A Bucket Full of Sugar

This week, the World Food Programme (WFP) and their partners convened for the 2014 World Economic Forum in Davos, Switzerland, united in their common goal to improve the nutritional status of children everywhere.

It was announced that a new project to establish best practices for tackling stunting has been launched in Malawi. Recurrent food insecurity, poor dietary diversity and repeated illness are among the root causes of stunting (low growth for age) among nearly 1 million Malawian children under five.

This project targets children up to two years of age, and their mothers, over a three-and-a-half year period, and is designed to reduce stunting by 5-10 percent, as well as build evidence for the best ways of tackling the problem. Later in the year, the project will be introduced to Mozambique. By helping children to first survive, and then thrive and grow into adults, this programme should ultimately contribute to national development through greater productivity and higher lifetime earnings.

Funded by the Children’s Investment Fund Foundation (CIFF) at a cost of US$10 million, the stunting prevention project is supported by the Government of Malawi, WFP and other members of the Scaling Up Nutrition (SUN) initiative. World Vision (WV) has been selected by WFP as the lead NGO partner for project.

This ‘innovative’ project claims to be founded on the latest evidence about the most effective nutrition and hygiene interventions. ‘This project will deliver the right foods at the right time and aims to improve education about feeding practices as well as access to proper nutrition.’ A stunting-focused communications campaign has been initiated to increase awareness about the best infant and child feeding practices, hygiene, and the use of a lipid-based nutrient supplement, Nutributter, which will be provided to all registered children aged 6 to 23 months.

No one disputes the evidence showing the potential to make the greatest difference in the lives of children lies in the crucial 1,000 days between conception and two years of age, but WFP’s and WV’s record of delivering ‘the right food at the right time’ is highly questionable. When WFP Representative, Coco Ushiyama, states, “Through strong partnerships, multi-sector engagement, a strong evidence-based approach and IT solutions, we want to show the world that we can and must address stunting,” I too feel excited, but let us look at the evidence.

One of the main reasons that people are undernourished in the first place is the ubiquitous consumption of refined cereal and sugar. Monoculture and NPK farming has already ensured that our cereal crops contain only a fraction of the nutrients they used to contain. We then compound the felony by refining them. This process removes most of the important micronutrients. What is left is best described as ‘empty calories’.

It would make sense to stop refining cereals, but that is not on anyone’s agenda. Instead, we attempt to fortify these empty calories with chemicals, courtesy of the pharmaceutical industry. This is on everyone’s agenda, despite the plethora of evidence that phytic acid in cereal grains forms insoluble and non-absorbable complexes with these added chemicals, and the overwhelming evidence from South Africa that the fortification of maize and wheat flour over several years has achieved little, if anything.

Despite this, the distribution of corn soya blend (CSB) – a refined and fortified cereal blend – continues to be promoted by WFP and WV.

Another approach, for which there is little evidence of benefit, is the use of Sprinkles. The idea here is that one can sprinkle the micronutrients that are missing from the diet directly onto the food. The Soofi study in Pakistan was a large and authoritative RCT within the SUN 1000 Days initiative. It used Sprinkles to get micronutrients to the study group. Intervention was for an extended period. But the results were appalling. Haemoglobin improved in the treated groups but they all remained anaemic. The improved growth in the one group was paltry. Serum zinc and retinol showed little change. One wonders what happened with the Vitamin C, Vitamin D and Folic Acid because, although they were in the intervention, they never got another mention. Side effects were serious and militated against any benefit. These included diarrhoea, even though zinc is believed to be important in controlling infant diarrhoea. This is not an intervention that anyone would wish to recommend and it comes as no surprise to those who understand the importance of nutrient form. The Nepal UNHCR research also showed no benefit.

Despite this, the use of Sprinkles enjoys widespread support.

But the big gun in our armoury is apparently Plumpy’Nut. In the Malawi project, a specialised, ready-to-use product, Nutributter, will be provided to all registered children aged 6 to 23 months. For Nutributter, read Plumpy’Nut.

Plumpy’Nut is promoted and marketed across Africa as a major breakthrough in the fight against malnutrition. Manufactured by the French company, Nutriset, it was designed by Dr André Briend to be used for a maximum of two to three weeks in cases of severe acute malnutrition. This may well be appropriate, but it is not the reality on the ground, where Plumpy’Nut is hailed as a miracle food and as the solution to malnutrition, particularly in Africa. This is complete nonsense, but it goes unchallenged as a claim.

