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Introduction to nutrient focused approach
- 1. Nutrient focused approach - introduction - Shunichi NAKADA, Senior Advisor (Ag. Policy) Japan International Cooperation Agency 4/21/2024 1
- 2. WHAT IS HEALTHY DIET? 2
- 3. There are no such things as healthy/unhealthy food, There exists only healthy/unhealthy way of eating • All things are poisons, for there is nothing without poisonous qualities. It is only the dose which makes a thing poison (Paracelsus, 1538) • Toxin can become medicine depending on “dose” (morphine, botulinus) 4/21/2024 3 “Dose makes the poison”: principal theory in toxicology Risk = Hazard(unit toxicity) × Exposure(amount of intake) → We must always think about quality and quantity Questions • How about the case of fat/oil? • Similarly, how about the case of salt? … diabetes, heart attack, fatigue … hyponatremia
- 4. What is healthy diet 4/21/2024 4 What is healthy diet Definition Source: Healthy diet (who.int) A healthy diet is essential for good health and nutrition. It protects you against many chronic noncommunicable diseases, such as heart disease, diabetes and cancer. Eating a variety of foods and consuming less salt, sugars and saturated and industrially-produced trans-fats, are essential for healthy diet. A healthy diet comprises a combination of different foods. These include: • Exclusively breastfeed babies for the first 6 months and continue breastfeeding until 2 years and beyond. • Energy intake should balance energy expenditure. • Keep total fat intake to less than 30% of total energy intake, with a shift in fat consumption away from saturated fats to unsaturated fats, and towards the elimination of industrial trans fats. • Limit intake of free sugars to less than 10 percent (or even less than 5 percent) of total energy intake. • Keep salt intake to less than 5 g/day. • Eat at least 400g of fruits and vegetables a day. How to assess quality of diet a) Diversity : if you consume food from variety of food source b) Balance : if your consumption from different food group is in adequate proportion c) Adequacy : if your consumption of food from different source ensure adequate intake of nutrients d) Moderation : if you do not overconsume specific type of food
- 5. What is sustainable Healthy Diet 4/21/2024 5 Source: Sustainable healthy diets – guiding principles, FAO - Guiding principles 1. Breastfeeding practice 2. Avoid highly processed food 3. Consume variety of wholegrain with variety of fruits and vegetables 4. Moderate amounts of eggs, dairy, poultry and fish; and small amount of red meat 5. Safe and clean drinking water 6. Adequate amount of energy and nutrients 7. Reduce the risk of NCD 8. Ensure food safety 9. Minimize environmental pollution from food system 10. Avoid biodiversity loss through food chain 11. Minimize use of antibiotics and hormone in food production 12. Minimize plastic in food package 13. Reduce food loss and waste 14. Respect local food & dietary culture 15. Ensure affordability and preference 16. Avoid adverse gender-related impact including time allocation for household management
- 6. Staple: Too much is as bad as too little Food group Negative impact Positive impact Recommended intake Staple Carbohydrate intake more than 60% of energy, was associated with increased total mortality (low-middle income country) Key source of energy Fiber reduce mortality risk 232 g/d grain 50 g/d tuber (2500 Kcal) 4/21/2024 6 Source: EAT-LANCET （2020） Carbohydrates play an important role in the human body. They act as an energy source, help control blood glucose and insulin metabolism, participate in cholesterol and triglyceride metabolism.
