04 October 2012

From Nutrition Education to Nutrition Leadership

One of the encouraging things about the Congress is the focus on nutrition education.

But what is nutrition education? To me, the term feels a bit archaic.

I was at an excellent session on Nutrition Education, chaired by Paul Amuna.

The session helped me clarify my own rather biased thinking about the landscape of needs for nutrition education:

1. Make sure nutrition professionals (whether front line workers or policy people) are updated with the latest thinking on nutrition science and implementation.

2. Equip nutrition professionals with the “non-traditional” skills--leadership, influencing, communicating, demonstrating impact—needed to work effectively across sectors.

3. Equip the non-nutrition professionals who affect (or could affect) nutrition profoundly with some basic understanding of nutrition. These non-nutrition professionals are the doctors, the agriculturalists, the social welfarists, the educators, the economists, and the politicians.

4. But to equip these non-nutritionists who are potentially strong allies, nutrition professionals need to understand a little about how they think: how do they frame issues and what are their professional drivers? This means nutrition professionals being exposed to one or more of these sectors in their own training.

Working across boundaries is hard. What’s in it for the nutrition professionals? Resources directed to nutrition, resources that they can have some influence over. What’s in it for the non nutritionists? Demonstrable impact. Development policies and interventions are under increasing pressure to demonstrate human level impact—linking up to anthropometric indicators is a good way of doing it.

All of these skills have the hallmarks of leadership: not being satisfied with the status quo, thinking broadly, building alliances, taking risks, communicating effectively—whatever the level you are working at.

Maybe the time has come to begin thinking about nutrition leadership instead of nutrition education. 

In that spirit, The African Nutrition Leadership Programme is an African-led initiative, and one that it is essential to support.


Jane Sherman said...

There are several concepts of “nutrition education” (NE) around, which makes any discussion wildly confusing. We have encountered all of them in our project for developing a module for professional training in nutrition education. At least two were featured in the presentations of the ANEC session that Prof Haddad refers to.
Concept A The concept that Prof Haddad commented on has mainly to do with the professional training of nutritionists – what they need to learn to do their job properly, get professional recognition, make a greater political impact etc. This was a real concern at the conference, and was addressed by Prof Alan Jackson in the ANEC session. I’ll call it concept A.
Concept B Concept B is any form of education designed to have a direct impact on people’s dietary or diet-related behaviours. It has been defined by several reputable practitioners and researchers, including Isabel Contento. Concept B may include behaviour change activities, social marketing, school nutrition education, dietary counselling, breastfeeding campaigns, nutrition promotion, awareness-raising, cookery classes, national dietary guidelines, leaflets, posters and other IEC. As far as we can see, “nutrition education” (even if archaic) is still the only term which encompasses all these activities, and is the main term in use in the USA at least.
Concept C Concept B activities are generally defined by their aims, not by their actual effect. Mixing these two criteria creates further confusion. Activities which focus mainly on disseminating information have very little effect, so Concept C refers to effective nutrition education which can measurably and sustainably improve diet. Our project has studied the desirable mix of actions and inputs which can achieve this, by reviewing the theory and best practices of NE in the literature and relating them to educational theory. Key elements in Concept C are the influence of the social setting and the nutrition environment; dialogue; hands-on practice, try-outs, feedback; passing on learning; and some level of ownership, self-monitoring and self-organization. The importance of related performance may explain why NE has shown itself essential in achieving nutritional impact in food security interventions and direct nutrition interventions of various kinds.
Concept C+ Since managing effective NE is a skilled affair, it needs a little professional training. Hence the need for training for nutrition educators, or “professional training in nutrition education” at the level of both management and implementation. “Nutrition educators” may be planners, policy-makers, health service managers, curriculum developers, teachers, health professionals and health workers, and NGO staff. This is what FAO’s ENACT project is trying to tackle.
Even where this kind of training exists, it is often not recognized that (a) it is not a course in nutrition, and (b) it needs to be work-related and competency-based. In fact although the field of health education is well-developed and has its own journals, nutrition education training has so far hardly begun.
Perhaps we can take this opportunity to say that the forum for sorting out these differences does not seem to exist: there is to our knowledge no thriving international network of those who are involved in nutrition education (B, C or C+). Our hope, when we can steal time from our project, is to get one going. We found a few kindred spirits at ANEC and would like to know if there is anyone else out there who is interested.

Lawrence Haddad said...

Thanks Jane, this is very helpful and authoritative.

It's interesting that concepts B, C and C+ are all so diet-related... there are so many more aspects to nutrition.

I find the C+ work is especially interesting.

I hope you can establish a forum for these kinds of debates.

On nutrition education as a term, why not nutrition learning?

Paul Amuna said...

