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Abstract

Background:

Global food insecurity persists despite continued international attention, necessitating evidence-based food assistance interventions that adequately address nutritional concerns. In June 2018, the US Agency for International Development’s Office of Food for Peace through the Food Aid Quality Review (FAQR) project sponsored a “Food Assistance for Nutrition Evidence Summit” to share evidence relevant to policy and programmatic decision-making and to identify critical evidence gaps.

Objective:

This article presents 4 priority areas to advance nutrition in the international food assistance agenda generated through presentations and discussions with the food assistance community at the Evidence Summit.

Methods:

Priority areas were identified after the Evidence Summit using a combination of FAQR team discussions, review of presentations and official notes, and supporting literature.

Results:

Key priority areas to advance nutrition in the international food assistance agenda are as follows: (1) increase research funding for food assistance in all contexts, paying particular attention to emergency settings; (2) research and adopt innovative ingredients, technology, and delivery strategies in food assistance products and programs that encourage long-term well-being; (3) redefine and expand indicators of nutritional status to capture contextual information about the outcomes of food assistance interventions; and (4) augment communication and collaboration across the food assistance ecosystem.

Conclusions:

These priorities are critical in a time of increased humanitarian need and will be key to fostering long-term resilience among vulnerable groups.

Keywords

food aid food assistance nutrition emergency response humanitarian development global health maternal and child health malnutrition

Highlights

Numerous evidence gaps remain regarding food assistance interventions that adequately address nutritional concerns; innovation and stronger collaboration are needed in food products and programs to help people thrive, not just survive; the cost of not investing in evidence to inform best practices is high and the payoffs to this evidence generation are substantial.

Introduction

In this United Nations Decade of Action on Nutrition (2016-2025), the global community recognizes the importance of nutrition for health and sustainable development. As a result, international humanitarian organizations, governments, multilateral agencies, researchers, and other allies are collaborating to improve understanding of what works in food assistance for nutrition. Food assistance activities including in-kind food transfers, local/regional food assistance procurement, and cash transfers and food vouchers have the potential to successfully address nutrition needs among vulnerable individuals.^1,2

Actively evolving research in this field has led to improvements in emergency food assistance response (eg, rapidity, reach, and ability to meet varied nutrient needs) and nutrition-related outcomes (eg, acute malnutrition, anemia, and birth anthropometry).³ Substantial efforts to build on this success are underway, but they must be pursued based on the best available evidence and with the goal of implementing cost-effective solutions that maximize the impact of every dollar spent.⁴

As part of this effort, the US Agency for International Development’s (USAID) Office of Food for Peace (FFP) through the Tufts University led Food Aid Quality Review (FAQR) sponsored a “Food Assistance for Nutrition Evidence Summit” in Washington DC, on June 27th and 28th, 2018. The Evidence Summit brought together over 250 global leaders in the food assistance community including researchers, policy makers, donors, implementing partners, and industry representatives (see Supplemental Table 1 for a list of all participating organizations). The purpose of the Summit was to review evidence on best practices, recent innovations, and remaining knowledge gaps in food assistance for nutrition for vulnerable populations in low- and middle-income countries. The Evidence Summit consisted of presentations in plenary and concurrent sessions, panel discussions, lightning talks, demonstrations in a tools and resources roundtable, and poster/table displays.(for a full list of presentations, see Supplementa1 Table 2). This summary elaborates 4 priority areas key to continuing momentum in the international food assistance agenda that emerged from a distillation by the FAQR team of the presentations and discussions given during the summit. Although there are other areas to consider for advancing the field, the 4 areas in this summary were identified as crucial during the Evidence Summit.

Methods

The Evidence Summit was prioritized by USAID/FFP as an output of the FAQR phase III contract (2016-2019). The agenda and session topics were determined based on discussion, review of current literature, and research topics prioritized by the FAQR team. Session topics were vetted through review by experts at World Food Programme (WFP) and USAID/FFP. The FAQR team identified and invited expert presenters in the topic areas for each session through a review of recently published studies and their overall bodies of work. The FAQR team then worked with session presenters to develop the content for each session.

