Foro Global sobre Seguridad Alimentaria y Nutrición (Foro FSN)

Dear Colleagues,

I hope you can review the following 3 pages from the www.smallholderagriculture.com website I manage. They deal with an issue in nutrition that I feel has been largely overlooked. Namely the energy to undertake a full day of diligent agronomic field work. Typically I can only document smallholder diets of approximately 2000 kcal/day or about half the 4000 kcal/day needed for a full day of agronomic field work. This results in substantially reduced work day, often less than 4 hrs unless paced. This then delays much of the field operations well past recommended time frames as well as reduces the quality, all of which reduces the yield potential.

It also raises the question of until you have enough calories to undertake the work expected which will be the individual higher priority, getting the necessary calories or more balanced diet?

I apologize for the late submission but hope you can review the material and included it in you results.

Thank you,

Dick Tinsley

Professor Emeritus

Colorado State University

Webpages:

www.smallholderagriculture.com

http://c.ymcdn.com/sites/www.echocommunity.org/resource/collection/62026577-227A-4FB0-8B25-B0838484CED7/Issue121.pdf (this was originally a webpage but converted to ECHO article.)

http://lamar.colostate.edu/~rtinsley/EthiopiaDiet.html

http://lamar.colostate.edu/~rtinsley/DietPoster.pdf

Reference to the email dated 4/8/2014, we would like to indicate that the framework for the implementation of Rome Declaration on Nutrition coincides with the national nutrition strategy. Please  note that communication with the project will be through your Organization’s website as related to the above mentioned subject.

This will be done by the Public Health Department.

This is for your information and action.

Dr. Ramzi Rasoul Mansour

International Health Manager/Minister’s Office

The Global Social Observatory welcomes this opportunity to encourage new thinking about multiple stakeholder engagement in the follow-up to the Second International Conference on Nutrition. The draft Framework for Action is helpful in moving forward on this new thinking. The GSO encourages consideration to be given to the broadening of network groupings as developed in Chapter 1.2. While the listing of non-state actors includes several important categories for advancing food security, there may well be other types of non-state actor categories that merit inclusion in a post-2015 framework.

The GSO notes in Chapter 2.2 that there is a reference to engaging all partners in the implementation of the Global Framework for Action. Similarly, Chapter 3.3 delves into the role of health systems. However, in neither case is there an elaboration of new types of non-state actors that may be useful for a future Global Framework for Action. The GSO encourages ICN2 to convene a special event on considering how to broaden the range of non-state actors who should be involved with governments at whatever level to advance the mission, goals and targets beyond ICN2.

We are delighted to have been given an opportunity to comment on the zero draft of the “Framework for Action” document for ICN2. We generally support the wide ranging aspirations and ambitions expressed in the document, but there are a few areas that warrant clarification and/or development.

We hope the following comments are helpful as the document is further refined.

General comments

The declaration aims to be comprehensive, pertinent to the whole range of nutrition related issues across the globe, from starvation to obesity, from the poorest to the richest countries. This sometimes leads to statements that are very general, with wide scope for interpretation, as perhaps is the nature of this kind of initiative. Nevertheless, some kind of classification or typology of issues and problems would have helped in the formulation of recommendations better tailored to the different types of problems and situations.

The declaration seems to want to place the “food system” at the heart of the issue. As a result, the other drivers and determinants of nutrition related health problems are somewhat neglected. This leads to the impression that policy solutions lie mainly in improved “governance of the food system”, a concept that is otherwise not explained and which remains nebulous throughout the text. The food system is composed of myriad elements and agents, from “farm to fork”, and differs radically between countries at different levels of development. We would suggest sticking to specific recommendations and actions applicable to the different economic sectors involved in ensuring the supply and safety of food.

We would also encourage the Secretariat to cover “demand-side” policies more thoroughly, including, in particular, actions on some of the dimensions of the demand for foods and non-alcoholic beverages, such as information on food ingredients, nutritional value and calorie content; awareness and perception of health risks; and commitment to dietary change.

