Sabri is a nutritional epidemiologist whose research focuses heavily on methods for population-based assessment of diet and diet quality, and understanding relationships between nutrition, food environments, and food systems in low- and middle-income countries.

Shireen [0:32]: On today’s episode, we welcome Dr. Sabri Bromage, whose research centers on developing and expanding tools conducting large scale nutrition surveys in low and middle income countries. He also investigates the connections between human nutrition and the environment, including natural and food environments, and how nutrients move through various ecological systems. Stay tuned. Dr. Sabri Bromage is a nutritional epidemiologist whose research focuses heavily on methods for population based assessment of diet and eye quality, and understanding relationships between nutrition food environments, and food systems in low and middle income countries. Welcome Dr. Bromage.

Dr. Bromage [1:22]: Thank you, Shireen. It’s a pleasure to be here.

Shireen [1:24]: It’s such a pleasure having you on Dr. Bromage. Just diving right in, I would love to learn a little bit more about what your journey has been like into nutrition. And then we’ll get into some of the work that you’re doing specifically as well. But what really sparked your interest in this space?

Dr. Bromage [1:38]: Yeah, so I’ve actually always been very interested in food culture. So what people eat in different cities in different countries around the world, different traditions and histories of the different cuisines, different dishes, I mostly got into nutrition because I wanted to travel and I wanted to learn about culture through food. But the anthropology and the cooking is sort of just my hobbies, I’m not really cut out to be like Anthony Bourdain, and you know, Parts Unknown, that show, which I always thought would be, like the coolest job in the world, go around the world and eat a lot of interesting things. But instead of actually kind of gravitated more toward physical science, Biological Science statistics, so I focus my education on nutrition science, nutrition epidemiology, in international settings, especially in low and middle income countries, like you mentioned, it’s mostly what I do, it’s been a very interesting journey. And it’s incidentally exposed me to a lot of food cultures. And I think nutrition is really interesting on a lot of levels, you know, they say that you are what you eat. And that’s literally very true. Every atom and every molecule in your body came from something that you ate, and something that you drank at some point in your life, which I think is a very interesting philosophical concept.

Shireen [2:54]: In tying to some of that work that you’ve done in low and middle income countries. Can you speak to your experience in terms of what are some key barriers, perhaps, to conducting regular surveys research within these countries? And how do they illuminate the diet situations in these countries?

Dr. Bromage [3:11]: Yeah, so I’m mainly an epidemiologist, I mostly deal with data and population surveys, you know, that collect food consumption data from individuals in large populations, like, for example, the National Health and Nutrition Examination Survey in the US in Haynes, these kinds of surveys are really critical for informing strategies to improve diets and improve nutrition and in populations, but they’re very expensive, they’re very time consuming to do, especially in developing countries. So in Sub Saharan Africa, for example, about half of the data that we have on population diets, that basically qualitative information, you know, consumption of a limited number of food groups over the past 24 hours, you know, in some very specific target groups. So that’s one big issue is the food intake data, we don’t really have it for a lot of populations. Also, a lot of countries, they don’t have a lot of money to analyze local foods for their nutrient concentration data, like what the USDA does in the US. This makes it difficult as well to analyze any population dietary measurements that we do have for nutrient intakes and understand let’s say, the prevalence or the distribution of different nutrient deficiencies. So these kinds of gaps, you know, in terms of validated methods for collecting the true data, local data on the food composition, methods for publicizing healthy dietary recommendations, like food based dietary guidelines, which are also kind of lacking a lot of countries. Without them, we can’t really easily develop again advocate we can’t really monitor evidence based strategies for improving diets improving nutrition and people end up suffering so much of the Global South, still burdened with key micronutrient deficiencies, but also now facing a big double burden of diet related diseases, heart disease, stroke, type two diabetes and certain cancers. 

