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Bringing a First Nations Perspective to the Program
Louisa Whettam (right) presents a painting to Salzburg Global Seminar as a gift
Bringing a First Nations Perspective to the Program
Claire Kidwell 
“I think that this is the first step in moving forward for First Nations people at a global level,” said Louisa Whettam, a cultural practice advisor for Opportunity Child. Whettam, a descendant from the Wiradjuri tribe in New South Wales, Australia, said she was honored to represent the First Nations Peoples of Australia at the Salzburg Global Seminar program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems. She spoke with Salzburg Global just after sharing an emotional and personal anecdote with participants about the impact of colonization on the health of First Nations people, as well as land and food resources. The colonization of Australia led to many conflicts, deaths, and settlers seizing the land of First Nations people. Whettam said, “[The colonizers] would just gather the people and put them in an area where they now had to live. But then [the First Nations people] also had to work the land for those who now occupied the land. So, that means vegetation was taken away. They had to clear their own vegetation, the food source that they were living off.” Whettam said First Nations people employed by settlers would be paid with staples of food - often flour and sugar. “So, nutrition then became really terrible for First Nations people.” The history of forced removals and loss of land and culture have all contributed to intergenerational trauma. The impact of the Stolen Generations, where Aboriginal Australian children were forcibly removed from their homes and put into institutions, has led to a “whole generation of lost adults who have never connected back to their family,” according to Whettam. In 2017, the Australian Institute of Health and Welfare published a report called “A picture of overweight and obesity in Australia.” The report indicated Aboriginal and Torres Strait Islander children and adolescents were more likely to be overweight or obese than non-indigenous children and adolescents.  The report said in 2012-13, 30 percent of Aboriginal and Torres Strait Islander children aged 2-14 were living with obesity or overweight, compared with 25 percent of their non-Indigenous counterparts. In August 2019, ABC reported on the rising trend of children in Australia experiencing malnutrition. The Food Bank of Australia estimated one in five children had gone hungry in the past year. Whettam said the affordability of food was a factor, and people won’t buy food with nutritional value if it is too expensive. Meanwhile, takeaway food from fast-food restaurants and other processed food remains cheap. In her work at Opportunity Child, Whettam helps ensure Australian children can succeed within their own communities. The organization provides practical support to backbone teams and community structures; it uses its social innovation hub to help communities find solutions to complex issues; it advocates with “One Voice” to drive systems change. Whettam said, “If you have children that have obesity or malnutrition, then that is a concern because they are not thriving within their own community.” Whettam is a respected representative of the Warril Yari-Go Committee and is passionate about systemic change and how it impacts First Nations people. But she’s not sure if she has the answers yet on how to tackle childhood obesity among First Nations people, suggesting other factors have to be taken into account as well. She said, “How do you fix that? Like, how do you look at the complexity of all the policies that have been made in the government that still continue to oppress a whole culture? How do you turn that around? I don’t know.” Whettam hopes to find more answers and clarity in Salzburg, which she described as a “fantastic opportunity” to bring her perspective forward and learn from other experts around the world. She said, “I think this is a great opportunity to make friends, where you can have friends from all around the world that can stand with you when you get back to your country [or] when I go back to my country and challenge and disrupt that system. I think that’s pretty awesome in moving forward.” A Gift for Salzburg Global At the end of the program, Whettam presented Salzburg Global a piece of Indigenous art she had created. The painting was a way for her to say “Thank you” for being able to attend and provide a perspective from the First Nations Peoples of Australia. Whettam said she wanted to depict the story of Salzburg Global, the past, present, and future. In her own words, we asked Whettam to describe what different parts of the painting symbolized. She said, “Salzburg Global Seminar is the big middle piece, and the globe represents all the people coming together… The U-shaped people sitting around that circle represent the people from all different countries coming together and being a part of a [program]. “The footprints represent the journey going there, but also the journey going back… The red dots represent the topic, and they’re red because, as the world, we all need to be looking at this [topic] because it’s an epidemic. I also had the cross-hatching around the globe, representing the complex systems that we’re talking about. “Then I had other dots representing the conversations that we’re all having together. There are ocean-like… coloured dots going out to the outer circles, and that’s the conversation carrying on outside of the [program]. We're taking back to our country all the warnings and all the knowledge from what's being given to us from other leaders around the world. “Also, we're cross-pollinating the conversation; we're still having conversations with those who we met there, but they might know some key people who could help us create partnerships or collaborations. That's why you see all those dots crossing… “You'll see white [dots] that are keeping the conversation in place so that it's not being swallowed up by other conversations. It's protecting that conversation so that you can bring it back and talk about the issue in your own country. “Then the outer circles represent your country, and the handprint in the middle represents the children. And that's looking at the child in the future, but also the child now…  that's who it's impacting on - future children, children in the present and it has also impacted on past children… Around that hand, I have the red dots and yellow dots representing the hard conversations we're having within complex systems... And then you got cross-hatching around that as well that represents the government or complex systems that you have to deal with around that topic. The different colored outer dots that surround the painting depicts all