- 7. Protein source and health impact 4/21/2024 7 Source: EAT-LANCET （2020） Important to build body cells, body fluids, antibodies, and other parts of the immune system. Good food sources are animal source foods such as meat, eggs, seafood, and legumes such as beans, peas, and lentils. Food group Negative impact Positive impact Recommended intake Total protein 56 g/day Meat Increased cause of death from any cause (especially processed meat) (in EU/USA) Red meat>poultry, fish> nuts, legume Processed>unprocessed Inverse association with all cause mortality (in Asian countries) 14 g/d red meat 29 g/d poultry Dairy No significant increase or decrease in risk of overall mortality or cardiovascular disease with increasing consumption of dairy foods 250 g/day Fish Important source of omega-3 fatty acid 28 g/day Egg Substitution of egg by plant protein can reduce NCD Replace calorie from staple improve diet quality and reduce stunting 13 g/day (1.5 eggs/week) Nuts & legume Alternative to red meat Energy dense with no weight gain 50 g/d nuts 75 g/d legume
- 8. Fat intake and health impact Food group Negative impact Positive impact Recommended intake Total added fat • Evidence from prospective cohort studies and randomized trials has not suggested a benefit of reducing total fat intake • Efficient body energy source • Protects organs (visceral fat) • Supports cell growth (cell membrane, hormone) • Help to absorb key nutrients (vitamin) 52 g/day Composition of fat Substantial reduction of cardiovascular disease risk by replacing saturated fat with unsaturated vegetable oils, especially those high in polyunsaturated fats that include omega-3 and omega-6 fatty acids 40 g/day saturated 11.8 g/day unsaturated 4/21/2024 8 Source: EAT-LANCET （2020） Dietary fats are essential to give human body energy and to support cell function. They also help protect organs and help keep human body warm. Fats help human body absorb some nutrients and produce important hormones, too.
- 9. Role of key nutrients commonly deficit in many countries Key micronutrients commonly deficit in many countries Iron Iron deficiency is a primary cause of anemia and can result in cognitive impairment, decreased work productivity, and death. Zinc Zinc deficiency in children is associated with poor health, increased risk of diarrhea, and impaired cognitive and motor development. Vitamin A Vitamin A deficiency has severe consequences, even with mild deficiency, including night blindness, increased susceptibility to infections, and death. Source: GAIN and UNICEF. Comprehensive Nutrient Gap Assessment (CONGA)
- 11. Agriculture, Dietary Diversity, and Health • Ruel conducted intensive review of 47 articles to examine impact of various agriculture intervention to nutrition improvement. Overall, number of studies showed clear impact of NSA to DDIs, while impact on nutrition outcome was limited (Ruel, 2018) • Eric conducted peer review from 137 articles to examine relationship between DDIs and health impact, found that associations between DDIs and health outcomes were largely inconsistent. (Eric et al. 2021) 4/21/2024 11 DDIs Health impact NSA Possible limitation limited evidence good correlation ● Diversity ● Balance ● Adequacy ● Moderation Potential Improvement through NFA image: Flaticon.com
- 12. Food based dietary guideline FCT Dietary Reference Intake Different type of dietary guidance 4/21/2024 12 Sex age protein Vit-A iron Male 6 mon. 10.2 375 9.3 Female 6 mon. 375 9.3 9.4 Item protein Vit-A iron Carrot 1.0 713.3 0.7 Soybean 35.9 1.0 7.3 Item consume Staple 150 Vegetable 300 milk 200 Meat 40 Egg 20 image: Flaticon.com Nutrition science Food science Diet culture Dietary Diversity Indicators Item consume Staple √ Vegetable Pulses √ Fruits √ ASF Oil
- 13. Copyright © 2020 JICA All Rights Reserved. Japan International Cooperation Agency How to optimize overall balance? One proposal: Planetary health diet (EAT-LANCET) Balanced diet concept, now going beyond simple diversity (quantitative aspect included)
- 15. OBSERVATION AT GLOBAL LEVEL 4/21/2024 15
