Food Bytes: December 2024 Edition

FOOD BYTES IS A (ALMOST) MONTHLY BLOG POST OF “NIBBLES” ON ALL THINGS CLIMATE, FOOD, NUTRITION SCIENCE, POLICY, AND CULTURE.

I am here in Gotham City, writing my final blog post for 2024 in the quiet. This is one of my favorite times of the year. Not because it is Christmas and New Year’s, but more so because the whole world pauses. Less email, less bustle, less stress. The opportunity to not have to click on that Zoom link for a week or two is just pure bliss. My posts as of late have gone from reflection to angst to dread, but at this moment, dear reader, I am feeling “set” — like a voluminous beehive hairdo or a delightful buttery pound cake. I am ready to take on whatever 2025 brings, as I hope you are.

This is my last Food Bytes of 2024. I managed to publish 9 (not 12) this year. I learn a ton gathering up material for the monthly Food Bytes as it forces me to do some reading, listening, and watching to highlight the prolific content being put out in the world on food systems, climate, and nutrition. I feel incredibly fortunate to work in an area so rich and doused with science, politics, culture, and controversy. This area of chosen work would be dull without those elements all jumbled together and needing constant teasing apart. So here it goes…my last Food Bytes of 2024. Hang onto your hats, guys and gals, for a very interesting 2025…

Let’s start with obesity. There is so much coming out related to obesity prevalence and trends, as well as the new GLP-1 anti-obesity class of medications (formally known as glucagon-like peptide-1 receptor agonists). Earlier this year, the NCD Risk Factor Collaborators published a paper in the Lancet showing the obesity and undernutrition trends among adults and children. They showed that we have moved from a world paralyzed by undernutrition to a world of obesity, with some countries struggling with both forms. One in 8 people are obese - or 1 billion people suffer. Many of you know this story of the nutrition transition and the double and triple burdens of malnutrition, but the overall picture over the last 30 years is quite staggering. Check out the circular bar plots of the changes in the underweight burden (the blue bar's length shows prevalence) and obesity (pink/red bar) among women in 1990 and 2022.

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Another paper just released, again in the Lancet, showed in the United States, between 1990 and 2021, the percentage change in the prevalence of obesity in adults was 123.6% in men and 99.% in women. They forecast that by 2050 if current trends continue, the total number of adults with overweight and obesity will reach 213 million. And I am not even reporting on teen prevalence. Wowsa. Yet, JAMA just published results that found that the prevalence of BMI and obesity in the United States decreased in 2023 for the first time in over a decade. Some pontificate it is because of the GLP1 inhibitors, others because of COVID-related deaths (obesity being a heightened risk factor for morbidity and mortality associated with COVID).

The difference could be that the Lancet paper by the Global Burden of Disease 2021 US Obesity Forecasting Collaborators didn’t investigate trends beyond 2021. In contrast, the JAMA authors showed a decline in 2023 specifically. Also, we don’t know the future of the GLP-1s. Currently, they are cost-prohibitive for many living in the United States and, moreover, the world. One report estimated that if half of U.S. adults with obesity took these drugs, it could cost the healthcare system $411 billion per year. The inequities in who has access to these drugs are staggering.

These medications certainly help people lose weight, with various studies showing reductions in body weight somewhere between 10-25%, as well as other benefits for those struggling with diabetes and cardiovascular disease, to name a few. I worry that we still know so little about obesity, its drivers, and the potential ramifications of medicalizing the challenge into one silver-bullet solution. I also fear that the scale-up of these drugs gets food systems and industry “off the hook.” Why stop making ultra-processed foods and ensuring food environments are healthy for people when they can easily take these drugs? But RFK Jr is going to solve all that, right? Don’t hold your breath. I appreciated this commentary by Francesca Celletti and colleagues in JAMA on where we are at in our understanding of obesity:

“The seriousness of the crisis is now widely recognized. Yet there are many challenges that continue to hinder a successful national and global response. Perceptions and attitudes toward obesity, including the debate about whether obesity represents a risk factor or a disease, are widely divergent. Efforts to address the stigma associated with obesity have, in some cases, evolved into a narrative that obscures the importance of obesity-related morbidity and mortality. Compared with other noncommunicable diseases, there remains a lack of knowledge on the associated biological and genetic factors, and there are inconsistencies in the appreciation of the effect of obesity on other noncommunicable diseases and the overall burden of disease. There is limited evidence on long-term management interventions and their effectiveness among populations most at risk and in low-income settings in relation to issues such as access and adherence.”