peoples from around the world.” Clare Shine, vice president and chief program officer at Salzburg Global, received the painting on the organization’s behalf. Shine said, “It’s fascinating to see how Louisa has used Indigenous Australian art forms to make sense of the complexity and trauma bound up with childhood obesity and depict the long-term impact we hope will radiate from this collaboration. I’m so moved by her generosity in creating this beautiful painting. We look forward to hanging it where as many people as possible can enjoy and learn from it.” One month on, Whettam is still reflecting on the program she participated in and is still in touch with people she met. Despite feeling out of place at the beginning, the mix of the people in the room left her feeling uplifted. She said, “I was really inspired by the influence that people had, which they sometimes don't realize that they had in terms of funding, policy, legislation, and decisions that are being made… I don't know if researchers realize this, but they have a massive influence in how that all gets processed. I didn't realize that myself, and I thought that policymakers had the biggest influence. But I now think that researchers have the biggest influence because funders won't give funding unless its evidence-based and the government won't act unless it's evidence-based and all that comes from researchers. “For me, that is inspiring me to come back to study and become a researcher, especially as a First Nations person, and what influence I can do in the field that will make a better world for future generations of First Nations people in Australia. That has massively influenced me. “I was also really inspired by the younger people over there. I was blown away by the passion they have. As an older person, the burden is really heavy, especially if you are a First Nations person, from whatever country you're from because of the impact that colonization has had on your people. There is a heavy burden that you carry; you want to see change happening, and you want to see the oppression stop. “Seeing them and their passion made me realize that they're going to be rising up and they're going to be taking over where you leave off. It's not just about when you finish work, but it's about making sure you're mentoring them, and you're encouraging them and also that they are also encouraging you and mentoring you. It's not just about elders being right and having the power, but we're learning off one another.” The Salzburg Global Seminar program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems, is part of our Health and Health Care Innovation multi-year series. This program is being held in partnership with the Robert Wood Johnson Foundation.
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“Gangsta” Gardening and Changing People’s Lives
Ron Finley in conversation at Salzburg Global Seminar
“Gangsta” Gardening and Changing People’s Lives
Claire Kidwell 
“We’re in a war where we’re fighting for souls. We’re fighting for life,” says Ron Finley, otherwise known as the “gangsta gardener.” Finley is speaking to me while attending the Salzburg Global Seminar and Robert Wood Johnson Foundation program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems. With the Ron Finley Project, he’s hoping to bring culture and community together. He envisions a world where children know their nutrition and communities embrace growing and sharing fresh-grown food. Finley says people should expect an uphill battle and recognize the problems they’re all trying to tackle didn’t start overnight. These problems won’t be fixed overnight either. “Sometimes, you’re going to get extremely frustrated and think that nothing’s happening,” says Finley. “But if your message is getting out, know that you’re affecting somebody. Know that somebody is hearing you, and you’re changing somebody’s life.” Finley wants to show children gardening is an art form, which also allows them to provide for themselves. These skills are tools children can utilize for the rest of their lives. His work also includes showing people how to be humane. He wants to teach people “how to take their neighborhoods back, how to take their lives back, and design them the way they want to live.” He adds, “Not the way that some clown has designed it for them.” However, Finley recognizes it’s not just enough to give kids tools. It involves gardening and life skills. “It needs to be a full circle,” he says, and many children don’t get this full lesson. As for the “gangsta” aspect, Finley wanted to change the vernacular of that word, of what people consider to be “gangsta.” If you have knowledge, that’s gangsta, according to Finley. “If you’re a gardener, that’s gangsta because you’re providing not only for yourself, you’re providing for your community and the people around you,” he adds. It’s not just about nutrition and gardening, though. Finley says there are “many lessons in that garden that are metaphors and truths for life.” For him, it’s about showing children their worth. “We as a race need to embrace our kids and tell them just how special, just how unique, just how brilliant they are.” Finley says it’s the adults who inadvertently show children they have little worth. “How do we show kids that they have no value? Easy,” he says. “We put stuff in front of them that they cannot obtain, and we don’t give them the tools to get these things. So, therefore, they think things are worth more than the things they have, and things have more value than they do.” As for what comes after this program, Finley says there’s more to get out of Salzburg Global than hope. He says, “I don’t really deal in hope. I don’t. I don’t even like the word hope. I like the word opportunity.” Finley wants to see action come from these discussions – measures which put an end to issues like childhood obesity, so hope is no longer required. He says, “I want to see something that we go out and affect people... I want to see us build and move mountains with this with. That’s what I’m here for. To hell with all this conversation - we know the problem.” Finley says research can take too long, and communities lose lives in the interim. He says he got his reputation through doing something about the issues he saw around him, not sitting and waiting for something to happen. “It’s like I said, good in, good out. If you put good in, that’s what you’re going to get out. And if we grow together, we grow together. Thism is about community, period. And this is our community, not just the community you live in. I mean, we’re all on the same planet. We’re all breathing the same air. Let’s bring it down to that.” Did you know? Ron Finley’s TED Talk, “A guerrilla gardener in South Central LA,” has - at the time of writing - received 3,489,528 views. The video was published in February 2013. Watch the video below.