At least 2 designated notetakers were present at each session of the Evidence Summit. Upon conclusion of the Evidence Summit session, leaders were asked to distill the key takeaways from each of their sessions after review of the presentations and official notes. The FAQR team then reviewed and discussed these takeaways and grouped them into priority areas. The following discussion elaborates on these 4 priority areas by grounding them in the existing body of literature.

Spread Research Attention Across the Development to Emergency Continuum

Emergency response and development programs have historically been treated as separate enterprises, each with different budgets, human resource allocation, and research activities for generating best practices. However, modern conflicts are more protracted and natural disasters are affecting more people, prolonging the need for food-based responses and necessitating coordinated humanitarian action addressing short- and long-term outcomes.⁵ Indeed, from 2009 to 2015, 70% of the WFP’s direct food assistance expenditure went to protracted, complex emergencies.⁶ These complex situations are blurring the lines between emergency and development programming.

Despite the changing nature of this field, the body of evidence says little about how best to deliver, ration, and program food assistance during emergencies and protracted crises.⁷ Research that will help address this evidence gap has been outlined by WFP⁶ and the No Wasted Lives Coalition Research Agenda.⁸ If existing or new studies can incorporate investigations of resilience (ie, the capacity to maintain food security in the face of stressors), we can begin to understand how to reduce the duration and depth of food assistance needs created by emergencies through more effective programming for this continuum.^7,9,10

Innovate Food Assistance Products, Programs, and Delivery Strategies With the Aim to Improve Long-Term Well-Being

Since food aid operations began, programs have mainly used blended, fortified flours delivered through blanket supplementary feeding and targeted distributions.¹¹ However, innovations like lipid-based nutritional supplements and interventions like behavior change communication have demonstrated significant added value that has unlocked reductions in mortality from severe and moderate malnutrition.^3,12 Food assistance must continue to evolve in the following ways.

Product formulations

Current product formulations are meant to meet the basic macro- and micronutrient needs of populations, but researchers are now experimenting with more specialized ingredients: added amino acids that can overcome deficits in protein quality¹³ and phytonutrients/antioxidants that can reduce inflammation,¹⁴ both of which may improve growth, development, and recovery. With global obesity on the rise,^12,15 research is needed on the long-term, potentially obesogenic effects of calorie-dense food aid products to stimulate child growth without increasing the risk of chronic disease.^16,17

Food and packaging technology

Food technologies can play a role in creating food products that can carry nutrients more effectively. For example, compaction of food aid products can reduce moisture and oxygen in packages, prolonging shelf life and reducing shipping volumes.¹⁸ Further research in food aid packaging should be directed toward reducing environmental impact and improving protection of products from mycotoxins and other contaminants.

Local and regional procurement

There are many arguments in favor of using local or regional procurement of food aid or loosening restrictions on purchasing for international food aid.^19,20 Using local resources and foods could improve community food security and resilience through sustainable, cost-effective, scalable, and economically stimulating means as long as these foods meet quality and safety standards.^20,21

Supply chain optimization

Currently, it takes an average of 5 months for a food aid product to travel from its origin to its destination.²² Ongoing research on optimizing choices at each point in the supply chain, from transportation to storage to the challenges of the last mile, will be crucial in getting food aid to the recipients rapidly and cost-effectively.

