Scientific Symposium Proceedings Final Draft - K4Health · SCIENTIFIC SYMPOSIUM March 21 ... phases...

PROCEEDINGS

Agriculture,FoodSecurityandNutritioninNepal‐TakingStockandDefiningPriorities

NUTRITIONCOLLABORATIVESUPPORTRESESEARCHPROGRAM:

SCIENTIFICSYMPOSIUM

March21‐22,2012

AUTHORS:

SUDEEPSHRESTHA

SWETHAMANOHAR

ROLFKLEMM

RAPPORTEURS:

DIPLAVSAPKOTA

AKRITISINGH

RAMANSHRESTHA

SUDEEPSHRESTHA

DISCLAIMER:Theauthors’viewsexpressedinthispublicationdonotnecessarilyreflecttheviewsoftheUnitedStatesAgencyforInternationalDevelopmentortheUnitedStatesGovernment.

TABLEOFCONTENTS

AbouttheNutritionCollaborativeResearchSupportProgram(NutritionCRSP)......................4

Acknowledgements.......................................................................................................................................................4

ExecutiveSummary.......................................................................................................................................................5

ProgramataGlance......................................................................................................................................................9

Opening..............................................................................................................................................................................12

SymposiumKeynoteAddress.................................................................................................................................14

Roleofevidenceinleveragingagricultureforimprovedhealthandnutrition

Session1............................................................................................................................................................................23

Agriculturetomarkets..................................................................................................................................................23

Session2...........................................................................................................................................................................27

LinkingFoodMarketsand/orHomeProductiontoHouseholdAccess....................................................27

Session3...........................................................................................................................................................................31

HouseholdAvailability,AccessandUsetoDietaryIntakeandNutritionandHealthOutcomesofWomenandYoungChildren.......................................................................................................................................31

Session 4.............................................................................................................................................................................33

Identifying,Defining,MeasuringLinkagesandEvidenceGaps....................................................................33

NextSteps.........................................................................................................................................................................40

APPENDIX.........................................................................................................................................................................42

Session1‐Abstracts....................................................................................................................................................42

1.1HouseholdConsumptionofGrainLegumesinNepalTerai:AStudyonImpactofImprovedTechnoglogies.RKNeupane,NSThakur,PJha,DNPokharel,BPMahatoandRASah.................42

1.2EfficienciesinLinkingAgriculturalDevelopmentwithHealthandNutritionTraininginNepal.L.ColavitoandM.Pariyar.......................................................................................................................................43

1.3HighImpactTechnologiesApproachesforImprovedFoodSecurityandNutritionofRuralPoor.JoeSanders.......................................................................................................................................................44

Session2‐Abstracts....................................................................................................................................................45

2.1ApplicationoftheHouseholdEconomyApproachforAssessingFoodSecurityandDescribingLivelihoodsinNepal.SavilleNM1,AkhterN1,ShresthaBP2,ManandharDS,OsrinD,CostelloA........................................................................................................................................................................................45

2.2HomesteadFoodProductioncontributestoDietaryIntakeofChildren6‐23montholdsinKailaliDistrict,FarWestTerai.DPAdhikari,PPandeyRana1,DDavis,NSharma,HBChand,RKNeupane..................................................................................................................................................................46

2.3FoodSecurity,FoodPriceandIncomeTrendsinDhanushaDistrict,Nepalbetween2005and2011.ShresthaBP,AkhterN,ManandharDS,OsrinD,CostelloA,SavilleNM................................47

2.4ValidatingDistrict‐LevelAssessmentwithSurveyData:ExamplefromtheNEKASP,WorldFoodProgramme.......................................................................................................................................................48

Session3‐Abstracts...................................................................................................................................................49

3.1NutritionInterventionthatImproveChildandMaternalHealthandSurvivalFindingsfromTrialsintheTeraiofNepal(Expandedabstract)KeithP.West,Jr.,SubarnaK.Khatry,ParulChristian,RolfD.W.Klemm,JoanneKatz,LukeMullany,StevenC.LeClerq,JamesM.Tielsch.49

3.2GrowthandHealthofRuralChildrenin3districtsofNepal:EffectofaCommunityDevelopmentIntervention.LCMiller,RShrestha,MLohani,PSingh,PSubba,DThapa,SNMahato,NJoshi.........................................................................................................................................................52

3.3ImpactsofChangesinGrainPulse(legume)ConsumptiononMicronutrientSupplyofRuralWomeninNepalAndNorthIndia.PAndersen...........................................................................................53

3.4CorrelatesofInfantandYoungChildFeedingPracticesinChepangCommunity.SubediN,PoudelS,RanaTandPaudelAK........................................................................................................................54

TitleListingsforPosterPresentations...................................................................................................................55

ListofParticipants.............................................................................................................................................................56

References..............................................................................................................................................................................61

ABOUTTHENUTRITIONCOLLABORATIVERESEARCHSUPPORTPROGRAM(NUTRITIONCRSP)

TheUSGovernment’supcoming‘FeedtheFuture’initiativesupportsanewparadigmthatlinksagriculturewithhealthstrategiestoaddressundernutritionindevelopingcountries.Thisintegratedapproachaimstoprovidelongtermandsustainablesolutionstoundernutritionbyaddressingitsdeterminants.TheNutritionCRSPwillworkwithUSAIDmissions,developmentpartnersandhostcountriesthroughthe‘FeedtheFutureImplementationPlanandFoodSecurityCountryInvestmentPlans’todeterminethekindsofinvestmentsinagriculture,healthandnutrition,institutionalandhumancapacitydevelopmentandpolicydevelopmentneededtoachievelargescaleimprovementsinanation'shealth.TheNutritionCRSPisaprogramof‘research‐to‐practice’thatsupportshumanandinstitutionalcapacitybuildingforresearchandpolicyanalysisinhostcountries,inpartnershipwithlocaluniversities,researchorganizations,andcentersofpolicyformulationwithinthegovernment.ItwaslaunchedinOctober2010,andismanagedbytheFriedmanSchoolofNutritionScienceandPolicyatTuftsUniversity,inpartnershipwiththeSchoolsofPublicHealthatJohnsHopkinsUniversityandHarvard,theCollegeofAgricultureatPurdueUniversity,theCollegeofAgricultural,Environmental,andNaturalSciencesatTuskegeeUniversity,DevelopmentAlternativesInc.,theUSAIDBureauforFoodSecurityandUSAIDmissionsinFeedtheFuturefocuscountries.

