undernutrition can be a consequence of hunger but can also exist in its absence, due to a lack of critical nutrients in the diet and a weakened immune system, which can make a person susceptible to infectious diseases and lower nutrient absorption. In addition, energy requirements are not uniform across body types. They also, for instance, vary by gender, level of physical activity and climate. There is also a lack of consensus on standards and norms. Food and Agriculture Organization (FAO) uses a Minimum Dietary Energy Requirement (MDER) (FAO 2013b), but FAO’s member countries may use others, as discussed below in the case of India (FAO 2013c).
Broad-based agricultural productivity growth is necessary for reducing poverty and ensuring food and nutrition security
Nutrition advocates note that undernutrition in the first 1,000 days of a child’s life (from conception until the age of two) can have lifelong and largely irreversible impacts. Undernutrition at that age impairs a child’s physical and mental development, increases the risk of chronic diseases and premature death in adulthood, and negatively affects the lifelong ability to learn, be economically productive, earn income and sustain livelihoods. In short, undernutrition perpetuates poverty. But of course, the reverse is equally true. Poverty leads to hunger and undernutrition. In the past, its elimination has been assumed to automatically reduce hunger and undernutrition. And while there is indeed an association, the relationship is complex. Since the 1990s, reduction in poverty and hunger has been fastest where economic growth has been accompanied by rapid growth of agricultural productivity involving smallholder producers. For example, agricultural total factor productivity grew about 90% and 50% in East and South-East Asia, respectively, between 1990 and the late 2000s, but by only around 25% in South Asia (Fuglie and Rada 2013). The number of undernourished declined by about 40% in East Asia and 53% in South-East Asia, whereas in South Asia the numbers hardly budged (FAO 2013). Undernutrition among children under five years of age also remains highest in South Asia, and is even higher than in Sub-Saharan Africa (World Bank 2014). East and South-East Asian countries also made a push for women’s education earlier than most South-Asian countries, with the exception of Sri Lanka and the Indian state of Kerala (World Bank 2014b).
But agricultural productivity growth is not sufficient: The Indian enigma
India illustrates the contribution of agriculture to nutrition, as well as some of the puzzles requiring investigation.
a. Decline in calories and increase in expenditure. More than three quarters of the Indian population lives in households with per capita caloric consumption below the requirements (2,100 kcal/day in urban areas and 2,400 kcal/day in rural areas by Indian standards) (Deaton and Dreze 2009). Oddly, Deaton and Dreze note a decline in average caloric intake during the last 25 years across the distribution of real per capita expenditure, despite increases in real income and an absence of long-term increases in the relative price of food. As a hypothesis, they posit that caloric requirements may have declined due to lower levels of physical activity or improvements in the health environment. If correct, they say, this does not imply there are no caloric deficits in the Indian population. Nothing could be further from the truth, as these deficits are reflected in some of the worst anthropometric indicators in the world. Yet, they say, this trend remains confusing, and there is an urgent need for better monitoring and understanding of the situation.
b. Changes in the composition of production affect diet quality, biodiversity and human and environmental health. Confirming these findings, Swamy (2012) states that “there is a clear decline in cereal and protein consumption, particularly of coarse cereals, which are more protein-rich than rice or wheat and are the major source of protein in the Indian diet. Similarly per capita availability of pulses, also a major source of protein in the Indian diet, has declined by more than 70 percent in 50 years. Although consumption of other foods has increased, including particularly fats, overall protein consumption in India still remains low”.
We begin to understand the complexity of connections between nutrition and agriculture by noting that pulses and other nutritious “minor crops” that provide protein are grown by some of the poorest farmers in India. Because of stagnant production, India imports large quantities of pulses that are actually native to India. Aware of this pulse deficit, the Indian Council of Agricultural Research (ICAR) has released over 200 varieties of pulses and launched various production campaigns, but adoption has been limited (Swamy 2012). Empirical farm-level analysis of obstacles to increasing pulse production is needed. One hypothesis is that scientists are rewarded for the number of varieties they release, rather than the number farmers adopt. This incentive system clearly needs to be better understood and changed.
The accompanying intensification of agricultural production in India has lowered food prices and helped to reduce hunger. It has been promoted through a variety of price supports and subsidies to crops, as well as to water and power. These supports have largely gone to rice and wheat, thus hampering the diversification of production and diets. The attention on a few crops has also led to fewer crop rotations and environmental damage, including soil degradation and deterioration in water tables and quality. The loss of biodiversity is a huge unintended consequence of development. There is large potential to use this biodiversity for the purposes of advancing nutrition, and we must take steps to preserve it and use it1.