Holistic and participatory programming

Nutritional status is influenced by environmental factors other than food, such as safe water sources and hygienic sanitation facilities, and adequate care practices; effectiveness of programs that address these factors is being explored by the research community. There is also a need to better understand how to make programs more context appropriate, ensuring that cultural norms and typical practices around food consumption are considered. Recipients of food assistance should not be overlooked. Methods to elicit recipient preferences such as community-based participatory research and consumer behavior experiments should be used to involve recipients in decision-making, leading to community empowerment, more effective and appropriate programs, and involvement in policy-influencing processes.^23,24

Cash and vouchers

Humanitarian and development programs are increasingly using cash and vouchers in place of or in addition to in-kind food aid.²⁵ The choice among the different modalities is complex and context dependent (ie, market availability, nutritional objective, household income, and assets).²⁶ If markets are functioning, cash and vouchers increase recipients’ autonomy and flexibility with what they consume. However, trials comparing cash and food transfers have shown mixed evidence; some report larger positive impacts on diet diversity with food transfers, and others show positive impacts of cash on nutritional outcomes.²⁷ More research is needed on what place cash and vouchers have in food assistance programs and how they affect program effectiveness and local economies. Practitioners should consider the evidence related to different food assistance modalities when designing context appropriate programs.

As we make improvements, we must keep in mind the need for cost-effectiveness research to ensure the best use of funding and other resources. In the long term, not doing cost-effectiveness research is arguably more costly than spending the resources up front to do it. While we endeavor to find more sustainable solutions to global food insecurity, we can work now to find ways of making food assistance as cost-effective as possible to the benefit of programs and recipients.

Redefine and Expand Indicators of Nutritional Status

For decades, nutritional status has been measured using combinations of height, weight, and age ratios by converting these measures into standardized “z scores” that describe how a person’s growth compares to a healthy population average.²⁸ Two of the most common summary measures are wasting, a low weight-for-height ratio, and stunting, a low height-for-age ratio. These fairly low-tech and low-cost measures have been shown to be associated with mortality and morbidity and predictive of future health and productivity.²⁹ Relatively easy to assess in the field, anthropometric z scores are frequently used to measure the effectiveness of food assistance programs.

However, nutrition researchers and program implementers are increasingly concerned with using z scores as the sole indicators of success, for several reasons.^30,31 z scores do not reflect body composition, neurological development, immune function, or other biological mechanisms that influence longer term outcomes. Stunting, in particular, may be misconstrued as a cause of poor outcomes such as delayed cognitive development, chronic disease, and lower productivity and wage earnings, despite only being associated with these outcomes.³¹ Changes in z scores are difficult to assess over the short term, and it is unclear whether measuring z scores over time reflect true changes in growth or whether these changes are obscured by the mathematical artifact of the increasing variability in children’s growth as they age.^32,33 Furthermore, inaccuracies in birth date reporting may distort z scores disproportionately for younger children.³⁴ As the goals of food assistance shift from simply preventing death to promoting well-being, our metrics need to tell us whether food assistance programs are contributing to more productive individuals and societies.^30,35 Three priority areas for food assistance outcome measures beyond z scores were identified during the Evidence Summit: body composition, brain health, and gut health. Examples of each are outlined subsequently; however, further research and testing are needed to determine the most useful and feasible field indicators in each category.

Body composition

Lean mass is associated with longer lasting recovery from undernutrition and less relapse, and body composition in children may be predictive of chronic disease later in life.^36
-38 There is controversy over the most precise and accurate ways of measuring body composition in the field. While measurements such as mid-upper arm circumference with skinfolds require minimal technology and are inexpensive, it is unclear whether they offer sufficient accuracy compared to more resource-intensive methods that may be more difficult to use in the field, such as bioelectrical impedance vector analysis³⁹ or isotopically labeled water.⁴⁰ New advancements such as use of digital images to assess body composition may address some of these concerns with noninvasive measures that could be easily adapted to both development and emergency contexts.⁴¹

Brain health

Studies have shown that children with severe wasting or stunting have lower cognitive function than those who are healthy.^42
-44 Even after “recovery” from wasting decreases the risk of mortality, deficits in cognitive function remain⁴² and can persist into adulthood.⁴⁵ Neurocognition can be measured feasibly in the field using a variety of performance-based cognitive tests and ones that measure physiological responses to stimuli.^46,47 These tests can be used to assess the impact of food-based interventions on neurocognition.⁴⁸ Further work is needed to improve efficiency of these tests and begin to incorporate them more regularly into food assistance evaluations.

