It is easy to see the beginnings of things, and harder to see the ends.

At least, that is what Joan Didion wrote in “Goodbye to All That.” She was referring to herself when she moved to New York City and unexpectedly stayed for a good long while. Maybe too long.

I have been thinking a lot about what she wrote, feeling the palpability of those words as we mark our 30th day in self-isolation amidst a global COVID-19 pandemic, without a clue to where we are within it. The end is indeed abstruse. Are we at the beginning of it? Are we in the middle? Or nearing the end? It is harder to see, know, or predict when this will all resolve, and no Jim Morrison, the end is not always near.

We saw COVID coming for a while now. We had early lessons of historical pandemics in which many of us mortal souls perished. The Plague (killing 200+ million), the Spanish Flu (killing 50+ million), and HIV/AIDS (killing 25+ million and still going on). The visual below shows the impact of these pandemics killing 25 to 35% of the total global population. We have also been warned over the last two decades that more and more zoonotic diseases — i.e. animal to human transmitted diseases — are coming and creeping into our food supply. Think avian and swine flu, SARS, and MERS.

Then there are other infectious diseases that are downright scary, but seem to be contained to certain regional epidemics. Think Ebola and Zika. These have never quite made the jump to be classified as a “pandemic” which is classified as a disease impacting every country in the world, yet.. Then there are the insidious, neglected and tropical diseases like river blindness, Leishmaniasis, and Guinea worm that impact people living in the poorest areas of the world. And Dengue and malaria continue to wreak their widespread havoc. The warnings were and are persistently there.

The beginning of COVID-19 was surreal, yet predictable to witness, much like watching the beginnings of Steven Soderberg’s movie Contagion (a virus that spread from China to the rest of the world via air travel, killing 25% of the global population, which stemmed from a bat to pig to human food system zoonotic transmission). Noticing events unfold mid-to-late December in China, as it quickly made its way through some Asian countries, and then slammed into Italy, were obvious signs that this virus moves fast and stealthy, and does not discriminate. And it was coming for everyone, leaving no one behind. Observing the way governments responded to tampering down the virus has been mixed, with the U.S. being way too slow to move and react, and with a “president” who not only doesn’t understand the science but doesn’t care to learn and listen to the experts (like the great Tony Fauci) who surround him reluctantly. Now, the country is reeling from the highest number of cases and deaths in the world.

We also had knowledge and evidence of how such a pandemic would unfold and how the food system is particularly vulnerable to being the source and breeder of these zoonotic type diseases. Now one might wonder if COVID-19 is truly a zoonotic disease. Its origins are being debated in the scientific literature. While there are some thoughts that the virus originated from a wet market in Wuhan, scientists are still unclear about its origin. Did it come from animal and if so, which one(s)? Did it really come from a seafood market or from food at all? There are many early assumptions that it came from snakes or pangolins. The science is leaning towards snakes not being the source. Viruses have a hell of a time jumping from warm-blooded to cold-blooded back to warm-blooded. And it is thought overall that COVID-19, like SARS, is a mammalian virus. There was one article in late January 2020 in the Journal of Medical Virology that though some of the genetic code of the COVID can be found in two snake varieties, but that has been discredited.

There is an interesting article in Nature that is trying to determine its origins. The starting point is the genome: 80% of the COVID-19 genome is shared with SARS and 96% with bat coronaviruses. They hypothesize that the origin of COVID-19 is either natural selection in an animal host before zoonotic transfer (bat to pig or bat to pangolin) OR (ii) natural selection in humans following zoonotic transfer (so human to human, i.e. SARS to COVID).

I am going to write more about zoonotic (also known as zoonoses) diseases for a new blog series myself and some stellar colleagues are curating on COVID-19 and nutrition. Still, for now, it is of the utmost importance for the global community to prevent these food-borne zoonotic diseases in the future. Scaling up a “One Health” approach is one way to prevent future pandemics.

Humans co-exist with animals - as companions for our overall wellbeing, as producers of food, and as a source of livelihoods. This interface between animals and humans and their shared environments can be a source of disease too. Those who work on One Health work at this interface to prevent zoonotic diseases from spreading by considering animal, human, and environmental connections.