ACKNOWLEDGEMENTS

WegratefullyacknowledgethesupportoftheUnitedStatesAgencyforInternationalDevelopment(USAID)forprovidingthefundstosupportthisscientificsymposiumandproceedings.Specialthanksgototheco‐hostsofthesymposium,theDepartmentofCommunityMedicineandPublicHealthatInstituteofMedicine(IOM)atTribhuvanUniversity,especiallytoDr.SharadOnta,DepartmentHeadandDr.RameshAdhikari,PediatricianandProfessoratIOM.AdditionalthanksgototheNationalAgriculturalResearchCenter(NARC),especiallytoDr.DevendraGauchan.WealsothanktheNepalTechnicalAssistanceGroup(NTAG)foralltheir“behindthescenes”workinassistingwithlogistics,communicationsandregistrationfortheevent.WealsowouldliketorecognizeMr.AtmaramPandey,NPC,Ms.ShabnamShivakoti,MoAC,andMr.DiplavSapkotaaswellasthenumerousindividualswhohelpedsolicitparticipation.WeextendourgratitudetoDr.MarieRuelandDr.SuneethaKadiyalafortheirvaluableadviceandcontributions.Weextendspecialappreciationtotherapporteursoftheevent:Dr.SudeepShrestha,Ms.AkritiSingh,Mr.DiplavSapkotaandDr.RamanShrestha;withouttheirkeenattentionandcomprehensivenotes,thisreportwouldnothavebeenpossible.ThankyoutoDrs.PatrickWebb,RolfKlemmandKeithWestfortheirguidanceandsupportduringthepreparatoryphasesandconductofthisevent.SpecialthankstoMs.SwethaManoharforleadingtheorganizationofthisevent.Finally,wethankeachofthepresenterswhoputanextraordinaryamountofeffortintomakingthiseventasuccessfromsubmittingabstracts,tomakingrevision,tocreatingandshowcasingtheirpostersandoralpresentations.

EXECUTIVESUMMARY

TheGlobalNutritionCollaborativeResearchSupportProgram(CRSP)‐Asiathroughitspartner,JohnsHopkinsBloombergSchoolofPublicHealth,organizedatwo‐dayscientificsymposiuminKathmandu,Nepal,co‐hostedbytheDepartmentofCommunityMedicineandPublicHealthattheInstituteofMedicine(IOM).TheNutritionCRSPisamultidisciplinaryresearchconsortiumwhichseekstodetermineinvestmentsneededinagriculture,healthandnutrition,institutionalandhumancapacitydevelopment,andprogramdevelopmenttoachievelargescaleimprovementsinnutritionoutcomes.Thepreliminaryreportofthe2011NepalDemographicHealthSurveyshowsanimprovementinchildnutritionalstatusbetween2001and2006withstunting,wastingandunderweightprevalencedecreasingfrom49%to41%,31%to11%and39to29%,respectively[1].Nonetheless,chronicundernutritionisstillwidespread,andwidedisparitiesexistacrosssocioeconomicgroupsandecologicalregionswithchildrenfromthepooresthouseholdsandthoselivinginthemountainandhillareasexhibitingthehighest levelsofstunting.NepalisoneofthepoorestcountriesinSouthAsia.Ahighproportion(estimatesrangefrom25%‐55%)ofitspopulationlivesonlessthan<$1.25/day[2].Over80percentofthepopulationworksintheagriculturalsector,mostofwhoworkonsubsistence‐orientedfamilyfarms.HouseholdsemployedinagricultureaccountformorethanthreequartersofNepal’spoor.Manyofthesehouseholdsweredeeplyaffectedbytheprotractedconflict,droughtandothernaturaldisasters.Improvementsinagriculturalproductivityhavenotmaintainedpacewithpopulationgrowth,particularlyamongsmalllandholdersandfemalefarmers,thelatterconstitutingover60%oftheagriculturallaborforce.In2009,theWorldFoodProgrammereportedthat43ofNepal’s75districtsfacedafooddeficit,and23districtswerechronicallyfoodinsecure.Theinabilityofhouseholdstosuccessfully“weather”transitoryfoodsupplyshocksfromdrought,flood,marketfailure,orcivilstrifecanimpacttheirnutritionalintake,nutritionalstatusandhealth.FAO’sreporton‘Guidingprinciplesforlinkingagricultureandnutrition:Synthesisfrom10developmentinstitutions’illustratedthatthelinkagesbetweenagriculturefacesfour“mainconstraints:(i)informationonwhattodo,(ii)howtodoit,(iii)howmuchitwillcost(perbenefitgained),and(iv)howitwillbesupportedorrewarded”[3].Further,Leroyetal.notedthattheimpactofmulti‐sectoralprogramsfocusingonnutritionislimitedin2008[4].Improvedagricultureleadingtobetterhouseholdfoodsecurityhasbeenidentifiedasafundamentaldeterminantofprocessesthatleadtofoodsecurity,adequatedietaryintakeandnutritionalstatus,andhealth,yetlimitedempiricalevidenceexistsonthekindsofactionsinagriculturethatdo(ordonot)supportnutritionandhealthforimpoverishedsegmentsofthepopulationorgroupspassingthroughvulnerablelifestages.Littledataexistsbeyondpilotprojectsthatrevealwaystooptimizetheproduction,availabilityandaccessoffoodproductsthatassuredietarydiversityamongthepoor.Thepathwaysthatleadfromfoodproductiontohouseholdfoodsecuritytoimprovednutritionarecomplicated,withmultipledeterminants.Yet,systemsdoexistthatconveyfoodwithinand

