nutrition and health education
Delighted to read the post by Daisy Alum which takes a realistic look at what happens to extra farming income generated by home-grown school feeding. I would very much like to know if Ms Alum has any data on this, but the forum is closing today. Is there some way we can hear more?
Jane Sherman, nutrition education consultant, ex-FAO.
POST 1 PROBLEMS
Many thanks for opening this subject on the FSN Forum. Of course gender issues are critical, but as a food educator I’d like to focus mainly on nutrition, in particular the needs for different kinds of food knowledge, motivation, action and training. Since it is rather long, I have divided it into two posts.
THE NITTY-GRITTY
There is so much talk about what AEAS could or should do, that it is good to hear about what is actually being done and how it has turned out: for example Helvetas on the “hard fight going on in the marketplace to catch the attention of consumers” and the need for a broad alliance of stakeholders to raise consumer awareness; Harvest Plus on getting local agents to promote and sell biofortified foods (the Tupperware approach?); Amtul Waris on approaches to engage children; Dick Tinsley on what poor people can do for themselves, and what services cash-strapped governments can pay for; George Bazayo of Tree Aid, Burkina Faso and Mahtab Bamji of the Dangoria Charitable Trust describing and evaluating integrated small farming projects with a nutrition education component; and Kenneth Oulu’s experience of promoting “women’s crops” in Tanzania.
They are all discussing problems and pathways, all involving some form of food education or learning, by whatever name. I’d like to add my own point of view based on my field experience and reading.
PROBLEMS
Overburdened?
Contributors mention several challenges to AEAS taking action on nutrition (also brought out in the GFRAS study by Fanzo [1]),such as lack of resources/ time/ transport/ training/coordination with other services; social and structural barriers and institutional barriers (e.g. gender attitudes, land ownership, the traditional AEAS focus on staples and productivity. It is generally felt that the AEAS (a) have enough on their plates, (b) may not see nutrition as a priority, or indeed as their business, and (c) could do with official guidelines about what to do.
Indeed, don’t they have some justification? There seems to be a general expectation that it’s the job of the extension services to compensate for low levels of food literacy in the population. Imagine how much malnutrition, stunting and obesity would be averted if children left school with some understanding of and practice in cooking, feeding babies, growing fresh vegetables, eating healthily, shopping wisely, protecting themselves against dangerous foods, adapting to change, recognizing and resisting misleading food advertising, and bringing up their children to do the same. These skills are part of the Right to Food. There is a general absence of effective food and nutrition education in schools, in public education (the media, public information sites, community programs [2]) and in social protection schemes. [3] I was heartened to read the proposals for comprehensive school food and nutrition education (SFNE) from contributors. This was also a recommendation of the ICN2 conference.
Limitations and motivations
There are also some inherent limitations on what AEAS can achieve for nutrition, which can affect the motivation of all concerned - farmers, households, AEAS and their ministries.
If global reviews have difficulty establishing reliable pathways from agriculture to improved nutrition,[5] how can ordinary households see the benefits and urgency of producing and consuming differently? Unlike harvests and market prices, nutrition outcomes have low visibility and many people do not think of varied vegetables or fewer soda drinks as concrete steps towards prosperity. Action for good nutrition is moved by attitudes and conviction as much as by reason. This has consequences for the approach. With resistance from established habits and social norms, competition from cash and convenience, and not a lot of clearly attributable outcomes, good information and sage advice are generally not enough to get people eating better.
POST 2 TRAINING
WHAT WORKS AND WHAT DOESN’T
If Ministries of Agriculture and the AEAS do want to take nutrition and diet into their sights, we know quite a lot about what works and what does not. Here are some of the ideas.
It is often recommended is that AEAS improve what they are already doing, with more personnel, more women, more resources, better seeds, better technology etc. Of course this will improve food security, but we can’t assume that improving supply will reshape food consumption patterns. On their own, supply-side interventions have a patchy impact on nutrition. Like rising household income or increased GDP, they tend to perpetuate and reinforce existing dietary patterns, or to improve them within the frame of what consumers already see as good (e.g. more meat). So I would risk the thought that if AEAS are to improve nutrition, they will need to go a little beyond what they are already doing.