Shireen [5:06]: And so just to add upon that help us even just understand infrastructurally how it is different there because of course, in the United States, a lot of those things are already set up. And we almost take that for granted. But what were you saying is, in these countries, a lot of those infrastructure elements with funding for this type of work data collection, the mechanisms through which this data is collected? Can you shed some more light on how that is starkly different from what we tend to find in the United States? 

Dr. Bromage [5:32]: Yeah, I mean, funding is definitely an issue, you need money to just, for example, to buy laboratory supplies to analyze a food for, let’s say, you know, different vitamins and minerals, protein, etc. That’s kind of a fundamental problem, but the machinery, the instrumentation, the infrastructure for preparing the lab, not just that, but also human resources, I mean, or institutional experience, and collecting these kinds of data, analyzing these kinds of data, it requires a lot of training, and requires a lot of people. So for example, universities, research institutes government Institute’s that take care of this, they have to be well equipped, well funded, and have a lot of experience. But there are even sort of more fundamental infrastructural issues, like for example, in a given population, you really want to have a tool, let’s say, to be able to measure diets in that specific population, because every population is different. So you kind of have to tailor your methods for each population. In order to have those tools. Ideally, you want to develop them and validate them and test them before you use them. So you have confidence you have context and what they’re measuring. And that’s a long process as well, in the US, you know, we’ve been doing this for a long time, but in many countries, the resources aren’t there. And the time you know, the funding is limited. So have to rely on maybe cheaper or easier methods that don’t always tell us exactly what we really want to know.

Shireen [6:57]: That is so interesting, you know, when you’re mentioning given the different types of interventions, in your experience, what have been some effective food based interventions for addressing nutritional deficiencies that you talked about earlier, even improving diet quality more broadly? And then how do you measure the effectiveness of that? 

Dr. Bromage [7:16]: Yeah so there are lots of different types of food based interventions. So for a while, to give an example, I was working on research in large scale industrial food fortification, it’s something that we kind of take for granted sometimes in the US, where we have cereals, or milk, orange juice, and things like that, that are enriched with a lot of nutrients, you know, vitamins and minerals that we may not even know about. So fully, for example, added to flour is a very cost effective way to prevent neural tube defects. So that’s where the tissue that forms the central nervous system and the infant, it doesn’t develop properly, and maybe winds up with permanent, you know, really horrible physical and cognitive problems for the whole life. That’s something that you can’t really addressed easily through, let’s say, nutrient supplementation, because it’s necessary for a woman type to be folate sufficient at the time of conception, in order to prevent this by the time they realize that they’re pregnant. And they start taking, let’s say, a folate, supplement, iron folate supplement, it’s already too late to mitigate that risk. So that’s something where fortification, let’s say can really help because it makes sure that your food is more nutritious, and you don’t even really need to consciously think about it. But for fortification, for example, there are different ways to measure it. One way is just to look at the countries that have food fortification with folate and the countries that don’t have it. And you can compare their rates of neural tube defects in the population. And it’s been pretty well established now that the countries that do fortify with folate, they have a significantly lower incidence of these kinds of defects. But, you know, this is just one approach fortification, for example, it has a lot of limitations. There are a lot of tools in the toolbox for improving population diet nutrition, like for example, supplementation, behavioral modification for diets, agricultural development, diversification, you know, economic policies and things like that. Ideally, you want to try and combine different strategies that complement one another to really improve nutrition based on the local context.

Shireen [9:16]: There’s a concept around environmental nutrition that I want to dig into with you, which is such a fascinating area of study. How do you understand this relationship between environment and human nutrition? How is it connected? 