Paul Amuna
I have read Lawrence's blogs on the Nutrition Congress Africa 2012 with interest. I have also read David Nabarro's response to his original blog.

I agree that the NCA with its large constituency of nutritionists and others working in nutrition from various other sectors including government, NGO and INGO groups across Africa and indeed Europe and America was an excellent forum for discussing the nutrition challenges in Africa as well as the opportunities for us nutritionists to be more engaged and involved in transforming the landscape.

Lawrence gave two brilliant keynote addresses relating to the conference theme of transforming the nutrition landscape and examining links between food policies and food and nutrition security in Africa. Among the questions posed by Lawrence was: Who are we training as nutritionists and where do they fit into the national and developmental agenda? He also argued that training should include 'outside the box' issues to equip nutritionists with knowledge for instance of economics and agriculture.
I wholeheartedly endorse these views partly because in my opinion, a good graduate and particularly one who aspires to nutrition leadership ought to know not just the core science of nutrition and practical skills to enable them practice, they need for example to be able to make inputs into agricultural extension practices with are "nutrition-centred". Plus, I feel that the "Economic Case" for investments in nutrition at national and global levels in my view do not seem to be made strongly enough and it is about time nutritionists and others working in the health sector were able to make such a case based on sound economic analysis, that investing in nutrition is not a drain on the economy but rather a sound investment.

There is sufficient evidence linking poverty, food insecurity, poor nutritional status and intergenerational risk factors for stunting (which we all accept is unacceptably high), poor maternal pregnancy outcomes, childhood undernutrition and as is increasingly being seen in developing countries, chronic non-communicable diseases. Indeed the burden of these NCDs is currently much higher in developing, than developed or highly industrialised "western countries". Within the developed countries, NCD burden is likely to be much higher among the poor sections of communities and indeed, much, much higher among migrants, especially from poorer countries. I have previously described this phenomenon which in my view is evidence of the nutrition transition playing out, as ‘migrants travelling with their disease risk in their suit cases’.

My overriding concern is that at the moment there is such momentum relating to the SUN concept and the SUN Movement. At very high levels involving influential persons e.g. the Leadership Group and governments, there is a lot of movement and discussion and at the recent UNGA, meetings were held with Civil Society leaders and business leaders etc. Furthermore, at a very high level, discussions are being held on the post- 2015 agenda and the framework relating to "what to do" about the Millennium Development Goals (MDGs).
To me, to "scale Up" simply means, you know what the problem is, you know what the solutions are, these have been tried and tested with evidence of success and you simply wish to 'expand coverage' so that more people can benefit in the short term. In addition, you want to set up structures to enable those successes to be taught, translated and SUSTAINED over time so that the 'begging bowl concept' where we re-visit these problems in cycles is at least minimised if not eliminated. My question is: WHO WILL DO THE SCALING UP? WHERE IS THE NUTRITION AND HEALTH PROFESSIONAL IN ALL THIS? WHY ARE THE POWERS THAT BE NOT INVOLVING AND LISTENING TO THE 'FOOT SOLDIERS' who will deliver the plans on the ground?

Paul Amuna said...

For me the missed opportunity at the NCA was more about WHY the leaders of the High Level discussions were not represented at least by their PROXYS. The fact is, you cannot hope to achieve even the early goals, let alone the medium to long term goals if the true professionals are ignored or are not an integral part of the process at all levels. You cannot hope to achieve the goals of "making poverty history" or reducing food and nutrition insecurity" or meeting the targets for the MGS or Scaling Up Nutrition interventions unless you have a strong, well informed and well trained workforce who buy into the vision and are part of the mainstream IN-COUNTRY workforce to tackle the problems through intersectoral engagement with all other relevant stakeholders in the equation.

Over the last 30 years, I have observed the nutrition and health landscape in Africa and despite 'pockets of progress' and some success stories (mostly on a small scale), it breaks my heart to see that the same old tired approaches are adopted and the same old personalities are involved in the process, not to talk of those who see malnutrition as a business opportunity. What is heartening is the sheer amount of fresh young blood that is the new nutrition graduates in Africa who are so enthusiastic and so willing to be part of this agenda. Ours at the NCA congress was partly to create a platform for this "New African Graduate" and to challenge, yet encourage them to find a home and A VOICE TO EXPRESS, and to participate both in the dialogue and contribute to solving what we all know is a problem. I hope that this constituency will not be let down, nor will they have to wait another 30 years to be invited to participate in what is going on.

My take home message is this: NCA 2012 provided a platform for debate (and there was plenty of it). The SUN symposium chaired by Jane Badham and the contributions made by various people including Lawrence Haddad and Anna Lartey (IUNS president-Elect) are significant in a number of ways. They provide both food for thought and challenge us all to be more proactive in all aspects. I believe Lawrence is one of the greatest advocates for nutrition there is about. But I have to say that we have many young people in Africa who have got the message and are rising up into leadership. That gives me great hope.