Some knowledge of food and nutrition is certainly a must. Nutrition awareness and perception do look like an obvious part of the professional repertoire for people who advise on what to grow and how to grow it, and whose mandate is to safeguard farmers’ interests and welfare. It is frequently suggested therefore that AEAS acquire and “disseminate information” about good nutrition. However knowledge alone is not enough for either AEAS or their clients. It is well attested[6] that it is a necessary but not sufficient condition for changing food practices (as we also know from personal experience). AEAS may like to test this for themselves by giving nutrition information and checking how far it is heeded.
Specific messages about what to do, shaped for particular audiences, are the mainstay of behavior change interventions, and are more successful than general information. It’s often proposed that AEAS should act as ancillary messengers in “delivering” dietary messages (face-to-face communications have been found very effective in promoting change). This however is only part of a multi-faceted intervention[7] and may limit the role of AEAS and not make much use of their special expertise and local knowledge.
Increasingly favoured are packages which mix experience and practice in growing and preparing foods with some knowledge of food and diet, and practice in changing habits, and which call on local experience and family/ group/ community support. Contributors have given interesting examples of how agricultural, marketing and nutrition knowhow are directly put into practice. Such packages have the potential to make full use of AEAS’ working skills and experience. However these are usually independently funded projects with specific targets and target groups. Can such approaches be promoted in the regular extension services, with their limited resources, manpower and time?
TRAINING
If AEAS are willing to take an interest in improving local diet and nutrition, then it seems that programs of action (and related training and guidelines) should aim at being economical in time and resources; should be practical, productive and rewarding; should make use of existing knowledge and skills and build easily into normative work patterns; should “breed” support wherever possible, and develop capacity in the AEAS. Effective national and ministerial policy, intersectoral coordination and easy access to accurate information can of course make everything much easier.
In the curriculum
We would surely expect local food experts to be primed to make health connections between what’s grown and what’s consumed, know what common foods are good for, recognize poor diet and see how locally grown crops could improve it. It cannot be ethical to keep nutrition knowhow out of the agriculture curriculum. Two relatively inexpensive and feasible strategies are:
In the field
Finally, on the-job learning, which is more important than any other training.
Field training programs should parallel the new job dimension. They should aim to generate small observable improvements in local food practices; build community initiative and capacity in undertaking them; get support from health and education services; train up AEAS teams in the art of instigating, monitoring, assessing, recording and recycling the process; and get some recognition for achievement from both communities and ministries. Ideally they are slow, systematic and incremental, and result in a capable, skilled and motivated workforce which can operate independently. The training period (a year?) can be guided by ministerial protocols and some basic materials.
I am sticking my neck out here! Such programs, if well organized, work fine in other kinds of professional work which are not so different from agricultural extension (e.g. teacher training, medical internships, social work, counselling), but I have never seen them in an AEAS service.
Is it feasible? Has it been done?
[1]Fanzo, Jessica, Q. Marshall, J. Wong, R. I. Merchan, M.I. Jaber, A. Souza, N. Verjee .
The integration of nutrition into extension and advisory services 2013. G-fras.org and World Bank Secure Nutrition. www.g-fras.org Global forum for rural advisory services
http://www.fsnnetwork.org/sites/default/files/gfras_nutrition_report.pdf
[2] The American community nutrition education program for low-income groups, EFNEP, covers many of these skills, and shows good results in its annual evaluation.
[3] Social protection programs are currently beginning to discover the very large supplementary impact of a food and nutrition education component. See Akhter et al. 2016 Which form of safety net transfer is most beneficial? Impacts on income, food security and child nutrition. IFPRI. http://www.slideserve.com/maine/akhter-ahmed-john-hoddinott-wahid-quabili-shalini-roy-fiona-shaba-and-esha-sraboni.
