Nutrient focused approach - introduction -

[Audio] Nutrient focused approach introduction In this slide, I am going to talk about basic concept of nutrient focused approach..

[Audio] What is healthy diet? To begin with, let's have common understanding about optimal diet.

[Audio] 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..

[Audio] 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.

[Audio] First food group is Staple. It is Key source of energy and dietary fiber from staple is known to reduce mortality risk As a negative aspect, it is reported that if carbohydrate intake exceed 60% of total energy, it will increase mortality risk..

[Audio] As mentioned in the previous slide, protein is an important constituent element of human body, can be source from plant and animal products. Different type of protein source have different health impact as shown in the table. In addition, this impact could be different by geographic location, due to probably dietary habit difference. In case of meat, it shows significant positive impact to mortality in Europe and USA, while opposite result was found in Asian countries. Daily products are believed as quality protein source despite scientific evidence is limited Plant based protein is a good alternative to red meat, which shows significant positive impact on mortality in Western countries.

[Audio] Fat is one of essential macro nutrient which have several key function such as energy storage, support cell growth, protect organ. Reduction of total fat does not necessary provide good health outcome, however reduction of saturated fat is significantly associated with cardiovascular disease risk. I believe this is main risk factor of red meat, which contain high amount of saturated fat..

[Audio] This table shows different type of fat, it's main source, and its health impact. Saturated fat is known to have risk factor of heart disease, and is high content in red meat, cheese, and coconut oil. Trans-fat fatty acid, which is contained in margarine also increase risk of heart disease. Those type of fatty acid is recommended to be replaced by unsaturated fat. For example, olive oil, canola oil contain monounsaturated fat, nuts, sunflower and maize oil contain polyunsaturated fat. And finally fish based products contain special type of polyunsaturated called omega3 oil, which cannot be generated inside human body and known to have different health benefits..

[Audio] In 2021, group of international experts published a report called EAT-LANCT. In this report, based on meta-analysis of existing literature related to food, nutrition and environment, the concept of planetary health diet was proposed. Planetary Health Diet include guidance on daily consumption volume of key food item to ensure healthy life, while minimize negative environmental impact. You can see orange number in the table. This number is daily recommended intake of eight food group, (1) Whole grains, (2) Tuber of starchy vegetables, (3) vegetables, (4) Fruits, (5) Dairy foods, (6) Protein sources, (7) Added fats, (8) Added sugars..

[Audio] Significant regional difference. Significant regional difference.

[Audio] 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..

[Audio] 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..

[Audio] Now I will share with you about similar assessment focusing on each country belongs to EAC.

[Audio] Dietary gap based on planetary health diet.

[Audio] This is a result of comparison between planetary health diet and current supply of each food group indicated in planetary health diet. Red color text indicate deficit supply, which is lower than 80% of recommended consumption. Yellow color text indicate oversupply, which is higher than 120% of recommended consumption. And green color indicate food supply is within appropriate range. As you can see most of food group is deficient in supply compared with Planetary Health Diet.

[Audio] Table in previous slide is converted into graph. It is clear that only tuber is surplus in EAC countries.

[Audio] Continue from previous slide. Again, we can see all food commodity is deficient.

[Audio] Dietary gap based on Dietary reference intake Now let's continue similar assessment focusing on nutrient, instead of food group.

[Audio] This is a case of DRC, comparing country protein supply with DRI. The bar stands for protein supply from combination of different source. Each bar is compared with protein DRI of 45g. Horizontal axis stands for national average and different income class average. Q1 stands for lowest income group, while Q5 stands for highest income group. As you can see, protein is oversupply in national average. However, if we disaggregate by income class, Q1 is deficient, Q2 is appropriate, Q3 and Q4 is little over supply and Q5 exceed recommendation by around four times. This result imply that statistics is good to capture overall picture, but to consider concrete intervention, we must conduct field survey to capture real situation..

[Audio] This graph shows that in DRC, supply of vitamin-A is less than 20% in national average, and significant deficiency in all income class. In addition, basically all vitamin-A is coming from staple foods. It can be understood that lack of vegetable and fruits must be key reason for significant deficiency.

[Audio] In case of iron supply, deficiency is more serious and again, most iron is from staple. Dietary diversification would be an important strategy again. This is an example case of DRC. Same analysis for all country would be shared with you as appendix..