acrosscommunitiesthroughouttheyear,withvariedefficiency,qualityandimpact.Itistheconnectedpathwaysthatweneedtounderstand,measureandclassify,andaddresstheirmodifiablecomponentsinordertoreducefoodinsecurityandundernutritioninhighriskgeographicareasandsocio‐economicgroups.Theserepresentcriticalstepstowardseffectiveprogramming.Theintentofthesymposiumwastoshare,understandandassimilatecountry‐relevantevidenceaboutfactorsthatcontributetocausalpathwaysthatleadfromagriculturetonutrition,innational,regionalandlocalcontexts.Anationalcallforabstractswasmadetoresearchersconductingworkacrossthesediversebutconnectedfieldstopresenttheirwork.Theeventwasattendedbyapproximately140participantsfromthescientific,research,program,policymakeranddevelopmentpartnercommunities.

Thesymposiumsoughttounderstand,fromdatarelevanttoNepal,(a)aspectsofagriculturalproductionthataffectfoodproductionquality,quantityandavailabilityinmarketsacrossecologicalzonesandseasons,(b)marketdynamicsthataffectyearroundandseasonalhouseholdaccesstofood,throughpurchaseorhomeproduction,(c)householdfoodsecurityandconsumptionnormsthatdeterminedietaryintake,and(d)elementsofdietaryadequacyandhygienethataffectnutritionalstatus,health,developmentandsurvival.Thesymposiumwasorganizedintofourthematicsessions:(1)Agriculture‐to‐Market,(2)MarketPurchaseorHomeProduction‐to‐Household,(3)HouseholdDiettoNutritionalStatusofWomenandYoungChildren,and(4)LinkagesAcrosstheCausalSpectrum.

Thefoursessionsdeconstructedandassessedthestrengthofevidenceofkeyfactorsalongthispathway,describedmethodsformeasuringthesefactors,exploredfactorsthatlinkdomainswithinthepathwayandattemptedtoidentifyevidencegaps.OralandposterpresentationsofabstractsonDay1coveredvariedtopics,includingtheimpactofconsumptionoflegumesonhealthoutcomes,resultsofcombinedinterventions(agriculturalproduction,incomegeneration,homegardening)onhealthandnutritional

outcomes,methodsavailabletoassessfoodinsecurity,andreviewsoffindingsfromrandomizednutritionalinterventiontrials.Day2ofthesymposiumconsistedofaparticipatoryanddynamicdiscussionofdomainsofconcernthatspantheagriculturetonutritionpathway,toidentifygapsinknowledge,designandmeasurementsissues,andcapacitybuilding.Themesraisedincluded1)improvingdietaryintake(quality&quantity)ofpoorandmalnourishedwomen&children;2)settingofpracticaldietarygoalsinthehomethatmayimprovenutritionalconditions;3)contextualfactorsthatinfluencedietaryadequacy;4)relationshipsbetweenhomefoodproduction,storageandprocessingtodietaryadequacy;5)marketfactorsthataffectyearroundfoodaccess;and6)agriculturalfactorsthataffectavailability,marketpricesandaccess(effectivedemand)tofoodinthehousehold.

Symposiumparticipantsidentifiedknowledgegapsbothwithinandbetweenthedomains.Theseincludedneedstobetterunderstand:(i)determinantsofhouseholdandchildmalnutrition,(ii)howdifferenttargetgroupsperceivenutritioninformation,and(iii)effectsofcommoncookingandfoodpreparationmethodsonnutritionalvalue,(iv)women’srolesinagriculturewithrespecttocontrolofhouseholdresources,decision‐making,intra‐householdfoodallocation,theirownnutritionandtheirabilitytocareoftheirchildren,(v)rolesofpovertyalleviationstrategiesforimprovingnutritionalstatusofwomenandchildren.

ThereisaneedtobuildresearchcapacitywithinNepalandtotranslateresearchfindingsintopolicyandprogramsacrossthecountryandmobilizingevidence‐basedadvocateswithingovernmenttopresentconvincingandbetterunderstoodfindingsarenecessary.

Basedondiscussionsthattranspiredthroughoutthesymposium,thesymposiumorganizingcommitteeidentifiedthefollowingpriorityactionsasrecommended“nextsteps”fortheNepalresearchcommunity:

Formacross‐disciplinaryworkinggroupcomposedofestablishedresearchersfromeachrelevantsector—agriculture,economics,marketing,foodsecurity,dietaryintake,publichealthandnutrition—toidentifythekeyresearchquestionsthatneedtobeaddressedinthenext3,5and10yearstoinformtheagriculture‐to‐nutritioncausalpathway.

Conductefficacy(i.e.underoptimalconditions)andeffectiveness(underreal‐lifeandprogrammaticconditions)researchonpromisingandrelevantinterventions.

Establishcommunity‐basedsurveillancesitesinthemajoragro‐ecologicalzonesinNepalto(i)providelongitudinalmeasuresoftrendsandchangesovertimeinfoodavailability,accessandutilization,andrelatethemtohouseholdfoodsecurity,dietaryintakeandnutritionandhealthstatus,and(ii)generateempiricalevidenceaboutintegratedagricultureandotherfoodandnutritionprograminterventionshaveaneffectonnutritionandhealthoutcomes.ThisshouldbeapriorityareafortheNutritionCRSP.

Organizeabi‐annualorannualforumforpolicymakersfromtheNPC,MoACandMoHPandresearcherstodiscussandtranslateresearchfindingsthatpertaintoimprovementofnutritionstatusthroughamulti‐sectoralapproach.

Organizeanannualscientificsymposiumor“evidencesummit”tofacilitatetherapidsharingoffindingsandinnovativesolutions.