Throughout the text it is sometimes difficult to judge whether a statement of a proposed recommendation or action is appropriate because it is expressed in very general or vague terms. At the top of page 7 it is stated that “appropriate regulation and incentives can increase the compatibility between market signals and improved nutrition” but no examples are given.On page 10 (section 3.1.1) it is stated that to improve access to and consumption of healthy diets “this requires implementation of measures to modify food environments to improve the availability, acceptability and affordability of healthy diets” and again there is no hint of what the authors have in mind here. The recommendation on page 11 to “Increase incentives for production of nutrient rich foods and their movement into processing and retail through the value chain at all scales” is another example. Here again it is difficult to have a view in the absence of any information about what is intended by incentives in that context.

In several places it is stated or implied that “local” is better, in others there is reference to smallholders. Backyard/homestead farming is encouraged. It should be noted that these approaches are not unambiguously good in terms of nutrition outcomes, and indeed may have negative effects in some contexts, or may have disadvantages unrelated or less strongly related to nutrition, such as spread of disease from unregulated backyard animal production.

Specific comments

Section 2.2.

The concept of “multi-sector working” should be clarified, especially whether this relates only to government actions, and what the scope of multi-sector coordination should be. Partly in connection with this point, the first priority action listed under the heading of “nutrition governance” is very vague in its formulation, and may generate confusion.

Section 2.3.

A high burden of disease, per se, does not necessarily provide an economic case for action. An economic case rests on the availability of actions which are of proven effectiveness and represent an efficient use of scarce resources.

Section 3.

What is meant by “food system” and “food environment” is not entirely clear, and definitions should be provided.

At the end of the third paragraph of page 7, the text seems to hint at the positive correlation observed between national income and obesity at the country level. If this is the case, the correlation should be mentioned explicitly, along with the social patterns typically seen in the spread of obesity when national income grows.

The fourth paragraph of page 7 would benefit from some examples of relevant policies.

The third paragraph of page 8, addressing the implications for nutrition of the changing role of women in society, should not ignore the evidence that reductions in meal preparation time, partly associated with increasing female labour force participation, have been linked with increased food consumption outside the home, consumption of highly processed and micronutrient-poor foods (mentioned elsewhere in the text as a contributor to malnutrition) and obesity.

The two large sets of priority actions listed, respectively, on pages 9 and 10/11 contain several areas of overlap as well as gaps (e.g. regulation of nutrition claims in food environments, or policies addressing specific dimensions or components of food systems, such as food retail). The relevant sections could be revised providing a clearer focus in the respective areas and avoiding overlap and confusion between the two.

Section 3.3.

The role of primary health care could be brought up more explicitly in several sections addressing possible interventions within the health care sector, recognising differences in the roles primary care can play in countries at different levels of income and development, and in addressing different types of nutrition problems.

Section 3.3.1.

In the discussion on wasting and stunting, there is not enough attention paid to the emerging evidence that sanitation (sewage systems, toilets) plays a large role in determining outcomes in some countries..

Section 3.3.4.

No priority actions are listed.

Section 3.3.6.

The section on anti-microbial resistance is especially sensitive. No mention is made of the role of misuse of antibiotics in human health as a contributory factory to resistance. The link with nutrition and the relevance of the subject to this document is not so clear. Some countries may not sign up to a declaration that sounds like “an admission of guilt” in an area where there is still controversy and some uncertain science, and which contains such specific and technical commitments. (The recommendation on removing industrially produced trans-fats, while difficult to disagree with, may well run into the same type of opposition).

Section 4.4.

We also have some particular concerns with the short section 4.4 on International trade and investment. The text could be more balanced in recognising the potential benefits, and not just unspecified risks, for food security and nutrition associated with international trade and investment. When it is assumed that the latter may harm nutrition or undermine governments’ ability to implement effective nutrition strategies, the mechanism for such negative nutrition outcomes should be explained or established.

In this section, we have a call for “incentives to farmers to produce healthy foods to be sold at affordable prices” as well as the statement that “the availability of and access to unhealthy foods should be effectively regulated and discouraged”. And all this under the heading of trade and investment, as if the provenance of the unhealthy foods in question is always trade and as if a clear and unambiguous definition of what constitutes an unhealthy food could be established and enforced. 

