Integration of Nutrition in Agriculture and Rural Development Projects

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2 Food Security Working Group 2015 Integration of Nutrition in Agriculture and Rural Development Projects Good nutrition is the foundation of human well-being. Before birth and throughout infancy, good nutrition allows brain functioning to evolve fully and immune systems to develop well. For young children, good nutrition prevents death or disease. It helps their body to grow and develop to its full potential. Good nutrition leads to better results in school and improved learning capacity. Later in life, it leads to better-nourished mothers who give birth to better-nourished children, and adults who are taller, less likely to be overweight or get diseases like heart disease or cancer. Good nutrition improves work capacity and productivity. Therefore, people with good nutrition are key to sustainable development. July,

3 2015 Food Security Working Group The Integration of nutrition in agriculture and rural development projects July 2015 The food security working group (FSWG) is a member-based network of non-government organizations, community based organizations and individuals addressing food insecurity in Myanmar, directly engaging with members to build their knowledge and skills on food security and mobilizing the collective capacities of the network to identify and formulate issues for research, dialogue and policy advocacy that will benefit the lives of vulnerable communities in Myanmar. The FSWG is a diverse network encompassing a wide and varying range of skills, capacities and competencies and depth of knowledge on issues relating to food security. Food Security Working Group 114, Danatheikdi lane, Gandamar Street, Kabaaye Pagoda Road, Ward 8, Mayangone Township,Yangon Tel : +95 (9) ~2 Website: The research was carried out by Janine Roelofsen and Nicholus Tint Zaw with financial assistance from Livelihood and Food Security Trust Fund (LIFT). The FSWG would like to acknowledge the team from Sympathy Hands Organization, ACF, CESVI, WHH, Save the Children International, Metta, KMSS and Ratana Ayar for their support and contributions for this research. The FSWG would like to thank all the individuals and the organizations that made this research possible. 2

4 Food Security Working Group 2015 Summary The FSWG is interested to gather positive examples of how to integrate nutrition in agricultural and rural development programs. Why should we integrate nutrition in agricultural and rural development programs? There is a misconception that nutrition can be done by health programs alone. Health programs, however, cannot improve food availability, nor improve production of nutritious food, nor improve people s income so they can afford to produce or buy sufficient and quality food. To improve nutrition, each household would need to have access to locally available and affordable nutritious food. Without that, the foundation of good nutrition is missing. We can create awareness about the importance of healthy food, but that would only make sense if people could actually access these kinds of foods year-round. To effectively improve nutrition, we need agricultural and rural development programs to think about nutrition. The foundation of good nutrition is availability and access to sufficient, safe and nutritious food for all family members. Local availability of food is directly linked to local production, local markets and in rural areas also to food availability from natural resources like forests and fisheries. In Myanmar, local food production is increasing through improved practices, techniques and (high-yield) varieties. On the other hand, food production and yields are threatened by climate change and related water shortages, persistent conflicts and emergencies, land rights issues and natural disasters. In addition, food availability from natural resources is declining with deforestation, land issues and reducing fish stocks. These challenges are compounded by changes in demand for food that are brought about by growing populations, increasing incomes and urbanization. In view of these challenges, protection of nutrition, let alone acceleration of progress, will entail more than improving nutrition & health-related knowledge and practices. To sustainably improve food security and nutrition status of Myanmar people, a new focus is required to address the underlying causes of under nutrition. The need for investments to boost agricultural production, natural resource management and increase incomes is undisputable. In Myanmar, around one out of three children under 5 years old are stunted (height for age) and one out of five children under 5 are under-weight (weight for age). These rates are classified as high according to WHO standards. High stunting and under-weight means that a high number of children did not get enough food for over a longer period of time. In addition to hampered growth, 75% of under 5 s has iron deficiency (not enough iron), while 71% of pregnant women and 45% of women of childbearing age have iron deficiency. Iron is needed for oxygen transport and storage in muscles, improves immunity, is required for growth, for energy production, for drug metabolism and proper mental functioning. With lack of iron, children s brain development and school performance is lower than it could be. Lack of iron leads to reduced physical and mental performance, tiredness and higher chance of getting infections and illness. The 5th leading cause of death of children 1-12 months is beriberi (not enough vitamin B1). Vitamin B1 is needed for energy production, growth in childhood and fertility in adults. Vitamin B1 maintains a healthy heart and nervous system; infants die of lack of vitamin B1 because their heart fails. If people lack enough food, they are hungry which is easy to see and easy to measure. However, if people lack iron or vitamins, it can go unnoticed, while the consequences can be serious. Good nutrition is the foundation of human well-being. Before birth and throughout infancy, good i

5 2015 Food Security Working Group nutrition allows brain functioning to evolve without impairment and immune systems to develop more robustly. For young children, good nutrition status averts death and equips the body to grow and develop its full potential. Over the course of the human life-span, it leads to more effective learning at school, better-nourished mothers who give birth to better-nourished children, and adults who are likelier to be productive and earn higher wages. In middle age, it gives people metabolisms that are better prepared to ward off the diseases associated with changes in diet and physical activity. Without good nutrition, people s lives and livelihoods are built on quicksand. Nutrition is integrated by around half of the FSWG members who responded to the survey. However, this might not represent the total number of FSWG members because only less than one quarter of all FSWG members responded. Additionally, it might be that organizations who do nutrition would respond while organizations who don t do nutrition did not respond. This would over-represent the proportion of organizations involved in nutrition. Furthermore, only a few organizations were actually providing examples of nutrition activities / objectives. E.g. 62% said they have nutrition as a cross cutting issue but only 4 organizations mentioned what they did. Therefore, it is likely that not that many FSWG are integrating nutrition in their programs. It is likely that there is a lot of room to increase nutrition-related activities among FSWG members. With most members already working on food security, food availability, economic access to food, and over half working on water and hygienic environment, it would be most suitable to promote nutrition-sensitive activities first. These are activities which address the underlying causes of malnutrition. The main barriers for organizations to integrate nutrition in their programs include: lack of understanding what malnutrition is, how to define it and how severe it is within their target group. Not many agricultural organizations are involved in nutrition which limits expertise in-country or the possibilities to learn from others. More technical training is needed for staff to be able to integrate nutrition well; it is easy to add nutrition-related activities but more difficult to choose the most relevant activities which have an actual impact. Equally important, communities need to better understand the importance of good nutrition; otherwise they will never request support. Finally, a main barrier is no organizational commitment. All literature sources agree that targeted agricultural programs can have a large role in supporting livelihoods, food security, diet quality, women s empowerment, and in achieving scale and high coverage of nutritionally at-risk households and individuals. Increasing the availability and consumption of nutrient-rich foods through a household s own production is considered to be a sustainable approach because the process empowers household members, particularly women, to take ultimate responsibility for the quality of the diet of the households through their own production and improved nutritional knowledge. Literature provides a wide variety of ideas and evidence of effective approaches. Nutrition experts and experiences from FSWG member organizations confirm and complement the evidence that is gathered worldwide. All organizations could at least think about Do No Harm to avoid projects harming nutrition security. Agricultural organizations that like to (start) implement nutrition-related activities should think about what they want to achieve and what they can t achieve; e.g. aim to improve dietary diversity but not aim to improve anthropometry. The selected case studies show that small organizations with limited funding can have an important impact, because they set realistic goals of what they could achieve (in this case, change the food consumption pattern of school children from processed food to healthy, nutritious food). ii

6 Food Security Working Group 2015 Table of contents Summary... i Technical nutrition terms... iv Introduction Why should agricultural or rural development programs include nutrition?... 2 Agricultural and rural development programs are needed to improve nutrition... 2 Food insecurity and malnutrition rates are high in Myanmar...3 Nutrition improves your program...6 Myanmar government have joined nutrition initiatives such as SUN and Zero Hunger challenge What are FSWG member organizations doing in nutrition? What are the barriers for organizations to include nutrition in their programs? How to integrate nutrition in agricultural / rural development programs? Recommendations from literature review Recommendations from nutrition experts in Myanmar Ideas from FSWG member organizations...23 Positive case-studies in Myanmar Final recommendations on how to integrate nutrition in agricultural and rural development programs Annex I. Conceptual framework linking food availability, food security and nutrition Annex II. References iii

7 2015 Food Security Working Group Technical nutrition terms 1,000 day window Complmentary feeding Exclusive breastfeeding Food intake Food security Lactating Macro-nutrients Micro-nutri ents Nutrients Nutrition gap Nutrition security Nutrition specific Nutrition sensitive Stunting Supplements Under-weight Wasting First 1,000 days of a child s life starting from conception to the child s second birthday. Complementary feeding is for infants and young children after 6 months old when, besides drinking breast-milk they start eating solid food. The solid food complements the breastfeeding, which is why it is called complementary food. Recommended for infants from 0-6 months to only drink breast-milk exclusively; meaning nothing else. Also no water or other liquids. Food consumption. Food security at the individual, household, national, regional and global levels is achieved when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. Lactating women are breastfeeding women. Macro-nutrients include protein, carbohydrates and fat; providing energy for an active and growing body. Micro-nutrients include vitamins or minerals which each have a specific role in one of the processes in our body; e.g. supporting nervous system, supporting eye functioning, supporting the heart etc. The word nutrition comes from the Latin word nutrire which means to nourish or to provide with the food needed for a healthy life and growth. A nutrient is a substance that provides nourishment. The gap between what foods are grown and available and what food are needed for a healthy diet. Nutrition security: A situation that exists when secure access to an appropriately nutritious diet is coupled with a sanitary environment, adequate health services and care, in order to ensure a healthy and active life for all household members. Interventions that directly influence nutrition; these include feeding practices (including breastfeeding, nutrient-rich foods), eating routines, care-giving practices, and burden of infectious disease. Interventions that address underlying causes of malnutrition; these include food security, food availability, economic access to food, resources for feeding and care-giving practices (for mothers, households, community-level) or access to and the use of health services, a safe and hygienic environment To check if a child is stunted (too small for its age), we measure its height and then compare it to the expected height for that age (height for age). If a child is stunted, it means that a child did not get enough nutritious food over a relatively long period and/or has been sick repeatedly. Stunting reflects chronic malnutrition. Dietary supplements provide nutrients that may otherwise not be consumed in sufficient quantities; e.g. micro-nutrient supplements such as iron tablets. To check if a child is under-weight, we measure its weight and then compare it to the expected weight for that age (weight for age). This indicator measures the combination of recent and long-term under-nutrition. To see whether a child is wasted, we can compare its weight to its height (weight for height). Wasting is a sign of acute malnutrition; it means that a child did not have enough food recently and is losing too much weight. iv

8 Food Security Working Group 2015 Introduction The main aim of this study is to gather good practices of integrating nutrition into agriculture and rural development projects, and particularly to compile good practices by FSWG s members. To do this, we have:(i) done a thorough literature review of international and Myanmar documents,(ii) talked to nutrition experts in-country and (iii) studied current programs of FSWG member organizations. The research was conducted from December 2014 to June 2015 in three phases. In phase 1, information was gathered from literature sources, from FSWG members and from nutrition experts in Myanmar. In phase 2, field visits were done to FSWG members which implement good examples of how to integrate nutrition. In phase 3, analysis, translation and reporting took place. Methodology In line with the ToR and as agreed with the research committee, the research was based on a thorough literature review and a qualitative research including questionnaires, key informant interviews, focus group discussions and field visits (direct observation). All FSWG members received a Welcome Questionnaire to gather basic data on what organizations are doing in agricultural and rural development and to know if they integrated nutrition in their programs. Key informant interviews were done with nutrition experts from different organizations working in Myanmar. Barrier analysis interviews were done with organizations who had been trained on nutrition, but who did not include nutrition in their programs. Furthermore, field visits and focus group discussions were done with FSWG members to gather positive case studies. Limitations The biggest limitation was the low number of participants in the survey. The Welcome Questionnaire was an easy-to-fill in questionnaire and was send a number of times by to FSWG members which only led to around 10 responses (out of 120 FSWG member organizations). Other pro-active approaches were used to increase the number of respondents. Eventually only 29 responses were received. It is possible that organizations or people who are not involved in nutrition are less likely to respond to a questionnaire about nutrition. And, that those organizations/people who are already integrating nutrition or at least who are interested in nutrition are more likely to respond. This might over-represent the proportion of organizations involved in nutrition. Approach On the following page an overview of technical terms can help non-nutritionists to understand the different terminology that is frequently used in nutrition documents. Throughout the report, an effort was made to keep terminology to a limit to improve readability for a wider audience. 1