Dr. Bromage [9:30]: Yeah, so it is interesting, you can kind of divide your let’s say, dietary habits into, let’s say, two different general domains. So one is sort of, you can say, an internal domain involves you, your tastes, your habits, the kind of choices that you make. I will say your education, your budget, you know, these are very important factors, especially if you have a lot of options available to you. But there’s also external domain, which is really just as important, I’m talking about the food environment, the food system that you live in, it largely determines what food is available to you, where it is, how its marketed, how it’s priced to advertise, you know, cultural drivers around food. These are all factors that ultimately, really shape what you eat, whether you like it or not, or whether you even are aware of it or not. So recently, we’ve been looking at food environments in terms of, you know, the availability of the affordability, accessibility of different foods in urban and suburban areas of Thailand, we’ve also been looking at the you can say, like the natural environment. So in terms of planetary impacts on nutrition, security, and particularly the impact of climate change, and related stresses and shocks on nutrition security, which is a really big issue in Southeast Asia, for example, it’s like the most flooded region in the world. And many parts of it’s still quite dependent on subsistence agriculture. 

Shireen [11:00]: Can you double click into a couple of these examples? I know you mentioned Thailand and Southeast Asia. Can you walk us through a specific project, but more specifically, what are some key findings within those projects? 

Dr. Bromage [11:11]: Yeah recently, we’ve been working on just to give an example, a concept for using artificial intelligence and machine learning to try and understand urban food environments. So the basic idea, we’ve collected ground based measurements of different, let’s say, nutritionally relevant parameters, like the location, the types of different food outlets, you know, what foods those outlets provide the prices, advertising practices, we use those ground based data to train a model based on open source data, like for example, text, images from Google Maps, or Facebook, for example, that model used to predict, let’s say, nutritionally relevant characteristics of food environments in different areas of the city at different times, you know, among different groups of consumers. The point of this is ultimately to create, like a user friendly map that people can use to understand urban and suburban food environments, in terms of their risk that’s associated with being in that environment, the nutritious of the different foods that are available to them, you know, the risks of their wallet, you can say, the price for this kind of research, AI is really very useful for, let’s say, interpreting natural language, let’s say from restaurant reviews, or understanding and interpreting images of foods or storefronts, for example that you can get from the internet, machine learning is very helpful to for scraping large amounts of information from different sources, and, you know, developing the prediction algorithm. So it’s been an interesting exercise in itself, but also methods development and are getting more experienced and some of these newer technologies that are going to be really important going forward in the future.

Shireen [12:57]: And what is the impact of looking at that or scraping that data and looking at sort of the some of the relational things and predicting them? What is the impact within a community from that? 

Dr. Bromage [13:07]: Right so I guess you can say that the whole purpose to doing something like this is kind of getting back to the earlier point about a difficulty of getting this kind of data, and a limited resource setting. You know, it would be ideal if we could send like teams out to different parts of the city, cover the whole city and understand, you know, the nutritional characteristics of different areas, food environments, using rigorous methodology. But that’s not really practical. Even in high income country, it would take a lot of experience a lot of people and a lot of money, what we want to do is use open source data, to do the prediction, where we already have that open source data, we just need to validate the method. So it’s basically a way of understanding the risk associated with different food environments, without needing to go through that very laborious process, we just need to validate it first and make sure that the methodology is robust. The ultimate impact would be that you would have an interface that people could use, and they could actually understand that, let’s say this part of the city for this kind of consumer for this time of day, this is going to be more or less risky, and let’s say in terms of the food quality that that they may be exposed to. And this is kind of getting, trying to engender and understanding that again, it’s not just a personal decision, it’s also your environment. And, you know, you can kind of mitigate and adapt to different food environments, at least if you understand what those risks are.

Shireen [14:32]: You mentioned the environment just a second ago, could you help us understand this term, which is agro biodiversity, and help us understand the role of food culture and agro biodiversity and improving nutrition? And then how can this knowledge really be applied effectively within public health interventions?