But here we are, with each day running into another, wondering if tomorrow will be different or more of the same. For now, we are stuck in this endless cycle of a beginning. But maybe this is a new beginning - one of a new reality, a new way to see the world and our place in it, and a new appreciation of what we have and a profound sadness and empathy for those who have less or have suffered loss, in every shape and form. The question is, when the end is near, or even better yet, comes and COVID-19 is in the rearview mirror, what will we be as a human society then? Hopefully, one that is better informed, ready, and resilient for the next one.

Food Bytes: July 8 - July 20

Food Bytes is a weekly blog post of “nibbles” of information on all things food and nutrition science, policy and culture.

Food environments seem to be on the tip of the tongue for everyone these days. Food environments are the “collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence people’s food choices and nutritional status.” Or to put it more simply, it is the place where consumers go to buy or order food - a market, a restaurant, a cafeteria.

The UN Standing Committee on Nutrition, also known as UNSCN, has just published a collection of papers on the food environment. It splits up the food environment into two entry points - the food supply shaping these environments and the consumer demand side - and what it would take to make change, also known as the enabling environment. The publication is chock-full of case studies from all over the world. I like the ones on Mexico, the private sector last mile, the flathead reservation, cash transfers, and the digital influence.

Food Environment Framework showing supply and demand. Source: Marshall et al 2019 UNSCN report

In South Africa’s Soweto hood, women struggle to be healthy. Food environments are pretty dismal (fries, fries and more fries), and exercising outside can be dangerous. It is not just about supply and demand of healthy foods, which the UNSCN publication focused on, but the whole built environment, the way women are treated in our society and urban safety. At the same time, its seems many South Africans are taking food security into their own hands. One study found that 2.2 million households have recently constructed food gardens at their homes in order to avert food insecurity.

While we are on the lovely UN, the UN Committee on Food Security is rolling out a series of regional consultations on what is known as the Voluntary Guidelines on Food Systems and Nutrition. This stems from the High Level Panel of Experts on Nutrition and Food Systems report which called for these guidelines to be developed by governments collectively and collaboratively. These voluntary guidelines are meant to create a global norm of reference in the governance of food systems and nutrition/diets. The guidelines outline principles and practices that governments can refer to when making laws and administering food systems. These guidelines should be seen as an internationally negotiated soft law or a set of guidelines in which all governments have reached a common ground. So, they can be important, and quite powerful. Anyone can comment on the zero draft - far from its final - here. The regional consultations started in Africa, Ethiopia. Then, Asia, Bangkok. Then Central and South America, Panama, North Africa, Egypt, Europe, Budapest and last but not least, North America. I had the pleasure of being at the Ethiopia meeting and it was quite fantastic to have so many African countries in one room talking about African food systems. Amazing stuff.

Source and Copyright: Johnny Miller, NYT 2019

Speaking of Africa, the diversity of cuisines and culture is what makes the continent so amazing. Take Nigeria. Reading Yewande Komolafe’s recipes made me want to jump on a plane to Lagos and eat my way through it.

But it is not always a rosy picture for Africa. The continent is still struggling with food insecurity, while at the same time, obesity is creeping up, up and up. The FAO State of Food Insecurity (SOFI) 2019 report just came out, two months early. It was reasoned that it came out to line up with the High Level Political Forum. Yeah sure. I think it was timed to be released right before the Director General, José Graziano da Silva stepped down to celebrate his 8 years as the leader of FAO. However, the report is nothing to celebrate. I digress…The major findings of the SOFI were the following:

  • More than a quarter of the world’s population now struggles to eat safe, nutritious and sufficient food.

  • Hunger is on the rise in most of Africa, in parts of the Middle East and in Latin America and the Caribbean. The situation is most alarming in Africa, where since 2015 undernourishment has steadily increased in almost all subregions. In Asia, undernourishment has been decreasing in most regions, reaching 11.4 percent in 2017. In Latin America and the Caribbean, rates of undernourishment have increased in recent years, largely as a consequence of the situation in South America.

  • Economic shocks are contributing to prolonging and worsening the severity of food crises caused primarily by conflict and climate shocks.

  • No region is exempt from the rising trends of overweight and “obesity rates are higher in those countries where moderate food insecurity is also higher.”