Resilience is defined as the ability of children, communities and systems to withstand, anticipate, prevent, adapt and recover from stresses and shocks, advancing the rights of every child, with special attention to the most vulnerable and disadvantaged children.

Why do nutrition and resilience matter to each other?

Shocks and crises have increased both in frequency and intensity in recent years.[2] The most significant increases have been in Sub-Saharan Africa – where the number of disasters per year more than doubled between 1990 and 2012 – and Asia, the world’s most disaster-prone region. Crisis-prone countries are often those with the highest prevalence of under-nutrition in young children[3]. Crises have a negative impact on nutrition outcomes while under-nutrition increases people’s vulnerabilities and undermine their inabilities to bounce back after periods of adversity. In other words resilience is necessary to prevent further deterioration of the nutritional status of crisis-affected populations and nutrition is a critical prerequisite to strengthen both community and individual resilience. They mutually re-enforce each other.

What does resilience mean programmatically?

While improving nutrition in high burden and high risk areas should be central to resilience which requires a multi-sectoral approach, programs and strategies aiming to address and prevent under-nutrition should also have a resilience focus through being risk-informed.  

Improving nutrition in crisis-prone areas will only be possible through a multi-sectoral approach. Humanitarian and development actors need to better work together to address underlying causes of under-nutrition through preventive and curative interventions. Resilience requires that such interventions be implemented before, during and after a crisis. Under-nutrition cannot be addressed in only a vertical manner or in a manner that merely addresses immediate underlying causes of under-nutrition. This has too often been the case in humanitarian situations. The continuum of care between prevention and treatment, short term and long term actions as well as humanitarian and development is critical.

In addition, nutrition programs and strategies need to have a resilience focus by being risk-informed. A better analysis of risks at community and system levels will help guide action to build capacities to adopt adequate and timely strategies, based on magnitudes of stress. These capacities can be classified  into 3 dimensions (Bene et al, 2012): a) Absorptive capacity: households, communities and systems protect themselves from shocks and mitigate the impact on their lifestyle; b) Adaptive capacity: gradual adjustment of lifestyles and systems to the effects of stress or shock so as to be less vulnerable in the future; c) Transformative capacity: the capacity or ability to create a new system or change lifestyles when conditions require permanently adapting to a new or changing environment. Better risk analysis at the program design and monitoring phases will also ensure that programs are flexible and adaptable, in order to respond to changing and increasing needs during crises.

What do we need to do?

Strengthening resilience is not about developing new, stand-alone projects.  It is about developing better programs, strategies and policies that will bring humanitarian and development actors together, and bringing concepts of resilience into each step of program design and delivery resulting in a holistic approach.

At situation analysis level:

• Analysis of risks and causes of under-nutrition. Strengthen risk and vulnerability analysis before developing or reviewing program strategies. Such analyses should look at: causes of under-nutrition; levels of capacities and assets (types of livelihoods, nutrition and health status, infrastructure, social services); types of shocks and stressors; potential impact and opportunities for response (mitigation, coping, adaptation strategies) at household, community and system level. Such analyses could be disaggregated by livelihood groups or other social categories and should take into account seasonality to improve on context- and population-specific interventions.

• Information and early warning systems. Integrate nutrition in food and agriculture information systems to better monitor threats and analyze situations. Strengthen early warning systems by incorporating indicators such as food consumption patterns[DH2] [DR3] . Such indicators will help to detect potential for deterioration in nutritional status in their early stages and define triggers that will help scale-up support and intervention.

At program design and implementation level:

• Program that aim to build both the nutrition and resilience of populations in crisis-prone areas. Program design and strategies should be based on risk analysis and help communities and countries better withstand, anticipate, prevent, adapt and recover from stresses and shocks. In addition, programs in high risk areas need to address issues of under-nutrition in a holistic manner, through the scale-up of high impact nutrition interventions at all times[DH4] [DR5] .