Dr. Bromage [14:52]: Right? I start with food culture, food culture is really kind of the key to good nutrition at the end of the day, from a public health standpoint, you can give people food, you can improve the quality of their food, you can give them nutrient supplements. But ultimately, you really need demand side interventions for a sustainable improvement. The only way that people are really going to adopt, let’s say, healthier diets, especially if you have a choice is if those diets are culturally acceptable, you can’t really make people eat what you think they should eat. It’s just not practical. Let’s say when a physician gives somebody medical advice, even preventive advice, people are usually inclined to follow that advice. But when it comes to nutrition, it’s different people don’t really see dieticians, let’s say, unless they’ve had a very serious health scare, or they’re very unhealthy. By then it’s pretty late in the game, if somebody is just, let’s say, giving nutrition advice, assuming it’s good advice, they’re not necessarily going to adopt it, let’s say 100%. You know, because nutrition is not really like medicine, it’s kind of closer to the heart, in that what you eat is sort of rooted in your family’s dinner table the way that you were brought up. So at the end of the day, we need to change the food culture in order to change what people eat. In practice, that really means, you know, supporting the uptake of healthy dietary practices that build upon some existing foundation in a given culture that are healthy. And also discouraging, let’s say unhealthy foods, unhealthy influences, without changing too much or too quickly what people are used to. So one way to do that is revitalization, let’s say of underutilized agro biodiversity, we’re talking about, let’s say, indigenous plants, or, let’s say herbs and spices or animals that may have been important in previous decades or centuries, or maybe among specific indigenous groups or ethnic minorities. Let’s say for example, in rural areas, let’s say in the case of Thailand, these kinds of foods that may have kind of been lost in the national food culture, they often have very beneficial nutritional or bioactive properties, you know, but their use has kind of been forgotten in many countries due to let’s say, globalization of the food market, industrialization, planetary impacts, like climate change, and things like that. So if we can revitalize these kinds of foods, we can have a window toward promoting better dietary practices, more sustainable dietary practices, nutritional dietary practices, also has a side benefit of beyond public health, which is revitalizing indigenous culture, fundamentally, you know, which is a livelihoods issue and sort of a deeper cultural issue.

Shireen [17:38]: You know, Dr. Bromage, as you share your experience here, one of the neat things I guess, about the research that you are doing in other parts of the world is that you just have this extensive experience developing in country international research with universities, research centers, NGOs, in Asia of countries like Mongolia, Bangladesh, Thailand, how has your contact with this central south southeast Asian region and the communities the research communities within it really shaped your understanding of human nutrition and environment? And then what are some inspiring anecdotes, stories that you can share with us of your experience? 

Dr. Bromage [18:16]: Yeah, it’s been really a lot of fun and a privilege to learn about different research cultures, different cultures in different countries. So when I first started working in nutrition, I was working in Mongolia. And I was basically training a lot of medical students there to collect dietary data across the country as part of a nationwide nutrition survey. In return the students they got like a public health internship credit for their graduation. So it’s kind of a win win. There’s a lot of fun, each field season, we train all the students, we’d pair them up with different families. And they would collect like prospective data on what their assigned family or subject ate over three days in the summertime, and then three days in the wintertime following and during each of these three day periods, my team and I will go and check in on each of the students at least once like just to check they had any challenges or any questions is just to make sure that they were doing the recording correctly. And when we visited them, especially if they were paired with like a rural nomadic subject in the countryside, it was a very big affair. So we would approach the yurt, you know, where they were living with the student was working, and the family would host us, they occasionally give us like food to eat. Sometimes they even would slaughter like a goat or sheep for us, which was, you know, kind of an honor. But it was also kind of awkward because the family members would join us to eat together and that would end up affecting their own diet, which was something we really wanted to kind of avoid because the whole point of this exercise was to, you know, measure a sample of what the free living population usually eats without being affected by a research process so that we had to kind of like find find ways around that, but it was really fun. And it was really amazing how hospitable how friendly pastoralists nomadic people are, you know, which is because they don’t really get a lot of visitors. Mongolia is one of the least densely populated countries in the whole world. You know, these nomads are often quite remotely located. Since an interesting in in Bangladesh, people are also extremely hospitable. But I think for the opposite reason. It’s like the most densely populated country in the world, I think. And you know, you kind of learn to get along with people because you don’t really have a choice. You’re sort of with people all the time. So it was amazing.