[5] A great chorus of review literature makes the point that agricultural programs may have great potential for improving nutrition but there is “little empirical evidence on the role of agriculture and other nutrition-sensitive sectors on nutrition” (HLPE of SCN 2016, draft report) or understanding of how to achieve the potential (Thompson and Amoroso 2010). See also Hodge et al. 2016, Fiorella et al. 2016 review, Yosef et al 2015 re Bangladesh, Webb 2013b), Masset et al. 2011, Hawkes et al. 2012).
[6]See e.g. Contento et al. (1995) The effectiveness of nutrition education and implications for nutrition education policy, programs and research: a review of research. Journal of Nutrition Education, 27(6), 355–364. Most behaviour change theory supports this finding.
[7] Researching, developing, trialling and disseminating behaviour change messages is a big job, so the AEAS role in behaviour change interventions is generally taken to be as extra support.
Dear FSN Forum,
Below are my comments on the workplan, together with tracking comments on the text itself (which are much the same).
Best regards,
Jane Sherman
___
Most of the following comments fall under Question 2 of the suggested areas for comment: What are your general comments to help strengthen the presented elements of the first draft work programme of the UN Decade of Action on Nutrition?
General points
Points on specific paragraphs
Para 13. Full support for inclusiveness and for making use of existing skills and expertise in the population, but can we also ask that nutrition education pay due attention to
Para 16.2 Does “essential nutrition actions” refer to the ENAs (i.e. for infant and young child feeding), or does it mean essential nutrition actions in general, for all the population?
Paras 16 and 28. In line with the framework of action developed by ICN2, nutrition education cannot be simply included with social protection in point 3. Nutrition education (which includes behavior change interventions) is integrated across the sectors in nutrition-sensitive interventions, and has shown impact at scale in several of them, in particular in home gardening and maternal and infant feeding as well as social protection. It has also shown impact in income generation schemes and is recommended at all levels of school education by the ICN2. It should therefore be seen as an intervention cutting across all sectors. There is also a great need for capacity in the field of nutrition education (quite distinct from expertise in nutrition), for understanding at all social and political levels, and for expression in national policy and programming. It is suggested therefore that nutrition education should stand a 7th action area headed “Food and nutrition education and professional training at all levels and in all sectors”.
Para 18. Add “including civil society organizations and consumer movements” after “other potential actors”, to balance the top-down emphasis.
Para 19. “A food system approach – from production to processing, storage, transportation, marketing, retailing and consumption – is thus important to promote healthy, sustainable diets and improve nutrition as isolated interventions have a limited impact.” If “consumption” includes “acquisition”, well and good. If not, “acquisition” needs to appear, otherwise the consumer has no role except to eat and the food system is presented as entirely supply-side.
Paras 20 and 21 need more attention to consumer demand: there are suggested tracking changes in the text. The paragraphs should also insist on the importance of implementing food-based dietary guidelines and evaluating impact as well as developing them.
Para 22. The description of food safety problems should be extended with suggestions on what to do about them, especially in the light of the high cost of refrigeration/regulation/inspection in low-income countries.
Paras 24-16 on health services. The emphasis here is mainly technical. The strength of health systems is not only determined by what they treat, or the evidence base for the treatments, but by the quality of the service in terms of (e.g.) training, numbers, presence, accessibility (is this the same as access?), consumer service (including respectful handling, follow-up and education) and accountability to communities. There is a body of action and expertise in these areas, and also on low-cost strategies for improving health services, which could be acknowledged here.
Para 27 Suggest expanding the role of the health services in nutrition education with a new para, e.g. “Health ministries are usually responsible for national campaigns to promote better nutrition and food practices, for advising the education and food security sectors on food and nutrition. They therefore need expertise in direct nutrition education, in training frontline workers in nutrition education, and in integrating nutrition and nutrition education into interventions in other sectors.
Paras 30 and 32 “Knowledge” and “education” appear to be treated as distinct. Does education not include knowledge? If “education” here does not mean “learning” by whatever means, perhaps its meaning can be defined. Alternatively, in some cases “education and knowledge” could be replaced by e.g. ““learning about food and how to improve diet”.