The Salzburg Global Seminar program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems, is part of our Health and Health Care Innovation multi-year series. This program is being held in partnership with the Robert Wood Johnson Foundation.
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Childhood Obesity: Holding Back the Water
Kölnbrein Dam - Photo by Jacek Dylag on Unsplash
Childhood Obesity: Holding Back the Water
Rich Taunt, Pasha Elstak and Vincent Busch 
This article was first published on Rich Taunt's Medium profile. Water engulfs our discussions of childhood obesity. The scale of the problem is a "rising tide." The majority of causes lie "upstream," yet we spend more time "downstream." Metaphor coincidence? Maybe. But thinking water can help us make a decisive breakthrough in how countries, cities, and organizations work out what they need to do to reduce obesity. One hundred fifty kilometers south of Salzburg, high in the Swiss Alps, sits the Kölnbrein Dam. Two hundred meters high and 40 meters thick, the dam generates the same energy as half a million wind turbines. Behind its walls sits 82,000 Olympic swimming pools worth of water, drawn from over 100 kilometers around. It took eight years to build — yet had been in planning for over 30, and didn't run at full capacity for 10 years more due to cracks appearing in construction. The sandbag is a more humble affair. Made out of scraps from textile manufacturers, each one costs 20p/€0.25 if you're happy to fill it yourself. They're a staple of responding to floods fast, having proved reliable defense for dikes and rivers up to six feet high. While engineers worldwide have perfected different techniques for their use (the US Army Corps of Engineers recommends pyramids), armed just with a spade and some sand, volunteers can do a pretty decent job too. Which of these metaphors helps us think better about childhood obesity? The magnitude of the problem draws us inexorably to the dam. If we're going to sort childhood obesity for the long-term, we need to plan carefully and build something robust. Given all countries are struggling with this, we need solutions which can be effective across large areas. Obviously, a dam is precisely the sort of decisive intervention we need. Yet we'd be wrong. A dam is a great solution to a complicated problem. By no means simple, equipped with enough water engineering degrees (and a lot of concrete), we can fairly reliably know how and where to build dams and what will happen when we do. But childhood obesity isn't complicated; it's complex There are very few easy to understand rules. Its causes are manifold, and you can't predict with any certainty how changing one part might affect another. Building an expensive dam to block one river doesn't help much when there are 50 more surging through elsewhere. To solve childhood obesity, we could spend many years perfecting the most beautiful system for cycle lanes, yet only to find that fears of crime meant they sat empty and unused. Instead, we need sandbags. Layers of interventions placed one on top of another capable of being established and rearranged quickly as we learn more about the problem we're facing. What matters is both the number of sandbags, but equally how they're assembled. For childhood obesity, new cycle lanes are laid next to public safety improvements, next to cycling classes in schools, next to cycle car parks at work for parents. We write this from two sides of the North Sea. We have both used sandbags to describe the policy approach needed, Rich Taunt writing in London about sandbags in the context of national health policymaking, and Pasha Elstak drawing sandbag pictures in thinking about Amsterdam's Healthy Weight Programme. (To complete our happy picture of European co-operation, we discovered this whilst in Austria attending the Salzburg Global Seminar, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems.) Another coincidence? Certainly. But we think this metaphor can play a critical role in helping those working to reduce childhood obesity frame what they need to do. Nor has it just been thought of now; sandbags being a metaphor used by David Katz in the US for some years. We're fighting against the way we normally think Our brains are far more prone to thinking about simple or complicated problems than complex ones. We desperately want there to be decisive interventions we can use, beautiful dams we can build, which will fix our problems in a nice easy to understand way. As HL Mencken wrote, "For every complex problem there is an answer that is clear, simple, and wrong." Thinking in terms of sandbags gives us the framework to avoid that trap. More than anything, it underlines three key approaches required to have a complex systems approach to childhood obesity. First, the volume of interventions matter It's simply not good enough to just think about physical activity, or food systems, or just the two together. In Amsterdam, the third pillar of our approach is sleep. The evidence of its importance is clear (for example, from one study, infants who averaged fewer than 12 hours of sleep a day had twice the odds of being obese at age three), yet most of our interventions to address it we have had to research and make up from scratch. Second, we have to care as much about the joins as the interventions Complex systems laugh at silos. For our interventions to be effective, we have to learn to work in a far more coordinated way, spotting gaps and perverse incentives, and fixing them quickly. It's one reason why in Amsterdam, we have merged all of our university public health research teams and work in the same room as our policymaking colleagues. Third, we need to evaluate the sum not the parts Asking about the impact of one individual sandbag is pretty pointless. Unless it has a big hole in it, it's probably fine. What matters for childhood obesity and sandbags alike is the impact of all of the interventions working together in their particular context. This is far harder to do than picking a single intervention and going all RCT. But easy here is wrong. Instead, as Harry Rutter argues, we need a far more nuanced approach to how we even talk about impact and evidence when traditional methods come up short. The tide of childhood obesity is rising. We do need to go more upstream. Both of these statements are true, yet we've been saying them for years with little sign of progress. We need a new perspective on an old problem: the humble sandbag. This article was written by Rich Taunt of Kaleidoscope Health and Care, Pasha Elstak and Vincent Busch of the Amsterdam Healthy Weight Programme. All three attended the Salzburg Global Seminar program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems. This program is part of our Health and Health Care Innovation multi-year series and is being held in partnership with the Robert Wood Johnson Foundation.