Gut health

A large proportion of children in low-resource settings have chronic gut infections, leading to a syndrome referred to as environmental enteric dysfunction.⁴⁹ The resulting changes in structure and function of the small intestine reduce the child’s ability to absorb nutrients from the foods they eat and inhibit normal growth processes, which may contribute to lower micronutrient status and poor growth and development.^50,51 In addition, nutritional status is related to the health of the microbiome, the ecosystem of organisms that populate the large intestine.⁵² Current measurements of gut health pose challenges for field use. The dual sugar test that assesses gut permeability through urine collection places a burden on participants,⁵³ and interpretations of fecal sample messenger RNA transcript levels as indicators of gut permeability and inflammation are not yet well understood.⁵⁴ Further development of gut health indicators is needed to determine whether supplementary foods can be absorbed and effective in the presence of chronic gut inflammation.

These measures promise a more nuanced understanding of the physiology underlying malnutrition and the ways in which supplementary food can affect the process and durability of growth and development. They would provide practitioners with a greater understanding of program progress, impacts, and shortcomings, allowing for more effective program targeting. There is still room for z scores, but we need to consider when they are appropriate summary metrics and when more sensitive measures are needed to indicate when people are on the path to achieving a more comprehensive definition of health.

Collaborate Across the “Food Assistance Ecosystem”

The food assistance ecosystem refers to the system of actors along the entire supply chain of food assistance activities including funders, suppliers, packagers, shippers, on-the-ground partners, recipients, and researchers. It is diverse, necessitating multisectoral collaboration to ensure optimal interventions and maximize impact. An enabling environment for strong collaboration is especially important to build the case for continued investments in research, as multiple actors are able to stay informed of new evidence, evolve their thinking, and advocate for improvements based on the most recent science.⁵⁵ The following are essential elements to facilitating multisectoral collaboration.

Communication

Different technical sectors use varying language to define problems and outcomes, creating barriers to communication; further, they may have disparate priorities for addressing the same goals.⁵⁶ For example, the goal of improving nutritional status of women and children may be approached through activities targeting gender-balanced decision-making by one sector and by improved farming techniques by another. Actors in the food assistance ecosystem should recognize and reconcile the differences in approaches by sector to collaborate successfully and implement mutually reinforcing interventions. With common theories of change, definitions, and priorities comes the ability to generate and share relevant data, to gain leverage in securing resources, and to use stakeholders’ varied areas of expertise to address problems efficiently and effectively.⁵⁷

Collective learning

Effective collaboration and communication require transparency and collective learning to ensure that limited resources are used wisely and that efforts are not duplicated. Operationally, this requires data sharing and technical tools and resources for more effective and cost-effective food assistance programming (see Supplemental Table 3 for examples). The Global Food Fortification Data Exchange pools data from across the food fortification community and makes those data available for all stakeholders; this could serve as a model for data sharing within the food assistance for nutrition community.⁵⁸ More opportunities are needed for collective learning, collaboration, and resource sharing, whether through in person meetings and workshops or investment in central databases to highlight available resources. Collective learning could draw from other humanitarian fields engaged in similar activities, leveraging their best practices and lessons learned to inform novel solutions to persistent problems.