Hester Vorster in her acceptance lecture as the 2012 recipient of the Nevin Scrimshaw Award for distinguished services to international nutrition, brought the message home very clearly by examining the links between the core science and evidenced based research which is what the Lancet Series and Landscape Analyses gave us, to implementation from small scale to large scale in terms of interventions and how these feed into national (and international policy) and national development. In other words, how to make full use of the scientific knowledge and translate it into practice to improve the human condition.

My own challenge to the global community and those championing the cause of nutrition and human and economic development is this: There are many out there in Africa who may not have a big grant per degree but who are far better at implementing on the ground what needs to be done to bring lasting benefits to countless millions. There is a professional body out there called the African Nutrition Society which is mobilising and harnessing this vast human resource across the continent of Africa to provide ONE MANY VOICES for nutrition and YOU MUST INVOLVE THEM, WORK WITH THEM AND PARTNER WITH THEM AND SEE THE RESULTS.
In South Africa, we had African professionals gather to discuss not only science but more importantly, HOW TO TRANSFORM THE NUTRITION LANDSCAPE. Do these people and their self-initiated efforts count for nothing? If not, then why not engage with them? What is the Global Community waiting for? A special Invite? This party is open to all and not under closed-doors or "invitation-only".

:Paul Amuna said...

I am pleased Jane Sherman has tried to clarify these issues around nutrition education and to contribute to the debate. From my point of view, if the Nutrition Transition Patterns are to be believed, then Jane's Concepts B and C would comfortably fall into Pattern 5 of the Nutrition transition as described by Barry Popkins of the University of North Carolina (and others). This pattern of trhe nutrition transition focuses on ACTIONS or BEHAVIOURS which are necessary to reverse the negative health effects of diet and lifestyle-related factors which impact on human health. Although the primary focus appears to be on Obesity and its related gammot of chronic diseases, the current focus of a lot of nutrition education messages and programmes seem to be on maternal and child undernutrition and related issues. I can understand the emphasis on the mother and early infancy and childhood. However nutritional problems need to be recognised as occuring and / or manifesting themselves across the life spectrum / cycle and indeed maternal undernutrition and early childhood nutritional problems are very much linked to later adult diseases including those related to obesity.
All these issues occur within a social and cultural context and an environmental context which is usually complex.
What this tells us is that "nutrition education" or educating people to be better custodians of their own health, wellbeing and that of their community MUST be an integral part of what I emphasise as "NUTRITION TRAINING" which is a complete formal educational or call it academic series of engagement leading to an award which may or nay not be regarded as a professional award (i.e. BSc, MSc, Cert, Diploma etc.).
In my opinion, Jane's description of Nutrition Education is needed in all cases and at all levels. For if a doctor cannot communicate their message to the patient, how do they expect to be successful in their practice?
This debate is useful and I hope it continues to allow for a better understanding of these issues. There is no doubt that nutrition and other professionals working in (e.g. nutrition, food, agriculture, social care and health)need to be trained in NEAC to make them better and more effective practitioners.

Jane Sherman said...

Thanks, Lawrence and Paul for your comments.
Just a quick word in answer to Lawrence to say that we did flirt with the term "nutrition learning" (in fact we incorporated it into the names of our websites)but it doesn't resolve the basic ambiguity of NE Concept A (learning about nutrition) and NE Concept B (learning how to help people improve their diets). And then with the term "nutrition education" at least we have the USA and a body of research and review literature on our side, while there are no global proponents of "nutrition learning" to my knowledge.
In desperation, we have also considered adopting a completely arbitrary name - Agatha? Carmen? Petrov?
Any other suggestions gratefully received.

Jane Sherman

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Unknown said...

The only question for me here is how comprehensive is the program? Personally, it should include everything from right diet to enough exercise and even maybe stuff like herbalife products.

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Gabrielle Clint said...

Nutrition education is always the focus of any state congress. Every year we have to adjust to the new types of food that we eat. I think that it will never have an end to it as long as people are continuing to create different types of food.

Andrea Thomas said...

Its about time that the government should pay attention in enhancing the education programs we got. Since, most of the times, the government tends to overlook this part of the society.

Clyde Rodriquez said...

Educating each and everyone of us on proper nutrition as well as good health is very important. This is for us to become more aware about the things we have to consider when it comes to achieving good health.

Rowan Brockhouse said...

Disseminating knowledge is important in the nutritional education of the populace. The educators need to network with non nutritionists to fulfill this.

Unknown said...

The foods that a you eat while young really effect your development. I'd say it's a good investment for parents to take nutrition education programs.

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