All credit to the Framework document for enlarging the scene to illuminate so many fields of action. Through the lens of nutrition needs, it also reveals the global scenario: on the one hand a picture of inequality, scarce resources, instability and changing relationships with food; on the other the response, which is moving from piecemeal and palliative measures to a more integrated approach, to which the ICN2 should contribute.
The Framework for Action outlines the relevant areas of remedial activity and for each provides an extensive checklist or toolbox of what can be and has been done.
These comments first look at the document as a whole, its purpose and use, and then focus on the coverage, coherence and vision of the field of nutrition education, as we see it and would like it to be seen.
1. THE DOCUMENT AS A WHOLE
1.1 The balance of the parts
A few adjustments might be made in the balance, mostly relating to Section 1.2.
The nutrition transition More is needed on some key elements of the nutrition transition, for example loss of food-related skills, commercial influences, high availability of low-cost highly processed foods (probably fuelling the obesity epidemic) and pre-cooked convenience foods, status considerations (e.g. in high-profile sports drinks and snacks for teenagers). These trends are changing diets, confusing people’s ideas of good food and affecting the education landscape.
Sustainability targets The goals need to be extended. The main goals (except for exclusive breastfeeding, which is a behavioural goal) are presented as physiological gains in nutrition status. However, these gains are not always sustainable, especially if they are dependent on outside funding, short-lived media campaigns, social mobilisation, a stable environment, or social support or institutional capacity which does not materialise. There is some evidence in nutrition initiatives of notable improvements being followed by backsliding. The physiological targets should be expanded to include the social, behavioural, institutional, attitudinal, educational or environmental improvements which will help to ensure that gains are perpetuated.
Capacity building The need for capacity development is implicit throughout the document in the scope and penetration of the actions recommended, yet it is seldom mentioned, leaving training institutions, universities and extension services with no obvious role. Possibly capacity development is seen as something to be discussed at a later stage. If so, this could be made clear in Section 1.2.
1.2 Purpose and use
The Framework has wide scope and presents measures at different levels of attainability and functionality: there are some incontestable utopian wish lists (e.g. universal health care, transparency, human rights); recommendations for some broad strategies (e.g. starting with policy, intersectoral collaboration); and tighter packages of measures with very specific aims (e.g. essential nutrition actions, prevention of maternal anaemia).
Criteria for assessment From a professional point of view, countries will presumably want to make use of the Framework to select and prioritise strategies and activities for their own situations, to support policy with evidence and arguments and to refer to models of success. Ultimately, therefore, there must be some means of establishing criteria to assess strategies and actions. Which initiatives, for example
- demonstrably have a substantial effect on nutrition status?
- best address priority needs?
- have other side-benefits?
- are particularly cost-effective?
- can be maintained by existing services or by people themselves?
- have long-term effects?
- work together well, or act as catalysts?
- empower women?
- change the outlook and behaviour of future parents?
- shift social norms of behaviour?
- develop flexibility in the face of changing food patterns?
It would be useful if the document could propose such criteria for discussion.
Evidence Assessment depends on evidence and there are frequent complaints in the nutrition field about the lack of clear pathways from action to impact. The Framework does not in general refer to supporting evidence: it therefore begs many questions, which may or may not be valid. For example:
- Government action with intersectoral collaboration (Section 2.2). The paper suggests that approaches must start with government policy and be implemented through multisectoral interventions in consultation with all stakeholders. It may be that this centrist approach is more effective than (for example) many piecemeal interventions, broad consumer movements, upgrading of single services, specific capacity-building, basic school nutrition education, or education of girls, but in view of the difficulties and costs of effective implementation and multi-sectoral collaboration through government structures, what is the case for putting all the eggs into this basket?
- Food systems (Section 3.1) The Framework gives a lot of attention to improving food systems. It has been claimed however that simply improving the food supply or the quality of the food supply is often not enough to improve nutrition status. At the same time it does seem unlikely that food systems are irrelevant to nutritional progress. Could the recommended pathways be spelt out more clearly, or the research agenda indicated?
- School feeding is dealt with as part of social protection (Section 3.2). There is ample statistical evidence that school meals can improve school attendance and reduce short-term hunger (see WFP annual reports) but it is also stated here that school feeding programs “ensure that dietary diversity is achieved with the daily school meal”. It would be good to have references to conclusive evidence for this broad claim, which has been queried in the past.
One cannot make judgements outside one’s own field of expertise, but this is all the more reason why decision-makers should know that claims are grounded in evidence or have attracted general expert agreement. Where evidence is available, perhaps technical units could provide the references. A casebook of convincing case studies would also be valuable as models and reference points.
2. NUTRITION EDUCATION
We are glad to see that the area of nutrition education (roles, settings and conditions) is well covered in Section 3.3.4. In the rest of the Framework, however, nutrition education deserves more prominence as a cross-cutting issue and as a practice and a coherent discipline which binds the issues together and establishes much common ground for their resolution. The role of nutrition education in establishing long-term social goals could also be more visible.
There are four ways in which these roles might be recognised by the Framework.