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Rich Taunt - The Talk of the Palace
Photo of Schloss Leopoldskron, as seen from the opposite side of Leopoldskroner Weiher (Photo: Rich Taunt)
Rich Taunt - The Talk of the Palace
Rich Taunt 
This article was first published on Rich Taunt's Medium profile. Gather 60 people together from around the world. Put them in a magical palace. Give them an unsolvable problem to debate, and five days to do it. While the method behind Salzburg Global Seminar isn’t exactly conventional, nor easy to replicate, it is rather wonderful. But given such a hospitable environment, there’s always a risk that disagreements go unexposed. That everyone’s happiness to be in a place where the hills are alive masks unresolved tensions. It’s a pleasure and privilege to be in Salzburg currently, discussing childhood obesity and complexity. Led by the Robert Woods Johnson Foundation, debate ranges from food to families, power to politics, and well beyond. Everyone sort of agrees. Perhaps. Here’s three tensions bubbling through from our early sessions: 1. How We Talk How you frame what the exact nature of the childhood obesity problem is hard. How you then talk about it with the public is harder still. Making it even harder is food industry competition wishing to disagree. It’s easy to think that the food industry always has a narrative which is ultra disciplined with public messaging full of joy (ooh, chocolate), while public agencies can only talk in academic terms and give the public messages of gloom (just stop it alright). Ok, it’s not a level playing field. Show me a public health communications team with the same resources as their industrial counterparts and I’ll eat my civil service issued hat. Yet the implication for those of us seeking to reduce childhood obesity is to up our game. First, by joining forces across organizations to make the most of limited resources, as shown by the Australian Obesity Policy Coalition. Second, to be more creative in our public messaging, as shown by the graphic novel approach in South Africa. Third is to reframe, such as talking about health not weight and to talk about the joy of eating, not just its risks. 2. What We Talk About This is a conference with ‘complex systems’ in the title. Its starting point is to work at a level of abstraction which isn’t just about individual organizations or people. But then how does this fit with constant talk about the need for a person first approach and the importance of understanding stories? The event so far has involved deeply personal testimony about individuals’ own lived experiences. So are we thinking systems or people? The glib answer is to say ‘both,’ which, of course, is true. We have to start with understanding how people live their lives. Making wrong assumptions is what got us into the cul-de-sac of thinking obesity is all about people’s own self-discipline in the first place. Yet we also have to think about the systems in which people operate in. Let’s not get confused between our internal plans and our public messaging. The plans have to be complex in order to deal with the complex system. The messages have to be simple in order to be understandable. It’s an approach championed by the public health professor Harry Rutter (and shamelessly stolen by me in a recent piece on policymaking). 3. The Breadth of Our Approach So we’re doing systems thinking. However, as one participant acutely put, we can do the thinking fine, it’s putting into practical change we struggle with. Everywhere you look there’s a way to expand the size of the system we need to think about. Obesity isn’t just about food, it’s about soil — so is it about climate change too? It’s not just about what food we buy, it’s about poverty — so is it about jobs and welfare as well? Taking this perspective, as another participant articulated, “we need to get obesity out of a debate about bodies and see it as a measure of community disempowerment.” The countervailing view is that we have to get stuff done. We don’t have the time or resources to solve everything, so let’s just pick a bit and get on with it. Once more, we’re dealing with a false choice. Leadership in complex systems requires a completely different skill-set to managing change in linear environments. It’s too easy to think about ‘driving’ change in complex systems. It’s not possible; much better is to think of ‘herding’ change, bringing lots of different pieces together and getting them all pointing in the same direction. The hard practical graft of the skills and resources to do this may be less intellectually stimulating than debating specific individual interventions, but without it, we’re sunk. At the organization I’m part of, Kaleidoscope, we run Holacracy, a management system which thrives off the raising of tensions by anyone who feels one. It works because it stops issues being glossed over or left to rankle, but instead, be dealt with and resolved. Palace tensions are welcome. Now the only issue is to act on them. Rich Taunt is a participant at the Salzburg Global Seminar program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems. This program is part of our Health and Health Care Innovation multi-year series and is being held in partnership with the Robert Wood Johnson Foundation.
