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It's heartening to hear of so many good strategies for reducing obesity.  What we also need is evidence. Today I received a communication circulated on the SNEEZE network which cites evidence of falling child obesity rates in some parts of the US. I am copying the communication below.  

The question is then - how did this occur?  Does it depend more on public debate, well-developed institutions and community nutrition education (very strongly established in the US) or on industry regulation?  Does it require the resources of a wealthy country?    Jane Sherman  

E-mail on SNEEZE network:

This morning RWJF released new stories and data from a growing number of states, cities, and counties that have measured declines in their childhood obesity rates. Many of these places have made broad, far-reaching changes to help support healthy eating and regular physical activity. For example:
·         Kaiser Permanente, the Safe Routes to School Partnership and the National PTA are running a “Fire Up Your Feet” campaign in Southern California to encourage kids to walk or bike to school.
·         All YMCA’s in South Carolina have adopted Healthy Eating and Physical Activity (HEPA) standards in their afterschool programs to help kids have healthy snacks and drinks and at least 30 minutes of physical activity. 
·         CentraCare Health, a nonprofit healthcare system in St. Cloud, Minn., is working with the local government and community organizations to help school districts update their wellness policies and implement nutrition labeling in grocery stores and schools.......

List of new or updated locations and their stories:
 
Just added to the RWJF Signs of Progress collection!
·         Cherokee County, South Carolina: The obesity and overweight rate fell from 43 percent in 2012 to 34.3 percent in 2015 among first grade students, a 20.2 percent relative decline. Among third graders, the obesity and overweight rate fell from 51.5 percent in 2012 to 40.7 percent in 2015, a 21 percent relative decline.
·         Colorado: The obesity and overweight rate fell from 22.9 percent in 2012 to 21.2 percent in 2015 among 2- to 4-year olds enrolled in the state’s Special Supplemental Nutrition Program for Women, Infants and Children (WIC), a 7.4 percent relative decline.  
·         Southern California: The obesity rate fell from 19.1 percent in 2008 to 17.5 percent in 2013 among Kaiser Permanente members ages 2 to 19, an 8.4 percent relative decline.
·         St. Cloud, Minnesota: The obesity and overweight rate fell from 17 percent in 2008 to 13 percent in 2015 among 12-year-olds, a 24 percent relative decline.
 
Updated with an additional year of data!
·         New Mexico: The obesity and overweight rate fell from 30.3 percent in 2010 to 25.6 percent in 2015 among Kindergarten students in public schools, a 15.5 percent relative decline. Among the public school students in third grade, the obesity and overweight rate fell from 38.7 percent in 2010 to 34.4 percent in 2015, an 11.1 percent relative decline.
·         Philadelphia: The obesity rate fell from 21.7 percent in 2006-07 to 20.3 percent in 2012-13 among Philadelphia public school students in grades K-12, a 6.5 percent relative decline.
·         Seminole County, Florida: The obesity and overweight rate fell from 34.3 percent in 2006-07 to 29.6 percent in 2013-14 among students in grades 1, 3, and 6, a 13.7 percent relative decline.
 

I have found the discussion so far very interesting and welcome the opportunity to give the point of view of an educator who has some experience of curriculum development and work-related learning.

It seems self-evident that agricultural officers and extension workers should know how to grow a good diet and be able to help others to do so. The potential impact of such capacities in the field has been described and so have the difficulties of achieving it (e.g. by Fanzo et al. 2013).  There are therefore moves to introduce nutrition into the pre-service curriculum of agricultural colleges and degree courses.  This seems to me to raise some important preliminary questions about the conditions necessary for successful work-related learning in this field.  

Question 1  Is it worth doing?  

Curriculum space is often jealously guarded and the status of a new subject may have to be fought for.  One danger is the offer often made to new entrants of “integration across the curriculum”, i.e. distribution across existing core subjects.  This generally means fragmentation, loss of coherence and importance, especially if the subject is not allowed its own staff, exams and assessments.   

Evidence of nutrition impact in normative agricultural extension activities is thin, hence it may be important to be able to produce evidence, cases and models of successful action, a strong rationale and a promotional plan (even plans for future assessment of impact) when arguing for a proper place for nutrition in the agriculture curriculum. 

 The evidence is important also in the curriculum itself.  If agricultural extension services (AES) are to carry advisory weight in their communities, staff and graduates need to believe in the value of action to promote good diet.

Question 2  What kind of syllabus should it be?

Nutrition learning for agricultural officers must be an applied subject if it is to have any effect on dietary practices.  The syllabus will certainly have a large knowledge component (topic-based), including understanding of the food environment and familiarity with the nutritional values of many foods.  However, since “nutrition” in the work of the AES largely refers to educational activities such as enquiring, communicating, explaining, advising and demonstrating, the syllabus must also aim to build working competences (task-based) relating to behaviour change and maintenance. 

Topic-based and task-based syllabuses have very different objectives, activities and assessments: for example, task-based learning requires considerable hands-on observation, practice and field application.  Many experts and institutions do not recognize the difference:  in nutrition, a common error is to assume that the syllabus (a) consists mainly of facts about nutrition, and (b) can therefore be delivered through a few extra lectures.  This cannot produce an effective change agent!  All those involved will therefore need to agree what kind of syllabus is needed, and may need to consider including specialists in work-related learning and nutrition education/behaviour change in the curriculum development team.

Question 3  Who else is involved? 

The team must ensure that all the players in the institutional environment are consulted and are active in support of the new initiative, for example, that

1. the MoA has adopted nutrition objectives in line with national nutrition aims and that the curriculum is in line with any national nutritional strategy.
2. AES services are prepared to collaborate in formative research into work practices, outlook and knowledge of extension practitioners
3. the institution has agreed to a curriculum review to incorporate nutrition and nutrition education objectives, and will allow time for field work
4. the institution and the AES agree to actions necessary to create a supportive service for nutrition-focused activities (e.g. training of supervisors, revision of TORs, adaptation of existing tasks)
5. the capacity is available to develop a curriculum which will be effective in helping to improve diets.   

There are plenty of other questions, but these three already seem to magnify the scope of the curriculum exercise considerably.  I would very much like to hear comments from participants in this forum, including institutions which are contemplating such a curriculum change.

Jane Sherman, Nutrition education consultant, FAO

Show us the way!

It is great to hear so many stories of improved agriculture, improved strains, better seeds and biofortification.  What concerns me is that we are not talking enough about the pathways from agriculture to better nutrition.  It is not at all clear that increased productivity, greater income, improved quality or variety of food production necessarily result in improvements in diet and health.  We need to know and show why and how this happens or does not happen. 

There has been some mention in this forum discussion of promising avenues for converting greater availability into better dietary practice:  for example behaviour change approaches, nutrition education, involving women, enabling people to make their own decisions and hands-on home-linked school education.  We need to do much much more in these areas, and integrate it better with the food security initiatives it supplements and catalyses. 

We also need to test what we do, making sure that these approaches get their own impact evaluation, quite distinct from agricultural/horticultural outputs and availability, so that we can show what mix of actions can best influence dietary change and make it last.

We are not alone.  The major players in the fields of agriculture and nutrition have not yet sorted out the answers to the how question.  What is very positive is that the challenge has been proclaimed, not least by this forum, and that we are beginning to try to meet it.

Jane Sherman, Nutrition Education Consultant, FAO, Rome

PREAMBLE

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.[1] The Framework does not in general refer to supporting evidence:  it therefore begs many questions, which may or may not be valid.[2]  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?[3]

-          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.[4]  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.

2.1  Terminology  

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.

Jane Sherman

Rome, August 2014