Speaking of nutrition trends, the Global Burden of Disease Group published their analysis on global, regional, and national progress towards achieving the six nutrition-related Sustainable Development Goal (SDG) targets by 2030. The picture ain’t so rosy. These are their high-level results: “In 2030, we project that 94 countries will meet one of the six targets, 21 countries will meet two targets, and 89 countries will not meet any targets. We project that seven countries will meet the target for exclusive breastfeeding, 28 for child stunting, and 101 for child wasting, and no countries will meet the targets for low birthweight, child overweight, and anaemia.” Looking at current trends, the authors show that in 2021, seven countries had already met two of six targets (Georgia, Mongolia, South Korea, Peru, Rwanda, American Samoa, and Puerto Rico). What are they doing right? Case studies, anyone?

Diets heavily weigh into dietary outcomes, and as the SDGs stand, there is no target or monitoring of a dietary indicator, such as dietary diversity. SDGs. One of the juggernauts of our diets is how much animal source foods we should or could consume that benefit our health and the planet. A PNAS special feature delves into this quandary in what I think is quite a balanced set of papers showing all the angles and issues. We contributed a piece laying out the biological nutritional vulnerabilities stemming from high micronutrient needs per calorie among infants and young children, women of reproductive age, pregnant and lactating women, and older adults, particularly older women, and the importance of nutrient-dense foods coming from both plant and animal-source foods. Speaking of nutrient-dense foods, some colleagues from the Blue Foods Assessment published a paper in the Environmental Research Letters that assessed nutrition-sensitive climate risk to five essential micronutrients across production systems. By mid-century (2041–2060), we estimate that 75% of calcium, 30% of folate, 39% of iron, 68% of vitamin A, and 79% of vitamin B12 produced in primary food products will face frequent climate extremes globally. Nearly 50 countries are projected to face high domestic climate risk for two or more micronutrients during this period. Check out the figure below.

Speaking of the climate crisis, I have written before about tipping points, but some scientists argue the framing is distracting and confusing. Regardless, people are fatigued and confused by all the terminology: diebacks, atmospheric rivers, bomb cyclones. Grist calls it “alert fatigue”. The question is, does the fatigue translate into inaction? The scientists in that Nature paper argue that urgency and the terms and definitions to illustrate that urgency do not always translate into political commitments. And sadly, people are being left behind. Did you hear about Cyclone Chido on the French island of Mayotte? Neither did I. People are dying from climate-related extreme events, and we aren’t even able to count the dead or notice. Unless you live in a rich country… We are really on the edge here, and leaders seem to be shrugging their shoulders. Look at this year’s various COP events - climate, biodiversity, and dry lands. Were any binding and bold commitments made? Nope. And science is under ever more scrutiny and openly ignored and disregarded by some. This title says it all: Good COP, Bad COP, science struggles under a year of environmental summits. As this editorial argues in the Lancet Planetary Health, somebody has to move first. As the editors wrote: “…The absence of consensus on the world stage should not hold back individual countries from moving rapidly away from fossil fuels and benefitting from this. Keeping warming below 2°C is still possible, and actions that limit warming to almost any degree will be beneficial, but some have to do the right thing and decisively move first.”  The question is, who will be brave enough?

But we scientists keep churning. The IPBES Nexus and Transformative Change assessment summary reports have been released (my hermano, Mario Herrero, one of the lead authors says the very long reports are coming soon). First, what is IPBES? It is the Intergovernmental Platform on Biodiversity and Ecosystem Services. It is similar to the IPCC in that it sits at the interface between science and policy and is meant to spur evidence-based political action. The Nexus report argues that we need to holistically tackle biodiversity loss, water and food insecurity, health risks, and climate change because these five areas interact, cascade, and compound each other, and addressing them separately is counterproductive, redundant, and inefficient. The Transformative report focuses on the underlying causes of the biodiversity crisis, the drivers of change, and available options and argues for a “whole of society” approach. Overall, their analysis is not a chipper one. Half of the world lives in areas hit hard by food and water insecurity and biodiversity loss. Biodiversity is in massive decline. And delaying action will be catastrophic. Action in these areas could unlock trillions of dollars in economic growth and jobs. The figure below is worth a lot. It shows a wheel of interconnected challenges (different colors) and barriers (different 637 letters) to transformative change.