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Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems
Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems
Claire Kidwell 
Obesity and overweight affect more than two billion people worldwide. As projections continue to show an upward trend in most countries, there are profound consequences for physical and mental health. Salzburg Global Seminar’s latest Health and Health Care Innovation program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems, seeks to identify solutions. Between December 14 and December 19, 2019, experts from around the world in nutrition, health, and advocacy will convene at Schloss Leopoldskron in Salzburg, Austria. Together they will review and build on existing strategies to enable all children to grow up at a healthy weight. Participants will be encouraged to broaden their understanding through networking and collaborating on new policy ideas to better support families. A key factor is ensuring public health interventions can reach the most socially disadvantaged populations. Participants will investigate challenges around food access, income inequality, inadequate public transportation, and the scarcity of affordable housing. During the program, participants will also consider what the key drivers are to prevent childhood obesity and how to ensure equitable access to healthy, nutritious food and opportunities for regular exercise. John Lotherington, program director responsible for Salzburg Global’s health and health care programs, said, “It’s not a problem about individuals and their habits. It’s about societies and systems. This program is going to bring together a diverse group of the most innovative people from across the world to work on the systems change we need to tackle this. We are delighted to be undertaking this again in partnership with the Robert Wood Johnson Foundation, building a Culture of Health.’ This program will highlight how global innovations and ideas in the childhood obesity prevention space could help optimize health outcomes for children everywhere. It will build on previous programs, including last year’s program on creating healthy environments and shared value for children, plus the Robert Wood Johnson Foundation’s approach toward creating a Culture of Health. This program seeks to: Seed new and innovative approaches through international and cross-border exchange and the transmission of best practice. Create the basis for ongoing networking and collaborations among participants and the institutions they represent. Co-create action plans designed and agreed by participants for them to take forward as appropriate at local and regional levels, and to leverage the global scope of the project to influence public opinion and democratic debate and policymaking. Issue a Salzburg Statement identifying best practice and framing opportunities for addressing the obesity epidemic. Publish an agenda-setting report The Salzburg Global Seminar program, Halting the Childhood Obesity Epidemic: Identifying Decisive Interventions in Complex Systems, is part of our Health and Health Care Innovation multi-year series. This program is being held in partnership with the Robert Wood Johnson Foundation.
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Salzburg Global Fellows Design New Global Principles for Measuring Patient Safety
Salzburg Statement on Moving Measurement into Action: Global Principles for Measuring Patient Safety | Group photo of participants from Moving Measurement into Action | Logos of Salzburg Global Seminar and Institute for Healthcare Improvement
Salzburg Global Fellows Design New Global Principles for Measuring Patient Safety
Salzburg Global Seminar 
Earlier this year, the World Health Organization declared September 17 the first World Patient Day and presented it as an opportunity to speak up for patient safety. A week or so beforehand, health leaders from across the world had met in Salzburg, Austria, at the request of Salzburg Global Seminar and the Institute for Healthcare Improvement (IHI) to explore ways of improving the measurement of patient safety. The Lucian Leape Institute, an initiative of the IHI, led the convening and content curation. Participants of Moving Measurement into Action: Designing Global Principles for Measuring Patient Safety agreed “that there is no single measure that allows all stakeholders in all settings to assess the past, current, and future safety of their system.” Participants agreed a system of measures must be carefully designed to assess the safety of patients throughout their health journey. The conversations in Salzburg have helped establish eight global principles for the measurement of patient safety. They feature in a new Salzburg Statement on Moving Measurement into Action: Global Principles for Measuring Patient Safety, which Salzburg Global is launching alongside the IHI and the Lucian Leape Institute. The eight principles are as follows: The purpose of measurement is to collect and disseminate knowledge that results in action and improvement. Effective measurement requires the full involvement of patients, families, and communities within and across the health system. Safety measurement must advance equity. Selected measures must illuminate an integrated view of the health system across the continuum of care and the entire trajectory of the patient’s health journey. Data should be collected and analyzed in real time to proactively identify and prevent harm as often as possible. Measurement systems, evidence, and practices must continuously evolve and adapt. The burden of measures collected and analyzed must be reduced. Stakeholders must intentionally foster a culture that is safe and just to fully optimize the value of measurement. These principles, which are expanded upon in the statement, are a call to action for all stakeholders to reduce harm.
Patricia McGaffigan, RN, MS, CPPS, vice president, safety programs, at IHI, said, “To truly advance safety, it is critical that we apply meaningful measures that proactively assess risk and provide an accurate picture of day-to-day care. “For too long, health care has lacked consistent standards for measuring the safety of care. These principles call for the creation of measures that can be applied across the continuum of care and across the globe, and be informed by the perspectives of all stakeholders.” John Lotherington, a program director at Salzburg Global responsible for health and health care programs, said, "Twenty years ago, Salzburg Global was privileged to be in a position to convene a meeting which helped to shape the vital agenda around patient safety. "We have been delighted now to work with the Lucian Leape Institute in the development of these principles to take patient safety to the next level. It is so crucial for patients, their families and loved ones, and everyone in health care working towards better, safer care." Download the Statement as a PDF View the Statement on Issuu To submit your endorsement of the Salzburg Statement on Moving Measurement into Action: Global Principles for Measuring Patient Safety, please click here.
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Global Food Systems, Culture and Nutrition
Photo of colorful selection of food by Dan Gold from Unsplash
Global Food Systems, Culture and Nutrition
Margaret Hannah et al. 