Plumpy’Nut is a combination of powdered milk (30%), sugar (28%), peanut butter (25%), cotton-seed oil (15%) and vitamins and minerals, as chemical isolates. It has the consistency of a paste. The dangers of high levels of refined sugar and fat for young children are now so well understood that the British Government recently banned all advertising to young children of such products. This ban would include Plumpy’Nut. Furthermore, high levels of protein in malnourished children can cause diarrhoea.

The only scientific evidence that I can find anywhere is that Plumpy’Nut increases body mass index (BMI) and mid upper arm circumference (MUAC). As I have stated, this may be useful to rescue someone who is dying, but increases in BMI or MUAC in the moderately malnourished tell us nothing about nutritional status, unless we believe that fatter kids are healthier kids. I have not seen any evidence that it makes children nutrient replete, or that it improves nutritional status. As far as the vitamins and minerals are concerned, Plumpy’Nut uses a micronutrient mix of chemical isolates that will have little impact addressing the nutritional needs of the malnourished.

The project protocol, entitled ‘Formative research to develop culturally-appropriate, supplementary feeding programs for children 6‐23 months in rural Mozambique and Malawi’, states, inter alia, that it will identify potential barriers and facilitating factors to appropriate complementary feeding, and that these findings will be used to develop culturally-appropriate message and communication strategies based on local food concepts and behaviour to successfully promote age‐appropriate, energy‐dense foods, including but not limited to Nutributter, which will yield appropriate and sustained usage among children 6‐23 months.

It frankly horrifies me that ‘developing culturally-appropriate, supplementary feeding programs for children’ is a euphemism for weaning them onto daily high fat, high sugar ‘treats’. In Davos 2013, Marc Van Ameringen, Executive Director of the Global Alliance for Improved Nutrition (GAIN), highlighted the links between under-nutrition and over-nutrition – or obesity – and how many emerging countries suffer from what is referred to as a double-burden of malnutrition.

So, wake up and get real. We should not be intervening in the diets of children unless we have solid evidence that our interventions improve their nutritional status. We need to measure the deficiencies and show that our interventions have corrected them. None of the interventions mentioned above are evidence-based, and none of them will produce nutrient-replete children. Nor will this so-called research add anything useful to our body of scientific knowledge, but then I suspect it was never meant to.  The children will continue to suffer, and we will have failed them yet again.

Geoff Douglas, CEO HETN

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Bioavailability and Bioefficacy

The failure of supplementation and fortification is an issue of bioavailability and bioefficacy. Bioavailability is about absorption and it is a prerequisite for bioefficacy. If a micronutrient is not absorbed, it cannot be effective. When, for example, ferrous sulphate or zinc chloride is added to milled grain, the phytic acid in grain forms insoluble iron or zinc phytates, which cannot be absorbed (low bioavailability) and, therefore, cannot be effective (low bioefficacy).

However, high bioavailability does not guarantee bioefficacy, which is about a beneficial metabolic outcome. Anything can get into the body via a concentration gradient but that does not mean it is necessarily useful or beneficial. Isolates may pass straight into the blood stream unchecked, whilst complex food molecules are directed through a series of metabolic processes which ensure correct metabolic outcomes. The associated food factors (amino acids etc) that are combined with nutrients in food act as intrinsic signalling agents – or messengers –  to direct the nutrients through uptake channels to the sites of need  (see Gunther Blobel’s Nobel Prize winning work). Unless the uptake of nutrients is regulated by the body, they do not necessarily end up where needed and can place an undue burden on excretory pathways.

Iron is a good example of this. In the form of ferrous sulphate and other isolates, it has low bioavailability (poor absorption) and low bioefficacy, in that much of what is absorbed is deposited in the liver, where it is not needed and where it is can cause damage. What remains in the gut can cause severe side effects, including bloody diarrhoea, and subjects can even end up more anaemic than they started. Hurrell evaluated current wheat flour iron fortification programmes in 78 countries, and concluded that most are likely to be ineffective.  Calcium is another example. In the form of calcium carbonate, it has low bioavailability and low bioefficacy, in that much of what is absorbed is transported to the kidney for excretion. Minerals in a food form do not have these disadvantages, yet ferrous sulphate and calcium carbonate remain the most commonly used supplements and fortificants.

Selenium-rich yeast has been deemed by the European Food Safety Agency (EFSA) to be wholly safe, non toxic, a protector against cancers, antiviral and beneficial to human health, whilst both sodium selenite and selenate are classified as dangerous and toxic. They are ineffective as antioxidants, they can be carcinogenic and genotoxic, and they may contribute to reproductive and developmental problems in animals and humans. Nonetheless, they remain the primary forms of the mineral prescribed, sold as supplements and used as fortificants in today’s mass market. The reason for the safety of selenium in a food form (yeast, in this case) is that absorption is self-regulating. Once the body is replete, selenium is no longer taken up.