PROGRAMATAGLANCE

March21,2012:Day1

9:00‐9:20 MorningTeaandParticipantRegistration

9:20‐9:30 Welcome(Dr.SharadOnta)

9:30‐9:40 WelcomeandRemarksonFeedtheFutureandGlobalHealthInitiative:USAIDMissionDirector(Mr.DavidAtteberry)

9:40‐10:00 KeynoteaddressonAgriculture–NutritionPathway(Dr.RolfKlemm)

10:00‐10:10 OfficialOpeningandInauguralRemarksbyChiefGuest(HonorableDr.ShivaKumarRai)

10:10–10:20 OpeningRemarks(Dr.PraveenMishra,MoHP)

SESSION1:AGRICULTURETOMARKET

10:30–10:50 StateoftheArt/Evidence(Dr.DevendraGauchan)

10:50–11:05 1.1HouseholdConsumptionofGrainLegumesinNepalTerai:AStudyonImpactofImprovedTechnologies(Dr.RamKrishnaNeupane,FORWARDNepal)

1105‐11:20 1.2EfficienciesinLinkingAgriculturalDevelopmentwithHealthand

NutritionTraininginNepal(Dr.LukeCovalito,IDE)11:20‐11:35 1.3Highimpact,integratedapproachesforimprovedfoodsecurity

andnutritionofruralpoor(JoeSanders,Fintrac)

11:35‐12:00 Q&A,Rapporteurkeycomments,identifyingtheevidencegaps

12:00–12:45 Lunch

SESSION2:FOODMARKETSAND/ORHOMEPRODUCTIONTOHOUSEHOLDACCESS

12:45‐1:05 StateoftheArt/Evidence:ImprovingAccesstoNutritiousFoodsinRuralMarkets(Dr.MarieRuel)

1:05‐1:20 2.1ApplicationoftheHouseholdEconomyApproachforassessingfoodsecurityanddescribinglivelihoodsinNepal(Dr.NaomiSaville,MIRA&UCL)

1:20‐1:35 2.2HomesteadFoodProductioncontributestodietaryintakeamongchildren6‐23monthsoldinKailalidistrict,FarWesternTerai(DebendraAdhikari,HKI)

1:35‐1:502.3Foodsecurity,foodpriceandincometrendsinDhanushadistrictNepalbetween2005‐2011(BPShrestha,MIRA)

1:50–2:05 2.4Validatingdistrict‐levelassessmentwithsurveydata:examplefromtheNepalFoodSecurityMonitoringSystem(MarikoKawabata,WFP)

2:05‐2:30 Q&A,Rapporteurkeycomments,identifyingtheevidencegaps

2:30–3:00 Tea

SESSION3:HOUSEHOLDAVAILABILITY,ACCESSANDUSETODIETARYINTAKEANDNUTRITIONANDHEALTHOUTCOMESOFWOMENANDYOUNGCHILDREN

3:00‐3:20 StateoftheArt/Evidence(Dr.RameshAdhikari)

3:20‐3:35 3.1NutritionInterventionsthatImproveChildorMaternalHealthorSurvival:FindingsfromRCTsintheTeraiofNepalNNIPSresearch(Dr.KeithWest,JHU)

3:35‐3:50 3.2Growthandhealthofruralchildrenin3districtsofNepal:effectof

acommunitydevelopmentintervention(NeenaJoshi,HeiferInternational)

3:50‐4:05 3.3ImpactsofChangesinGrainPulse(legumeconsumption)onmicronutrientsupplyofruralwomeninNepalandNorth(Dr.PeterAndersen,UIB)

4:05–4:20 3.4CorrelatesofInfantandYoungChildFeedingPracticesinChepangcommunityofMakawanpur(Dr.Subedi,NepalPublicHealthFoundation,IOM)

4:20‐4:45 Rapporteurkeycomments,identifyingtheevidencegaps

4:45‐5:00 Closingremarks(Dr.Adhikari/Dr.Klemm)

March22,2012:Day2

SESSION4:IDENTIFYING,DEFINING,MEASURINGLINKAGESANDEVIDENCEGAPS

9:30‐9:45 ObjectivesforDay2(Dr.KeithWest&Dr.SharadOnta)

9:45‐12:15 Agriculture‐NutritionPathway:ResearchgapsintheNepalcontext(GeneralDiscussion,Moderators:Dr.KeithWest&Dr.SharadOnta)

12:15‐12:20 Closingremarks(Dr.PatrickWebb)12:20‐12:30 VoteofThanks(Dr.SharadOnta)12:30‐1:30Lunch1:30 Meetingadjourned

OPENING

Dr.SharadOnta,theDeanofCommunityMedicineandPublicHealthattheInstituteofMedicine,co‐hostfortheevent,openedtheNutritionCRSP’s“NepalAgriculture,FoodSecurityandNutritioninNepal:TakingStockandDefiningPriorities”symposiumbysettingforththepurposeforthesymposium.Theaim,Dr.Ontastatedwastoreviewevidenceandassessresearchgapsrelatingagriculture,markets,householdfoodsecurityandultimatelynutritionstatus.Throughthis,Dr.Ontastatedthesymposiumwouldserveasaplatformtomapfutureresearchagendas,prioritiesandcollaborations.Dr.OntawelcomedhonorableguestsandparticipantsandthenintroducedDr.PraveenMishra,theSecretaryoftheMinistryofHealthandPlanning(MoHP).

Inhisopeningremarks,Dr.PraveenMishra,Secretary,MoHP,statedthatthecomponentsoffarmtohealthandfitnessneedtobeexploredinatime,costandresourceeffectivemanner.Healsopointedouttheneedofidentifyingandaccessingmechanismoffoodsource,flowandtrendsofavailabilitythroughoutthecountry.