Para 30. The program for nutrition education, again in line with the recommendations of ICN2, needs to be expanded, for example by adding the following words:
“It (NE) also maximizes the impact of nutrition-sensitive interventions in food security, health, social protection, which may all need some element of FNE/SBC. Achieving such results requires specialist capacities in the relevant services, beyond technical knowledge of nutrition, health or agriculture, which should be recognized in training curricula for educators, agriculture and health professionals. FNE/SBC requires an enabling physical and institutional environments, and hence calls for action at several levels of society, including policy and programming. It is also enabled by a supportive social environment and a general climate of interest in food and health, hence the importance of an extensive action-oriented school curriculum, well-publicised government actions (e.g. labeling, subsidies, taxes), and ongoing media attention. In all cases where FNE/SBC is an important arm of a program, allowance should be made for some form of impact evaluation.”
Para 37 should be followed with some recommendations on (a) the information and communication environment, e.g. the control of deceptive information/advertising, food advertising to children, free access to information on good diet and the role of the media and (b) the food environment – guidance for institutions, workplaces etc on how to create nutrition-friendly environments
38. Is a multi-sectoral umbrella committee essential? Have we any evidence of success with such committees or of the demands they pose (e.g. costs, time, transport), the necessary level and quality of communications, and the time-span (e.g. for collaborative training, curriculum change)? Outside projects can do this, but in the end the praxis has to be institutionalized . The answer would seem to be to do things bit by bit, but I have not seen this recommended anywhere. When giving counsel of perfection, there should be some attention to the challenges.
Jane Sherman 11.02.17
“Innovations from the field to the cooking pot” What does the second FSN forum on pulses tell us about consumer education for better diets?
From the field to the cooking pot … The forum title was right. The shaping questions in this second FNS Forum discussion on pulses (http://www.fao.org/fsnforum/activities/discussions/pulses2) did indeed have an eye on consumers and consumption as well as on production. They brought the two ends of the food system together and closed the circle. This is joy to food educators.[1] We know from both research and experience that consumers’ practices and attitudes, the influences on their food choices, and the interaction between their environments and their outlooks are generally crucial in impacting diet. But we are also very aware that until recently the international focus has been far more on supply and access than on consumer behaviour, expectations and attitudes: they have concentrated on field and market and not on the path to the cooking pot.[2]
The Year of Pulses is a unique phenomenon in many ways, perhaps unprecedented. It integrates nutrition and agriculture; it takes a step towards sustainable diets; it confronts a problem common to many societies, yet different in all of them; it has the single (though complex) task of promoting just one food group with a rich nutrition profile; it brings together a diverse body of professionals (economists, agronomists, nutritionists, extension workers, policy-makers, not educators unfortunately), and it aims to improve food consumption in the general public, not only in one needy segment. For food educators, a special feature is that it has the explicit purpose of improving consumption as well as access.
The forum opened up the question of how this is done. With its consumption-oriented questions and its call for responses grounded in experience, it opened a window on dietary promotion where contributors involved in the program across the sectors were drawn to analyse the situation on the ground empirically and call on their working experience to propose strategies which they saw as necessary and appropriate. The resulting picture was complex but coherent.
What influences people’s consumption of pulses?
Several posts discussed this basic question. Influences were seen as culture and habit, knowledge and understanding, time and convenience, but above all food status and taste. Existing food cultures determine what people are ready to accept – for example red “silk” beans are popular in El Salvador, while in Nigeria the only pulses seen as normal food are cowpeas. Hence simple lack of familiarity with the foods available may be a barrier, as may “inadequate information on the advantages of pulses”, i.e. ignorance of nutritional value or value for money. More frequently mentioned, however, was the move away from consuming traditional pulses, sometimes because of time-consuming preparation, but more often because of their perceived status as “the protein of the poor” or “desperation food”. Lupines in rural areas of Ecuador, for example, were seen as the food of rural poverty. City dwellers or the educated middle class would not “stoop so low” as to eat dishes made with pulses. If incomes rose, or food choices widened as people moved to cities, these traditional foods tended to be abandoned in favour of more prestigious foreign foods, meats, or highly processed fast foods. Poverty, it seems, also has a taste. Traditional pulse dishes were often unvarying and unvaried. “Being a poor man’s food, there are only a few traditional recipes, which have not evolved over time.”