9 2015 Food Security Working Group 1. Why should agricultural or rural development programs include nutrition? The main reason why agriculture and rural development programs should include nutrition is because agricultural and rural development programs are needed to improve food security and nutrition. Secondly, compared to other Asian countries food insecurity and malnutrition rates are still high in Myanmar with millions of Myanmar s population being food insecure and/or malnourished. Thirdly, research has shown that including nutrition in agricultural or rural development programs improves the quality and the impact of the program. These are important reasons why it is necessary, effective and recommendable to include nutrition in agricultural and rural development programs. Agricultural and rural development programs are needed to improve nutrition There is a misconception that nutrition can be done by health programs alone. Health programs cannot improve food availability, nor improve production of nutritious food, nor improve people s income so they can afford to produce or buy sufficient and quality food. To improve nutrition, each household would need to have access to locally available and affordable nutritious food. Without that, the foundation of good nutrition is missing. Health programs can create awareness about the importance of healthy food, but that would only make sense if people could actually access these kinds of foods year-round. Health programs can find out who is severely malnourished and then provide therapeutic feeding, vitamin pills or extra food packages, but those are costly activities which create dependencies as well. To effectively improve nutrition, we need agricultural and rural development programs to think about nutrition. Many FSWG member organizations aim to improve food security through their agricultural and rural development programs. The most commonly used definition of food security is based on the definition from the 1996 World Food Summit: Food security at the individual, household, national, regional and global levels is achieved when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. Many programs only focus on ensuring sufficient food is available and accessible; for example they ask beneficiaries if they had enough food in the past 12 months. If the program manages to reduce the number of months of food insecurity (or hunger), that is a good achievement. However, looking at the above definition, food security also includes whether households have access to safe and nutritious food for each family member; is it locally available and can people afford it? To ensure food is accessible at all times, we have to look at seasonality of foods and improve year-round access by promoting a diversity of foods. Finally, the definition of food security also includes that all people should have access to food that meets their dietary needs and food preferences for an active and healthy life. The dietary needs that people have differ depending on their age, their work or for example if they are pregnant. Children who grow, people who are involved in labour-intensive jobs and pregnant mothers have higher dietary needs than other people. Food security therefore is only achieved when each person has the sufficient quantity and quality of food they need to be healthy and active. Food security is not yet achieved if people have just enough food to survive. 2

10 Food Security Working Group 2015 What is the difference between Food security and Nutrition security? Food security is fully achieved when the availability and access to (sufficient, safe and nutritious) food is ensured. Nutrition security is fully achieved when, in addition to the availability and access to food, all people actually eat (food intake) and their bodies use (food utilization) the food that is needed for an active and healthy life. Food security focuses on availability and access to food; which is primary related to agricultural production, home gardening, fruit-trees, livestock, fishing, aquaculture as well as any kind of support to livelihoods which will improve people s resources to buy different kind of foods. Agricultural programs therefore play a very important role in improving food security, which health programs can t. Health and nutrition specialists on the other hand know how to improve actual consumption of different foods and optimum use of nutrients by the body. To improve use of nutrients by the body, the nutritious diet needs to be complemented with a sanitary environment, adequate health services and care; if people drink dirty water or are sick, their bodies do not absorb the nutrients very well, even though they might eat healthy food. Therefore, to improve nutrition security, different sectors have to work together. FAO definition of nutrition security: Nutrition security: A situation that exists when secure access to an appropriately nutritious diet is coupled with a sanitary environment, adequate health services and care, in order to ensure a healthy and active life for all household members. Agricultural programs are not only needed, but crucial to improve nutrition and to address the underlying causes of under-nutrition. Without sufficient, year-round locally available safe and nutritious food, it will be extremely difficult to improve nutrition. Annex I shows the conceptual framework linking food availability, food security and nutrition. Food insecurity and malnutrition rates are high in Myanmar. As explained above, food security is fully achieved when the availability and access to (sufficient, safe and nutritious) food is ensured. How is the food availability and access in Myanmar? Food availability is linked to local food production and availability of food in local markets or natural resources like forests. Food production in Myanmar is developing with updated techniques, new (high-yielding) varieties, and large-scale agricultural support to improve production. At the same time, food production in Myanmar is threatened by climate change and related water shortages, persistent conflicts and emergencies, land rights issues and natural disasters affecting agriculture production and yields. These challenges are compounded by changes in demand for food that are brought about by growing populations, increasing incomes and urbanization. Particularly small-holder farmers and farmers in remote areas have more difficulties to overcome these challenges as they don t have the resources to prevent or mitigate them. Similarly, the poorest households without access to land have difficulty to buy enough food to feed their families. Furthermore, natural resources such as forests and fish stock are declining, further hampering local food availability. The MDG Data Report of the Integrated Household Living Conditions Survey in Myanmar (2011) 3

11 2015 Food Security Working Group states that the proportion of the population living below the minimum level of dietary energy requirements is 5% in With current population 1 of 51.5 M people that would mean that 2.6 M people in-country lack enough food to meet their energy requirements. Note that energy requirements are related to macro-nutrients (protein, carbohydrates and fat) which provide energy to the body. Without sufficient macro-nutrients we do not have enough energy and will feel hungry. In addition, we also need micro-nutrients (vitamins and minerals) which support different processes in our bodies; such as ensuring our heart and nervous system is working well or our eyes are functioning well. People do not feel hungry if they miss necessary micro-nutrients, which is also why it is called hidden hunger. However, they might experience that certain parts of their body are not working well.in severe cases they may become blind (lack of vitamin A) or they may even die if their heart fails to work (lack of vitamin B1). The table below shows that in Myanmar, malnutrition is a combination of both macro- and micro-nutrients deficiencies. 2 Myanmar Children under % stunted (height for age) Pregnant women Non-pregnant women Adolescent girls Adult men Adult women 7.9% wasted (weigh for height) 22.6% under-weight (weight for age) 8.6% of babies born with low birth weight (less than 2,500 gram) 75% has iron deficiency (not enough iron) 5th leading cause of death of children 1-12 months is beriberi (not enough vitamin B1, which is also called thiamine) 2% are overweight 71% iron deficiency anemia (not enough iron) 45% iron deficiency anemia (not enough iron) 26.4% iron deficiency anemia (not enough iron) 20.5% are underweight (< 18.5 body mass index) 21.7% are underweight (< 18.5 body mass index) Stunting, wasting and under-weight are the most common indicators to check if a child is malnourished. Stunting or height for age ; To check if a child is stunted (too small for its age), we measure its height and then compare it to the expected height for that age (height for age). If a child is stunted, it means that a child did not get enough nutritious food over a relatively long period and/ or has been sick repeatedly. Stunting reflects chronic malnutrition. Wasting or weight for height ; To see whether a child is wasted, we can compare its weight to its height (weight for height).wasting is a sign of acute malnutrition; it means that a child did not have enough food recently and is losing too much weight. 1 Population census National Plan of Action for Food and Nutrition , Myanmar 4

12 Food Security Working Group 2015 Under-weight or weight for age ; To check if a child is under-weight, we measure its weight and then compare it to the expected weight for that age (weight for age). This indicator measures the combination of recent and long-term under-nutrition. Most states in Myanmar show stable or decreasing stunting rates 3, except for Chin, Rakhine and North Shan where stunting rates are the highest of the country and also have increased to 40-50%. The World Health Organization (WHO) classified the severity of malnutrition in a population of children as show in the table below. Stunted Indicator (height for age) Wasted (weight for height) Underweight (weight for age) Prevalence Low Medium High Very high Myanmar < % < % < % This shows that in Myanmar stunting and under-weight rates are high, while wasting rates are medium.high stunting and under-weight means that a high number of children did not get enough food for over a longer period of time. In addition to infants and young children, one out of five adults in Myanmar is under-weight, while iron-deficiency is wide-spread among women, particularly if they are pregnant. Pregnant and lactating women need more nutritious food than other adults. If they cannot access sufficient and healthy food, their reserves will be depleted, even more so if they have more children close together. This will not only affect the mother, but also the children. Looking at micro-nutrients, the biggest deficiencies are iron and vitamin B1 (also called Thiamin). Iron deficiency is very high in Myanmar, despite iron supplementation 4 for pregnant women, adolescent girls, and children. Iron is needed for oxygen transport and storage in muscles, iron improves immunity, is required for growth, energy production, drug metabolism and proper mental functioning. People who lack iron experience reduced physical and mental performance, fatigue, poor circulation, depression, decreased resistance to infection and illness. Iron deficiency as fetus or child under the age of 2 has serious consequences and hampers brain development, which cannot be compensated anymore after the age of 2. Vitamin B1 (or Thiamine) is needed for energy production, growth in childhood and fertility in adults. It maintains a healthy heart and nervous system. Infant mortality (children dying before their first birthday) is high in Myanmar with 44.9 children dying out of 1,000 who were born alive. The 5th cause of death for infants is heart failure due to lack of vitamin B1. 3 MICS 2009: 4 Iron supplementation is provided by the Health facilities for free (usually pills with daily rate of iron need ed). 5

13 2015 Food Security Working Group Nutrition improves your program. Optimum nutrition has a wide range of impacts which will improve your program and the lives of the beneficiaries: sickness and deaths of children brain, body, socio-emotional development school performance and learning capacity adult height overweight and non-communicable diseases work capacity and productivity Good nutrition is the foundation of human well-being. Before birth and throughout infancy, good nutrition allows brain functioning to evolve without impairment and immune systems to develop more robustly. For young children, good nutrition status averts death and equips the body to grow and develop its full potential. Over the course of the human life-span, it leads to more effective learning at school, better-nourished mothers who give birth to better-nourished children, and adults who are likelier to be productive and earn higher wages. In middle age, it gives people metabolisms that are better prepared to ward off the diseases associated with changes in diet and physical activity. Without good nutrition, people s lives and livelihoods are built on quicksand. Research has confirmed that optimum nutrition leads to: 1. less sickness and deaths in children, 2. smarter, healthier, social and strong children, 3. better performance in school and learning in general. In addition, it has been proven that when children had optimum nutrition, it even influences them when they are adults; 4. they will become taller and have less chance of being overweight or getting non-communicable diseases (such as heart disease) and 5. they will have better work capacity and are more productive. If we do community development work, and particularly agriculture and livelihoods, we need our target groups to be healthy and strong. If people have improved health and nutrition status it will help to reduce costs for health care and will improve their school and work performance. Therefore, including nutrition in your programs will improve your impact. Myanmar government have joined nutrition initiatives such as SUN and Zero Hunger challenge Scaling up Nutrition (SUN) caling up Nutrition (SUN) is a global movement which unites governments, civil society, businesses and citizens in a worldwide effort to end under-nutrition. SUN was launched in 2010 and Myanmar joined in The SUN Strategy includes a Road Map to significantly reduce under-nutrition in participating countries. The SUN movement is country-driven and builds on progress achieved in country. Countries in the SUN movement are increasing people s access to affordable nutritious food and other determinants of nutritional status such as clean water, sanitation, health care, social protection and initiatives to empower women. Their aim is to collectively meet the global targets agreed at the 2012 World Health Assembly (including a 40% reduction in the number of stunted children by 2025). Political commitment of the participating countries is transformed to effective action by uniting efforts across disciplines and sectors, by adopting methods that have proven to be effective, by learning from available best practices and by mobilizing sufficient resources to achieve measurable results. SUN countries aim to achieve their nutrition goals through two strategic approaches: 1. Scaling up nutrition-specific interventions that have proven to be effective, and 2. implementing sectoral strategies 6