Food forms of Vitamin C are stable, complex molecular structures with many associated flavonoids, flavones and esters. The associated food components are responsible for the tissue uptake and storage of food vitamin C, which is retained by the body until needed. Vitamin C in this form is a powerful antioxidant, helps form and maintain collagen, supports the immune system, helps iron absorption, the growth and repair of tissue, etc. However, the most commonly used form of Vitamin C is pure ascorbic acid – a simple molecule that is notoriously unstable and heat susceptible. It is well absorbed, but is excreted within two hours of ingestion. During its short journey in and out of the body, it will carry with it water-soluble free radicals, which is beneficial, but it is not the totality of the potential of vitamin C found in food. Moreover, in high doses, pure ascorbic acid is a gastric irritant, whereas food forms are well tolerated. So both are bioavailable, but the food form is more bioeffective.

If you look at Paul Offit’s article, Don’t Take Your Vitamins, just published in the New York Times - http://www.nytimes.com/2013/06/09/opinion/sunday/dont-take-your-vitamins.html - what he is writing about is low bioefficacy. Although he doesn’t make the point, he is actually writing about the harmful effects of isolate micronutrients.

Geoff Douglas

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A Fly in the Ointment

I have recently attended two meetings in Amsterdam and Frankfurt in support of Ashoka’s Nutrients for All initiative – http://nutrientsforall.org. Within this framework, HETN is solidly behind Ashoka’s aim to promote and build a Nutrient Economy – a value chain built around nutrient repleteness, encompassing the environment, agriculture, food and human health. A focus on the full nourishment of people, food and land uncovers clear priorities for action and provides an explosion of opportunity for economic and social transactions.

This is exciting stuff. As I stated in Frankfurt, the Ashoka conference was the realisation of a dream – the realisation of a hope that social entrepreneurs, people of influence, NGOs, international agencies and big business could begin to sit down together, roll up their sleeves and make a plan.

But there is a fly in the ointment. When I was doing my masters in occupational medicine many years ago, we learned about REC – Recognition, Evaluation and Control. Nowadays this all seems to fall under the heading of Risk Assessment, but what remains crucial is that no evaluation will ever take place and no control will be effectively implemented until there is recognition that there is a problem.

The problem that I was yet again raising is the issue of nutrient form and its influence on bioavailability and bioefficacy. Before you switch off and read someone else’s blog, let me hasten to suggest that if your doctor diagnosed iron deficiency anaemia and suggested that you suck a few rusty nails (ferrous oxide), or diagnosed osteoporosis and suggested you munch on some chalk, you might decide to find another doctor. But, I hate to tell you, this is almost exactly what your doctor does.

Those who have bothered to look at the evidence know that our soils and our foods have become depleted of nutrients in the race to maximise yield. It is also true that it is not the primary producers, but the processors of our food who take the lion’s share of any profit, and it is the grain refiners, in particular, who go out of their way to remove every last trace of useful nutrient from flours (to meet consumer demand, I am reliably informed). But the very industries that conspire to deplete our food are ready with the solution in the form of chemical fortification.

Please take a look at my slide presentation on The Challenge of Form on HETN’s website – http://www.hetn.org. In Frankfurt, representatives from both Nestlé and GAIN (Global Alliance on Improved Nutrition) attacked me for suggesting that current mainstream fortification programmes were in some way flawed, but they are.

Geoff Douglas

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Nutrition and the Millennium Development Goals

After a recent visit to South Africa, Swaziland and Mozambique, I feel that it is necessary for me to expand on this subject.

Close to a billion people suffer from hunger, and malnutrition has implications for all of the UN Millennium Development Goals.