What strategies are needed?
Ideas for tackling these barriers grew out of these observations. They converged on two strategies: one was to make pulses attractive (delicious, convenient, healthy, modern/trendy, valued); the other was to get a lot of people into the act. A top priority was to update recipes, widen the range, add vegetables and flavourings and develop new products, give value to “heritage foods”, “create excitement around traditional recipes” and promote them on the media. Contributors proposed ways to make preparation easier and quicker, for example by introducing low-cost pulse processing machines in villages and developing “easy-to-cook high-quality branded products” and ready-to-eat meals. Information would be available on packaging and labeling, and through government campaigns, backed by the media (testimonials from soccer champions and video rap music, to be evaluated for impact). A new image was felt to be essential “to make the humble legumes modern or desirable”: “social media together with gastronomical innovation” could help pulses become “the next quinoa”.
Society, it seemed, had to be taken by storm – but slowly. Many groups would interact with or influence consumers: chefs, restaurants, food services in public institutions; producers, markets and the food industry; policy-makers in agriculture, trade, health and education; and “influencers who are reaching consumers to help change their dietary behavior”, such as nutritionists, dieticians, health professionals, health workers and food industry representatives, who would “make sure that pulses are accepted as a normal household food”.
What does this say about consumer food education?
The ideas about the process of dietary change are not new, but neither are they widespread in food security discussions. What is interesting is that
They therefore carry a certain conviction born of direct observation and experience. Underlying them there is also some consensus on a cluster of guiding principles in food education. They recognize for example that:
Many of these principles are not recognized in “nutrition-sensitive” initiatives which rely only on improving supply or regulation and do not see the need for consumer capacity to respond to the supply. The Year of Pulses seems to be in a position to blaze the trail to the pot. It should trumpet its conclusions.
[1] In “nutrition education” we include SBCC, health promotion for good diets, nutrition counseling, social marketing and behavioural economics aiming at healthy eating.
[2] Most major International papers on nutrition and food security have focused on the supply side – examples are (see second blog). The latest of these was the GLOPAN brief on food systems and nutrition (link), an exemplary paper except for the total neglect of consumer behaviour. After the launch Lawrence Haddad commented in his blog: "Perhaps the most glaring omission in the report is the treatment of consumers as shapers of food systems. It is true that we don’t spend much time in the report on nutrition education and behaviour change of consumers. This is definitely an important area and one where we need more answers."
..
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 thought Dr Gartuala expressed very well the potential tension between the formal curriculum in the college setting and the farmers' knowledge and perceptions in the social and workday landscape:
Especially in the rural communities the community-based informal education and curriculum-based formal education are two intersecting knowledge spheres, which can become imporant components to increase food literacy. Our study shows a negative correlation between these two knowledge spheres ....
Reconciling these two spheres seems to me to be an essential component of the college curriculum, enabling students to create bridges through dialogue and experience with the community, through which they learn as much as the community does. This constructivist approach, "starting where people are" can use an agricultural metaphor: before you plant, first know your soil and your microclimate!
Jane Sherman
Nutrition education consultant, FAO
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
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
Though posts have been few so far, we have had a really interesting spread on this really interesting subject, and I have appreciated all of them very much. The pictures of the children and the eggs were especially nice - thank you, Dr Emal, and thank you for telling us a tale where the eggs went into the family meals and not just to the market.
Social security schemes seem to be a foundation stone of social democracy and I don't see a lot of difference from social protection schemes (maybe someone can correct me). However, I'm bypassing the question of whether such strategies should be put in place by governments to redress inequity. I am also risking the wrath of Claudio Schuftan by flying the flag for food education, which in my vision is everyone's birthright, especially in view of the nutrition transition and the present power of Big Food.