Some parts of the Framework do not recognize the need for nutrition education; some believe that nutrition education refers to information dissemination and formal instruction; others have their own ways of referring to nutrition education. There is a need to recognize that nutrition education today is a coherent action-oriented concept, with research backing and some established processes and strategies, which aims at conscious lasting changes in food practices and outlook or “the voluntary adoption of food choices and other food- and nutrition-related behaviors conducive to health and well-being”(Contento 2007). It would be very useful if the Framework were to recognize that promotion, advocacy, guidelines, IEC, counselling, empowerment, consumer education, campaigns, behaviour change communication and social marketing, insofar as they have to do with food consumption, are all forms of nutrition education. This particular coherence cannot be neglected in a framework for action which depends so much on people’s willingness to act on their own behalf. A footnote to this effect near the beginning of the document would help.
2.2 Recognizing the role of education within other action frames
Nutrition education in this sense should feature more visibly in discussions of the essential nutrition actions, IYCF, breastfeeding, sanitation, institutional food and food safety, which all depend heavily on choices and awareness for their success. The need for nutrition education in schools, which must be seen as a basis for citizen empowerment, should be indicated wherever it is relevant to other activities. Nutrition education also plays a catalytic role in several of the major activities recommended in the Framework – for example:
o Food security. There is some hard evidence of the essential role of nutrition education in food security interventions, which needs to be captured more explicitly and at greater length in the section on food systems (3.1). It would be useful to spell out at each stage of the food chain what education or capacity-building is implicit, e.g. in the list of actions to be taken (pp.9-10).
o Social protection In both social protection schemes and nutrition-focused income generation, the role of nutrition education has been noted not only as a positive enhancer but as a turnaround element (see e.g. the history of SNAP and SNAP-ED). This could be highlighted in section 3.2. Nutrition education to enhance dietary diversity and combat the effects of the nutrition transition could refine the notion of “appropriate design” in social protection, which the document recommends but does not specify.
2.3 Conceptual coherence
Although education of some kind is implicit in most of the recommended actions, there is not much consensus on what is meant, what outcomes are expected and what particular prescription is good in each case. Sometimes the need for education is not presented; or education is mentioned as an add-on or side activity, or as a particular formula (BCC, social marketing, health promotion), without elaboration.
As an example, three health interventions pp.16-18 (Section 3.3.1) to prevent wasting, stunting and anaemia in women of reproductive age generally agree that what is needed from an education component is changes in practice, but otherwise do not show a coherent picture of education strategies. For example:
- No kind of education is called for in activities to prevent wasting – can this be intended?
- Social marketing is suggested to promote consumption of iron-fortified foods, but there is no agenda on education for enriching the diet with normally available iron-rich foods – was this intended?
- Social marketing is not however called on for breastfeeding, complementary feeding or food hygiene (to reduce stunting), and nor is nutrition education; instead these practices are to be promoted and fostered – what does this mean in terms of actions or outcomes?
- Nutrition education is recommended in schools to prevent anaemia – but it is not clear what it is expected to do.
If there is time before ICN2, it might be that contributors to the Framework could consider what kind of nutrition education they envisage in their own action frames and discuss with FAO Nutrition Division how to formulate the activities required. Apart from the added value for the Framework, this would be an interesting exercise in lateral institutional awareness-raising.
2.4 People and provisions
The final point is simply about vision. The document deals mainly with what programs can do for people (providing supplements, foods, cash, investment, services etc.). Such agendas sometimes overestimate the importance of supply and the impact of the actions of the change agents (governments, agencies, ourselves). In this picture the “beneficiaries” tend to recede from view and appear inert.
Nutrition education by contrast puts people at the centre of the picture, considering what they can do for themselves with help and support from programs which create an enabling environment for change. This is more a practical than a sentimental stance. It sees people as the most powerful actors and change agents, since food and eating interest them intensely; they influence and are influenced by social norms; they operate the food chain; they bring up children. Sustainability in food behaviour has a lot to do with people’s ownership of change and the development of critical social mass in supporting behaviours. In line with the social-ecological model, all levels of society need to acknowledge this revolution and play their part in it: ministry staff, university lecturers, associations, civil society, health workers, the media, the commercial sector, as well as the general public.
This vision of an active health-seeking population is needed to complement the physiological goals outlined by the document in Section 1.2 and the program actions which are set up to achieve them. A parallel social goal is needed: to produce nutrition-literate people who can (among other things) look after themselves and their families, demand services, make good choices, shop and cook, resist commercial pressures, talk knowledgeably about food, and advise others.
This expanded outlook can start with a small change. Each section of the Framework has a list of actions to be carried out by change agents. Each section could provide a parallel short list of what people should be able to do, understand and perceive – an educational aim alongside the physiological one. We would then have a more balanced and complete idea of what we are aiming for.
Rome, August 2014
 Research findings also need to be evaluated: e.g. one question is how far short-term physiological gains can predict sustainable long-term behavioural effects. In nutrition education, which calls on complex models of motivation and behaviour, some expert opinion is that most interventions are too context-dependent to draw convincing conclusions about wider application).
 If these questions are due to the writer’s ignorance, it can only be pleaded that others may be equally ignorant and that answers need to be more readily available.
 The success of Bangladesh in improving nutrition reflects some of these doubts. See Sullivan (2014) Mysterious success: understanding Bangladesh’s rapid reduction in undernutrition.
 Ruel, Marie. 2014. Micronutrients and improving nutrition through food systems.
A number of reputable voices, including the World Bank and HKI, have indicated the need for nutrition education to enhance the effect of improvements in agricultural provision.