Intensification has also been accompanied by increased pesticide use and increased agricultural chemical residues in food and water. There is a growing concern about adverse impacts of pesticides on human health, especially farm workers, and talk of “cancer trains from the Punjab”. The potential adverse impacts of genetically modified organisms (GMOs) on human and environmental health are widely debated (with a growing resistance to GMOs), but in the face of a strong industry lobby there has been silence on the impacts of pesticides on human health.
c. Policies, investments, and programmes leave women, children and socially excluded people behind. Government policies have helped to build up stocks to stabilise supplies and prices. And while storage policies have in-creased efficiency in some parts of the food system and for some groups, they have left others behind, particularly the poor, women and marginalised populations. Chand and Jumrani (2013) note that India presents high levels of hunger even as its public granaries are overflowing. Part of the stock even rots, needing proper storage and maintenance. The Mahatma Gandhi National Rural Employment Scheme (MNREGA) intends to counter some of these inefficiencies by creating employment among the poor, but we need to better understand the impacts of these safety nets on food and nutrition.
The particular vulnerability of women and girls, especially among the most socioeconomically disadvantaged, must not be forgotten. Poor households contain a large share of female-headed households. They tend to have limited access to production services and also to food, education and health in most of South Asia. Thus even if agricultural productivity increases, social indicators for women remain low in states such as Punjab and Gujarat. FAO estimates that focusing on women farmers will increase agricultural productivity and incomes by 20% to 30% (FAO 2011).
Marginal, socially excluded populations are even more vulnerable. Disproportionately high child mortality rates occur among Adivasis and other tribal populations that constitute well over 80 million of the 213 million under-nourished in India (Das, Kapoor and Nikitin 2010).
d. Poor sanitary conditions affect nutrient absorption and nutritional status. Waterborne diseases are common in areas where sanitation is poor, and adversely affect the capacity of the human body to utilise food. We should then be sure to address the issues of poor, unequal access to services, such as water and sanitation, in order to enhance the link between agriculture, food and nutrition.
Cheap food can be an asset as well as a liability
Scale economies in farming have replaced labour with machinery and computers, reducing the share of labour in agriculture and bringing real food prices down in countries like Argentina, Brazil and the United States of America. At the same time, corporate agriculture exists side by side with millions of hungry. Poor adults and children in urban areas increasingly become beneficiaries of cheap agricultural prices and safety net programmes, for example cash transfers or vouchers, rather than direct contributors to agricultural or economic growth. Even in these countries the benefits to diets and nutrition remain unequal. While the poor lack access to a balanced diet, neighbourhood farmers’ markets are mushrooming for upscale neighbourhoods, countering the effects of industrial agriculture and highly processed foods.
Despite the importance of productivity and affordable food, cheap food can be a liability, leading to increases in obesity and incidence of non-communicable diseases. Easy access to sugary drinks, low-cost calorie-dense foods with added fats, sugar and salts, and a rising proportion of food obtained away from home have steadily increased per capita caloric consumption (Unnevehr 2013). Among OECD countries, the USA has the highest rate of adult and childhood obesity, with the highest rates among the poor (Sassi 2010). Annual health costs associated with obesity amount to between US$ 147 billion to US$ 210 billion worldwide (Finkelstein et al. 2012, Cawley and Meyerhoefer 2012). According to the World Health Organization (WHO), the globally overweight population increased to 1.5 billion by 2010. Globally, being obese and overweight is linked to more deaths than being underweight (WHO 2013). In short, nutritional challenges from riches are as devastating as those from poverty and are explained by the industrialisation of agriculture and the growth of the cheap processed food industry.
Lessons of experience
We must make a greater effort to understand development of agriculture and its contribution to food and nutrition as societies modernise. The broad outlines are clear. Properly managed, a modernising broad-based agriculture and the improved livelihoods it creates will have a largely positive effect on food and nutrition. This broader view of the determinants of nutrition, taking policies, investments and their impact on agriculture and food systems into account, goes beyond the micro focus of more project-based interventions recommended in The Lancet. It seeks to provide sustainable support for all the actions in what is, at bottom, the foundation of good nutrition: a healthy food and agriculture system that supports an economically fair, equitable and nutritious food system.
A version of this column has appeared in SCN news, a publication by the United Nations Standing Committee on Nutrition (UNSCN).
- Globally only three staple crops contribute 60% of all calories consumed, 120 species are used for 90% of all calories consumed whereas 7,000 species have been used in agriculture throughout history (Fowler 2006).
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- te Lintelo DJH, L Haddad, R Lakshman, K Gatellier (2013), ‘The HANCI donor index 2012: measuring donors´ political commitment to reduce hunger and undernutrition in developing countries’, Evidence Report 26: Reducing hunger and undernutrition, Institute of Development Studies, Brighton.
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- WHO (2013), ‘Obesity and Overweight’, World Health Organization, Geneva, Fact Sheet no. 311.