Food affordability, Optifood, and the complexity of developing nutritional solutions for children

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Peter Rohloff has training in parasitology, internal medicine and pediatrics. He practices in Boston, MA at Brigham and Women's Hospital and Boston Children's Hospital. Since 2003, Peter has been working in Guatemala, where he serves as the medical director for a health systems NGO – Wuqu’ Kawoq | Maya Health Alliance. Peter’s interests include the management of chronic diseases of children and adults in resource poor settings and how indigeneity, cultural, and language barriers impact access to and utilization of health care. @wuqukawoq

optifood-smallA few weeks ago an interesting and important technical report from the FANTA project was released on dietary research conducted in Guatemala. The report has several important findings which I think have relevance not only for nutrition programming in Guatemala—-which has some of the highest rates of chronic malnutrition in the world—-but elsewhere as well.

The research reported here is, as far as I know, the first to use the Optifood program, a new piece of modeling software which uses dietary recall data to construct hypothetical diets from local foods which approximate ideal energy and micronutrient recommendations. The program was developed by the WHO and collaborators and will be available for download from the WHO website eventually, although it is not clear what the timeline is for availability.

In the meantime, we have this project by FANTA, which used Optifood to analyze optimal diets for young children (and also pregnant and lactating women, but I’ll focus mostly on the child data here) in Guatemala. The key findings of the study are as follows:

1. Although local diets generally contain enough calories, under no circumstances (breastfed children in the 6-8, 9-11, and 12-23 months categories) could daily micronutrient requirements be met without adding fortified foods or supplements to the local diets. This is not surprising, since we know that traditional diets in Guatemala–and elsewhere–are largely plant-based, and it is very hard to meet dietary recommendations with just plant-based foods.

2. The Optifood software came up with hypothetical diets, using local foods, that could meet all dietary recommendations for children 6-24 months of age – but only when combined with a daily micronutrient supplement. It is important to note, however, that the diet recommended by the software was significantly different from the baseline diet. For example, the recommended diet requires that all children consume seven servings per week of meat, poultry, or fish. In contrast, the dietary recalls of the baseline diet reported in the study note a “complete absence” of these foods.

3. The researchers generated cost estimates for the optimal diet recommended by Optifood. They estimated that the optimal diet – which must still be combined with a micronutrient supplement in order to be adequate – would cost around $ 0.25 per day for infants 6-8 months of age, $0.35 per day for 9-11 month old children, and $ 0.57 per day for children 12-23 months of age. The optimal dietary costs for a pregnant or lactating woman would be $2.08 or $2.53 per day, respectively. These cost estimates are important, because around 50% of the population in the study area earned $3.00 per day or less.

My overall impression from reading the report is once again to be struck by how difficult it is to guarantee adequate nutrition for women and children in impoverished global settings. Although the report is very even-handed in addressing the significance of its findings and qualifications, nevertheless the technical tone of the document tends to deemphasize how challenging its core findings really are. The report finds that the local diet can’t come anywhere close to meeting the nutritional needs of the population. Micronutrient supplementation is no an easy technical fix either, because it needs to be complemented by an optimized version of the local diet which is vastly different from the diet that individuals actually consume (mostly in terms of amount of animal-sourced foods).

Finally, the optimized diet which is recommended is completely unfeasible from a cost perspective. For example, let’s remember that much of the study population here lives on about $3 per day. A typical young family in this region would include a lactating mother ($2.53 per day), one toddler ($0.57 per day), and one young infant ($0.35). Guaranteeing optimal nutrition for just these three members of the family would cost 40% more than the family’s entire income, without even considering the cost of the also-recommended micronutrient supplement, or anything else.

It is also interesting to compare my own reaction to the report with the press that the report has been getting in official outlets. For example, USAID has a blog post about the report here:

Next steps in the process include testing the diet to see whether mothers can really feed it to their young children. We’ll be asking questions like, “Do mothers have any difficulties? Is cost really a problem? Are the recommendations hard to understand or follow? Do children like the combinations of food?” Once the diet is found to be practical, feasible, and affordable, FANTA will work with partners to develop a strategy and plan to promote the recommended foods in the right combination, quantity, and frequency to improve children’s diet intake as well as promote the use of Chispitas to help meet iron and zinc needs.

Did we just read the same report?! Of course cost is a problem! And the data in the report fairly clearly establish that the diet is neither feasible or affordable!

If anything, the report simply underlines, once again, that there is no such thing as an obvious technical solution to the problem of child malnutrition. And too much enthusiasm for any new technical solution–whether its “Optifood” or something else–obscures the political realities that lead to hunger and malnutrition. As I’ve written about recently, if we are going to be serious about child malnutrition, we have to address unemployment, low wages, and rising food costs.

FANTA. 2013. Summary Report: Development of Evidence-Based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands in Guatemala. Washington, DC: FHI 360/FANTA.