We see this in the United States too. I just wrote a piece for Bloomberg Opinion (I didn’t choose the photo.) showing that food insecure adults in the U.S. are 32% more likely than others to be obese — especially if they are women. Poverty and unemployment have driven the dual rise in food insecurity and obesity since the 1960s, especially in rural America. But many city dwellers subsisting with inadequate social services and support structures are also susceptible. Every time I write a piece in Bloomberg Opinion, I always get lots of interesting email comments. For this piece, most commenters feel that if you are fat, it is your fault. If healthy foods are available, affordable and easy to access, “these people” will always make the wrong choice. My reaction? WOW. It is so hard to eat healthy in our perverse food environments. Blaming and shaming is not going to make things better. But it seems, consumers are catching on in the U.S. - diet quality is improving.

But what does the latest evidence suggest for those who are overweight and want to lose weight? I will soon dedicate a longer blog to this issue because the literature is confusing. Is it a keto diet? Is it intermittent fasting? Is it low-carb? Is it putting a teaspoon of oil in your coffee every morning? New evidence suggests that cutting 300 calories per day, from any food, can lead to substantial weight loss in adults (7.5 kilos over two years) compared to the control group. Tamar Haspel of the Washington Post, argues that eating ultra-processed foods comes down to increased calorie consumption. We consume more of those foods, and they are calorically dense. She wrote:

“In a nutshell: The root of obesity is palatability and calorie density, combined with ubiquity and convenience. Satiety hormones and other metabolic machinations have much less to do with it. We’re responding to cues from without, not from within. One new study doesn’t prove it, of course, but it’s the hypothesis that best fits the preponderance of the evidence.”

I really appreciate this article that “Being Fat is Not a Moral Failure.” Damn straight. This Scientific American article argues “Individual behavior change is ineffective in the face of social and structural barriers that constrain individual choice. These barriers are uniquely relevant among racial and ethnic minorities and impoverished adults who are more likely to be obese.”

A bunch of scientific papers and media articles came out this week on diets, nutrition, and food systems. Here are some highlights.

Kathmandu food stall - healthy and unhealthy foods. Source and Copyright: Jess Fanzo

  • “Ultra-processed” foods or what I call, junk food, are in the news again. This article outlines four dangers with food reformulation - redesigning an existing processed food product with the objective of making it healthier. This article argues that reformulation just tinkers around the edges, and isn’t really fixing the root problems of the food system, and what the authors say is food and beverage industries.

  • Case in point? Nearly 10,000 cases of heart disease and stroke and 1,500 cases of cancer could have been avoided in England if the government had not switched to a voluntary deal (as opposed to mandatory) with the food industry to cut salt in food. England is doing so much good stuff in the food space right now, but man, there are potential setbacks with Brexit and political shifts. This BMJ post by Annie Purdie and colleagues is concerned about Boris Johnson’s recent decision to look at “sin taxes” and creating a nanny state. The authors argue that the public health community needs to “move beyond debating the cost-effectiveness of interventions, and engage with the underlying political nature of the issue.” We need to pay more attention to the language (sin, nanny, liberties etc) used to highlight the problem and the proposed solutions like taxes on soda and regulating the levels of salt and sugar in foods. As Bob Marley sang, “don’t let ‘em fool ya.”

  • There is more and more coming out that nutritional sciences is “broken.” In this article, they use the “eggs are again bad for you” study that came out in JAMA. Waah. Is it? I disagree! Of course, when we focus on specific foods and nutrients, the data is not clear, but dietary patterns show basically the same thing. Give it a rest dudes.

  • While these researchers argue that more evidence is needed, they did find that snack foods and sugar‐sweetened beverages are providing a substantial proportion of energy intakes (ranges from 13 to 38%!) among children below 2 years of age in Latin American and South‐east Asian low and middle income countries.

  • A study in the capitol of Nepal, Kathmandu, showed just that consumption of unhealthy snack foods and beverages contributed 47% of total energy intake among the wealthiest consumers, compared with 5% among the poorest. This pattern of junk food consumption among young children was associated with inadequate micronutrient intakes. The reason that mom’s give these foods to their children? Convenience - they are easy to prepare and easy to feed. Makes sense. Looks like even among very poor countries, we are seeing the nutrition transition play out in real time. Ever try making dal bhat from scratch? Not easy and incredibly time consuming…

  • I love that the Lancet is calling on oral health researchers to review the evidence and conflicts of interest of the impacts of what we eat on our dental health and the caries that come with sugar consumption. The lead scientist argues, and this goes back to the infant studies: “A particular concern is the high levels of sugar in processed commercial baby foods and drinks which encourage babies and toddlers to develop a preference for sweetness in early life. We need tighter regulation and legislation to restrict the marketing and promotion of sugary foods and drinks if we are to tackle the root causes of oral conditions.”