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We continue to push out sound data to inform policymakers across food systems. The Food Systems Countdown to 2030 Initiative will publish its 3rd annual paper in January, so stay tuned for that. Meanwhile, a few of us at the Columbia Climate School wrote a piece for IFPRI’s Impact group on food system data gaps and the future potential to measure food systems data with new big data technology.

As you may know, I am a big fan of rivers. This poem, Rest, Like a River by Leena Danawala is a fitting way to close out 2024:

I like the idea of a river yawning:

its mouth a vast open width,

just a symptom of fatigue.

I think of how it wraps its length

around itself, serpentine and sure;

how its waves rock back and forth,

a cradle on an unsteady floor.

on days like today, when the

spring fog has melted into my bones,

or when time seems to stop or slow,

I think of my spine as that river

and curl into myself like the letter “c.”

breath floating downstream,

body swaying like the currents of the sea.

Food Bytes: January 2023 edition

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

A little warm-up

Are you doing dry, damp, or wet January? Me, semi-dry…I have a good excuse, though. My lovely partner and I had to celebrate with a bottle of prosecco because I have accepted a full professorship at Columbia University’s new climate school, where I will lead their Food for Humanity initiative. I am sad to leave Johns Hopkins, but alas, change is good. I start in June, so get ready Gotham…

I also quit Twitter after 12 years. Felt good. I should have done it years ago…No toxicity! More time! Less self-promotion!

Let’s get the political stuff out of the way…

Is globalization over? The elite will again meet at the World Economic Forum in Davos, Switzerland, for some strained global discourse. When I say elite, gathering of the world’s 0.001 percent. Every year one asks if Davos has relevance or are these elitists more and more out of touch with what is truly happening in countries and communities. This NYT article on how Davos will confront the new world order says it all:

“The World Economic Forum in Davos, Switzerland, finds itself navigating troubled waters. Long the affluent symbol of a globalizing world where the assumption was that more trade would bring more freedom, it now confronts international fracture, ascendant nationalism and growing protectionism under the shadow of war in Europe and sharp tensions between the United States and China.”

I am sure climate change and food security will be on the agenda, but again much of it will be talking, among the elite few, with little action. As it stands, with the global food security crisis, rich countries have fallen short in providing much-needed assistance with increasing risk of hunger and, for some countries, such as Somalia, starvation. Sci Dev wrote an important piece on global starvation looming and rising food prices (see graph below. It deserves attention.

As the world tenses, doing nothing is not good enough, and flying to Davos in your private jet pontificating about poverty is getting tiresome.

If Davos doesn’t get you depressed enough, take a gander at the World Economic Forum’s global risk report. One word: polycrises.

Let’s confront the scary stuff…

California’s “atmospheric rivers”—these doom terms, I tell ya — yield all kinds of chaos for the Californians. The damage due to these intense storms and flooding is estimated to cost the state 30 billion. It is ironic, though, that droughts are a major issue and all roads point to these torrential storms as not helping, but perhaps they will contribute to the necessary snowpack in the long term. What hasn’t been discussed much in relation to storms is the potential damage to crops. California is a massive horticulture producer in this country, growing nearly half of the fruits, nuts, and vegetables in the United States. California’s agriculture also matters to the world because its products are exported to approximately 200 countries. Why is this such as issue? This is why:

“The rains are critical in breaking the worst drought in the US southwest in 1,200 years. The dryness has hurt crops across California’s Central Valley, one of the world’s largest agriculture economies, put large cities under stress, threatened water supplies for many smaller communities, and contributed to some of the largest and deadliest wildfires in state history. Dwindling flow in the Colorado River bordering California has also put hydroelectric supplies in danger.”