14 Food Security Working Group 2015 that are nutrition-sensitive. Nutrition-specific interventions are interventions that directly influence nutrition; these include feeding practices (including breastfeeding, nutrient-rich foods), eating routines, care-giving practices, and burden of infectious disease. Examples of nutrition specific interventions are: adolescent health and pre-conception nutrition, maternal dietary supplement, micro-nutrient supplementation or fortification, breastfeeding, infant and young child feeding, dietary diversification, treatment of severe malnutrition, disease prevention and management, nutrition interventions in emergencies. These examples show that nutrition-specific interventions are usually done by health programs, although not exclusively. Nutrition-sensitive interventions are interventions that address underlying causes of malnutrition; these include food security, food availability, economic access to food, resources for feeding and care-giving practices (for mothers, households, community-level) or access to and the use of health services, a safe and hygienic environment. Examples of nutrition-specific interventions are: agricultural and food security programs, social safety nets, early child development, women s empowerment, child protection, education, water & sanitation, health and family planning. These examples show that nutrition-sensitive interventions are done by a variety of sectors. Zero hunger challenge Myanmar s Ministry of Agriculture and Irrigation (MoAI) and the UN, with support of FAO have launched the National Zero Hunger Challenge on World Food Day in November The challenge wants to ensure that every man, woman and child enjoy their Right to Adequate Food; that women are empowered; that priority is given to family farming; and food systems everywhere are sustainable and resilient. The Zero Hunger Challenge means: 2. What are FSWG member organizations doing in nutrition? All FSWG member organizations received a welcome questionnaire to participate in the nutrition study. Out of 120 organizations, we received 29 filled in questionnaires, which is just under a quarter (24.2%) of all FSWG members. Therefore, the results below might not fully represent all FSWG members. Most of the responding FSWG members are involved in vegetable growing (69.0%) or sustainable agriculture (65.5%). Agro-forestry and rice production (both 58.6%) are also common activities. Around half of the responding organizations support fruit (55.2%), animal husbandry / dairy (51.7%) or agri-businesses (51.7%). A limited number of organizations are involved in fish/ aqua-culture or agricultural research (both 17.2%). 7

15 2015 Food Security Working Group Only 38% of FSWG responds are involved in Primary Health Care, while over half are doing WASH (55.2%), Natural Resource management (51.7%), micro-finance or saving groups (55.2%) or women empowerment (58.6%). As many as 62.1% of responding organizations confirm that they have nutrition as a cross-cutting issue in their projects. However, only a few actually describe what they do: one organization integrates nutrition sessions in their Farmer Field School sessions and two in their home gardening activities. Another organization does a School feeding program. Similarly, 62.1% of organizations say they do innovative nutrition activities, however these are slightly different organizations than those who have nutrition as cross-cutting issue; 41.4% of organizations have both nutrition as cross-cutting issue and have innovative nutrition activities. Only nine organizations described clearly what their innovative activities include: one organization based their project activities on a comprehensive initial assessment including assessing nutritional status of children under two, micro-nutrients deficiencies, food consumption patterns/dietary intake/care practices, barriers and positive deviance, and also identified micro-nutrient rich crops and assessed wild foods. The same organization also does nutrition screening to be able to measure the impact of their Food Security Livelihood/WASH program on nutritional status. A second organization also did a comprehensive assessment and has developed Behavior Change Communication (BCC) strategies for nutrition, which are implemented through an innovative approach and Food Security/Livelihood staff mainstream BCC in their activities. A third organization is involved in raising indigenous chicken in the Dry Zone, while a fourth organization does innovative vegetable production in containers for landless or land poor households. An additional four organizations say that they promote nutritious vegetables and/or fruits instead of traditionally grown vegetables. Finally, one organization is involved in producing fortified rice. The number of organizations with nutrition objectives is substantially lower at 31.0% and only four organizations describe their nutrition-related objectives which typically include improve knowledge on nutrition, diversifying diets and/or improving consumption of nutrients. One organization also notices the importance of land security and economic instruments (saving groups, health insurances, rice banks) in relation to food security. Only one organization mentions that their objective is to treat malnutrition and to address underlying causes of malnutrition through a multi-sectoral approach. Nearly half of responding FSWG members measure (1) food availability at household level, (2) household coping mechanisms during food crisis and (3) food consumption habits in the household (such as HDDS: Household dietary diversity score, HFIAS: Household Food Insecurity access scale, nutritious food or micro-nutrient consumption). Some 38% of organizations do (4) growth monitoring of children (weight, length) and (5) monitor breastfeeding practices. Only 21% of organizations measures diarrhea prevalence. To conclude; FSWG member organizations are involved in a variety of projects that are interesting from a nutrition perspective as they cover different food groups: vegetables, fruits, crops, forest products, meat, and fish. As many as 62% say they have nutrition as a cross-cutting issue, 62% does innovative nutrition activities, while 31% has nutrition objectives. Nearly half of organizations measure relevant nutrition indicators such as food availability, coping mechanisms during food shortage and food consumption habits. These figures would suggest that nutrition is integrated with around half of the FSWG members, however there are a few things to keep in mind. First of all, only less than one quarter of all FSWG members responded and filled in the questionnaire. It might be that organizations who do nutrition would respond while organizations who don t do nutrition did not respond. This would 8

16 Food Security Working Group 2015 over-represent the proportion of organizations involved in nutrition. Furthermore, only a few organizations were actually providing examples of nutrition activities / objectives. E.g. 62% said they have nutrition as a cross cutting issue but only 4 organizations mentioned what they did. Therefore, it is likely that there is a lot of room to increase nutrition-related activities among FSWG members. With most members already working on food security, food availability, economic access to food, and over half working on water and hygienic environment, it would be most suitable to promote nutrition-sensitive activities first. These are activities which address the underlying causes of malnutrition. 3. What are the barriers for organizations to include nutrition in their programs? Barrier analysis interviews were done with four organizations, both national and international. Similar to the welcome questionnaire it was difficult to find respondents and some did not want to participate. It might be that some organizations/staff didn t want to participate in the survey because they don t do any nutrition-related activities or have any experience or knowledge on nutrition at all. This was confirmed by one of the barrier analysis interviews; the participant said that they are not aware of malnutrition in their target area, that they don t know much about nutrition, that it s a health related issue and that not many livelihood organizations are involved in nutrition. Although the number of organizations is small, their responses give some insights into the actual barriers that organizations face. Organizations who received nutrition training (either by LEARN or by FSWG) but who did not include nutrition in their program were selected. Participants were asked about their perception of how serious malnutrition is in Myanmar or in their target area. In general, participants had the impression that malnutrition is a moderate issue for most people and a serious issue for certain groups. Some perceived that no adults in their target area were malnourished although for children it was recognized. Others thought that no adults or no children in their target area are malnourished, but also add that this is because the community cannot define malnutrition. One participant states that since they are not experts, it is difficult to truly say if malnutrition is a problem or not. Lack of understanding what malnutrition is or how to define it, how to measure it, as well as understanding of the severity of the problem in Myanmar is an issue. Therefore, it is important to explain clearly what malnutrition is and how many people (adults and children) are affected in Myanmar. This should be done at community level as well as staff level. Participants were asked about the efficacy of nutrition programs: if they thought that by including nutrition in their programs, the quality of their program would improve. Or if by including nutrition, beneficiaries would have improved their food security and well-being. Participants agreed that including nutrition would improve the quality of their programs and it would also improve the beneficiaries food security and well-being. The participants we spoke showed that they had good understanding that nutrition can only be improved if the program would include nutrition objectives and would address actual problems that lead to food insecurity or malnutrition. Some participants mentioned that adding nutrition would actually very well fit with their current work on improving food availability, especially the projects on farming and home gardening. 9

17 2015 Food Security Working Group Selected participants had good understanding of the difference between food security and nutrition security. Good understanding of the difference between food availability, food access and food utilization and consumption. Furthermore, they were aware of the importance of different sectors that are needed to improve nutrition. They agreed that including nutrition would improve the quality of their program. Note that those organizations/people that would have less good understanding might have declined our request to participate in the barrier analysis. Participants were asked if many agricultural organizations are mainstreaming nutrition in their programs. Participants commonly agreed that only a few organizations are really mainstreaming nutrition in agricultural programs and that only bigger organizations work on nutrition. One participant said that even after receiving nutrition training not many organizations adopted it. They mentioned that most agricultural programs focus on food availability and access (food security). Participants thought that not many agricultural programs mainstream nutrition, even after training. Participants were asked if they thought that their organization would be able to implement nutrition-related activities, considering their knowledge, staff, and resources. Participants agree that some nutrition-related activities are easy to implement; for example conduction awareness training, forming women support groups, organizing cooking demonstration, supporting home garden or animal breeding with more nutritious foods. Some participants think that it is more difficult to choose the right activities or to choose and measure nutrition indicators. To be able to do it well, additional technical persons who know about nutrition would be needed. It seems that organizations only have a few staff who could implement nutrition-related activities and some even have no staff at all. All agree that more intensive training is needed as well as access to IEC materials. Participants commonly agree that it is fairly easy to implement several nutrition-related activities. They think it is more difficult to select the right activities and to truly have an impact on nutrition; to do that, their teams would require more training or add nutrition staff to their team. Participants were asked about any cues for action Participants were not convinced that their target communities ask for nutrition activities, except maybe for home garden activities and animal husbandry for their children s nutrition. For the international organization the HQ office did not include nutrition in their strategy, therefore, nutrition had not been promoted by the management. To promote inclusion of nutrition, it is important that communities clearly know the causes and effects of malnutrition otherwise they will not request support to improve nutrition. It is more likely that the management of organizations supports the inclusion of nutrition if organizations have included nutrition in their strategy or policy documents. 10

18 Food Security Working Group 2015 Participants were asked about positive and negative attributes to include nutrition Participants know where to get advice on nutrition; LEARN, WHO and MoH were mentioned. Similarly, participants also confirmed they are able to attend trainings on nutrition. Funding for nutrition is accessible through 3MDG and LIFT funding. Interestingly, when asked if the participants would like to add nutrition to their projects, they all confirmed that they would like that. Participants are positive about adding nutrition to their projects and have several ideas how to start. Further technical support is needed as well as improved expertise and staff within the organization. This is more likely to happen if there is an organizational commitment to include nutrition. 4. How to integrate nutrition in agricultural / rural development programs? Recommendations from literature review An additional investment of US$ 8 billion per year globally would reduce the number of under-weight children by 10 million and of hungry people by 201 million by Note that agricultural production might solve the problem of scarcity of calories or energy (hunger) but not the problem of scarcity of access to nutritious and diverse diets. A new emphasis on making agricultural systems and food and agricultural policies more nutrition-sensitive is called for. All literature sources agree that targeted agricultural programs can have a large role in supporting livelihoods, food security, diet quality, and women s empowerment, and in achieving scale and high coverage of nutritionally at-risk households and individuals. Increasing the availability and consumption of nutrient-rich foods through a household s own production is considered to be a sustainable approach because the process empowers household members, particularly women, to take ultimate responsibility for the quality of the diet of the households through their own production and improved nutritional knowledge. Below an overview of approaches and activities that have proven to be effective as well as lessons learned to improve program quality. Food-based approaches Food-based approaches 6 as the name says- mean to solve food insecurity and malnutrition with food, as opposed to medicines, ready-to-use-therapeutic food (RUTF s) or pills. In the case of Myanmar with high numbers of stunted and under-weight children children lacked food for a longer-period of time and this suggests that there is a structural problem. Structural problems should be solved by structural solutions; improving year-round access to nutritious food. Severely wasted children (acute malnutrition) need therapeutic feeding. Also, pregnant/lactating women who need higher than normal amounts of nutrients need supplements. However, these treatments should not be used to solve all nutrition problems because of several reasons: they are expensive, they create dependencies, and they cannot reach all people who need it (some people cannot access health care but also no government or organization could afford to reach all people). Equally important, they might replace healthy and existing feeding practices. The advantages of food-based approaches are that they are: affordable, sustainable and longer term, have social, cultural, economic and environmental benefits, and are local and not top-down. 5 Lancet series #3, nutrition-sensitive interventions and programs, June Improving diets and nutrition: food-based approaches, FAO