Shireen [20:35]: You mentioned and the work that students have done for you over a decade, 12 years now you’ve conducted training supervision for approximately 400 students, researchers, professionals of diverse educational professional backgrounds across middle income countries. What is your philosophy toward mentoring early career researchers, perhaps someone who will be listening to this episode here today?

Dr. Bromage [20:57]: I think that really wherever you go, it’s good to dedicate some time to really understand the culture that you’re working in, including taking some time off from work, just understanding people, the language, if you can, how the culture shapes people’s approach to learning and research different countries. Also, keeping in mind that there are limits to how you can understand people just to their culture, because everybody’s different wherever they are. Some people they like to work alone, or work in groups, etc. Despite what people gravitate toward. Also, it’s kind of helpful to expose people to different ways of learning. So I’ve tended to try and understand people individualize things, but also mix things up a little bit in terms of was a more collaborative approach, more didactic approach, or a more hands on versus more hands off sort of mentorship style, something that I’ve struggled with, and continued to kind of struggle with and try to find ways of improving in terms of my, let’s say educational approach is trying to help folks, early career researchers understand the value of exploratory research approaches. So that means really hypothesis generating research. You know, when most people are learning about science, in their own education, early career researchers are students, they start with learning about the scientific method, how to test hypotheses, etc. But that only really works if you have a hypothesis to test to begin with. So hypothesis generation is also very important. Sometimes that’s just involves collecting data, looking at patterns or developing platforms for harvesting data. That’s something that early career researchers and particularly they don’t always understand the value of that kind of approach. But it’s a very important part of science, in addition to hypothesis driven research, which is sort of more traditionally what we learn in school. So one good example of this, I think, is artificial intelligence. Ai used to be designed for like, specific tasks, like for example, image recognition, voice recognition, but now it’s at a level really, where it’s such a powerful platform that we can use it for lots of different things. We don’t even really know what those things are yet, but people have the tools available. And they’re kind of figuring that out, you know, hopefully for a good purpose for society.

Shireen [23:17]: And so to the researchers, do you encourage them to then explore some of these avenues and embrace these types of technologies in their approach? 

Dr. Bromage [23:26]: Absolutely. I think AI in particular, basically, I’ve encouraged everybody who I’m working with, to become more familiar with it, even free algorithms and tools for AI. I think if you’re doing research, it’s almost imperative, in my opinion, that you become more fluent with AI, even the basics, because it really is incredible tool. It has the power to essentially transform every research endeavor that we’re working on. So yeah, it’s very exciting.

Shireen [23:55]: Lovely. With that Dr. Bromage, we are unfortunately toward the end of the episode at this point, can you tell our listeners how they can connect with you and learn more about your work?

Dr. Bromage [24:04]: Sure, you can connect me on LinkedIn Sabri Bromage. That’s pretty much the only social media that I use. You can also check my website scholar.harvard.edu/sabri, My first name, it has my publications and it also has my email address on there. If you want to drop me a line and have any questions or collaboration, stuff like that, happy to connect.

Shireen [24:25]: Lovely. With that. Dr. Bromage, thank you so very much for your time to our listeners. Thank you so much for tuning in to another episode of the English podcast. At this point, we will ask you to head over to our social media, I answer this quick question, which is, what steps do you think individuals or communities can take to improve their nutritional health in a sustainable way? Again, I’ll repeat the question What steps do you think individuals or communities can take to improve their nutritional health in a sustainable way? Head over to @Yumlish on Facebook on Instagram? Find this very podcast post comment below to answer This question, we will continue the conversation there. Dr. Bromage, thank you again.

Dr. Bromage [25:04]: Thank you so much Shireen and thank you all for listening.

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