Bringing social protection and food education together, I would like to raise three points:
The first, which now has quite a lot of supporting evidence, is that many interventions aiming at increasing food security (including social protection handouts, food vouchers, income generation, agricultural projects etc.) fail to have a significant impact on nutrition status because they simply enhance existing inadequate dietary profiles and patterns of household expenditure. Adding a little food education to the mix can significantly tilt the outcomes of such actions towards better family diet. The best-known case in social protection is probably that of SNAP in the USA, which found it necessary to create SNAP-ED to introduce the missing education component.
The second is about how we measure nutrition status. In one major social protection scheme the indicator selected was dietary diversity. This was shown to be increased by regular cash handouts, mainly because most households enjoyed their higher income by eating more meat. This was all to the good, but they did not at the same time eat more fruit and vegetables, in which their diet was also deficient, and which were equally important to improving nutrition status, nor was dietary varied assessed. Meat generally has status in poor communities and vegetables do not, while fruit is often regarded as a non-food, nice but not necessary. I am asking if our indicators are sufficiently sensitive to the concept of a good diet.
My third question is Why are we not hearing from the social protection people?
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
This is a good discussion, thank you Stefano.
All agree that street food is here to stay, that it is a vibrant market sector and provides a good service to people who need it. But all also agree that food hygiene and safety standards are low (see e.g. Ilaria Proietti). The technical and social means of dealing with this are clear: training, inspection, rules and standards, clean water supplies, good sanitation, clean transport etc. It is not at all clear however how these are to be achieved where public funds are lacking.
The only alternative I can see is improved consumer education and influence, the market “pull” factor that Hélène de Lisle described in the NFSI project in Benin where (as I understand it) children learned to ask vendors for healthy food, and vendors duly responded (I must find out more). But can that work more widely? The Good Greens polling system where customers give vendors red or green marks according to their price/ taste/ hygiene/ freshness and nutritional quality, is very direct and appealing and I imagine that consumers can probably generally see freshness (though even in a stew?). But how can they recognize good hygiene (e.g. if they cannot see how food or plates have been washed) or judge nutritional quality or know if foods are contaminated or if colour is due to chemicals?
I have tried to find out from FAO if consumer education can achieve these things but have had no joy. I have not seen these skills covered in school or public education materials. Does that mean that consumer education can't achieve much? And if regulation can't be afforded, does that mean we can't fix the problem of safety in street food? Can anyone show the way here?
Jane Sherman, nutrition education consultant, FAO
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
[1] 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).
[2] 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.
[3] The success of Bangladesh in improving nutrition reflects some of these doubts. See Sullivan (2014) Mysterious success: understanding Bangladesh’s rapid reduction in undernutrition.
[4] Ruel, Marie. 2014. Micronutrients and improving nutrition through food systems.
http://www.ifpri.org/blog/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.
Some really interesting contributions on this forum.
Great to hear about Chris Miller’s program in Peru. It sounds as if the secret is community ownership + greenhouses (magic ingredient?), which together are making it possible to increase income and also providing more dietary diversity – Chris, have I got that right? Is this a permanent ongoing program or a limited-term pilot? Tell us a bit about how the dietary behaviour change is assessed. (Q: Are you by any chance related to Mark Miller who ran that excellent school gardening program in Belize?)
Also very interesting to read Sonia Gonzalez’ story about the agricultural labourers and their families in Sinaloa who are working 12 hours a day in the sun gathering tomatoes, corn, sorghum, avocados, lychees, plums, presumably for big producers. I wonder what the labourers themselves eat. This group (often migrants?) has not I think had a lot of attention in discussions of nutrition education.
Hope to hear more stories!
Jane Sherman Nutrition education consultant, FAO
There is a food chain which leads to health, and a chain for farmers which leads to a viable livelihood. Can these two chains run together?
Do we want nutrition education for farmers or for the public? Can nutrition education induce farmers to produce (for example) more fruit and vegetables to promote dietary diversity? Will they ever do this unless there is very visible market demand? And then is it possible for public nutrition education to generate enough market demand to change farming practices?