19 2015 Food Security Working Group Setting the right goals and objectives As explained earlier in Chapter 1, there is a clear difference between Food Security and Nutrition Security. Food security is achieved if all people have access to sufficient, safe and nutritious food. Nutrition security is one step further in that besides access, people actually choose to eat and their bodies actually use the food they need to live a healthy and active life. To improve nutritional status, we need to ensure people s bodies use the nutrients they eat well. This means that in addition to eating healthy food, they need to have access to clean water, have good hygiene and sanitation, and have access to health care (to cure diseases which hamper nutrient intake) as well. Therefore, nutritional status (such as height, weight) can only be improved if we address all these issues together. Depending on our program, we have to think which goal we can achieve: Agriculture Program Agriculture plus nutrition education Agriculture, nutrition education plus wash and health programs Goal Improve year-round availability of sufficient, safe and nutritious food Improve year-round access to sufficient, safe and nutritious food Improve dietary diversity scores Improve dietary energy supply per person (kcal) Improve share of dietary energy supply from non-staples Improve nutritional status, such as e.g.: Reduced stunting Reduced iron-deficiency anemia Reduced infant beri-beri (vitamin B1 deficiency) The table shows that agriculture is the foundation on which the other activities build; without yearround availability of sufficient, safe and nutritious food, we cannot improve people s diets. The above table also clearly shows that if we only do agriculture without any nutrition education or other related activities; we will not be able to reduce stunting rates substantially. This is something that is shown again and again in research and literature. Therefore, each program and organization has to decide for themselves what they want to achieve. Even if you prefer to focus on agriculture alone, you can think about ways to improve year-round access to food and ways to increase a diversity of food sources. That would be your (important) contribution to improving nutrition. To further improve the impact of your program, you might consider linking with an organization who is involved in health, wash and nutrition. Improve knowledge of and access to storage facilities and saving & loan groups 12

20 Food Security Working Group 2015 Storage facilities (such as rice granaries) help households to overcome the lean season and improve year-round access to food. The storage facilities ensure that farmers do not need to sell straight after harvest when prices are low. Also, combining a storage with a saving/loan group such as a Rice Bank helps farmers to access low-interest loans in times of need. Additionally, farmers can use the affordable loans to purchase farm inputs as well. Post-harvest support, including food processing and transportation might further increase the price farmers get for their projects. Improved prices and reduced dependence on high-interest loans, frees up household money to grow or buy nutritious foods. Proper storage and processing can improve food safety as well. Production surpluses are often lost as a result of poor harvesting practices and inadequate processing, packaging, storage and preservation techniques. Postharvest losses can be especially high for micro-nutrient-rich foods, which are highly perishable and lose substantial amounts of vitamin C and carotenoids (pre-vitamin A) after a few days. Strategies to reduce postharvest losses that are low-cost and appropriate for smallholders do exist. For example, solar drying of carotene rich fruits and vegetables (e.g. mangoes, pumpkins and orange-fleshed sweet potatoes) can preserve vitamin A levels for up to 6 months. Simple solar drying can be used for green leafy vegetables, which are typically high in iron and possibly vitamin C. Improve home garden practices Helen Keller International (HKI) 7 has been able to improve household garden practices in different countries. In most rural areas in Asia, home gardening is already common practice; however, the gardens do not offer adequate nutritious year-round products. HKI has classified three categories of household gardens: traditional, improved and developed. Traditional gardens Improved gardens Developed garden Are seasonal, often maintained on scattered plots with a few traditional fruits and vegetables. Are maintained on fixed plots that produce more varieties of fruits and vegetables, but only during certain times of the year. Are maintained on fixed plots and produce a diversified variety of fruits and vegetables that are available year-round. Using categories helps to see if your beneficiaries have improved year-round access to nutritious foods. The model encourages both the improved and developed gardens, but promotes and assists households to ultimately establish the developed type of garden. HKI combines the home garden support with small animal husbandry (poultry). The reason to include animal husbandry is because the bio-availability of micro-nutrients (such as vitamin A and iron) is lower from plant foods and higher from animal sources. The model works by providing technical assistance, training, agricultural supplies and management support to primarily women farmers from poor households. A village model farm is established in the target community to serve as a continuous community-based resource for the supply of seeds, seedlings, saplings and chicks to participating households for their year-round food production. These also work as focal point for demonstrating agricultural 7 Contribution of homestead food production to improved household food security and nutrition status; lessons learned from Bangladesh, Cambodia, Nepal and the Philippines. 13

21 2015 Food Security Working Group methods and providing training, as well as to coordinate women s groups of producers and link them to health and agricultural services as well as to markets. The majority of HKI programs are implemented with 3 to 4 years of support, after which such support is withdrawn and the community takes over. In addition to year-round access to nutritious food, HKI also managed to improve dietary diversity scores, increase household income as well as improve nutritional status (reduced child anemia) with this approach. They managed to achieve that by specifically encouraging micro-nutrient rich fruits and vegetables, increase year-round production of poultry and eggs, improve consistent consumption of fruits, vegetables and animal source foods. These were combined with behavioral change communication to ensure optimal care, feeding, hygiene and disease prevention practices and to stimulate demand for primary health services. Improve animal production Animal source foods (ASFs), particularly meat of a wide variety, fish, fowl meat, milk, eggs, snails, worms and other small animals supply not only high-quality and readily digested protein and energy, but also readily absorbable and bio-available micro-nutrients. The inclusion of ASF s in the diet promotes growth, cognitive function (brain function), physical activity and health, and is particularly important for children and pregnant women. Even modest amounts of meat and other ASFs in the diet from a variety of sources can greatly improve the overall nutrition and micro-nutrient status. ASF s have proven to substantially increase test-scores of school children; with greatest effect from meat and still a good effect from milk. Milk consumption was found to improve both weight gain and growth in the stunted children and younger children. Support to household animal production with nutrition education lead to reduced diarrhea infections, respiratory infections, pneumonia and stunting. Animal source foods are richer sources of specific micro-nutrients, particularly iron, zinc, riboflavin, vitamin A, vitamin B12 and calcium than are plant food. Note that meat and milk have different nutrient mix and therefore, milk cannot substitute meat. The relatively high fat content of animal source food increases its energy density, which is very useful in young children given their small gastric volume (small stomach). While the positive impact on nutrition is clear, there are some difficulties with raising animals. Animals need grazing land, water, feed and immunizations, while veterinary care is not widely available in rural areas. Successful/innovative programs included: training and utilization of community-based women animal health workers. These women veterinarians train local women to take care of animals, provide simple treatments for minor conditions and carry out immunizations. Another problem with rearing animals, including fish, for consumption, is the need for preservation of the meat to prevent spoilage in the absence of refrigeration. Smoking and solar drying are common options for producing safe, shelf-stable products under controlled conditions. Another innovative option that has been successful is to solar dry rabbit or chicken meat to produce finger foods such as chips that can also be powdered to add it to weaning porridge. Weaning mixes can be sold for income generation. Small freshwater fish provide an important source of protein, iron, zinc, (pre-formed) vitamin A and are an excellent source of calcium when consumed whole. The small fish can be sold fresh 14

22 Food Security Working Group 2015 or in dried form; it is usually relatively affordable and has a long shelf life. When eaten whole, it can make a major contribution to food security and diet quality improvement. One study presented that small fish can prevent and control iron deficiency anemia in adolescent girls. Promoting varietal diversity (growing multiple varieties of a crop) There is a growing body of evidence suggestive of an association between greater crop diversity, improved dietary diversity and improved nutrition. Something that is not often looked into is the many individual varieties (or cultivars) that are available within one crop, for example rice. Different varieties of the same crop species can vary considerable in terms of nutrient composition. Knowing if a household consumed rice X times in the past week is one thing; knowing that a household has consumed X variety of rice X times in the past week is something else entirely. Understanding which varieties are being consumed and which are not increases understanding of nutrient intake. Households which grow multiple varieties of a crop were found to eat this crop more frequently as well; possibly because of continuous availability or the fact that more varieties means that more tastes (adults and children alike) can be pleased at once. Improving crop diversity in rice producing countries in South-East Asia Most areas where rice is grown have dry seasons during which non-paddy crops can be harvested. Facilitating the cultivation of dry season crops can be especially important in areas where rice mono-cropping is common. In some regions, cultivation of lentils, peas and other pulses has declined partly because rice is a more lucrative crop, but also because the growing season of pulse crops is longer than that of rice, and because many pulses require more inputs and maintenance than rice crops. Introduction or reintroduction of nutritious, low-input, short-duration crops might, therefore, appropriate for improving the availability of and access to a more diversified diet. Mung beans are high in protein (and particularly lysine which is a limiting amino acid in most cereal grains) and also high in iron, B vitamins, folate, vitamin C and a number of other nutrients. Recent improvements in the nutritional content of mung beans, and in their pest and disease resistance and maturation cycle could facilitate their reintroduction. Additional selling points include a short production cycle (around 60 days), minimal moisture requirements and improved soil fertility via nitrogen fixation. Soybean for local consumption is another option; they can be encouraged among smallholders to diversify production and capture positive rotation effects. They are high in protein and a good source of poly- and mono-unsaturated fats, as well as of omega-3 fatty acids ( good fats ). Mustard is also an alternative: in addition to having highly nutritious and edible leaves, this plant s hardy oilseeds could increase fat intake. Mustard is appropriate for many rice-based food typologies, particularly those that are rain fed and hence drought prone. Note that the introduction or reintroduction of food must be accompanied by social marketing and education efforts to encourage consumption. Populations might not be open to new crops or new foods, even those that are nutritious and practical. Investing in agricultural extension services and nutrition education services is crucial. 15

23 2015 Food Security Working Group Integrated horticulture/aquaculture projects Integrated horticulture/aquaculture projects are one way to improve household access to animal source foods, fruits and vegetables at the same time. Additionally, in many areas of South-east Asia, they fit into traditional production strategies we well. Integration of the home lot, garden, livestock and fishpond have been promoted in Vietnam since the 1980s. The livestock or poultry pens are situated near or over the pond to provide an immediate source of organic fertilization. Gardens include both annual and perennial crops for year-round food provision, as well as products for market and garden waste may be used for pond fertilization. The promotion in Vietnam is believed to have had a positive impact on the country s nutrition outcomes, which showed market improvements in terms of consumption of animal source foods, fruits and vegetables. From a nutrition perspective, these strategies are exemplary in that they address deficits in ASF s and fruits and vegetables simultaneously. Even a small amount of haem iron (found only in animal source foods) consumed with a meal where most of the iron is non-haem (plant-derived), will enhance the absorption of the iron in the meal. The addition of a small amount of fish or meat (e.g. 30 g) to a meal containing non-haem iron will result in much greater absorption of iron. If this meal contains vitamin C-rich fruits or vegetables, iron absorption will be further improved. In South-east Asia, where iron deficiency anemia is especially pronounced, such projects present culturally acceptable and viable opportunities to increase the dietary availability of iron and other essential micro-nutrients. Improving poultry production Farmers struggle with extreme high losses of small ruminants and poultry to diseases. A solution suited to smallholders, especially those facing budget constraints, is to increase the productivity of existing local animals. Introducing improved housing and supplementary feeding through improved extension services can go a long way to reduce high losses among small ruminants and poultry. In areas where losses are high, farmers might allow the majority of eggs to hatch in order to maintain the flock as an asset base, rather than to use them for consumption; thus reducing the opportunity to improve dietary intake. If poultry mortality rates can be reduced through improved housing and supplementary feeding, as opposed to simply letting chickens forage, the consumption of eggs might increase. From a nutrition perspective, improving egg consumption increases the intake of protein, fat and vitamin A. Forestry in improving food security and nutrition Forests and trees can make a big contribution to improving diets and nutritional quality, by adding variety to diets, improving taste and palatability of staple foods and providing essential vitamins, protein and calories. Forests provide a large range of edible foods, such as seeds, fruits, leaves, roots, mushrooms and gums; they are habitat for wild animals, insects, rodents and fish; they provide fodder for livestock; and they provide fuel wood for food processing. There has been increased realization that local people depend on forests and trees to meet important needs such as food and income. Inequality in ownership and access to productive resources, such as land, causes poor households to rely even more on forest products for income and nutrition. Examples of contributions of forests and trees to improved nutrition: 16