Next,Mr.DavidAtteberry,USAIDMissionDirectorprovidedopeningremarksonUSAID’seffortsand

commitmenttoamulti‐sectoral,integratedapproachtoaddressandfoodinsecurityandmalnutrition.AccordingtoMr.Atteberry,agriculture,foodsecurityandnutritionarethetopthreeforeignassistanceprioritiesoftheUnitedStatesGovernment.Heemphasizedaclearintersectionacrossdevelopmentsectorstoachievebetterandacceleratedresults.Henotedgapsinourunderstandingabouttherelationshipsbetweenagriculturalproduction,consumption,marketaccessandnutritionoutcomes,andtheneedtofillthesegaps,especiallyinlightofUSAID’sflagshipprogram,FeedtheFuture,whichseekstoimproveagriculturalproduction,incomegenerationandhealthandnutritioneducationalactivitiestodecreasehungerandpoverty.Aresearchagendatobetterelucidatetheagriculture‐nutritionlink,heemphasized,ispartofthisnewprogram.AtteberrynotedkeyUSAIDinvestmentsinNepal’seffortstoimprovenutritionthroughagriculture,includingtheSuaaharaProgramwhichwillcommenceimplementationin2012,theGlobalAgricultureandFoodSecurityProgram(GAFSP),managedbytheWorldBank,andaNepal‐based‘FeedtheFuture’program.HelaudedtheGON’scommitmenttowardsmulti‐sectoralplanningasevidencedbytheNationalPlanningCommittee’sformationofajointfoodsecurityandnutritionsteeringcommitteeanditsMulti‐SectoralNutritionPlan.Hestressedtheimportanceofresearchtoinformevidence‐basedprogramming.He

encouragedamulti‐disciplinaryresearchspanningtechnicalareasofpublichealth,socialsciences,economics,andagriculturetocollectivelystudytherelationshipbetweenmalnutritionandfoodproductionandcreateinnovativemethodsandsolutionstoaddressmulti‐facetedproblem.Heconcludedbychallengingtheparticipantstoremovetheir“technicalhats”andstepoutsideoftheirtechnicalsilostofindinnovativewaystosolvethispersistentandsignificantglobalpublichealthproblem.

FollowingMr.Atteberry’sspeech,Dr.RolfKlemmoftheJohnsHopkinsBloombergSchoolofPublicHealth,gavethekeynoteaddress.Detailsofhistalkarefoundinthenextsection.

TheHonorableMemberoftheNationalPlanningCommittee(NPC)andChiefGuest,Dr.ShivaKumarRai,officiallyinauguratedanddeclaredtheScientificSymposiumopen.Hewelcomedallparticipantsandreiteratedtheimportanceofevidenceasabasisforinforminggovernmentpolicy.HeexpressedtheGON’scommitmentforamulti‐sectoralapproachtoaddressmalnutritionand

foodsecurityinthecountry.Heremindedparticipantsabouttheimportanceofintegritywhilstconductingandpublishingresearchandtheneedtobevigilantofresearchersfalsifyingresultsfortheirownprofessionaladvancement.Heralliedforresearcherstocontinueintheireffortswhilstfulfillingallethicaltotheirsubjectsandthelargerresearch,programandpoliticalcommunities.

SYMPOSIUMKEYNOTEADDRESS

ROLEOFEVIDENCEINLEVERAGINGAGRICULTUREFORIMPROVEDHEALTHANDNUTRITION

BackgroundNepalisafooddeficit,land‐lockedcountryof~30millionpeople,withhighlevelsofundernutritioninwomenandchildren.Recentestimateshaveshownadeclineinstuntingprevalenceamongchildrenunderfiveyearsofagefrom49%in2006to41%in2011(DHS,2011),butaggregateratesmaskdifferencesacrossregions,socio‐economicorcastestrata.Childhoodstuntingremainshighestamongruralchildrenresidinginmountainsandhilldistricts,whichalsohavethehighestratesoffoodinsecurity(FAO,AssessmentoffoodSecurityandNutritionSituationinNepal,2010).Thecausesofpoormaternalandyoungchildnutritionaremultifacetedandaregenerallyage‐specific.Atbirth,infantweightandlengtharedeterminedbymaternalfactors‐‐includingnutrition‐‐andgestationalage,i.e.whethertheinfantisfullterm.However,fromaboutsixmonthsthroughtwoyearsofageinfantfeedingpractices,particularlybreastfeedingandcomplementaryfeedingpractices,alongwithexposuretoinfectiousdiseaseappeartobethemaininfluencesongrowth.Studiesconductedinpoorpopulationsindicatethatthisisalsotheperiodwhengrowthfailureandnutritionalstressaregreatest.Amongundernourishedyoungchildrenpoornutritionisassociatedwithincreasedmortality,higherincidenceandgreaterseverityofinfection,suppressedimmune‐competence,anddelayedmotorandcognitivedevelopment(Figure1).Sub‐optimalnutritioninearlylifeoftenleadstopermanentsmallsizeinadulthood,andincreasesawoman’sriskofcomplicationsduringchildbirthanddeliveringasmallbaby,thusperpetuatingpoorgrowthintothenextgeneration.Amongundernourishedwomen,risksforobstetricmorbidityanddeliverycomplicationsarehigher,asisinfection,anemiaandriskofdeath.Earlylifenutrition‐InfluenceonlifelonghealthTheeffectsofearlylifenutritionareknowntohavelifelonginfluencesonhealth(Figure2).Awoman’snutritionalstatusatthestartofandduringherpregnancyinfluencesthenutrientsavailabletobetransferredtoherfetusandfetalgrowth.Itiswellknownthat