The following article was produced by Salzburg Global Fellows, who attended Healthy Children, Healthy Weight, in 2018. The corresponding author is Margaret Hannah. Other authors include Kathryn Beck, Jeanne d'Arc Bisimwa, Angelica Herrera, Katherine Kreis, Kopano Matlwa Mabaso, Dorji Ohm, Shalini Rudra, Marysol Ruilova, Elvira Thissen,  and Henrike Winkler. Helping children survive and thrive is one of the greatest challenges we face as a global community. Infinitely complex in nature, we are just beginning to understand some of the more nuanced links between health, development, and the environment, and how they relate to health outcomes. The landmark 2013 Lancet series on Maternal and Child Undernutrition identified this as the leading underlying cause of child morbidity and mortality worldwide[1]. Its publication galvanized the Scaling up Nutrition (SUN) movement among some 90 countries, spurring significant progress in addressing both acute and chronic undernutrition, and to some extent, vitamin and mineral deficiencies. Yet despite this progress, overweight and obesity and related non-communicable diseases are on the rise. Many countries, most notably low- and middle-income countries, are now facing undernutrition and overweight and obesity, while high-income countries are having limited success in addressing rising rates of overweight and obesity[2].   This paper considers the “syndemic” of inter-related processes between obesity, undernutrition, and climate change[3]. It explores how cultural practices offer opportunities to act at the local level to improve food choices and points to recent developments in nutrition research, which offer new routes to enable current and future generations of children to thrive.  Stresses and Strains in the World Food System The world food system is under strain in many ways. As the world population grows, so the demand for food rises. Furthermore, as incomes rise, people increase their consumption of animal food sources, which in turn increases pressure on the natural resources of land and water as well as grains, which are used to feed livestock rather than people. An increased use of grains for biofuels is also depleting the available land for food production.  The increasing variability and extremes of climate brought about by global warming are having profound impacts on food security. In particular, the increasing frequency of floods and droughts makes each year’s harvest less predictable and affects yields. It is also leading to large scale migration as pastoralists around the globe have to go further to find food and water for their livestock. Current food production is highly distorted by agricultural subsidies, particularly in high-income countries. In the USA and European Union alone, over $70 billion is spent each year in direct grants to farmers. These subsidies favor cereals and animal produce over fruit, vegetables, and nuts, which impacts on the price of the latter, even though they are healthier foods.    A further concern is the heavy dependency of modern agriculture on fossil fuels – as fertilizers, pesticides, and fuel for farm machinery. This dependency, as well as the high volumes of methane from livestock farming, make agriculture a heavy contributor to carbon emissions, further exacerbating climate change. The EAT-Lancet Commission describes the Great Food Transition that is necessary for 10 billion people to live on the planet by 2050 within its ecological carrying capacity[4]. They set out a universal healthy reference diet to achieve this but recognize this can only be achieved if other aspects of food production and distribution are addressed. These include political commitments globally, regionally and locally, a shift from high volume to healthy food production, intensification of agriculture globally, better governance of land use and the oceans, and reducing food waste by half. Challenges for Food Policy and Regulation Strengthening the policy environment for food production, pricing, processing, and sales is a prerequisite to addressing this syndemic. This is itself a challenge as regulatory policies span many stakeholders in agriculture, government, non-government organizations, and the food industry. In addition, relevant policy areas cover complex international trade agreements, national sectoral policies (around agriculture, food, health and family welfare, women and child development), fiscal policies on taxes, subsidies, government procurement, and pricing. Yet reversing or substantial revision of these policies and subsidies could open up a new era of sustainable food production[5].  Fiscal policies informed by a public health evidence base may have a contribution to play. For example, introducing legislation on a sugar tax, mandatory fortification of foods (such as flour with folate), and control on the advertising, sale, and consumption of harmful products like tobacco and alcohol. In 2018, South Africa came into line with other countries, namely France, Mexico, the UK, and some cities in the United States, in introducing a “sugar tax” on sugar-sweetened beverages as a strategy to curtail the rising obesity rate. The sugar tax is equivalent to about an 11% levy on a can of Coca-Cola.  However, the response of the World Health Organization (WHO) shows a clear challenge in the implementation of such taxes. While in 2017, WHO endorsed a 20% tax on sugar-sweetened beverages[6], an independent commission on non-communicable diseases was unable to reach a consensus on the use of taxation to reduce sugar consumption and failed to continue the endorsement of this recommendation[7]. Food cultures around the world – some examples of opportunities and challenges to good nutrition Understanding decisions around the introduction of foods and their cultural meanings opens up a bottom-up approach for addressing nutritional challenges for families and communities.  