24 Food Security Working Group Leaves: wild leaves and leaves from planted trees can be excellent sources of vitamin A and C, protein and micro-nutrients such as calcium and iron. - Fruits: wild fruits are especially good sources of minerals and vitamins, and sometimes contribute significant quantities of calories. Agro-forestry trees such as guava or mango are important sources of vitamin C to many households. - Seeds and nuts: In addition to the calories, oil and protein, they are also important for the absorption of vitamins A, D, E and K. - Roots and tubers: a large variety of forest plants (climbers) can provide carbohydrates and some minerals. - Mushrooms: mushrooms, gathered wild from forests and woodlands, are much liked in many cultures, and are added to sauces and relishes for flavoring. In many cases, they provide substitutes for meat. - Honey: is an excellent source of sugar and is an important ingredient for traditional medicines. - Gums and sap: Sap is frequently tapped for beverages and is often high in sugars and minerals. Gum is used as a food supplement and can also be a good source of energy. Both have medicinal uses. - Animal foods from forests and farm trees: wild animals and fish are other important forest food products. Forested areas, mangroves and streams provide a habitat for many wild animal species and fish. The range of species consumed includes birds, eggs, insects, rodents and other larger mammals. Collection and sales of forest-derived products can be an important income source as well, which can provide part-time, seasonal, or full-time year-round employment depending on the product. Bio-fortification of food Bio-fortification, through conventional plant breeding, can improve the nutritional content of the staple foods that poor people already eat, and provide a comparatively inexpensive, cost-effective, sustainable and long-term means of delivering micro-nutrients to the poor. New varieties of staple foods (such as rice) are being developed that are high in iron, zinc and/or pro-vitamin A. These foods cannot have too high concentrations of micro-nutrients because people eat them daily. Therefore, they can t be the single solution to severe deficiencies. However, the can be one component of a larger strategy to eliminate micro-nutrient deficiencies, such as vitamin A and iron deficiency. Research on iron fortified rice and beans has been positive and showed favorable agronomic qualities including equal/higher yields and greater disease resistance and drought tolerance. Challenges on the other hand might be that industrial fortified foods can be more expensive. To be successful, the farmers need to adopt the fortified seeds, and the consumers need to accept the final product. It is good to keep this option in mind and organizations might want to test these new varieties when they are available in Myanmar. Iron-fortified rice is being promoted by Myanmar Consumers Union. A country strategy and production plan for fortified rice was developed in February

25 2015 Food Security Working Group A pilot project; optimized feeding recommendations and in-home fortification to improve iron status in infants and young children. Anemia is a widespread public health problem (also in Myanmar) that affects particularly infants and young children. Nutrition has an important role in addressing this condition, and integrated foodbased strategies can be adopted to improve complementary feeding practices. A pilot project 8 was done to compare children who were fed recommended complementary feeding with children who were fed recommended complementary feeding plus Sprinkles (micro-nutrient powder used at home). Recommended complementary feeding practices for children between 6 and 23 months which were promoted in the project: - timely introduction of animal source foods (meat, egg, dairy products), beans, fresh fruit and vegetables - discourage to give the children black tea which prevents the absorption of iron - increase consumption of iron-rich foods - daily consumption of fruit, vegetables, cereals, milk - guarantee a balanced daily distribution of meals and snacks Nutrition education was done through local existing health workers who were trained on infant and young child feeding practices. The health workers then would advice the mothers on a monthly basis using interactive approaches such as cooking demonstrations and group discussions. In the group discussions other community members (such as elderly women or mothers-in-law) would be welcomes as well since (young) mothers might find it difficult to change a common practice particularly when it comes to feeding children and family. Also, in the group discussions any misunderstandings or problems as well as potential solutions could be discussed. To promote mothers feeding their children nutritious food, locally available food was promoted and prepared using local household utensils. The mothers received the lessons on how to feed their children in book form with pictures. The same pictures were used during the nutrition education sessions. A child s nutritional status is strongly correlated with the mother s education. If the mother has difficulty reading or interpreting nutritional recommendations provided in written form it is very unlikely that she will comply with recommendations. In contrast, the power of a picture, designed to represent commonly used foods and tools, helps to understand the message more clearly. Assessing if mothers would indeed feed their children the preferred food was again done with a picture booklet in which food and food preparation pictures were combined to show recommended and standardized amounts/portion sizes. Mothers were asked to simply tick, on a daily basis, the food consumed by the child. Within this study, one group of children received Sprinkles (micro-nutrient powder which can be added to food at home) while the second group of children did not get those. All children were anemic at the start of the study (100%). The study found that the number of children with iron-deficiency anemia dropped dramatically after 3 months already to 40% (only improved feeding 8 Optimized feeding recommendations and in-home fortification to improve iron status in infants and young children in the republic of Tajikistan: a pilot project, Marina Adrianopoli, INRAN and WHO 18

26 Food Security Working Group 2015 practices) and to 10% (improved feeding practices plus Sprinkles). After one year, the number of anemic children was 35% (only food-based) and 20% (food and Sprinkles) respectively. It was noted that mothers who did not receive Sprinkles were better following the recommended feeding practices. An important conclusion from the study is that in-home fortification is an appropriate intermediate solution when there is a risk of micro-nutrient deficiency. However, micronutrient powders are not food, and cannot be consumed without food; thus the use of effective and affordable food-based recommendations using locally available foods should be strongly encouraged. Improve targeting / beneficiary selection Including households with pregnant / lactating mothers, children under the age of two and adolescent girls in nutrition programs is effective and has high return rates. Interventions focusing on children during the first 1,000 days of life (from conception to a child s second birthday) have high return rates because of their importance in enhancing economic productivity later in life, through higher schooling, higher-paying jobs, and overall improvement of physical, cognitive and reproductive performance. Most nutrition programs and strategies focus on improving nutrition of children during their first 1,000 days of life; it is also called the 1,000 day window of opportunity. If a child is under-nourished during this time, it has missed this important opportunity and the effects will be irreversible. To improve nutrition of children during their first 1,000 days, we need to ensure their mothers also have good nutrition since they are the main food providers (when pregnant and when breastfeeding). To improve the mothers nutrition status, it is important to start before they actually become mothers. Therefore, it is good to include adolescent girls in the program as well. Women are key mediators because of their role in intra-household resource allocation, family nutrition and child nutrition. Impact on nutrition is more likely when agricultural interventions target women and include women s empowerment such as improving their knowledge and skills. Programs improving women s social status, power, control over resources, and reduce women s time constraints are important to improve nutrition. Targeting households with malnourished children? A disadvantage of targeting or supporting mainly households with malnourished children is that it may create an incentive for a family to keep a child malnourished. While such abuse is possible, verifying or disproving the extent of such behavior is difficult. This form of targeting has also the disadvantage of only reaching children who are malnourished already, rather than being preventative. Instead it might be better to target households with increased risk; target the most nutritionally vulnerable households. Improving nutrition through multi-sectoral approaches The World Bank compared different pathways to improve nutrition status, show in the table below. These results are in line with earlier parts of the report which also showed that economic growth or improved income or improved access to food will not automatically lead to improved nutrition status. 19

27 2015 Food Security Working Group Still it is interesting to compare the different pathways and to note that empowerment of women through targeted agricultural interventions has strong evidence of improving nutrition. Pathway Increase macro-economic growth overall Increase access to food by higher production and decreased prices Increase household income through selling agricultural products Increase nutrient dense food production for household consumption Empower women through targeted agricultural interventions Strength of the pathway Modest effect. Doubling per capita agricultural income is associated with an approximately 15-21% decline in stunting on average, which would result in very slow and uneven progress in reducing undernutrition. Modest effect. Of the countries meeting the MDG1 target to halve hunger, fewer than one-third are on track to meet the MDG1 target to halve undernutrition, demonstrating the limited translation of national-level grain availability to nutritional improvements. Variable effects. On average, income poverty and undernutrition are correlated, but increases in household income do not necessarily lead to improved nutritional status of its most vulnerable members. Increasing women s income has stronger positive effects on nutritional status. Existing empirical evidence shows commercialization based on cash crops has limited nutritional effects on vulnerable individuals in producer households. Some evidence. The best evidence to date is found from increasing small-scale production of nutrient-dense foods. Nutrition education enhances dietary consumption and the potential for consumer demand. Strong evidence. Over 50% of the reduction in child underweight from is attributable to improvements in women s status. In agricultural activities, increasing women s income and reducing women s time and labour constraints appear to be especially important to improve nutrition. Even though these pathways alone might not lead to improved nutrition, they may contribute an important part to improving nutrition. For example: improving livelihoods and income has only a modest effect on malnutrition. At the same time, improving livelihoods and income helps to create choices for poor households; including the choice to produce or buy nutritious food. This is very important. In summary: people need income to make healthy choices and to acquire nutritious food, but only improving income does not automatically lead to improved nutrition. If we want people to make these healthy choices, we need to integrate nutrition into our livelihood programs. And if we want to achieve even more; if we want to improve nutrition, we need to address all issues that hamper nutrition. As explained earlier (for example on page 16: setting the right goal for your program), although our program might not improve nutrition status, we might want to improve food availability or food security as an important step towards improving nutrition. Global Nutrition Report 2014 Actions and accountability to accelerate the world s progress on nutrition. The Global Nutrition Report 2014 provides recommendations at global level and country level. They state that people with good nutrition are key to sustainable development and therefore, they advocate for inclusion of nutrition indicators in the Sustainable Development Goal targets for The Sustainable Development Goals are the post-2015 development goals, replacing the MDG s which run until The SDG s include developing and developed countries. 20

28 Food Security Working Group 2015 They also recommend focusing a greater share of investments to improve underlying determinants of nutrition to have larger impact on nutritional outcomes. To do that, it is important to provide more guidance on how to design and implement these approaches. The report calculated which targets are needed in food security, water, education to achieve the worldwide target of reducing number of stunted children by 40% by 2025 (this is equivalent to a level of about 15% of stunting in 2025). To achieve that goal, the following underlying determinants are needed: 98% has access to improved water source, 75% has access to improved sanitation facility, 98% of females enrolled in secondary school, 2905 kcal dietary energy supply per capita, and 48% of dietary energy supply from non-staples. Government efforts, lessons learned: improvement of nutrition status of children under 5, growth of school-aged children and adolescents during the period of rapid economic growth in China. China managed to reduce stunting rates in the countryside from 40.3% in 1990 to 12.6% in The median height of various age groups of school-aged children and adolescents in cities are close to the reference used by the WHO. At the same time however, micronutrient intake (iron) did not improve and iron-deficient anemia was not reduced. Furthermore, chronic diseases such as obesity, hypertension, and diabetes rapidly increased. These results are linked to improved and more balanced diets in rural areas of China and a worse dietary pattern in urban areas. With the rapid economic development in China, people enjoy a better income and standard of living. Money for food is basically secure, but the dietary pattern has become unbalanced and nutrition has turned out to be the most important factor leading to the rapid increase in major chronic diseases. Any improvement in nutrition is the outcome of the concerted efforts of the government, especially in agricultural development. Agricultural production is the basis for the availability and sufficient food and income in both urban and rural areas of China, and the application of policies favorable to farmers since 2000 has stimulated the improvement of nutrition of rural poor children. The Chinese government has combined agricultural production with rural development and farmers livelihoods together as 3 Agri in national planning. This included: tax exemption for agriculture, direct subsidies for growing grains, risk funds for grain purchasing at a protected price, construction plans for new villages, subsidies for rural households on electric appliances, tuition fee waivers and free textbook supplies for rural schools, subsidies for the poorest households, pensions for rural elderly, meal subsidies for rural boarding schools, public health services. The number of extremely poor people fell from million (10.2% of rural population) in 2000 to million in Agriculture is, therefore, considered not only in terms of production or yield, but also as the integration of rural development and farmers wellbeing, which is extremely important in relation to the improvement of nutrition. Recommendations from nutrition experts in Myanmar A variety of nutrition experts were interviewed, mostly from the NGO sector. These included Andrea Menefee Nutrition Advisor Save the Children, Matt Tat Lan manager Save the Children, Celine Lesavre Head of department Health and Nutrition ACF, Janis Differt Food Security and Livelihoods Head of Department ACF, Elizabeth Whelan Program Manager LEARN Project, Saw Eden LEARN Project, Joy-Desta Brandsma Senior Program Manager Maternal, Neonatal, Child Health and Nutrition Plan International. 21