FIGURE1

FIGURE2

deficiencyiniodineandconsequentthyroidhormoneproductionduringcriticalperiodsoforganogenesiscandamagethebrainandnervoustissueofthedevelopingfetus,causingirreversiblementalretardationandotherdevelopmentalabnormalities.Inadequateweightgainduringpregnancycaninfluencethebaby’ssizeatbirthandotherdeficienciescompromisethephysiologicendowmentandmaturityoftheinfantatbirth.Duringearlyinfancyandchildhood,inadequatedietaryintakesofthemotherandinfantaffecttheyoungchild’sgrowth,abilitytoresistandfightinfectionandcognitivedevelopment.Eachofthese,inturn,canaffectthechildintohisschoolyearsandadultlife.Theperiodfromconceptionthroughaninfant’sfirsttwoyearsofliferepresentsacriticalwindowofopportunitytopreventthelifelongconsequencesofmalnutrition.Thisperiodisknownasthe“first1000days”andevidencesuggeststhatoncethiswindowofopportunitycloses,itisdifficultifnotimpossibletoreversethenegativeconsequencesofpoorgrowthandnutrition.EssentialNutrientFactsMuchhasbeenlearnedaboutessentialnutrientssincethefirstvitaminwasidentifiedalmost100yearsago,butthisknowledgeisoftenunderappreciated.Micronutrients,suchasvitaminA,iron,zinc,iodineandothers,cannotbeproducedbythebody,sotheymustbeprovidedthroughthediet.Thesenutrientsperformmillionsoffunctionsinthetrillionsofcellsinthehumanbody.Theyserveasco‐enzymes,regulatemetabolism,areinvolvedwithoxygentransportandcellularrespiration,playanactiveroleintheimmunesystem,andarecriticalforfunctionsinvirtuallyallcells,allofthetrillionsofcellsthatmakeupthehumanbody.

AlignmentoftheFoodSystemwithNutritionalOutcomesAgriculture,nutritionandhealthareinterrelated.Producingandconsumingadequateamountsandkindsoffoodpromotehealthynutrition.Inreality,however,foodproductionandconsumptionpatternsvarywidely,andareoftennotwellalignedandcanworkatcross‐purposes.Whenfoodsystemsarealignedwithnutritionalneedsintermsoftheamount,quality,safety,availability,affordabilityandaccessibility,theycancontributesignificantlytotheproductionofanutritionallyhealthypopulation(Figure3).Whenfoodsystemsaremisalignedwithnutritionalneedsofapopulationtheycansignificantlyinfluencetheratesofunderandover‐nutrition.Ofcourse,thefoodsystemoperatesinacontextwherecultural,socioeconomicandotherfactorsalsoinfluencehealthandnutrition,andwherethesefactorscanpositivelyornegativelyinteractwiththefoodsystemtoinfluencethepopulation’snutritionandhealth.Sounderstandingboththefoodsystemandthecontextinwhichitoperatesisvitalforunderstandingwhatpartsofthefoodsystemshouldbereshapedtobetterimprovenutritionalwell‐being.Nepal:TheAgriculture‐NutritionConnectionInNepal,considerableprogresshasbeenmadeinreducingpoverty,increasingproductivity,andreducingstuntinginchildreninthepast5‐10years.However,wastingprevalenceorabnormalthinnessamongchildrenhasincreased.Disaggregatingnationalestimatesrevealimportantandimpressivereductionsinchildhoodstunting–thatis,childrenbeingabnormallyshortfortheirage‐‐acrossallecologicalzones,rangingfromalowof14.7%inmountaindistrictstoahighof17.2%intheterai(Figure4).Butstuntingprevalenceremainsathighlevelsinallthreeecologiczones.Adifferentpictureemergeswithrespecttowastingprevalence.Theteraihasshownmajorreductionsinchildhoodwasting;butwastinghassignificantlyincreasedinthehillsandmountaindistricts.Largedisparitiesinbothstuntingandwastingratesremainbywealthquintile.Poorchildrenarealmosttwiceaslikelytobestuntedandwastedcomparedwiththeirwealthiercounterparts.MuchlessisknownaboutthechangesthathaveoccurredwithrespecttomicronutrientdeficienciesinNepaloverthepast5‐10years.ThelatestDHSshowslittleoverallchangeinanemiaprevalenceamongpregnantwomenandchildren,withsteepincreasesamongwomenintheHillsandMountains.ResearchpublishedbyNNIPSinSarlahirevealsthat

FIGURE3

micronutrientdeficienciesarecommon,concurrentandvarybyseasonamongruralNepalesepregnantwomen(JiangTetal,JNutr.2005).Newopportunitiestore‐focusagriculturetoachievebetternutritionandhealthoutcomesWhileNepal’sprogresshasbeencommendable,itstillfacesenormouschallengesrelatedtofoodsecurityandmalnutrition.ItalsofacesmanyopportunitieswiththeresurgenceofinterestandinvestmentinagricultureandstartofnewprogramslikeUSAID’sSuaaharaprojectwhichis,bydesign,attemptingtointegratenutritionandagricultureinterventions.Amajorquestionishowtousethesenewopportunitiestore‐focusandrealignagriculturetoimprovenutritionandhealthamongwomenandyoungchildren.Severalbroadstepsareneeded:

identifyandfillknowledgegaps ensurethatagriculture,healthandnutritionsectorsdonotworkatcross‐purposes proactivelyfindandscaleupinnovativeapproacheswithinappropriatecontexts,

and createanenablingenvironmentforcross‐disciplinarycollaborationand

cooperationPathwaysofimpactofagriculturalinterventionsonnutritionAgriculturecanworkthroughseveralkeypathwaystomightimpactnutritionaloutcomes(Figure5).Themostdirectpathwayisproducingfoodforhouseholdconsumption.Thesecondisthroughincreasedhouseholdincomethroughthesaleoffoodproducedorwagesfromfarmlabor.Athirdpathwayisthroughagriculturalpoliciesthataffectfoodprices.A