There is some hope, though. According to Civil Eats, farms that practice regenerative agriculture seem to weather the storms through innovation.

Let’s give a shout-out to great science…

The AI DALL-E’s rendering of when I asked for “her?” to draw an abstract painting of the Mediterranean diet.

• Some colleagues at GAIN and Cornell just published this fantastic review on how animal-source foods—meat, fish, eggs, and dairy—can play an important role globally in ensuring healthy and sustainable diets.

• Another paper by Amanda Woods and colleagues makes the case for resilience in food systems management and governance.

• Remember that pesky EAT-Lancet Commission report that came out with a planetary diet (very similar to a Mediterranean diet, in my opinion…so what’s the big deal)? Yah, I am guilty of having been a commissioner. Since its publication in 2019, it has been cited about 6,000 times (no joke), and much science has followed. Take this article showing that 86 nations representing 51% of the global population can secure a nationally sourced EAT-Lancet diet from a land-availability perspective. That leaves 3.7 billion living in countries without enough land to source a planetary health diet. I guess trade is important after all!

• Loved this Nature piece on the importance of indigenous knowledge for food security. This line. YES. “I am under no illusion about what it will take to achieve true collaboration at scale — both at the individual and systemic level. Yet in my interactions with Indigenous people and local communities, people’s generosity and willingness to work collaboratively has impressed me again and again.”

• A modeling study published in the Global Food Security Journal from a multi-country collaboration examined the impact of the Ukraine-Russia war on food security. Their model show that food trade would decrease by 60%, wheat prices will increase 50%, and severe food insecurity would increase 30% in 2023. Dire.

• A study in the Lancet Planetary Health examined 83 Food-based dietary guidelines (FBDGs) for their inclusion of environmental sustainability. Of the 83 they examined, only 37 mention ES and of those, none really emphasize why it is important, and how diets can be made to be more sustainable. My question is, who cares about FBDG? Does anyone follow them?? Yes, I get it, they inform public procurement, but they don’t really help individuals with dietary guidance. If you want a snarky take on the United States guideline, listen to this Maintenance Phase podcast (hands down the best podcast on poking holes in nutrition and dietary science).

Still baking, after all these years…

I am still baking, and it has become a relaxing ritual. This weekend? A castelvetrano olive, rosemary, whole wheat sourdough. My prettiest loaf yet! I followed this recipe more or less.

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How much does it cost to eat a decent meal?

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The incredible Alex Honnold, also a vegan… Copyright: The great Jimmy Chin for National Geographic

The answer to that question turns out to be a lot for some people. There are have been some recent projects and papers as a result aimed at trying to understand whether or not people can afford the kind of diets recommended in national food-based dietary guidelines, the EAT Lancet, and other publications. Many have pontificated that these healthy, higher quality diets — promoted in such guidelines and Commissions made up elitist scientists — are unaffordable for most of the world. Some argue the recommendations are just downright dangerous (beef industry responding to the EAT Lancet) or unfair. GAIN argued that meat is important for child growth, and athletes. I don’t think they meant it is an absolute essential for athletes, as Alex Honnold is a vegan and that dude climbed El Capitan with nothing but sheer muscle strength, stamina and maybe an insanely lack of feeling of fear. If you have not seen the documentary Free Solo, I highly recommend it. What a human feat, and with no meat! Yes, I wax poetic.

This debate is not new, and there has been a lot of science articulated the cost. And there are more papers to come. But a few new papers are looking beyond just a specific country, a specific national dietary database or a specific population, and looking at the costs of foods and diets around the world from low- to high-income countries, whether they fulfill nutritional needs, and if not, what disease outcomes are they associated with.

IFPRI’s Derek Headey and Harold Alderman, two pretty stellar researchers in nutrition, published a fantastic piece in the Journal of Nutrition. They tested relative caloric prices (RCPs) for different food categories across 176 countries. One will have to read the methods in some detail to understand how they come up with this calculation but one key piece is how they calculate the RCP. They measure the ratio of the price of 1 calorie of a given food (the edible portion) to the price of 1 calorie of a representative basket of starchy staple food in each country. As the authors articulated: an RCP of 5 for eggs implies that it is 5 times as expensive to obtain a calorie from eggs as it is to obtain a calorie from starchy staples. Easy yes?