29 2015 Food Security Working Group Recommended activities or approaches for organizations involved in agriculture or food security to include nutrition included the following main suggestions: General recommendations: - Important not to force organizations to do nutrition but rather encourage / motivate first - Important to provide sufficient staff training and support - For programs which mainstream nutrition; think about what to do and what not to do (e.g. aim for improved dietary diversity but not for improved anthropometry). In other words, it is important to carefully think what your organization can and cannot achieve or do. - At least think about Do No Harm; try to avoid that your project activities are harmful to nutrition - Important to think about targeting; focus on women, adolescents and children up to 5 years old - Agricultural programs typically focus on main crops; change into a more holistic approach to food and aim for a sustainable and value added food system. The problem is that this will require more expertise. - If your organization aims to improve nutrition status, be aware that you have to consider the different needs in different sectors that influence nutrition. Recommendations for nutrition assessments: - Important to do a thorough need assessment which includes the different aspects of nutrition, taking into account the local context and looking at people s knowledge, attitude and practices. - Important to do a thorough need assessment to know which needs or deficiencies need to be addressed; then promote locally available foods which are related to these needs. - Important to assess the real barriers for people to adopt nutrition recommendations. Recommendation for nutrition-related activities - Nutrition-related activities do not always mean that we have to add on additional activities; sometimes we can design our current activities differently so that they become nutrition sensitive. For example, if we support agricultural production, not only consider cash crops but also consider nutritious crops. - It is important to consider gender and knowing the role and responsibilities of men and women in nutrition-related decisions. - Consider setting up a breastfeeding room if you do a cash for work project - Consider setting up village child care near farm fields - Consider promoting wild foods to improve year-round food access to nutritious foods - Important to think about the influential people in the community such as the elderly; they influence the pregnant or young mothers and can have a big impact on community members. They might 22

30 Food Security Working Group 2015 not be interested in flip-charts but more interested in shows and performances. Recommended nutrition-related indicators for agricultural programs include: - Yields of different food groups - Household Dietary Diversity Score (HDDS) - Individual Dietary Diversity Score (IDDS) - Food prices - Proxy indicators: e.g. consumption of vitamin A rich foods - % of mothers who exclusively breastfeed - % of beneficiaries that benefit from nutrition and food security activities For some indicators, detailed descriptions exist online of how to measure and calculate them; including the HDDS and IDDS. For the more technical indicators (e.g. stunting) support might be needed from nutrition advisors. Before selecting indicators, it is important that field staffs are clear why they need to collect them. Recommendations on where or how to train staff on nutrition: - Hire a nutrition consultant - LEARN is for LIFT implementing partners LEARN has developed a facilitators manual for non-nutritionists to do nutrition training in the community (English and Myanmar), including: 3 food groups, nutritious foods in market, what plants to grow in home-garden, micro-nutrients, 1000 days window, basic nutrition, home hygiene and signs of malnutrition. LEARN has taught LIFT IP s and they are able to do these trainings in the community. The manual includes IEC materials, flip-chart story and games. The manual could be spread to interested organizations, also those who are not (current) LIFT IP s. - Important notice with regards to training: should be done at management and field level because managers are typically involved in design of new projects and make the decision to include nutrition or not. - SUN (Scaling up nutrition) will be involved in sharing knowledge and information, evidence and learning, involving grassroots level and government levels. Ideas from FSWG member organizations FSWG member organizations provided their ideas and current approaches of how to integrate nutrition in agricultural or rural development programs. These include: - Nutrition awareness and trainings, home and school gardens, differentiation of agricultural production. - Capacity building of field teams. - Diversify food sources, improve production of micro-nutrient rich and energy-dense food. 23

31 2015 Food Security Working Group - Address seasonality of access to food. - Target women/caregivers and empower them. - Sensitize beneficiaries on nutrition aspects and on hygiene, Infant Young Child Feeding practices. - Include relevant assessments to properly design activities in order to address malnutrition. - Incorporate indicators to track nutrition impact, or at least, impact on dietary intake and food diversity at households and individual level. - Distribute school feeding, care for improved health and support organizational plan. - Publish a book on nutrition values of Myanmar vegetables and foods, so that people can select suitable foods. - Not assume that nutrition will improve for all family members just by increasing income or agricultural production. Invest in understanding knowledge, attitude and practices of nutrition and address nutrition as a topic in itself. - Give special focus to the 1,000 day window and nursing/pregnant women. - Special food support program for children under five years old who are not going to school. - Include livestock activities (chicken, goat, duck, cow for meat and milk) and fishery activities. - Include nutrition related activities such as nutritious food, cooking demonstration and nutrition progress status document for children. - Improve farmers and consumers awareness on safe and nutritious food. - Produce healthy and safe food through sustainable agricultural activities. - Support added value for local vegetable and food products. - Integrate homestead garden with traditional livestock. - Support rice seed bank and animal bank. Positive case-studies in Myanmar Four positive case-studies are selected; representing different areas in Myanmar and different type of organizations. The first good example is from a local CBO and the two others from international NGO s. 1. School garden project in Delta by local CBO The selected project involved school-based gardening in 5 local schools in 5 villages. Purpose of the project and what could be achieved? The purpose of the project was to change the food consumption practice of children and their family from a food safety perspective and to increase gardening practices not using chemical fertilizer. The project indeed succeeded in changing the food consumption practice: after the project, the food choice and selection of school snacks among students changed because of the food safety education activities. Some food/snack sellers had to change their products; instead of processed/chinese snacks the children wanted traditional Burmese snacks made from real food. The noodle seller also changed the preparation of the sauce and currently uses traditional sauce like tamarind sauce. After the project, people improved the seed selection in vegetable gardening, also considered nutrition 24

32 Food Security Working Group 2015 and food safety when selecting snacks/meals in school and at home. Children denied fast food in school or at home and demanded their parents to provide more fruits and vegetables. Children and their families gained new knowledge on food safety and understood how it affects their health. The community only did limited home gardening before and they usually bought vegetables/fruit for consumption. Through the project however, technical knowledge how to do home gardening was disseminated to more people and when people saw the school garden they wanted to grow one themselves. In one village with lack of good soil, the people placed good planting soil in plastic bags to grow vegetables. This technique was new to them and was spread by the community. The project was visited two to three months after it finished, and the children were very well able to recall the nutrition education they received; three food groups, nutrition value, unsafe food and its negative effect on health, as well as the practical lessons on vegetable growing. How was the project able to achieve these changes? What kind of activities did you do and how? Activities Description 1. Community Awareness Raising Contact the Township Education Officer to explain about the project activities and to get approval. Hold a community meeting with community members in the village and explain about the project activities and objective including Parents and Teacher Association and Senior Students. 2. School Garden committee Form School Garden Committee with Parents & Teacher Association, Headmaster and Senior Student who take the main responsibility to take care of the garden and management of the funds gained from gardening activities. 3. Good Agricultural Practice Training Arrange training on each school with support from Vegetable and Fruit Research and Development Center (CFRDC) on good agricultural practice and how to cultivate vegetable. 4. Seeds Selection In school, discuss the seed selection with the committee including seed selection of nutrient-rich vegetables (one month after the project started). The following types of seeds were selected:lady finger, Pumpkin, Egg plant, Rosella, Carrot, Watercress, Bitter guard, Tomato, Long bean, Other green leafy vegetable (Hin Nu Nwe). After the selection process, the project team did the procurement of the seeds with the school garden committee. 5. Set-up School Garden Make land selection which is close to school and easy to get water. Made agreement with headmaster to share the school Exercise Time to do school gardening activities with some active member from P&TA. Made fence for school garden to prevent animals entering and destroying the plants. Seed planting was done in one session with all students through demonstration on how to plant and grow a seed, for it to become a small plant. Every student who was interested to grow a 25

33 2015 Food Security Working Group home garden in their house received those small plants from the school garden. Regular watering on school garden was conducted by some active committee members and students during Exercise Time of schooling. 6. Education Activities Since the first month of the project, the education and awareness promotion activities on food and nutrition were started. The reason why the project focused on children for the Behavioral Change Communication was to promote awareness on disadvantages of chemical fertilizer, food group & nutrition value of food and how ecology is support since childhood so that they can practice this when they become an adult. a. The very first education session was conducted in each project village school on Food Safety. The Consumer Protection Association of Myanmar was requested to conduct that session and it took 2 hours to cover how food safety is harmful in Myanmar especially in daily foods what we consume and in school snack market. Pamphlets and CD on food safety were shared. b. After a month, another education session was conduct in all project areas on Nutrition 3 food groups and nutrition value in food. One nutrition staff from WHH was asked to conduct the education session and to disseminate pamphlets to participants. This included a quiz and game session to select vegetables to which food group. Pumpkin eating was also promoted through this education session and therefore it was put in the school garden as this is very rare in this area. The education session messages were discussed during the seed selection process when the team talked about seed selection with the committee and the students. c. The third topic covered by the education activity is the eco system, environment and food, for which the project invited one environment specialist who is also working as one of the chair parsons of Sympathy Hand Organization. d. After three education activities, the organization had the chance to attend the LEARN training on basic nutrition and got the field manual for education sessions and the LEARN video clip on 1,000 days. Those were used for the last education session including Quiz for 1000 days. e. Apart from this kind of education activities, the project also did an Essay Contest in three project schools on World Food Day on Our School Garden. Positive: - The education on three food groups with quiz and games was mentioned by the children as fun. Also, 3 months after the project finished they were able to mention which food belonged to which group. (This session was done by WHH.) - The children also liked the essay contest in school. - The children shared the new knowledge with their parents and asked their parents to cook according to the different food groups and not just fast food which is unhealthy. - The children came up with good suggestions such as selling the vegetables from the school garden and use it for the school or for food needed in school events. 26

34 Food Security Working Group 2015 Lessons learned: - School gardens itself are not very sustainable; hybrid seeds were used for the home gardens and there is no system set up to earn money by selling vegetables to buy new seeds next year. Better to set up a system or to think ahead how to make it sustainable. - There was no specific person responsible to take care of the garden during the days that there is no school and especially before harvesting. With the garden being beside the road, some people just took the vegetables with them. Good to have one person committed to take care of the garden, possibly supported by some incentive based on the time they actually spend on the garden. - Timing of school garden activities; overlapped with exam period at schools which made it more difficult to implement although students were very active in both education and gardening. - School gardens lead to less ownership and the committee members were not very interested in the activities as they didn t believe it would bring physical incentives/benefits for them. The project team might need to do better sensitization on the project objectives and activities. - The pamphlets and CD was disseminated to the whole community which helps to promote and spread the awareness. The project activities however focused only on students and school, so they had limited reach to the community. Maybe consider to do both school garden and also a community demo plot next time. - Although the Township Education Officer approved the project, some school head masters were not interested. To implement this kind of project again, it would be good to get the approval official letter from the Township Education Officer to help deal with the school headmaster. - Due to bad weather, all seeds were lost just after planting. Even though there are some lessons learned to improve sustainability and to improve the project further, the project itself was able to make some good changes for the children and possibly their families. The children enjoyed the activities, are interested to continue them and like to learn more. The project clearly shows that by working together with others pays of. It is a clever idea to invite experts from different organizations to ensure quality of information and techniques. Also, it is a good way of learning more; within communities and within the staff team. The project also shows creative ways to use and build on existing local systems such as using the school s exercise time or combining the nutrition education sessions with the monthly religious sessions at the monastery to reach more people. The project s aim was very clear and focused; changing the food consumption practice of children and increasing gardening practices not using chemical fertilizer. This small project is considered a good example for other small organizations of how to achieve changes in food consumption patterns. 27