Culture, defined here as a system of shared understandings that shapes and, in turn, is shaped by experience, plays an important role in families’ and children’s beliefs and practices regarding food selection, preferences, portion sizes, and meal preparation[8][9]. Interventions that fit into families’ cultural understandings are generally more accepted than those that are viewed as belonging to another culture. We examine how interventions in India, Rwanda, and Austria draw on cultural practices and values to impact families’ behaviors related to the provision and consumption of healthy foods. India Interventions focused on pregnant and lactating women and children below six-years-old are provided in Anganwadi Centres in India[10]. Annaprahshan is a traditional Indian ritual that celebrates the onset of weaning. Community health care workers leverage the Annaprahshan community-led celebrations at the Anganwadi Centers to raise awareness among mothers of the importance of timing of weaning and foods that are appropriate and healthy to use[11]. Rwanda In Rwandan culture, the mother plays the primary role in caring for infants. Women generally carry their children on their backs for at least the first year or until they bear another child, and, at night, mothers sleep with the babies in the same bed. It is estimated that these practices result in 87% of children aged between zero and five months in Rwanda being exclusively breastfed[12]. Interventions in Rwanda focused on weaning and healthy foods for pregnant or lactating women have used the fortified blended food, shisha kibondo, which is used to make a highly nutritious porridge. Shisha kibondo is freely distributed to vulnerable populations in Rwanda with the intent to address malnutrition in children. Community health care workers also use Ongera Intungamubiri, a micronutrient powder of 15 essential vitamins and minerals that can be added to semi-solid or mashed food allowing a care provider the option to “home fortify” food. Austria Most Austrian households prefer to eat homemade meals, and many families eat regional, seasonal, and organic products[13]. However, many Austrians favor traditional dishes that have high amounts of animal proteins and fat, as well as sweet dishes, cakes, and pastries high in carbohydrates and fat[14]. Community- and national-level campaigns have been launched to change Austrian’s food habits. For example, several parent-child-centers offer workshops focused on nutritional education. “Baby isst mit” (“the baby eats with you”), a nationwide health promotion program rolled out by the statutory health insurance, focuses on pregnant and lactating women and nutrition for children up to three years[15]. Promising developments in nutritional science New avenues of research are opening up different paths to supporting better nutrition in childhood.  For example, studies have examined the role of gut health or enteric dysfunction (inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine) in nutritional status, indicating that a child’s ability to absorb nutrients plays a key role in nutritional status[16]. Increasingly the literature suggests that animal-based proteins have an important role to play in contributing to the fight against stunting. Eggs, for example, are considered a perfect protein and packed with macro and micronutrients such as Choline, that promote the healthy growth of children and in most communities are relatively affordable and accessible[17]. A randomized controlled trial in Ecuador has found that giving an egg a day to children aged between six and nine months, in addition to their existing diet statistically significantly improved child growth outcomes, with stunting reducing by 47% in the intervention arm[18].   New data and recommendations are also emerging regarding the importance of the condition and care practices of the parent or primary caregiver starting in (pre-)pregnancy and into the early years of a child’s life in reducing stunting and overweight[19]. Integrating parental support, psychosocial stimulation of the child and nutrition interventions have the potential to target multiple child outcomes, with some studies showing additive effects of combined interventions over any one approach alone[20].   A further area for intervention is in relation to maternal mental health. Research from a South African cohort study found that women who suffered from postnatal depression were more likely to have stunted children[21]. Maternal depression has been found to negatively impact a pregnant or new mother’s motivation to attend routine health care visits, adhere to chronic medications, bond with her child, as well as persist with exclusive breastfeeding, all of which put the fetus at risk of low birth weight and the infant at risk of malnutrition and stunting. The relatively new field of epigenetics, which studies biological factors affecting gene control, is also starting to shed light on the long-term effects of in utero conditions – including on metabolic disease in adulthood. A study of babies born to mothers who lived through the Dutch Hunger Winter of 1945, found exposure to an adverse environment during early development and health outcomes in adulthood are mediated by epigenetic factors, showing among other things higher rates of obesity by middle-age[22]. Infant sleep has also been linked to obesity in later life, and several studies have emerged that suggest newborns whose parents receive support to help their children sleep better were less likely to be obese in later life[23].   