While the authors find that there is a lot of variety in the food prices nationally, in high-income countries, most non-cereal foods were relatively cheap, including sugar- and fat-rich foods. In contrast, in low-income countries, healthy foods were expensive, especially most animal-sourced foods and fortified infant cereals. Oils/fats were notably very cheap in all regions as were unprocessed red meat, which was moderately cheap in all regions. As the authors wrote in a recent blog:

“As countries develop, their food systems get better at providing healthier foods cheaply, but they also get better at providing unhealthier foods cheaply. Hence the problem in less developed countries is that poor people also live in poor food systems: Nutrient-dense foods like eggs, milk, fruits and vegetables can be very expensive in these countries, making it much harder to diversify away from nutrient-sparse staple foods like rice, corn and bread. The problem in more developed countries is rather different: Unhealthy calories have simply become a very affordable option. In the U.S., for example, calories from soft drinks are just 1.9 times as expensive as staple food calories and require no preparation time.”

The authors then looked at the association of these prices with nutrition outcomes, controlling for confounders like education, urbanization and income. Higher milk and fortified infant product prices were positively associated with childhood stunting. They also found that little children consume less of these important foods when expensive. An increase in soft drink prices was associated with a reduction on overweight prevalence.

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Headey and Alderman show the association of milk prices with childhood stunting. Copyright: IFPRI

A few years ago Adam Drewnowski and Nicole Darmon published a study, using very different methodology and from French databases, showing that foods of lower nutritional value and lower-quality diets generally cost less per calorie and tended to be selected by groups of lower socioeconomic status. A number of nutrient-dense foods were available at low cost but were not always palatable or culturally acceptable to the low-income consumer. Acceptable healthier diets were uniformly associated with higher costs. They argue three things:

1. Energy-dense foods composed of refined grains, added sugars, or fats are cheaper per calorie than are the recommended nutrient-dense foods.

2. Lower-quality diets, with a higher content of added sugars and fats, were generally less expensive on a per-calorie basis.

3. Cheaper and more energy-dense diets, often devoid of vegetables and fruit, tend to be selected across different countries by lower-income groups.

Another paper coming out in the Lancet by IFPRI (including Headey) and Tufts colleagues including the great Will Masters, examined retail prices of foods and identified the most affordable foods to meet EAT-Lancet targets. They compared the total cost per day of these foods to each country's gross national income to see if the MOST affordable EAT-Lancet diet exceeded household incomes.

Here is what they found: Examining 744 items across 159 countries, revealing that the most affordable EAT-Lancet diets cost a global average of $2.89 per day ($2.44 per day for low-income countries and $2.77 for high-income countries). The largest share was the diet cost was fruits and vegetables (31.2%), followed by legumes and nuts (18.7%), meat, eggs and fish (15.2%) and dairy (13.2%). While this is a pretty cheap diet in high-income countries, it is not affordable for 1.56 billion of the poorest households in the world where this diet would cost households 70% of their daily income (national averages)! Where is this diet unaffordable? Mostly in sub-Saharan Africa and South Asia.

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On the left side is the cost of the EAT-Lancet diet by country income levels and major regions. On the right side, is the cost of the EAT-Lancet diet as a percentage of Gross National Income per capita. Copyright: Lancet.

They also concluded that the EAT-Lancet diet would cost 64% more than achieving minimally adequate levels of essential nutrients and is currently unaffordable in low-income countries, because “it requires larger quantities of higher-cost food groups such as dairy, eggs, meat, fish, fruits and vegetables than the near-subsistence diets that are currently consumed by very low-income people.” The authors argue that:

“Our findings indicate that a widespread global shift to the EAT-Lancet diet recommendation is feasible only through some combination of higher earnings, more favorable market prices and nutrition assistance for low-income people, in addition to changes in local and global food systems that drive food choice among more affluent populations. Meeting EAT-Lancet targets in low-income areas will require higher farm productivity and improved access to markets, plus greater non-farm earnings and social safety nets, allowing people to shift consumption away from starchy staples and increase their intake of more nutritious but currently unaffordable animal-sourced and vegetal foods.”