35 2015 Food Security Working Group 2. Non-timber Forest Products survey in Delta by an INGO Purpose of the project and what could be achieved? The Non-Timber Forest Product Survey was done to identify good sources of food and nutrition in the wilds for the purpose of increasing nutrient intake as well as household incomes. The participatory way this survey is conducted is a good example and might be useful for other organizations particularly in areas where people face seasonal food shortage or where agricultural development is more challenging. Furthermore, the methodology of the survey is very straightforward so it is easy to copy and also not so expensive, which makes it doable for smaller organizations as well. Therefore, this survey has been selected as a positive case study. Through the survey, target beneficiaries identified edible wild plants and fish species consumed by local people in the survey area. The result of the survey was a list of edible foods including pictures, names, descriptions as well as locations of where to find them. The foods were divided in three categories, depending on their usage for: food consumption, income generation or medicinal use. The food names were presented in the local language, Burmese, English and Latin name. How was the project able to achieve these changes? What kind of activities did you do and how? Activities Description 1. Selecting participants In each village, three community groups were selected: the local elders group, a women group and a school teachers and children group. The elders contribution was very useful because of their long time presence in the area and particularly the men knew very well the existing natural resources of plants, fishes and trees. The women were very familiar with the natural resources used for household consumption and were also good practitioners of medicinal plants. 2. Participatory exercise to identify wild foods To start the participatory exercise, the survey team first explained what Non-Timber Forest Products are and why we want to identify them. Then, the survey team showed the community group a poster which had different pictures of Non-Timber Forest Products (NTFP) and discussed with the participants which ones are existing in places near their homes, in paddy fields or village surroundings. The groups discussed the following topics: natural vegetation (trees) grown in the area, edible plants that are collected, medicinal plants that are available, and marine species (fish) that are caught. The groups also discussed about which products are sold and can provide income as well as ideas for possible income generation activities with wild products. Furthermore, the survey team showed the map of each village on Google Maps and made sure the participants could locate their village on the map. Then the team copied the map into a new sheet to prepare for resource mapping. The participants then marked possible location of specific NTFP products on the map. Eventually, the survey team and group members went around the village to see the natural trees, edible plants, medicinal plants and fish species as discussed in the meetings. All available NTFPs were recorded as photo-images. 28

36 Food Security Working Group Recording lists of identified wild foods The photo records of plant specimen were identified under the supervision of the botanists of the Forest Research Institute in Yezin. Fish species were recorded under the supervision of the principal of the Fishery School in Phar-Pone Township. All species were verified and corrected with available resources on the Internet. A list of books that are particularly relevant to identify wild species from Myanmar include: - Medicinal Plan List of Myanmar (Eng) by Dr. Khin Maung Lwin (FAME pharmaceutical Industry) - Burmese Medicinal Plants (MM) Agricultural Corporation - Medicinal Plants of Myanmar (Eng) Dr. Kyaw Soe & Tin Myo Ngwe (FREDA) - Collection of Commonly Used Herbal Plants (No-2) (MM) Department of Traditional Medicine, Ministry of Health - An illustrated Encyclopedia of Myanmar Medicinal Plants Myanmar Agriculture Enterprise, Ministry of Agriculture and Irrigation - Mangrove Medicinal Plants (MM) Metta development Foundation - Edible Plants (MM) Myanmar Agriculture Enterprise (Ministry of Agriculture and Irrigation) - Medicinal Plants of Myanmar (Eng) Department of Traditional Medicine (Ministry of Health) - ASEAN Herbal and Medicinal Plants (Eng) E-book - A checklist of the Trees, Shrubs, Herbs, and Climbers of Myanmar W. John Kress, Robert A. DeFilipps, Ellen Farr, Daw Yin Yin Kyi, National Museum of Natural History, Smitsonian Institute. The plant species and fish species were numbered and listed in Myanmar name, English name, Latin name, Habitat and Seasonality. In a second table, all plant species and fish species were listed by their number and scientific name with a short description. In a third table, all plan species and fish species were again listed by number and scientific name as well as if they are for: household consumption, medicinal use or income generation. A short description was provided which part of the plant would be used for consumption or which part would be used for medicinal use and to treat or prevent which disease. If a wild food would be interesting for income generation, a short description was provided on potential market prices (local market). Positive: The survey report did not include positive points since a survey is not like a regular activity. The report did state that the participants were active and interested to conduct the NTFP survey. We can assume that by doing this kind of survey in a participatory way with different groups (elderly, women and teachers/children), the knowledge of which species are locally available and locations of where they can be found is improved and spread over a larger group of people. 29

37 2015 Food Security Working Group Lessons learned The survey report did not include nutrient values of the identified plant or fish species which might be worthwhile to include as well. Given that the lists already have Myanmar and English as well as Latin / scientific names of the species, it would probably be not too difficult to find out nutrient values from other sources. 3. Nutrition-sensitive food security program by an INGO The program is implemented in five agro-ecologically and culturally distinct regions of Myanmar: Northern Rakhine, Northern Shan, Ayeyarwaddy Region, Sagaing Division and Yangon Division. The program is a nutrition-sensitive food security intervention and addressing the underlying causes of undernutrition. Purpose of the project and what could be achieved? The objective of the program is to improve the nutritional status of vulnerable populations through innovative and pro-poor food security and livelihoods interventions. The program aims for a sustainable increased consumption of micronutrient-rich foods/products, and enhanced practices of optimal nutrition and care. Improvement of physical and financial access to micronutrient-rich foods occurs in all villages due to Healthy Home Gardening and Community Gardening. The community garden committees and mother groups are very active and functioning. Women participation and empowerment can be seen in the project implementation. When meeting with the mothers, they explained that the new practices result in their children having good body weight, being strong and less vulnerable to being sick. One mother shared that her youngest child who received colostrum (first breast milk after delivery) and was exclusively breast fed until 6 months (not getting water), was much stronger than her other children. Other mothers also shared they changed their complementary feeding practices; before they would only give rice and start 2 or 3 days after delivery, but now they add oil, egg, long bean and potato for the children s food and start at 6 months. Home garden families report that they take a larger variety of vegetables from their garden and that their home garden saves some money for their household. Beneficiaries confirm that before only corn was grown in their area, but now they know how to use their land properly and benefit from growing other seasonal foods and plants. Beneficiaries state that at first they worry about growing new vegetables (carrot, green leafy vegetables, water cress and long bean) but after training and support, it really worked. Now they appreciate these new foods. Also because home gardening food is safe as no chemical fertilizer or insecticide is used; the food is fresh and is rich in vitamins. How was the project able to achieve these changes? What kind of activities did you do and how? Activities Description All activities focus on 20 villages from Kayah State and target all households with aged women, but with higher priority on households with pregnant and under 2 children. IYCF: Infant and Young Child Feeding practices. 30

38 Food Security Working Group Implement an innovative comprehensive baseline survey (including in-depth understanding of food consumption patterns, dietary intake) and additional informative surveys (agro-biodiversity, IYCF and care) The comprehensive baseline survey helped to better understand food consumption patterns, dietary intake and micronutrient adequacy, seasonality, nutrition needs of group at risk, gender considerations, and feeding habits in the five areas of interventions. The baseline survey included a KAP survey on IYCF, hygiene, child and maternal care. The outcomes were used throughout the intervention s implementation. 2. Tailor and implement a Behaviour Change Strategy including the identification of actionable, locally adapted messages in nutrition and care and production of IEC materials. Behaviour change strategies (BCS) targeting mothers, caregivers, family members including children, decision makers and community agents are central to improve nutrition and care of infants and young children as well as women of childbearing age. Technical experts designed the BCS strategy based on the findings from the baseline study. They also trained the team and supported the implementation. The consortium, in consultation with other stakeholders (Ministry of Health (MoH), UNICEF, National Nutrition Center, MoA, health centers/hospitals, local organizations, private media agencies),developed sets of actionable messages and adequate IEC materials for each approach. Whenever possible, the agencies use the existing IEC materials to avoid duplication. 3. Roll out nutrition, IYCF and care training rounds with staff, key-stakeholders, targeted communities and households. Households received support and training on nutrition, IYCF and care, using IEC materials adapted to Kayah state. IEC materials are mainly visual, in order to include illiterate people. The main topics of nutrition education sessions were: Principles of nutrition & identification of the symptoms of malnutrition Nutritional needs of individuals (especially children under two and pregnant and lactating women) Breastfeeding and complementary feeding Child and maternal cares Planning healthy family meals under budget constraints Promoting healthy cooking to preserve nutrients Designing mixed local recipes and food combinations to improve nutrient absorption Sessions prioritize women of reproductive age, mothers and caregivers. Specific sessions are organized with men, or relatives that are also involved in childcare or in decisions related to food and nutrition. Other community stakeholders such as traditional or trained birth attendant, religious, and village leaders are involved in part of the training sessions. The approach pays specific attention in promoting low cost, balanced and local food recipes. The team identifies the composition, cost and nutritional value of the main dish/recipes and organizes 31

39 2015 Food Security Working Group cooking demonstrations to help households how to cook nutritious meals, handle food safely and learn about the nutritional needs of family members. In each village, mother leaders were selected as one person from 10 household and those mothers received training from project staffs and they organized multiple trainings to their responsible households. 4. Train households on healthy home gardens and provide them with appropriate inputs. Households were supported to set up healthy and low-input gardens to improve their food intake and potentially generate additional income. Sacks gardens and key-hole gardens were promoted for households with limited access to land. Healthy community gardens were used as demonstration plots and training centre. This needed a strong community mobilization to discuss participation and guarantee that beneficiaries maintain the village s garden, share roles and responsibilities as well as benefits (e.g. provision of food to cooking demonstration). The selection of crops was done according to their nutritional content (especially protein, minerals and vitamins), agronomic characteristics and the prevalence of micronutrient deficiencies. Crop diversification was promoted to improve crop security, household food security and dietary intake, and included vegetables, fruits, but also legumes; because they are rich in energy and a good source of both macro and micronutrients. Perennial and wild plants such as MoringaOleifera are grown and can be used for their multiple utilizations. Local seeds were promoted, purified, multiplied and progressively disseminated. New seeds or forgotten indigenous plants were re-introduced step by step via demonstrative plots during the different growing seasons to ensure farmers acceptance, as vulnerable households may be reluctant to adopt new techniques or varieties. Other safe and sustainable agricultural practices were promoted such as intercropping, crop rotation, mulching or direct sowing to improve soil fertility and increase yield. Proper individual storage systems were developed to preserve micronutrient content. While the lack of water during the dry season hinders the home gardening production, the project aimed for evergreen gardens. This could be done either through the identification of wild crops which are able to resist drought/limited water or through irrigation techniques. Households were provided with the required inputs for the rainy and summer/winter season (inter-season). Experienced ACF staff conducts the rounds of technical trainings (agricultural calendars) and build on beneficiaries knowledge and labour capacities. Practices and time spent in the demonstration plots were linked to theory. At least 4 rounds were organized on the following 6 topics: Crop diversification Fertilization (composting and appropriate dosing) and pest management Watering/irrigation techniques Harvesting and post-harvest handlings Seeds conservation and purification Market linkages Each staff was assigned to 5 demonstration plots. While the daily management of the plots was under the beneficiaries responsibilities, staff ensured that benefits are shared as initially agreed. 32