• Flexible programs. Programs must be flexible to adjust to increasing scale and type of needs during crises. Program objectives should incorporate building long-term beneficial assets in normal times, but should also incorporate financial and operational flexibility to allow programs to switch quickly to relief operations when shocks hit.
• Strengthening national institutions and service delivery systems and empowering communities: Interventions should be designed and implemented with and through national institutions with strong participation from local populations and CSOs, to support their integration and sustainability. This could entail, for example, integrating the management of acute malnutrition in public health services and of nutrition-sensitive agricultural interventions in extension systems.
• Monitoring nutritional impact: Nutritional impact of programs that aim to strengthen resilience should be monitored and evaluated, using indicators of food consumption, nutritional outcomes, and key risk factors for under-nutrition in children (e.g. feeding and caring practices).  

At policy level:

• Legislative and policy environments should be strengthened to ensure that nutritional considerations are fully taken into account in developing resilience-focused  programs and coordination frameworks; Make prevention, preparedness and response activities more nutrition-sensitive to reduce impact of shocks and threats on individuals’ and households' nutrition situations; Ensure that policies on resilience are using a multi-sectoral approach (building on or borrowing from the Scaling Up Nutrition Movement); Ensure that sector specific policies are resilience-focused.

• Develop or strengthen national strategies for food and nutrition security that are risk-informed and address immediate nutritional needs and empower institutions and individuals to prevent malnutrition.

A Guide to Develop and Deliver Nutritious Food Products For An Effective Intervention Strategy

Woven throughout the Framework for Action (FFA) are references to priority actions that seek to: (1) promote good practices for improving nutrition enhancing food and agriculture; (2) address micronutrient deficiencies; (3) improve micronutrient intake through food fortification; (4) strengthen facilities for local food production and processing; (5) promote the consumption of affordable nutritionally enhanced foods; and (6) increase incentives to achieve these and other priority actions.     

A series of papers were prepared for ICN2’s November 2013 technical meeting.  One of these papers focused on how partnerships can be used to shape new market-based business models for improving the nutritional quality of food products to deliver nutrition solutions and to identify and assemble the essential collateral components to achieve success.

This paper took note of the dearth of successful experiences in earlier approaches and presented a unique tool that recognized the: (1) need and value that stakeholders see for supporting more transparent and essential roles for the private sector, including food manufacturers of all sizes in all countries; (2) adaptability of tools, expertise and capabilities of food companies to address food insecurity through multi sector collaborations at local levels; and (3)  necessity of larger companies to explore how to adapt to local conditions in developing countries by building appropriate business models with local partners that achieve sustainable, mutual social, economic and health values.

The development and delivery nutritious food products is only one of many nutrition intervention strategies that country driven nutrition programs may wish to consider. Likewise, the success of this intervention, as with others, will be dependent on collateral activities that facilitate access, use and effectiveness by the target populations. This paper details the essential aspects of this methodological tool as tracked via a Decision-Tree Mapping Matrix (Tree) which provides an open and transparent framework process to reach go/no go decision points along the roadmap. The complete paper may be found at:  http://www.fao.org/about/meetings/icn2/preparations/document-detail/en/c/224903.

The paper was prepared by J.B. Cordaro based on his development country experiences. J.B. currently serves as the Chair, Nutrition Group of the Private Sector Mechanism of the UN CFS and is a consultant for Mars, Incorporated. in the areas of food security, nutrition security and food safety. The views that he expresses do not necessarily represent those of IAFN or of Mars, Incorporated. 

Comments on ICN2 Framework for Action

By Global Harvest Initiative, Washington DC

Thank you for this opportunity to comment on the zero draft of the ICN2 Framework for Action. 

The emphasis in this document on public-private partnership is encouraging. We welcome the Framework’s recognition of the important role of science and information-based technologies in providing sufficient nutritious and affordable food and reducing food waste and loss.

As participants in the Private Sector Mechanism’s working group on nutrition, we support the comments submitted by IAFN.  In addition, we would like to note the following concerns and suggestions.