Sam Bloch tested out the EAT-Lancet diet in early 2019 and wrote up a great piece in the New Food Economy (love this site). He found it hard to follow and it was more expensive. And he is probably a high-income consumer (living in New York City) and his wife is a chef!

A group at World Food Programme is doing a “Fill the Nutrient Gap” (FNG), which aims to “support identification of strategies to increase availability, access, and choice of nutritious foods, to ultimately improve nutrient intake.” This approach looks at the nutrient intake of different target groups, and then uses linear programming to look at the barriers to nutrient intake including the availability, cost and affordability of nutritious diets for households and target groups with higher nutritional needs. They then model potential interventions to improve them. I have heard they have done at least 25 countries. So they are taking it further as compared to these other studies. They are not only looking at the cost of diets, but why they are expensive and what households can do about it.

In last year’s Global Nutrition Report, we showed some preliminary data on the range of non-affordability of a nutritious diet across areas in different countries. The data shows a range of non-affordability depending on the region in each country – for example, across different regions of El Salvador, 9% to 44% of households cannot afford a nutritious diet, whereas the range is much greater in Lao People’s Democratic Republic (17% to 95%).

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The range of “non-affordability” of the typical diet in select countries. Copyright: GNR 2018

There are others working on the cost of a diet. Marco Springmann will also test out the cost of the EAT-Lancet diet, as an EAT-Lancet Commissioner. I think his study will look more at the cost of dietary patterns - vegetarian, pescetarian, omnivorous etc. So keep your eye out on that publication!

Nutrition and Agriculture Research: Some Thoughts

I recently was asked to provide some commentary at the International Food Policy Research Institute (IFPRI) at the ARENA-II (Advancing Research on Nutrition and Agriculture) project policy seminar. I thought I would post my speaking notes on what I think is a really fascinating set of research findings stemming from the project. The seminar presented new research on food markets and nutrition including cross-country studies of the costs of nutritious foods and nutritious diets as a whole, and case studies of fish, dairy, and poultry products. The event can be watched here.

ARENA is trying to understand markets in low-income contexts. Markets play a key role in delivering food and nutrition, even for poor and remote rural households. But nutrient-rich foods, especially animal-sourced foods, are very expensive in poor countries, suggesting that markets for perishable but nutritious foods are not functioning well. Both scientific research and real-world programs have largely focused on farm-level interventions to diversify household production and consumption, not recognizing the important role of market purchases.

The major findings coming out of ARENA:

1. Nutritious foods are typically very expensive sources of calories in low income countries, although there are exceptions.

2. Consumption patterns are strongly associated with prices - price variations explains a LOT of the gap between low and high consumers.

3. Indirect evidence that non-price factors (also implicit price factors) matter a lot: e.g. refrigeration and water quality.

4. No single solution for improving affordability or increasing consumption:

• Eggs: domestic productivity is key, often improving feed sectors (maize, soybean, fishmeal).

• Dairy: production in some countries, but trade in others. Markets work incredibly badly in rural areas.

• Fish: cheap and nutritious but under-appreciated by consumers.

• Domestic and international value chains very important, but also important to think about industrial policy: e.g. How do we create a viable modern dairy industry that delivers affordable safe milk to both rural and urban consumers?

My talking points:

Diets are significant risk factors of morbidity, disability and mortality

The Global Burden of Disease based out of the University of Washington in Seattle has recently assessed the burden of malnutrition in all its forms for the Syndemic commission report in the Lancet. Globally and in the lower income countries, malnutrition in all its forms (shown as the contributions of undernutrition, high. body-mass index, and dietary risks) contributes as much disease burden as high blood pressure, tobacco, high fasting blood glucose and water, sanitation and hygiene combined. For countries with a low Socio-demographic Index, undernutrition incurs a much higher burden both in absolute terms and relative to the other leading contributors. The recognition that undernutrition and obesity are both due to poor diet quality and a low variety of healthy foods is a more helpful perspective to resolve nutrition problems collectively.