Systems thinking

The complex food assistance ecosystem necessitates a systems thinking perspective when problem solving and considering the feasibility and sustainability of innovations. This means considering the perspectives of all stakeholders involved in food assistance, especially recipients, and their respective implementation contexts. An optimization model developed by the WFP connected traditional supply chain considerations (commodity choice, transport modality, time horizon) with nutritional objectives. Using this model to optimize programming of their food basket in Iraq resulted in a 17% reduction of cost, while still being able to deliver 98% of target kilocalories.⁵⁹ Considering all points and actors across the supply chain and incorporating data analytics to understand the gains made from changes large and small provided tangible improvements to decision-making within this sector of food aid. This thinking should be taken all the way down to the “last mile” of product delivery when products are distributed to and used by recipients. Recipients are a critical part of the food assistance ecosystem who should be considered in interpreting research findings and subsequent decision-making regarding programs, policies, and innovations.

Public–private partnerships

Critics of public–private partnerships argue that proprietary product development for food aid limits the scope and pace of innovation and reach.⁶⁰ Competing organizational mandates and uncomfortable histories have prevented collaboration and impeded working relationships in the past.⁵⁶ But there are opportunities to leverage expertise, technology, and resources to spur innovations. The partnership between VALID Nutrition and Ajinomoto Co Inc, for example, combined VALID Nutrition’s existing field programs and Ajinomoto’s amino acids manufacturing abilities to develop alternative effective ready-to-use food formulations.¹³

Conclusion

Using evidence to make context-based decisions of optimal actions in food assistance for nutrition is critical in a time of increased need and constrained resources. The 4 key areas discussed here offer stakeholders a roadmap for a food assistance research agenda that will generate rigorous evidence, address outstanding questions and knowledge gaps, and inform cost-effective programs and policies. The cost of not investing in evidence to inform best practices using innovations and new insights is high, while the payoffs to such evidence generation are substantial. If food assistance is done well, it can contribute to more resilient societies and support global development goals that aim for good health and nutrition for all.

Supplemental Material

Supplemental Material, Advancing_nutrition_Green_at_al_Supplementary_Table_3 - Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit

Supplemental Material, Advancing_nutrition_Green_at_al_Supplementary_Table_3 for Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit by Lindsey Ellis Green, Ilana R. Cliffer, Devika J. Suri, Kristine R. Caiafa, Beatrice L. Rogers, Patrick J. R. Webb and On Behalf of the Food Aid Quality Review Project in Food and Nutrition Bulletin

Supplemental Material

Supplemental Material, Advancing_nutrition_Green_et_al_Supplementary_Table_1 - Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit

Supplemental Material, Advancing_nutrition_Green_et_al_Supplementary_Table_1 for Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit by Lindsey Ellis Green, Ilana R. Cliffer, Devika J. Suri, Kristine R. Caiafa, Beatrice L. Rogers, Patrick J. R. Webb and On Behalf of the Food Aid Quality Review Project in Food and Nutrition Bulletin

Supplemental Material

Supplemental Material, Advancing_nutrition_Green_et_al_Supplementary_Table_2 - Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit

Supplemental Material, Advancing_nutrition_Green_et_al_Supplementary_Table_2 for Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit by Lindsey Ellis Green, Ilana R. Cliffer, Devika J. Suri, Kristine R. Caiafa, Beatrice L. Rogers, Patrick J. R. Webb and On Behalf of the Food Aid Quality Review Project in Food and Nutrition Bulletin

Footnotes

Authors’ Note

L.E.G., I.C., D.S., and K.C. conceptualized and wrote the paper jointly. BR and PW provided guidance and comments on the manuscript. All authors read and approved the final manuscript.

Acknowledgments

This article is written on behalf of the FAQR project team. This article resulted from the Food Assistance for Nutrition Evidence Summit, supported by the USAID’s Office of FFP. The FAQR project is grateful for the contributions of all speakers, presenters, and participants in this event.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Food Assistance for Nutrition Evidence Summit and this publication are made possible by the generous support of the American people through the US Agency for International Development (USAID). The contents are the responsibility of Tufts University under the terms of Contract AID-OAA-C-16-00020 and do not necessarily reflect the views of USAID or the US Government.

ORCID iD

Lindsey Ellis Green

Supplemental Material

Supplemental material for this article is available online.

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