I am not sceptical - but I want to know how this can work! Does anyone have a really convincing example?
Jane Sherman, nutrition education consultant
Question for Sofia Bustos.
It is great to hear of a successful change in community dietary behaviour related to changes in farming practices. Tell us how it is achieved! And how it is assessed!
Jane Sherman, nutrition education, FAO
Sra. Jane SHERMAN
I feel like a lone voice in this Decade of Nutrition advocating food education for all. Please can we call it "food education" instead of "nutrition education"? There is overlap, but nutrition education has different scope.
All the contributors have hit important nails on the head, but for me food education is the nail that pins supplyside solutions together and makes them work.
What do we think it is? The impression from the references in the text is that "nutrition education" is manifest in (a) feeding messages and dietary guidelines (ENAs and FBDGs); (b) school meals and some kind of school education (seen as complementary in the text, although seldom in real life); and (c) labelling of food products. Did I miss anything?
These are not in themselves food/nutrition education, although they can all be useful inputs in a dynamic learning process. They are static elements which have to be activated and put to work to develop the capacities of adaptation, self-defence, discovery and change which are going to be essential to citizens in a needy world. They manifest the lack of HOW, the "black box of implementation" (noted by the Society for Implementation Research in Nutrition).
I think the health service has learned to turn the ENAs into maternalaction, but school meals, school food education and the FBDGs have seldom been evaluated for nutrition impact (a forthcoming survey and article on the FBDGs make this point). Why do they continue to be routinely recommended in frameworks for country action?
Food education in its most fundamental sense is what everyone learns about food, mostly informally, through observation, experience, action and conversation, from birth (or before) and throughout life. It includes beliefs, practices habits, preferences, skills and knowhow, perceptions and prejudices, social norms and status, capacity for change and experiment, interest and enjoyment. Influences on this learning are many and various and have been extensively analysed in formative research. In formal programs food education calls on many well-known practices, such as behaviour change, social marketing, IEC, promotional campaigns, awareness-raising, school food projects, which are more or less successful according to the processes they adopt.
The outcome is some level of food literacy which manifests itself in action. The levels of food literacy in the world are universally appalling, as the obesity epidemic has demonstrated. So is the fragmentary incoherence of most of the food education efforts to improve it. They lay the public open to the worst effects of the food industry. They must both be recognized as inherent in the Right To Food
My second point: food education is seldom much use if it stands alone, confined to the classroom, counselling session or side-along project component (I have seen many examples. It has to be hands-on and mouth-on and embedded in its real-life contexts and settings. Children can learn from school meals by observing them, asking about them, trying them out; the same applies to the many successful community classes which combine shopping, budgeting, cooking and tasting with practical action and feedback in the real world. (NB Husbands and children big obstacle to improving household diet).
This brings me to the point about hitting the right nail on the head. What has not been properly recognized in the development world is that this interaction works both ways. Not only do individuals learn better nutrition through putting it into practice, but nutrition-oriented development actions magnify their impact through some form of food education. It stands to reason. People do not easily renounce theif food habits, but they are more likely to do so if they think and believe it's a good idea, can see how to go about it, try it out and share the experience, above all if they have some ownership of the process. The reverse has been repeatedly demonstrated, Consumers have veto power.
There is a steady accumulation of demonstrated successes (I have a dossier): in agriculture (generally seen as a nutrition-sensitive flop), there are the Farmer Nutrition Schools in Bangladesh; other homestead gardning projects are proving that they can transform diet and food practices; in biofortification, the long journey of the orange sweet potato in Africa shows how much consumer education is needed to create demand, but that it can be done; in social protection there is the striking control experiment (again in Bangladesh) where adding a food education component to cash and food handouts multiplied the impact; in Norway a multi-sectoral program focused on fish at every level of the food system and evaluated positively. I have also seen many project reports which propose incorporating or improving a food education or behaviour change component.
It's the mix that matters. Of course the HOW is crucial. There is a lot of very ineffective activity around which calls itself nutrition education and behaviour change. We think we have most of the answer to this, but that's another post.
Jane Sherman