Our knowledge of diets is still a black box

Understanding what people are eating is important to shape food system and nutrition policies, including dietary guidelines. However, determining what people are eating, remains somewhat of a black box. We don’t know key questions such as, what are people actually eating? Where do they get their food from and how much do they pay, or are willing to pay for food? What influences their dietary choices? Does health or even the environment factor into their decision making? Data on diets and their sourcing and costs are developing with better use of metrics and surveys that feed into larger databases. We are learning more and more with each passing year. We still have significant gaps in low-income settings on many of these questions.

Diets are inequitable

We are really living in a time of haves and have nots. Globally, there is a significant debate going on about the impacts of animal source foods (mainly large ruminants) on climate change, the environment and on human health. Clearly, this debate sits with high-income countries and those countries which produce and consume vast quantities of meat that do not align with the sustainable development goals. However, we know that the production and consumption practices of some, will impact the many living in low-income countries who do not have the resources to adapt and change rapidly and are limited in their options. The inequities are staggering - the rural, the poor, the geographically isolated struggle to get enough animal source foods that are important, particularly for young children who are growing and developing and need nutrient-rich foods high in iron, zinc, protein, D, B12 etc. The ARENA study advances are understanding of the challenges that rural populations face in getting access to these critical foods – eggs, dairy and fish, rich in important nutrients and other health promoting properties – through both informal and formal markets. While the evidence is growing on the impacts of on-farm production to dietary diversity of households, we know rural peoples, smallholder farming families and day labor workers are net buyers of food and they need market that work.

 My questions

I know the ARENA is meant to of course shed and shine a light but it is also meant to set out a research and policy agenda. Here are some of my questions that I was left wondering about for future research:

• Infrastructure is so important. Not just roads but technology and innovation along supply chains. What would be the role of the private sector or PPPs to accelerate action and get over the barriers to access?

• We cannot think about commodities as stand alone. They interact (the ARENA shows how important feed sectors (maize, soybean, fishmeal) are critical for the growth of animal source foods). How do we grapple this with land use changes?

• The enabling environment is key. What should policies focus on? Subsidies? Trade?

• Changing food environments or markets. How shall we measure changes and rapid shifts that we are seeing in many rural places, with the encroachment and influence of urban hubs? I would be keen to see how processed, packaged foods are changing the diets and market landscape in rural places.

• Many consumers all over the world are driven by the same issues - price, convenience, taste. Other factors matter too like reliability and safety. How do we get consumers to care more about nutrition or is that completely unrealistic? What are the trade-offs?

• Eggs: Can these rural areas shift from scavenging systems to intensive systems? How realistic is that? How much does that cost? Is there infrastructure and investment to do this? There is new evidence showing eggs increase cholesterol and heart disease risk - once again, eggs are deemed to not be god for us. Should we be worried about future burdens if we are promoting these foods to children to improve nutrition?

• Dairy: Lactose intolerance. The expression of lactase which digests lactose from milk in humans is generally lost after weaning, but selected mutations influencing the promoter of the lactase gene have spread into the human populations. This is considered a classical example of gene-culture co-evolution, and several studies suggested that the lactase gene has been under strong directional evolutionary selective pressure in the past 5000 to 10,000 years. These data indicate that a combination of socio-economic, ethnic and evolutionary factors converged to shape the genetic structure of lactase persistence in East African populations. A Lancet systematic review study in 2017 showed that lactose malabsorption is widespread in most of the world, with wide variation between different regions and an overall frequency of around two-thirds of the world's population. 63% (54–72) in sub-Saharan Africa. Lactose malabsorption was also widespread in Africa. including northern Africa (53–84%) and sub-Saharan Africa (77–100%), with the exception of Niger (13%), Kenya (39%), Sudan (55%), and Tanzania (45%) - pastoralist populations. I am keen to learn more about this?

• Fish: What would be the strategies to improve the status of fish among consumers as they get wealthier? What role does aquaculture play in these areas and ensuring feed is affordable and more sustainable? What about alternative feeds?

• Are there gender links to any of these commodities as they become commercialized and how does that change household intake of these foods?

• How do we ensure these rural places thrive? Someone needs to feed this growing urban population. Who will it be and how if rural places struggle to feed themselves?