But if we are serious about improving nutrition, at a minimum we need to:

  • Remunerate producers on nutritional content, rather than yield. Deep ploughing, monoculture and artificial fertilisers have conspired to reduce the nutritional content of our food. A growing plant takes up to 60 minerals from the soil. Fertilisers put three back – N, P & K.
  • Eat fresh, local and seasonal. ‘Dig for Victory’ was the successful wartime mantra that called for everyone in Britain to keep an allotment. In Southern Africa, rural people used to grow a little maize (plus sorghum, millet, ground nuts, pumpkin, sweet potato and cabbage), pound it locally (whole grain) and eat it as part of a balanced diet that included wild spinach, hibiscus shoots and guavas. 
  • Stop refining grain. In Southern Africa, refined maize has become the staple food. The milling process removes the husk (roughage), the membrane (vitamins) and the germ (omega fats, vitamins and minerals). What is left (empty calories) is sold for human consumption. We forget that it was polished rice that caused the fatal disease, beriberi (thiamine deficiency), and that it was the introduction of the National Loaf (wholegrain) in wartime Britain that helped to ensure that, by the end of the war, the UK was healthier than it had ever been. Nearly 70 years on, it is disconcerting to read in the British Food Journal, Volume 44, 4 of 1942: 

The unanimous verdict of those who are best qualified to express an opinion supports the conclusion that adequate nutrition is the prime requirement for the physical well-being of mankind. It is deplorable, therefore, that so little has been done hitherto in the sphere of national welfare to support the findings of science in favour of the more adequate loaf which has been so powerfully advocated for years. It is no exaggeration to state that the ‘white loaf’ has been a real impediment to an improvement in the hygienic development of the growing child, more especially those of the poorer section of the community for whom bread is the main food. As the much impoverished wheat of the ‘white loaf’ is a matter for considerable national concern, it is an anomaly that it should be permitted, seeing that similar impoverishments of natural foodstuffs (such as the watering of milk) have long been punishable by law.

  •  Ban trans fats. We used to be taught that margarine was healthier than butter. I am referring here to the margarine of the day, which still abounds in many parts of the world. We now know that this trans fat is vastly inferior to butter and extremely dangerous to health. 
  • Seriously reduce our consumption of sugar, high fructose corn syrup, fat and salt. In rural Africa, diabetes, high blood pressure and ischaemic heart disease used to be extremely rare. They have now reached epidemic proportions, and sugar (fructose), saturated fat and salt are the culprits. We should traffic light label all processed foods. The FSA in the UK supports this. 
  • Stop filling the bellies of hungry children in the third world with refined cereal (CSB) or products that are high in fat and sugar (Plumpy’Nut). Plumpy’Nut contains powdered milk (30%), sugar (28%), peanut butter (25%), cottonseed oil (15%) and vitamins and minerals (as chemical isolates). The dangers of high levels of sugar and fat are now so well understood that the UK Government bans all advertising to young children of such products. André Briend, its creator, states that Plumpy’Nut does contain a lot of sugar and fat, but argues that it is designed for short term use in severe acute malnutrition (SAM). I accept that Plumpy’Nut has a place in such emergency situations, but this is not how it is being promoted. 
  • Stop believing that mid upper arm circumference (MUAC) and body mass index (BMI) are useful measures of nutritional status. MUAC correlates with risk of death in SAM, but increases in BMI or MUAC in the moderately malnourished tell us nothing about nutritional status, unless we believe that fatter kids are healthier kids. 
  • Stop believing that we can correct micronutrient deficiencies by adding these to food in the form of chemical isolates, courtesy of the pharmaceutical industry. GAIN has been doing this in South Africa for years and has not addressed the problem. 

The typical shopping basket in Southern Africa today contains refined maize meal, refined white/brown bread, white sugar, cooking oil and traditional margarine. People everywhere need a diet that is based on whole grains. It should be low in fat and sugar. It should contain all the vitamins and minerals that would ideally be sourced from fruit and vegetables in a form that is bioavailable.

Geoff Douglas, CEO – Health Empowerment Through Nutrition

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Cholesterol Confusion

I recently spotted an article in a magazine which stated that doctors have finally decided that eggs are good for us, and that the old adage ‘Go to work on an egg’ might actually be good advice. And why was this ever in doubt? The problem is that eggs are rich in cholesterol, along with shellfish and other exciting foods, and cholesterol is bad for us, isn’t it?

Oh dear, oh dear. When I was a biochemistry student in the 1960s, I had to write a lengthy essay on the difference between a cholesterol lowering diet and a low cholesterol diet, and to discuss the health importance of each.

 We knew then – 50 years ago – that a cholesterol lowering diet was one that was low in saturated fat (animal fat) and contained a higher proportion of polyunsaturated fat (vegetable oil), and that a low cholesterol diet was of no significance to health because our blood cholesterol level is not influenced by the cholesterol in our diet. So, it has taken 50 years for this to permeate down to some of the nutritional gurus, and many of us have denied ourselves healthy food because it might contain a smidgeon of cholesterol.