FIGURE4

fourthpathwayishowincomeobtainedfromagriculturalproductionorlaborisspent.Andafinalpathwayisthroughtheimplicationsthattheincreasingroleofwomenasagriculturallaborershason(i)theirabilitytoinfluencedecision‐makingregardingnutritionandhealthinthehome,(ii)timetocarefortheirchildren,and(3)impactontheirownhealth. Overthepast40‐50years,muchhasbeenlearnedabouthowagriculturalinterventionsdoordonotinfluencenutrition.TheGreenRevolutionofthe1960’sand70’sfocusedonincreasingfoodproductionandagriculturalproductivitythroughimprovedseedvarieties,agriculturalextensionandirrigationprojects.Whiletheseeffortsincreasedcerealproduction,theyignoreddistributionalissuesandnon‐cerealcrops,andthereforewereinsufficienttoeliminateundernutritionbecausethepoorestdidnothaveaccesstobothanadequatequantityandqualityoffood.Fromthelate1970’s,especiallyafterAmartyaSen’sworkoncausesoffaminein1981,malnutritionwaslinkedtofoodsecurity,andthefocusshiftedtowardsincreasingincomesandlivelihoodsratherthanfoodproduction.Butincreasesinincomedidnotimmediatelytranslatetoincreasedcaloricconsumptionorimproveddietaryquality.Thisrealizationinspiredanewwaveofresearchthataimedtoaddressbothissuesatthesametime.Projectssuchasdairydevelopment,andthepromotionofvegetablegardens,fisheriesandlivestock,aimedtoincreaseincomesofthepoorandincreaseavailabilityandaccesstonutritiousfoods.Theseinterventionswerethefocusofarecentlycompletedsystematicreview.DepartmentforInternationalDevelopment(DFID)SystematicreviewDFIDcommissionedasystematicreviewofagriculturalinterventionsthatassessedtheimpactofpotential“win‐win”agriculturalinterventionsthataimedtoimprovechildren’snutritionalstatusbyimprovingBOTHtheincomesANDdietsoftheruralpoor.Previousreviewsonthesamesubjectfoundmixedresultsornoimpactofagriculturalinterventionsonnutritionalstatus.Thisreviewbuiltonandexpandedpreviousreviewsbycoveringtheperiodof1990‐2010.

FIGURE5

Thekeyconclusionofferedbytheauthorsofthisreviewstated,“Weattributethelackofimpactofagriculturalinterventionsonchildnutritiontomethodologicalweaknessesofthestudiesreviewedratherthanspecificcharacteristicsoftheseinterventions”.Inotherwords,theauthorsconcludedthatweakstudydesignsandmeasurementissueswereresponsiblefortheinconclusiveevidence.Thus,thequestionofwhetheragriculturalinterventionshaveapositiveimpactonthenutritionalstatusofchildrenremainsunanswered.Thereviewhighlightedfourmethodologicalweaknessesofstudieslinkingagriculturetochildnutritionstatus:(1)thelackofacrediblecounterfactual,(2)theuseofinadequateandoftenincomparablemetrics,(3)thelackofdataonparticipationratesorcharacteristicsofparticipantsofagriculturalinterventions,and(4)thelackofstatisticalpowertodetermineanimpactonchildnutritionalstatus.Theseweaknessesarebrieflydiscussedbelow:1. Lackofacrediblecounterfactual.Amajormethodologicalweaknesswhichledto

90%ofstudiesbeingexcludedfromthereviewwasthelackofacrediblecounterfactual.Acounterfactualenablestheestimationofeffectsthatwouldhaveoccurrediftheinterventionhadnotbeenimplemented.Crediblecomparisongroupsarenecessarytoestimateeffectsthatcanbeattributedtoanintervention.Thus,whenmeasuringtheimpactofanagriculturalprogramonanutritional(orother)outcome,anappropriatecounterfactualisneededsothattheobservedimpactcanbeattributedtotheintervention,andonecanruleoutotherfactorsthatmighthavehadanindependenteffectontheoutcome.

FIGURE6

2. Inadequateandnon‐comparablemetrics.Asecondmethodologicalweaknesscitedbythereviewisrelatedtothemeasurementstakenornottaken,theirvalidityandtheircomparabilityacrossstudies—particularlymeasurementofchangesinincomeanddietrelatedtoagriculturalinterventions.Forexample,studiesmaycaptureincomefromhomegardeningoroncashincomefromsalesoffooditemspromotedbytheagriculturalintervention.Butthesecanbeveryimprecisemeasuresofincomebecausepeoplemayinvestmoretimeandlaborinthisincomestream,whiledecreasingincomefromanothersource.Thus,withoutmeasuringtotalhouseholdincome,onecannotestimatetheoverallimpactoftheinterventiononhouseholdincomeandfoodexpenditure.Similarly,programsmeasureimpactondietdifferently.Someuseconsumptionoffooditemsspecificallypromotedbytheintervention,butthisalsoignoresthepotentialofa“substitutioneffect”.Soitisimportantthatstudiesfocusonindicatorsofdietaryconsumptionthatlookatthewholediet.Inaddition,someprogramsmeasurehouseholdexpenditureonfoodandstillothersmeasurethequantityoffoodsconsumedalthoughtheymayusedifferentmethods(24hrfoodrecall,semi‐quantitativefoodfrequencies),differentrecallperiods(pastday,pastweek,pastmonth),andreportconsumptionfrequencydifferently(e.g.yes/no,consumptioncomparedtoacut‐off,orbyusingadietarydiversityindex.Validandcomparableindicatorsareneededinordertoassesstheimpactofagriculturalinterventionsonnutritionaloutcomesacrossstudies.

3. Datalackingonparticipantratesandcharacteristics.Thereviewalsocitedthelackofdataonparticipationratesorcharacteristicsofparticipantsintheagriculturalinterventionsasaweakness.Agriculturalinterventionsareoftentargetedatspecificpopulationgroupsorattractindividualswithspecificcharacteristics—typically,thepoorortheverypoorparticipateintheseprograms,orthosewithaccesstolandandperhapswater.Becausethesegroupshavebaselineorpre‐interventioncharacteristics,includingnutritionalstatus,whichdifferfromthoseinthegeneralpopulation,theycannotbecomparedtothegeneralpopulation.Thelackofdataonparticipationratesandcharacteristicsofparticipantscompromisesourabilityto(1)assesstheimpactofinterventionsonspecificvulnerablegroups;(2)assessthetargetingefficiencyofinterventions;(3)understandwhodoesandwhodoesnotparticipate

intheintervention,and(4)whethertheinterventionimpactdependsonorismodifiedbythecharacteristicsoftheparticipants.Studiesshouldmakeanefforttocollectdataonbothparticipantsandnon‐participantsintheinterventionandcomparisongroupstoassessselectionandparticipantbiasandtoinvestigatethedeterminantsofparticipationandtheimpactoftheinterventionacrossvulnerablegroups.