[Audio] Now I share the result of WFP publication, fill the nutrient gap for Kenya. This is a comparison of the cost for three different type of diet, energy-only diet, nutrient-adequate diet, and healthy diet. Energy-only diet stands for the combination of food ingredient only to satisfy energy requirement. Nutrient-adequate diet stands for combination of food ingredient to satisfy DRI Healthy diet stands for combination of food ingredient to satisfy FBDG As you can see, to improve dietary balance, cost of food is a biggest burden.

[Audio] 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.

[Audio] 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..

[Audio] This is a summary of follow-up question. There is no challenge in consumption of staple and legume. In case of non-consumption of fruits and vegetable, the reason was seasonal availability, unavailability. People respond they do not eat specific fruit and vegetable simply because it was off-season. I also noticed that they do not care about non-consumption. In answering the question, "what is your best diet", no one included fruits and vegetables. Everyone picked up some of animal source food. In case of Animal source food, the reason of non-consumption is very clear, high price. In case of dairy product, non availability due to lack of cold chain From this case of Madagascar, we can learn typical dietary gap, and typical challenge to overcome non-consumption. Typical gap is consumption of fruits, vegetable, and animal source food. Typical challenge is seasonality, awareness, and cost..

[Audio] Up to now, we have been discussing about concept of dietary guideline including DRI and FBDG. Current dietary gap and nutrient gap at country level, household level. Now, let's discuss about how can we guide local people to fill dietary gap. The key point is how to tell food quantity to target beneficially.

[Audio] This is FDBG in Japan on the right side, and the way to tell quantitative recommendation to beneficiary. In Japanese FDBG, recommended volume of different type of food group is presented. To tell this volume to the beneficiary, community health worker and nutritionist use hand measurement method. Figure on left-top indicate quantity guidance for staple food. Double hand for rice, or single hand for bread. Figure on lift-middle indicate vegetable consumption. Single hand for cooked vegetable, or double hand for fresh vegetable. Figure on left-bottom indicate main dish consumption. Palm size is good for fish, meat, or egg..

[Audio] This is Myplate of USA. Quantity of different type of food group is explained by dividing plate into four. Green color stands for vegetable, which compose one fourth of the plate. Red color stands for fruits, which compose another one fourth of the plate. Brown color stands for grains, again one fourth of the plate. Last one fourth is protein in purple color. One glass of milk is added at the side in blue color..

[Audio] As we have seen, in case of Japan and USA, dietitian try to provide semi-quantitative dietary guidance to achieve balanced diet. Now, let's see the typical dietary guidance in Africa. This table is extraction from IYCF guideline developed by UNICEF. 15 indicators are set to monitor diet of children. Key indicators are Minimum Dietary Diversity, Minimum Meal Frequency and Minimum Acceptable Diet. These indicator counts number of food group consumed and number of meal during last 24 hour. These indicators have strong advantage, easy to understand and implement, methodology is solid and concrete, universal data is available to compare. However it does not provide information of overconsumption. It also does not provide guidance of commodity balance in a meal. When we consider triple burden of malnutrition, we need to consider measures to evaluate over and under consumption of certain type of food group in near future..

[Audio] In IFNA, through NFA approach, we are trying to provide support on this situation using smartphone based application. The application is used to conduct quick assessment of local dietary gap compared with DRI or FDBG. Based on this dietary gap, application will recommend locally available commodity to be promoted in target area. Based on this recommendation, agriculture officer can support local farming household for improving access of nutrition dense food. They also need to collaborate with health expert, to improve awareness on balanced diet and preparation, consumption of selected food item..

[Audio] This is common scenery we observe in many rural African community. Community health worker have well established teaching material to guide local people for better diet. However due to lack of access to nutrient dense food, which is key to fill the dietary gap, dietary shift does not easily occur. This failure mainly comes from the fact that regular agriculture program is not fully integrating nutrition sensitive agriculture.

[Audio] 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..

[Audio] Application helps to identify key commodity to be promoted in target area based on the result of dietary gap assessment. For more detailed explanation, you can follow youtube link in the slide..

[Audio] Thank you very much.. Thank you very much! Any question? ⇒ nakada.shunichi.2@jica.go.jp.