1. Page 5, Paragraph 1
   1. The phrase “subordination of interests which conflicts with government policies, agreed implementation strategies, or human rights” is vague and unnecessary.  The paragraph’s emphasis on “aligned efforts”, “synergy of action”, and “trust and mutual accountability" adequately capture what is intended here. 
   2. SUGGESTION: Rewrite the last sentence of the paragraph to read: “Engagement of multiple partners requires transparency, trust, and mutual accountability.”
2. Page 7, section 3.1 Food Systems
   1. Paragraphs 3-4:  The references to “traditional” and “modern” supply chains in these paragraphs are ambiguous and open to value-laden interpretations.  What makes a supply chain “traditional” or “modern”?  Is the inputs used? The scale? The socio-economic circumstances of the actors involved?  The juxtaposition of “traditional” to “modern” food systems creates a false dichotomy that does not accurately represent the complexity of how, when, and where people procure the food they consume.
      1. SUGGESTION: Replace “traditional” and “modern” with “short” and “long”.  Focusing on the length of value chains recognizes two essential complexities of the food system: (1) many food value chains have both “traditional” and “modern” elements and (2) people at all economic levels, in high-income countries and low-income countries, consume food produced from a variety of value chains
         1. EXAMPLE: In 2009, Land O’Lakes International Development, USAID, and CIC Agri Business, a Sri Lankan dairy company, launched a three-year dairy enhancement in Eastern Province (DEEP) program designed to introduce improved animal nutrition, care and disease management technologies and link smallholder women farmers to commercial markets.  Today, relying solely on milk production from the participants in the DEEP Program, CIC Agri Business is selling 50,000 cups of yogurt a day, as well as 15,000 small packets of milk for children.  Thanks to “modern” inputs of technology and financing, women working at a “traditional” scale are contributing to a longer value chain that produced dairy products consumed across Sri Lanka. (Source, GHI’s 2013 Global Agricultural Productivity Report, 28-29.)
   2. Replace supply chain with value chain in paragraphs 3 & 4.  This distinction seems subtle, but in the context of this document, it is significant.  Economically, socially, and nutritionally sustainable food systems need to do more than “supply” nutritious food to consumers – they must create “value” for the actors along the entire chain: from the scientists, engineers, and entrepreneurs who are creating more productive and sustainable technologies, to farmers and producers, aggregators and processors, risk management providers, retailers, and consumers. 
   3. Add “consumption” to the last sentence of paragraph #4.  “However, they have also increased the availability and consumption of highly process foods…”

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

Dear Sir/Madam

Please review below my responses and comments on Framework for Action

1.                   Do you have any general comments on the draft Framework for Action?

• Can we make some explicit references to micronutrient malnutrition in the framework while setting measurable outcomes?

Anemia among women is already mentioned. However, there are a number of other deficiencies such as vitamin A, D, folate, B12, zinc, iodine, etc. that are widespread among women and children in developing countries. Including goals for reduction in these deficiencies would maintain focus on them as the framework goes through various stages of implementation at international, regional and national level.

• Can we add a bit more about how food systems can cope with effects of climate change at national level? This would be especially important for some parts of Asia which bear a great burden of malnutrition and are more likely to be affected by climate change.

A number of economic factors which affect nutrition have been comprehensively mentioned, could we also specifically address flood price inflation here and possible policy options to address it.

• Do you have any comments on chapter 1-2? No specific comment, general comments mentioned above
• Do you have any comments on chapter 3 (3.1 Food systems, 3.2 Social Protection; 3.3 Health; 3.4 International trade and investment)? No specific comment
• Do you have any comments on chapter 4-5? No specific comment

2.                   Does the Framework for Action adequately reflect the commitments of the Rome Declaration on Nutrition, and how could this be improved? Yes

3.                   Does the Framework for Action provide sufficient guidance to realize the commitments made? Yes

4.                   Are there any issues which are missing in the draft Framework for Action to ensure the effective implementation of the commitments and action to achieve the objectives of the ICN2 and its Declaration?  No

Thanks & Regards

Dr Sajid Bashir Soofi

MBBS, FCPS

Associate Professor

Consultant Pediatrician & Public Health Expert

Department of Pediatrics & Child Health

Women & Child Health Division

Aga Khan University

Pakistan

Thank you for the chance to contribute our comments on this Framework for Action. The International Union for Health Promotion and Education is honored to submit the attached inputs for your consideration.