Of course, some more pernicious myths have been debunked over time. Any doctor my age would have been taught that margarine was healthier than butter. I am referring here to the margarine of the day, which still abounds in many parts of the world. Of course we now know that this trans fat is vastly inferior to butter and extremely dangerous to health. Do I hear any apologies? Has it been withdrawn from the market? Sadly, no.

Is it any wonder that the general public is confused and sceptical?

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Nutrition and the Millennium Development Goals – Let’s get real

It is well worth reading the recent statement from the UN Standing Committee on Nutrition.

It is true that close to a billion people still suffer from hunger. It is also true that malnutrition has implications for all eight of the Millennium Development Goals.

The problem I have with the recommendations is that they include nebulous statements like:

‘Scale-up and adapt direct nutrition interventions that have proven effective. It is urgent to build on existing efforts and experience, to review and disseminate good practices and to ensure integration of relevant sectoral interventions’.

What on earth does this mean?

If we are serious about improving nutrition, at a minimum we need to:

  • Remunerate producers on the nutritional content of the food they produce. Currently they are remunerated on the yield.
  • Eat fresh, eat local and eat seasonal. Home grown is best.
  • Stop refining grain.
  • Ban trans fats.
  • Seriously reduce our consumption of sugar, high fructose corn syrup, fat and salt.
  • Traffic light label all processed foods. The Food Standards Agency in the UK supports this. The European Commission, most manufacturers and many supermarket chains reject it. I can guess why.
  • Stop filling the bellies of hungry children in the third world with corn soya blend (refined cereal), Plumpy’Nut (high fat, high sugar) or XanGo Meal Pack (non dairy creamer).
  • Stop using mid upper arm circumference (MUAC) and body mass index (BMI) as a measure of nutritional status – unless we believe that fatter kids are healthier kids.
  • Stop believing that we can correct micronutrient deficiencies by adding these to food in the form of chemical isolates, courtesy of the pharmaceutical industry.

Unfortunately, these basic measures involve trampling on the toes of vested interest, so are unlikely ever to be implemented.

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Now is the time to tax sugar

In the current global economic recession, governments are looking for ways to increase income and reduce expenditure. They need look no further than sugar. Our love affair with sugar is an addiction and it is killing us. No one needs it.

Sugar (sucrose) is a disaccharide made up of two monosaccharides – glucose and fructose – in equal proportions. Many people believe that sucrose is healthy because it is a natural substance, and infer that fructose is even healthier because it is found in fruit.

Let’s begin by dispelling these myths. Firstly, there are many natural substances that are toxic, and some are extremely toxic. It is true that fruit contains fructose, but when we eat fruit – rather than fruit juices – the amount of fructose we consume is modest.

Whereas every cell in the human body can use glucose as an energy source, only one organ can handle fructose – the liver. This fact alone should alert us to its ‘foreign’ nature. And what does the liver do with all the surplus fructose? Well – surprise, surprise – it turns it all into fat. This is then shipped off to other parts of the body for storage.

So, fructose makes us fat? It does indeed, but the bad news doesn’t end there. When consumed in excess, fructose also causes an increase in:

  • Blood fat levels – triglycerides, total blood cholesterol and LDL (bad) cholesterol
  • The prevalence of type 2 diabetes
  • The prevalence of high blood pressure
  • The prevalence of abnormal blood clotting and heart disease

Today, the average US citizen consumes 20 teaspoons of added sugars per day. For teenage males the figure is 34 teaspoons. This equates to some 25% of total calorie intake – ‘empty calories’ that not only fail to provide food value, but actually rob the body of essential nutrients. 70% of the consumed sugars come from manufactured foods, where the label may describe them as corn sweeteners, dextrose, glucose, honey or high fructose corn syrup. Whatever the source of the sweetener, it is no longer associated with the naturally occurring vitamins and minerals found in the original plant source.

If you live outside the US, don’t feel smug. Other countries are catching up fast.

So serious is this health problem that urgent consideration should be given to taxing sugar in the same way we tax alcohol and tobacco. Activists wax lyrical on the issue of tobacco and liquor advertising, and argue that tobacco products should be kept out of sight in supermarkets. For the sake of our children’s health and longevity, we should be applying these ideas to any food and drink that contains added sugar.

I was chatting with a ‘nutritionist’ in South Africa, who made the observation that many of the indigenous people were listless and lacking in energy. He felt that any nutritional supplement should be rich in fat and sugar, because these are the foods that provide energy. He was dismayed when I argued that most of the people he was referring to were drowning in fat and sugar. Any listlessness was almost certainly due to a lack of essential micronutrients – vitamins and minerals.

If you want more science – see Appleton

If you want a lecture – see Lustig

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