Conclusion This paper highlights evidence of existing challenges and offers opportunities to support all children to reach and maintain a healthy weight. In addition to working towards a one-planet diet for all, successful action needs to take into account cultural diversity and specific bio-psycho-social issues affecting families and communities. References [1] The Lancet 2013, Maternal and Child Nutrition, The Lancet, <https://www.thelancet.com/series/maternal-and-child-nutrition>. [2] Food and Agriculture Organisation of the United Nations 2018, The State of Food Security and Nutrition in the World 2018, Rome. [3] Swinburn, A, Kraak I, Allender, S, Vincent, A et al. 2019, ‘The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission Report’, The Lancet, vol. 393, no. 10173, pp. 791-846. [4] Willet W, Rockstrom, J, Loken, B, Springmann, M, Lang, T, Vermeulen, S, Garnett, T, Tilman, D, DeClerck, Wood, A, Jonell, M, Clark, M, Gordon, L, Fanzo, J, Hawkes, C, Zurayk, R, Rivera, J, Vries, W, Sibanda, L, Afshin, A, Chaudhary, A, Herrero, M, Agustina, R, Branca, F, Lartey, A, Fan, S, Crona, B, Fox, E, Bignet, V, Troell, M, Lindhal, T, Singh, S, Cornell, S, Reddy, K, Narain, S, Nishtar, S & Murray, C 2019, ‘Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems’, The Lancet, vol. 393, no. 10170, pp. 447-492, doi:10.1016/S0140-6736(18)31788-4. [5] Nugent R 2019, ‘Rethinking systems to reverse the global syndemic’, The Lancet, vol. 393, no. 10173, pp. 729-728, doi:10.1016/S0140-6736(18)33243-4 [6] World Health Organization 2017, Taxes on sugary drinks: Why do it?, Geneva. [7] World Health Organization, 2018, Time to deliver: report of the WHO Independent High-level Commission on Noncommunicable Diseases, Geneva. [8] Caprio, S, Daniels, R, Drewnowski, A, Kaufman, R, Palinkas, A, Rosenbloom, L, Schwimmer, B 2008, ‘Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment: A consensus statement of shaping America’s health and the obesity society’, Diabetes Care, vol. 31, no. 11, pp. 2211-2221. [9] Patrick, H, & Nicklas, A, 2005, ‘A Review of Family and Social Determinants of Children’s Eating Patterns and Diet Quality’, Journal of the American College of Nutrition, vol. 24, no. 2, pp. 83-92. [10] Chaturvedi, A, Nakkeeran, N, Doshi, M, Patel, R., & Bhagwat, S 2018, ‘Determinants of Micronutrient Fortified Blended Food (Balbhog) Consumption among Children 6-35 Months of Age Provided through the Integrated Child Development Services Program in Gujarat, India’, Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive and Social Medicine, vol. 43, no. 2, pp. 97-101. [11] Chaturvedi, S, Raven, J & Patwardhan, B 2017, ‘Addressing child under nutrition: can traditional practices offer a solution?’, Global Health Action, vol. 10, no. 1, 1-3, doi: 10.1080/16549716.2017.1327255. [12] National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda] & ICF International 2015, Rwanda Demographic and Health Survey 2014-15, Rockville, Maryland, USA. [13] Bundesministerium für Nachhaltigkeit und Tourismus 2014, Die Ernährungsgewohnheiten der Österreicher, Bundesministerium für Nachhaltigkeit und Tourismus, <https://www.bmnt.gv.at/land/lebensmittel/qs-lebensmittel/lebensmittelkonsum/ernaehrung_habits.html>. [14] Rust, P., Hasenegger, V., König, J. (2017). Österreichischer Ernährungsbericht 2017. Department für Ernährungswissenschaften Universität Wien m Auftrag von Bundesministerium für Gesundheit und Frauen. [15] Crane, R, Jones, K & Berkley, J 2015, ‘Environmental enteric dysfunction: An overview’, Food and Nutrition Bulletin, vol. 36, no. 10, pp. 76-87, doi:10.1177/2F15648265150361S113. [16] Iannoti, L, Lutter, C, Bunn, D & Stewart, C 2014, ‘Eggs: The uncracked potential for improving maternal and young child nutrition among the world’s poor’, Nutrition Reviews, vol. 7, no. 26, pp. 355-368. [17] Iannoti, L et al. 2017, ‘Eggs in Early Complementary Feeding and Child Growth: A randomized Controlled Trial’, Paediatrics, vol. 140, no. 1, pp. 1-9. [18] The Lancet, 2016, Advancing Early Childhood Development: from Science to Scale, The Lancet https://www.thelancet.com/series/ECD2016 [19] Grantham-McGregor, S, Powell, C, Walker, S & Himes, J 1991, The Lancet, vol. 338, no. 8758, pp. 1-5, doi:10.1016/0140-6736(91)90001-6. [20] Madlala, S, & Kassier, S 2018, ‘Antenatal and postpartum depression: effects on infant and young child health and feeding practices’, South African Journal of Clinical Nutrition, vol. 31, no. 1, pp. 1-7, doi:10.1080/16070658.2017.1333753 [21] Tobi, E, Slieker, R, Luijk, R, Dekkers, K, Stein, A, Xu, K, Biobank-based Integrative Omics Studies Consortium, Slagboom, P, van Zwet, E, Lumey & Heijmans B 2018, ‘DNA methylation as a mediator of the association between prenatal adversity and risk factors for metabolic disease in adulthood’, Science Advances, vol 4, no. 1, pp. 1-10 doi:10.1126/sciadv.aao4364. [22] Taylor, R, Gray, A, Heath, A, Galland B, Lawrence, J, Sayers, R, Healey, D, Tannock, G, Meredith-Jones, K, Hanna, M, Hatch, B & Taylor, B 2018, ‘Sleep, nutrition, and physicial activity interventions to prevent obesity in infancy: follow-up of the Prevention of Overweight in Infancy (POI) randomized controlled trial at ages 3.5 and 5 y’, The American Journal of Clinical Nutrition, vol 108, no. 2, pp. 228-236, doi: 10.1093/ajcn/nqy090. [23] Paul, I, Savage, J, Anzman-Frasca, S, Marini, M, Beiler, J, Hess, L, Loken, E & Birch, L 2018, ‘Effect of a Responsive Parenting Educational Intervention on Childhood Weight Outcomes at 3 Years of Age: The INSIGHT Randomized Clinical Trial’, JAMA, vol 320, no. 5, pp. 461-468, doi: 10.1001/jama.2018.9432.
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