- 16. Economic development and dietary transition 4/21/2024 16 ① ② ③ surplus → ← deficient Source: IFPRI 2022, Consumer demand for healthy diets
- 17. OBSERVATION AT COUNTRY LEVEL 4/21/2024 17
- 18. (300) (250) (200) (150) (100) (50) 0 50 100 150 Rice, wheat, corn and other Tubers or starch vegetables Vegetables Fruits Legumes Nuts All sugars Dietary gap (g/capita/day) Country dietary gap with planetary health diet -1 Northern America South America Asia Africa Europe 4/21/2024 18 Regional average food supply (gram/day/capita) is compared with Planetary Health Diet oversupply deficient image: Flaticon.com
- 19. (300) (250) (200) (150) (100) (50) 0 50 100 150 Dairy foods Beef, lamb and pork Chicken and other poultry Eggs Fish Unsaturated oils Saturated oils dietary gap (g/capita/day) Country dietary gap with planetary health diet -2 Northern America South America Asia Africa Europe 4/21/2024 19 Regional average food supply (gram/day/capita) is compared with Planetary Health Diet oversupply deficient image: Flaticon.com
- 20. OBSERVATION AT HOUSEHOLD LEVEL 4/21/2024 20
- 21. Why dietary diversity is difficult - case of Mozambique -
- 22. Why dietary diversity is difficult - case of Mozambique - consume situation health agriculture staple 〇 • Essential. Always consumed legume 〇 • Essential. Always consumed Fruits & vegetable △ • Consume only when if it is available（seasonality） • Do not care if not consumed (awareness) 〇 〇 Meat, fish, egg × • Everyone like it, but not consumed frequently due to affordability (production & distribution cost is high) • I would like to produce if there are good market demand. But market size is not big enough yet. (market creation) △ 〇 Dairy product × • Difficult to access (cold chain) △ 〇 4/21/2024 22
- 23. BEHAVIOR CHANGE FOR BETTER DIET 4/21/2024 23
- 24. Major cause of not having balanced diet Typical cause Japanese practice Because it is expensive • Combination of commercial agriculture and kitchen garden • Make use of unused food Because it is not available • Farming technology (greenhouse, variety development, irrigation) • Preservation technology, processing technology • Kitchen garden I don’t care about balanced diet • Nutrition is not top priority in daily life • How to change mindset?
- 25. Behavior change strategy BCC stage Possible action Realize the issue • Conduct survey and Data Visualization • Personalize nutrition issue (this is my problem!) • Healthy life tree (how to improve QOL) Nurture thinking farmer Identify challenge and opportunity • Resource mapping (time, money, workload, available resource) Seasonal calendar Daily routine analysis SWOT analysis Start from simple action • Identify what you can do today without big investment • Provide technical support • Link with expert and key stakeholder Monitor / review • Evaluate the action, discuss result • Consider next action (small improvement)
- 26. HOW DIFFERENT COUNTRIES TRY TO GUIDE BALANCED DIET? 4/21/2024 26
- 27. How dietary guidance is conducted in other countries? 4/21/2024 27
- 28. How dietary guidance is conducted in other countries? 4/21/2024 28
- 29. How dietary guidance is conducted in other countries? 4/21/2024 29 Current development of FDBG in Africa
- 30. 4/21/2024 30 Source: Indicators for assessing infant and young child feeding practices (UNICEF) How dietary guidance have been conducted in African countries? 食べた食材の 種類 特定食材の摂取 の有無
- 31. NFA application: quick dietary survey, followed by crop identification IFNA handbook & NFAApp Health & extension workers Adequate knowledge of nutrition, but no nutritious foods to practice. ① Assess local nutrition gaps and identify agricultural interventions based on the NFA concept. ② Produce nutritious food. ③ Create synergy between the health and the agricultural sectors. Eat nutritious foods! Stay healthy and happy! 31
- 32. Promising area of collaboration ？ Health Sector - Expertise in guiding local people for better diet. Agriculture Sector - Limited access to nutritious food due to failure in food system. 32 Improved knowledge, but lack of access to nutritious food makes it difficult to practice. Let’s eat a balanced diet! Nutrition sensitive approach has not been fully integrated.