40 Food Security Working Group 2015 Whenever possible, the project seeks the inclusion of staff from the department of Agriculture and Irrigation. Exchanges visits are promoted with other villages to foster sharing of experiences and best practices. Women are targeted as a priority as they already have less access to resources and opportunities. However, the project pays specific attention to avoid creating extra work to women or prevent women from fulfilling their social roles and normal tasks. Planning of the intervention was done carefully taking into account the normal workloads and after discussing with the women targeted in the intervention. In a do no harm approach, lactating women enrolled in the project have access to safe and quiet breastfeeding corners, where pregnant women are also encouraged to rest. In order to maximize women participation in the healthy gardens, the intervention -in collaboration with the community-support the creation of 10 pilot baby friendly shelters. With these shelters, care practice sessions for proper care practices are conducted for women of under two years old children. 5. Set up and follow up of small-scale and pilot demonstrative fish ponds and training of 80 selected lead farmers on fish breeding. The possibility was explored to increase the protein intake of the community by innovative fisheries. According to the preliminary surveys, the community has to rely on less diversified seasonal vegetables for the household consumption and limited consumption of protein rich foods such as meat, fish, eggs, pulses, etc. Because of the mountainous region and limited income level, the community limits purchases of meat or fishes. Four pilot fish ponds were used first as demonstration ponds. The plan is to multiply the fingerlings and disseminate them among the target groups. Fishery experts were recruited as consultants and 80 lead farmers were trained on technical fish breeding. Whenever possible, inclusion of representatives from the Ministery of Fishery (MoF) is organized with the participation of technical experts for the development of demonstrative ponds. 6. Implement participatory development of nutrition-sensitive IGAs. Beneficiaries receive support for the implementation of nutrition-sensitive IGAs to address seasonality. Participants receive basic trainings in business management to optimize the running of their activity and specific training sessions in accordance with the type of activities. The project promoted nutrition-sensitive IGAsi.e. activities mainly developed around the transformation and processing of nutritious food. For instance, this includes improving local snack recipes, food processing (fish, meat, vegetables), developing low cost food complements (enriched flours). IGA activities include nutrition-sensitive livelihoods such as commercial production of home gardens, nutrition-sensitive grocery shops, depending on the community interest. Each beneficiary received a capital (in kind, in cash or both) to start the activities. In order to benefit, beneficiaries were requested to show determination and commitment (e.g. necessary contribution to the capital needed to start the activity). A business plan was a prerequisite to receive the grant. Previous experience showed that a small grant is not enough to guarantee the long-term running of the activities, since beneficiaries do not have sufficient capital to inject into the IGA during the initial phase, when input is most needed. Therefore, the recipient received enough capital to kick start the activity according to the local prices of commodities. 33

41 2015 Food Security Working Group Positive: - The project started with a multi-sectoral baseline survey and 3 additional surveys including: <2 vitamin A and iron deficiency, wild food survey and anthropometry survey) which could identify clearly the specific needs. - The team regular reviewed their strategy and if activities were not feasible in the local context, they were changed to other innovative activities; e.g. bio-fortification was changed to paddy fish farm. - Community garden committee and mother group was founded through a participatory approach; both are active and functioning. - Improvement of knowledge and practices of IYCF, care and nutrition was achieved in all villages through Behavioral Change implementation on Exclusive breastfeeding, timely initiation of complementary feeding, consuming three food groups, preparation of rice and vegetables, immunization of children and ante-natal care practices. Lessons learned: (based on recommendations from mid-term evaluation and field visit) - Include data about how many % of people take wild foods before and after intervention of wild food survey - Share community needs on environmental sanitation and hygiene to WASH team. - Develop revolving fund for each village with community garden from selling cultivated crops. - Give nutrition and care training to key stakeholders such as community health workers, nutrition volunteers, and nurses. - Consider involvement of men, other care givers or influence people such as mother in law, TBA or grandmother to strengthen involvement and support. - People started eating spinach after they saw the cooking demonstration and after seeing the project staff eating it in front of them. They trust the project staff and tried it later themselves. - Mothers appreciated personal support and specific techniques on breastfeeding like how to position the baby, how to attach the baby and how to prevent common breastfeeding problems. 5. Final recommendations on how to integrate nutrition in agricultural and rural development programs. Recommendations FSWG- Lobby The National Plan of Action for Food and Nutrition (NPAFN) will be renewed as the current plan runs from 2011 to The renewal of this plan will be an opportunity to improve inclusion of multi-sector approaches. The FSWG could lobby with the government to have different ministries involved, included and responsible for the renewed NPAFN. There are currently no nutrition courses at university level in Myanmar (both Bachelor and Masters). Within the doctors and nurses education, there is some nutrition education included but from 34

42 Food Security Working Group 2015 a health perspective. The FSWG could lobby with agricultural government and agricultural universities to include nutrition in agricultural education. The Global Nutrition Report notes that India managed to reduce stunting by 9.1%, wasting by 5% and increase exclusive breastfeeding by 25.2% from to ; an 8 year time period. The average annual rate of reduction in stunting (47.9% to 38.8% in 8 years) is 2.6% per year. The rise of exclusive breastfeeding from 46.4% to 71.6% in 8 years represents an average annual rate of increase of 5.5%. These numbers represent all 29 states in India. This impressive improvement was possible because of sustained commitment from the government and civil society. There was high-level political commitment to improve nutrition. The FSWG can lobby with the Myanmar government that change is possible and that India has good experience how to achieve that change. Recommendations FSWG- members FSWG and FSWG members involved in agriculture are encouraged to join discussion meetings to develop the new National Plan of Action for Food and Nutrition. By being involvement from the beginning, ownership among agricultural organizations will be improved while at the same time we make sure that the national plan includes relevant and feasible nutrition-sensitive strategies. FSWG and FSWG members are encouraged to participate in nutrition-related forums and platforms such as SUN in Myanmar. These are good platforms to share learning and to have access to information such as available trainings on nutrition. FSWG members are encouraged to at least consider Do No Harm on nutrition. To integrate nutrition, FSWG members can start by looking at the activities and projects you are doing already and looking at them through a nutrition-lens. If you do home-gardening; how can we use the home-gardening to improve availability of nutritious food? Think about diversity and seasonality. Besides agronomics and economics, also consider nutrition. Think carefully about what your organization aims to achieve and what you can t achieve. Reducing anthropometric rates (such as stunting) is not easy and needs a multiple years integrated program addressing all factors that contribute to under-nutrition. When your organization starts to integrate nutrition, set lower goals such as: Improve year-round availability of sufficient, safe and nutritious food. If you also include nutrition education, you can aim for: Improve dietary diversity score or improve dietary energy supply per person (in kcal). Availability of sufficient, safe and nutritious food can be improved through a wide variety of activities: improving storage after harvest, improving food processing of nutritious foods or setting up rice banks to enable poor households to overcome the lean season. Furthermore, targeted home gardening can be a powerful way to improve year-round access to safe and nutritious food; particularly since these are fresh food that can be grown without chemical fertilizer or pesticides near the house. Support to animal production is important to improve availability of meat and milk, which even in small portions can benefit particularly children to grow. Supporting production of multiple varieties of one crop helps to diversify availability of different nutrients because each variety can have a different set of nutrients (e.g. different rice varieties). Promote crop variety instead of mono-culture and support integrated systems such as integrated horticulture / aquaculture. Support innovative vegetable production at places which have limited water or salty soils; different systems have been tested 35

43 2015 Food Security Working Group including growing vegetables on elevated wooden or plastic containers using household waste water. Improve protection of natural resource such as forest products and wild fish which are important coping mechanisms for people to use. There are numerous ways to integrate nutrition in agricultural or rural development programs and that would fit very well into what FSWG members are already doing. If organizations, in addition to improving availability of sufficient, safe and nutritious food, also like to improve food consumption, different materials to do nutrition awareness sessions are available. LEARN has developed materials that can be shared to interested organizations which have trained staff already. Organizations without staff trained on nutrition are recommended to first have their team trained on basic nutrition. Capacity building is highly needed and mentioned by different stakeholders; it will be relevant for FSWG to set up (refresher) trainings on nutrition for its members. If organizations aim to improve specific nutrition needs of their target population, it is recommended to do a thorough needs assessment to ensure your project is relevant to the actual needs. It might be necessary to hire expertise to do these kinds of assessments considering that some parts are technically complicated. If your organizations knows about specific nutrition needs; e.g. mother do not provide proper food to their infants and young children, you can also do a more simple needs assessment fully focusing on these feeding practices. By assessing the people s knowledge, attitude and practices, you might be able to understand more clearly the barriers for mothers to provide healthy and nutritious complementary feeding to their children. This will help to target your intervention. If your organization aims to improve nutrition, consider targeting pregnant and lactating mothers as well as children under 5 because these groups need more nutritious food than other groups. Also, targeting these groups is most effective and has highest returns. Targeting women in your program and empowering women has proven to be an effective way of improving nutrition. Consider adding nutrition to your organizations strategy or lobby with your management to include nutrition. Remember that nutrition will improve the quality and impact of your program. Nutrition will improve children s development and health, as well as adults work productivity and work performance. All people and children have the right to sufficient and nutritious food they need for an active and healthy life. 36

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45 2015 Food Security Working Group Annex II. References Brian Thompson and Janice Meerman. Towards long-term nutrition security: the role of agriculture in dietary diversity. Charlotte G. Neuman, Nimrod O. Bwibo, Constance A. Gewa and Natalie Drorbaugh. Animal Source Foods as a Food-Based Approach to Improve Diet. - Chunming Chen. The current nutritional status in China. - FAO, edited by: Brian Thompson and Leslie Amoroso, Improving diets and nutrition, Food-based approaches. - HKI, AmimuzzamanTalukder, Akoto K. Osei, Nancy J. Haselow, HouKroeun, Amin Uddin and Victoria Quinn. Contribution of Homestead Food Production to Improved Household Food Security and Nutrition Status Lessons learned from Bangladesh, Cambodia, Nepal and the Philippines. - Ian Darnton-Hill. The underestimated impact of Food-based interventions. - International Food Policy Institute, Global Nutrition Report Actions and Accountability to accelerate the world s progress on nutrition. - Lancet 2013 Series, Maternal and Child Nutrition 1. Maternal and child undernutrition and overweight in low-income and middle income countries. - Lancet 2013 Series, Maternal and Child Nutrition 2. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? - Lancet 2013 Series, Maternal and Child Nutrition 3. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? - Lancet 2013 Series, Maternal and Child Nutrition 4. The politics of reducing malnutrition: building commitment and accelerating progress. - Marina Adrianopoli, Paolo DÁcapito, Marika Ferrari, LorenzaMistura, ElisabettaToti, Guiseppe- Maiani, Ursula Truebswasser, KhadichamoBoymatova and Santino Severoni. Optimized Feeding Recommendations and In-home Fortification to Improve Iron Status in Infants and Young Children in the Republic of Tajikistan: A pilot project. - Michael C. Latham. Perspective on Nutritional Problems in Developing Countries: nutrition security through community agriculture. - Ministry of Health of the Republic of the Union of Myanmar, National Plan of Action for Food and Nutrition ( ). - Per Pinstrup-Andersen. Food systems and human nutrition: relationships and policy interventions. - Rosalind S. Gibson. Enhancing the Performance of Food-based strategies to improve micro-nutrient status and associated health outcomes in young children from poor-resource households in low-income countries: challenges and solutions. - Scaling Up Nutrition (SUN) website: and org/sun-countries/myanmar for specific info on Myanmar. - Ted Greiner. Food-based Approaches for Combating Malnutrition Lessons lost? - UNDP, Integrated Household Living Conditions Assessment in Myanmar (IHLCA) - UNICEF, Myanmar Ministry of Health, Ministry of National Planning and Economic Development, Myanmar Multiple Indicator Cluster Survey. - World Bank, DFID, Government of Japan, Rapid Social Response, January Improving Nutrition Through Multi-sectoral Approaches - Zero Hunger Challenge (Footnotes) 1 National Plan of Action for Food and Nutrition , Myanmar 38

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