Chronic non-communicable diseases such as diabetes, cardiovascular disease and cancer are responsible for the vast majority of deaths in all but the poorest low and middle income countries (LMICs). They are particularly rising in LMICs and are higher in many LMICs than in high income countries. A key driver of this health burden is poor quality nutrition, including diets high in energy dense and highly processed foods and low in fruit, vegetables and fibre. There are several factors that may contribute to poor diets, including poor conditions for growing, storing and transporting fruit and vegetables, and a reliance on relatively expensive food imports. In small island developing states (SIDS) the relationship between a reliance on food imports, poor nutrition and a high burden of chronic diseases is particularly apparent.

Community-based agricultural food production initiatives are one possible approach to improving food and nutritional security and to reducing the risk of chronic diseases. They can also help to improve 'food sovereignty' by increasing the ability of populations to influence their own food systems in ways that are sustainable and promote health. Such initiatives may take several forms, but are owned, organised and managed locally, and produce either fresh or minimally processed food for local consumption. While the potential contribution of such initiatives is recognised, there is very little evidence available on what their impacts actually are in terms of health, social well-being, economics or the environment. There is an urgent need for improved evidence on their impacts, and this proposal is concerned with developing and testing methods to contribute towards filling this evidence gap.

The proposal is designed to help establish a transdisciplinary research programme with the conceptual and methodological skills necessary to undertake robust evaluations of community-based food production initiatives in LMICs. The evaluation of the initiatives will include their contribution to promoting health and social wellbeing, their economic and environmental impacts, and their sustainability. The development work proposed here will be undertaken in two contrasting middle income SIDS, St Vincent and the Grenadines and Fiji. Both are actively engaged in promoting local food production for local consumption, and their well-defined geographical boundaries and relatively small size provide ideal settings to undertake development work. However, the overall goal is to develop a framework and methods that are readily adaptable and applicable to other LMIC settings in which nutritional insecurity is a major contributor to the risk of chronic diseases, including many settings in sub-Saharan African, where levels obesity and diabetes are already high and increasing.

In this project we will update and expand existing evidence reviews on community-based food initiatives in LMICs. In the two chosen settings, we will develop and test research methods to investigate the current nutritional adequacy of local diets and the contribution of community-based food production, and find out who is involved in and supports local food production. We also aim to develop methods to estimate the environmental impacts such as on local water use and carbon emissions. Finally, we aim to determine the major challenges and successes in establishing and sustaining selected initiatives, and how barriers to success might be overcome. The findings will enable us to develop an evaluation framework and refine methods to design a programme of work to robustly evaluate and compare community-based food production initiatives in Africa, the Caribbean and Pacific from the perspective of their impacts on chronic disease risk, social and economic well-being and the environment.

Technical Abstract:
Rates of obesity, diabetes, cardiovascular disease, and many cancers, are higher in many low and middle income countries (LMICs) than in high income countries. Poor quality diet, characterised by the consumption of energy dense and highly processed foods, low intake of fruit, vegetables and fibre is a major determinant of this increasing burden. There is an urgent need for improved evidence on the impact of agricultural interventions in LMICs on nutrition, health and other aspects of well-being. The proposal is designed to help establish a transdisciplinary research programme with the conceptual and methodological skills necessary to undertake robust evaluations in LMICs of community-based food production initiatives.

In this project we will update and expand existing systematic reviews of published and grey literature on community-based food initiatives in LMICs. In the chosen settings, St Vincent and the Grenadines and Fiji, with established community-based food production initiatives (CFPI), we will develop and test mixed methods to investigate the current nutritional adequacy of local diets and the contribution of community-based food production, and map key stakeholders and potential economic and social benefits of local food production. We also aim to develop feasible methods to estimate the environmental impacts such as on local water use. Focusing on selected CFPIs in each setting as evaluation targets, we aim to determine the major challenges and successes in establishing and sustaining such initiatives, and how barriers to success might be overcome. We will collate findings to derive an evaluation framework and refine methods to design a programme of work to robustly evaluate and compare community-based food production initiatives in the Caribbean and Pacific, and in comparable LMIC settings in Africa, including South Africa, from the perspective of their impacts on NCD risk, social and economic well-being and the environment.

Potential Impact:
Relevance: Chronic non-communicable diseases (NCDs) are responsible for the vast majority of deaths, and age-standardised prevalence rates of obesity and diabetes and mortality rates from cardiovascular disease and many cancers are higher in many low and middle income countries (LMICs) than in high income countries. The burden of NCDs is an urgent concern beyond the public health field for governments, society at large, and regional and international organisations. The UN high-level declaration on the prevention of chronic non-communicable diseases (NCDs), for example, has committed governments around the world to taking concerted action, recognising the direct impact of NCDs on the economic and social development in particular for LMICs and calling for a multi-sectoral response. Food security and sovereignty are central upstream determinants of NCDs and community-based food production a poignant example of such multi-sectoral effort required.

Who will benefit: While a multi-sectoral ('whole of government' and 'whole of society') response has been identified as playing a vital part in comprehensive approach to prevent and control NCDs, multi-sectoral collaborations require evidence and guidance to develop, implement, evaluate and sustainably support their initiatives. Direct beneficiaries of this project will be civil society organisation as organisers of community-based food production initiatives. Further direct beneficiaries will be governmental and non-governmental organisation as initiators and supporters of such initiatives. This includes governments in the selected countries but also regional policy-makers as both in the Caribbean and the Pacific setting intergovernmental regional collaborations are established to pool resources and expertise. Furthermore, policy-makers of governments in regions that are similarly vulnerable can benefit from the findings of this project. For example, our South African partners have a strong interest in this research programme and see relevance for policy-making in their setting. Finally, research partners will directly benefit from this project. There is an increasing interest in natural experimental studies to evaluate policy responses and 'real life' initiatives that tackle upstream determinants of health. As a relatively novel research field, this project will contribute to further develop methods for such evaluations, with strong guidance within the MRC Epidemiology Unit who contributed to the MRC guidance on evaluating natural experiments.

How will they benefit: As a development project, the short term benefit will be to identify specific needs to support the development and maintenance of community-based food production initiatives, particularly for relevant key organisation in the two identified regions. The impact plan outlines how these will be engaged.
In more medium term, with the successful establishment of a comprehensive programme of research, we can cumulate robust evidence for their complex impact, including potential unintended consequences for the settings such as the potential negative environmental impact in terms of water pollution or carbon emission. With robust evidence beneficiaries across sectors will be able to make a case for further support of such initiatives and identify concrete factors that might need addressing to reduce negative impacts. The researchers directly involved in the project, at the University of Cambridge, the University of the West Indies, the University of the South Pacific and the University of Witwatersrand will be involved in highly innovative methods development work; this will include local colleagues and postdoctoral researchers. Researchers beyond the direct collaboration will benefit will be access to tools, conceptual framework and related guidance made publically available (see academic beneficiaries).