- 33. What is NFA (Nutrition Focused Approach)? ① Recomm ended intake Recommen ded intake Which nutrients are needed and how much? By using Dietary Reference Intakes (DRIs) developed by WHO By using secondary data at national level, or Apps at the local level 33 GAP Usual Nutrient Intake
- 34. What is NFA (Nutrition Focused Approach)? ② 34 Egg Broccoli Local Food 3 Better access through improved food system Nutritional requirements per meal Protein Fat Carbohydrate Vitamin A Iron Iron Dietary diversity score (DDS) 3 4 5 https://www.youtube.com/watch?v=RZG7zkwpgM8
- 35. • Thank you very much! • Any question? ⇒ nakada.shunichi.2@jica.go.jp 4/21/2024 35
Hinweis der Redaktion
- Now we are going to confirm role of key nutrients commonly deficit in many African countries. Protein. Protein is an Important to build body cells, body fluids, antibodies, and other parts of the immune system. Good sources of protein includes animal base foods such as meat, eggs, seafood, and plant base foods such as beans, peas, and lentils. Iron. Iron deficiency is a primary cause of anemia and can result in cognitive impairment, decreased work productivity, and death. Zinc. Zinc deficiency in children is associated with poor health, increased risk of diarrhea, and impaired cognitive and motor development. Vitamin A. Vitamin A deficiency has severe consequences, even with mild deficiency, including night blindness, increased susceptibility to infections, and death. Other than these item, iodine deficiency, vitamin D deficiency are also observed in many countries I briefly explained role of key nutrients for human in this slide. Then In the next slide, I will explain the role of key food group in human health
- There are wide range of dietary recommendation we experience in our daily life. We will make use of two key recommendation out of them, Dietary Reference Intake, referred as DRI and Food Based Dietary Guideline, referred as FBDG. So what is DRI and FBDG? DRI tells us required amount of daily intake of nutrients such as protein, vitamin A, iron. Background of DRI is nutrition science and food science, which tries to link specific nutrient and human health, Typical use case of DRI is by the nutritionist to design healthy meal for certain population, such as school children, hospital inpatient FDBG tells us required amount of dairy intake of key food groups such as egg, vegetables, dairy products. FDBG is designed to be understandable and usable for ordinary people, setting consumption target of food ingredient or menu instead of unfamiliar nutrient name. FDBG is designed to satisfy DRI requirement by combining different type of food item in a good balance. This combination is designed based on the survey of national and local diet culture.
- So far, we have went through the concept of healthy diet, especially two typical tool of food guidance, DRI and FBDG. Now let’s look at the real situation. What is the gap between those recommendation and our current dietary culture.
- This graph is from research paper published by international food policy research institute. Food supply data from each country is compared with global reference FDBG, which is synthesized by author by reviewing ten representative country’s FDBG. Horizontal axis, all country are sorted by GDP per capita. Vertical axis stands for oversupply or deficient in each country group. Each graph has six coloring, each color stands for different food group, as indicated in the legend. From this graph, we can understand dietary transition in the course of economic development. By looking at each food group from low-income country status to high income status, we can realize there are four type of commodity group. First group, oversupply during low income status, gradually decrease supply and become deficient at high income status. Starch food group belongs to this category. Second group, deficit at low income status, gradually increase as income grow, and oversupply at high income status. Animal source food and oil fats belong to this category. Third group, regardless income status, always deficit. Vegetable, fruits and pulses belong to this category. Fourth group, regardless income status, always oversupply. Sugar belongs this category. We can make use of this findings to consider medium to longer term strategy to ensure balanced diet.
- Now I will share with you about similar assessment focusing on each country belongs to EAC
- Table in previous slide is converted into graph. It is clear that only tuber is surplus in EAC countries
- Continue from previous slide. Again, we can see all food commodity is deficient
- Observation at local level Up to now, we have observed dietary gap based on national agriculture statistics. This is simple and easy to analyze. However, this is just an estimate, does not necessary give us real picture of local diet. In the following slide, I share the result of quick dietary survey conducted in Mozambique
- I conducted small survey in Niassa province, Mozambique. I conducted quick 24hour dietary recall survey for around 20 households. Most of household showed quite similar result in terms of food group consumption. So, this is just extraction of four household. As you can see, there are two type of food group which all household do not consume. First group is animal source food. Second group is vitamin-a rich fruits and vegetables Then we asked follow-up question why you don’ t consume specific food group, and what is your ideal diet. Answer is summarized in the following slide.
- Observation at local level Up to now, we have observed dietary gap based on national agriculture statistics. This is simple and easy to analyze. However, this is just an estimate, does not necessary give us real picture of local diet. In the following slide, I share the result of quick dietary survey conducted in Mozambique
- Observation at local level Up to now, we have observed dietary gap based on national agriculture statistics. This is simple and easy to analyze. However, this is just an estimate, does not necessary give us real picture of local diet. In the following slide, I share the result of quick dietary survey conducted in Mozambique
- 赤字でのご訂正、ありがとうございます。 文字の色を元の色に変更させていただきました。
- Nutrient Focused Approach (NFA) is an approach to identify nutrient deficiency and design the context-specific dietary diversification solutions to tackle the nutrition issues that are identified. This also can be used as a tool to guide specific roles of the agricultural sector in the nutrition issues.