  • New microbiome research shows that a specialized food made up of chickpeas, soy, peanuts, bananas and a blend of oils and micronutrients substantially boost microbiome health in severely malnourished children. Yummy.

  • Do cookbooks need nutrition labels? Great question but sort of takes the fun out of cookbooks no?

Some things have improved for food security and nutrition. Source: Byerlee and Fanzo, 2019 GFS Journal

Derek Byerlee and I wrote a piece looking back 75 years on commitment to hunger when the first international commitment to ending hunger was made at the UN Conference on Food and Agriculture, at Hot Springs, Virginia, USA in 1943. That conference set the goal of ‘freedom from want of food, suitable and adequate for the health and strength of all peoples’ that should be achieved ‘in all lands within the shortest possible time’ (US Department of State, 1943). It is sobering and shameful that 75 years after this clarion call, as well as the dozens of similar global declarations since 1943 for ending hunger, some 800 million persons are estimated to be undernourished and over 2 billion adults and children suffer from other forms of malnutrition be it obesity or micronutrient deficiencies. We remind readers of the significance of the Hot Springs conference and briefly trace the long road that has led us back to the original vision of ending hunger that recognized the several dimensions of nutrition, from undernourishment to micronutrient deficiencies. While there has been progress, this reflection over 75 years helps appreciate the fact that today for the first time, the links of agriculture, health and nutrition outlined in 1943 are again at center stage in the global hunger challenge as embraced in SDG2. Accordingly, SDG2 offers a better foundation for accelerating progress in reducing malnutrition in its several dimensions, although we recognize major gaps in knowledge, financing, and implementation capacity for realizing SDG2 targets.

Someone else is realizing the importance of agriculture. It seems Bill Gates has woken up to the fact that the CGIAR exists. His article is titled “You’ve probably never heard of CGIAR, but they are essential to feeding our future.” Hate to spoil it Billie Boy, but we have heard of the CGIAR…and I don’t confuse it with the word “cigar,” cigarillos, ciggies, or ziggie stardust.

Country ratios of fruit and vegetable availability to WHO age-specific recommendations. Source: Mason-D’Croz et al 2019

Country ratios of fruit and vegetable availability to WHO age-specific recommendations. Source: Mason-D’Croz et al 2019

On the environmental and climate change front, lots going on. The World Resources Institute released a mother of a report - 564 pages - on Creating A Sustainable Food Future. You may have seen the abbreviated version released 6 months ago. But this one goes into great detail a 22-item “menu” which is divided into five “courses” that together could close the food, land and greenhouse gas gaps: (1) reduce growth in demand for food and agricultural products; (2) increase food production without expanding agricultural land; (3) protect and restore natural ecosystems; (4) increase fish supply (through improved wild fisheries management and aquaculture); and (5) reduce GHG emissions from agricultural production. Richard Waite and Janet Ranganathan are seriously my heroes in creating these action oriented solutions. Well done.

Following on the heals of that report, two Lancet Planetary Health papers came out. One paper shows that even under optimistic socioeconomic scenarios future supply of fruits and vegetables, central components of a healthy diet, will be insufficient to achieve recommended levels in many countries. Consequently, systematic public policy targeting the constraints to producing and consuming fruits and vegetables will be needed. The second paper shows climate change and increased atmospheric CO2 will impact the availability of protein, zinc and iron availability. The many countries that currently have high levels of nutrient deficiency would continue to be disproportionately affected.

This expose by the Guardian shows that Brazil’s huge beef sector, and the appetite for beef, continues to threaten health of world’s largest rainforest, the Amazon. This is just downright sad.

And while those of us in nutrition don’t really get to the larger social determinants of food insecurity and malnutrition, it is important to do so. This article in NPR’s Goats and Soda delve into the practice of trading sex for fish in Lake Chilwa in Malawi. This is driven by poverty and food insecurity and the impacts are catastrophic in this southern African country - HIV, violence and stigma - for these women.