4. Studieswereunderpowered.Anothermethodologicalweaknessidentifiedbythereviewwasthelackofpower—inastatisticalsense—todetectanutritionalimpactifoneexisted.Statisticalpowerislargelydeterminedbysamplesizeandthesizeoftheimpactonehopestodetect.Amongthestudiesreviewed,theaveragepowertodetectsmall(i.e.2%),medium(i.e.10%)andlarge(i.e.30%)differencesinstuntingprevalencewasonly4%,15%and51%,respectively.Therefore,futurestudiesshouldbedesignedtobesufficientlypoweredtodetectnutritionalimpactofagriculturalinterventions.

Awayforward? Fillinformationgaps.ForNepalandothercountriestodesignthemosteffective

policiesandprograms,moreneedstobelearnedabouthowmuchandwhatarethetypesormixesofagriculturalinterventionsarebestfornutritionandhealth.Forexample,shouldNepalinvestinstaplecrops,high‐valuecropsorlivestock?Whattypesofagriculturalinterventionswillimprovetheconsumptionofadiverseandadequatediet,especiallyamongvulnerablegroups?Whatconditionalfactors,suchaslandownership,caste,education,women’sstatus,marketstructures,andruralinfrastructure,dothemosttoleverageagriculturalgrowthforbetternutritionandhealthofwomenandchildren?Thereisanurgentneedtofillthisgapinknowledge.

Prioritizeresearchablequestions.Fillingeverygapinknowledgeimmediatelyisnot

possible;thusthereisaneedtoprioritizeresearchablequestionsthatwillhavethegreatestpotentialtoinformpoliciesandprograms,especiallyinthehillandmountaindistrictswherechildundernutritionratesarethehighest.

Createanenablingenvironmentfor“integrated”cross‐disciplinaryresearch.Modelsfor

successfulresearchthatbridgesinglesectorperspectivesareneeded.Researchersacrosssectorsneedtobecomeconversantineachother’s’professionallanguage,andincentivesmaybeneededtofostercross‐sectoralresearch.

Identifyandorcreatemetricsthatbridgetheag‐nutpathway.Thereisaneedto

identify,createandusevalidmeasuresthathaveutilityacrossthedomainsandsectorsalongtheagriculture‐to‐nutritioncontinuum.Forexample,inpublichealththeoutcomesweareconcernedwitharenutritionalstatus,morbidity,mortalityandincreasinglychilddevelopment.Importantagriculturaloutcomesincludeproductivity,agriculturalgrowth,incomeandreturnsoninvestments.Aretherewaystobridgethesetwoparadigms,and

Identifyasetofindicatorsthatarebothvalidandfeasibletocollectunderfieldconditions?

Disseminateresultsandlessonslearnedacrossdisciplinessothatinnovativeapproaches

canbetakentoscaleinappropriatecontexts.Waystodisseminateresultsquicklyandbroadlyacrossdisciplinesandsectorsareneeded.Mechanismsneedtobecreatedtodothis.Publichealthnutritionsymposiararelyattractagriculturalistsoreconomistsandviceversa.Newplatformsandforumsforinformationandideaexchangeandcollaborationareneeded.

Embracefailureandsuccessandlearnfromthem.Finally,ascross‐disciplinaryresearchthataimstoilluminatethepathwaysbywhichagricultureimpactsonnutritionaloutcomesisconducted,thereisaneedtoembracebothfailureandsuccess.Programsuccessesandfailuresneedapost‐mortumtounderstandwhy,amongwhomandinwhatconditionstheinterventionssucceededorfailed(Figure7).Ifthechoiceofagriculturalinterventionsaddressesthemajorcausesofinadequatedietaryintakeandiftheyareimplementedwell,onewouldexpecttoseeimprovementsinnutritionalstatus.Ifthedesiredoutcomesarenotachieved,thebasisforinterventionchoicesaswellastheadequacyofprogramimplementationmustbereviewed.Wastheimplementationchoicecorrect?Wasimplementationadequateintermsofcoverage,qualityandreachingthoseatgreatestrisk?Werethestudydesignsusedtomeasureprogramimplementationandoutcomesadequate?Didtheinterventionchoicestrulyaddressanimportantunderlyingdeterminantofmaternaland/orchildundernutrition.Adequateandrobuststudydesignsandimplementationareneededtoassessif,andwhatkindsof,investmentsinagriculture‐andfood‐basedstrategieseffectivelyachievesignificantandacceleratedreductionsinmaternalandchildundernutritionatscale,overandabovenutritionandhealthinterventions.

FIGURE7

SESSION1

AGRICULTURETOMARKETS

Session1focusedonresearchthatexploredthelinkbetween‘agriculturetomarket’andfactorsthatinfluencedagriculturalproductionandmarketavailability.Althoughagricultural(food)productionisconsideredadirectpathwayforhouseholdconsumption,thereexistseveralkeyintermediatepathwaysorfactorsthatimpactnutritionaloutcomesatthehouseholdlevel.Oneintermediatepathwayisthroughincreasedfoodproduction,whichmayincreasehouseholdincomethroughthesaleoffoodproducedorwagesfromfarmlabor.FindingsaddressingthisintermediatepathwaypresentedinSession1were:

increasedhomesteadandoff‐seasonfoodproductionandtheuseofimprovedtechnologyincreasedfoodavailabilityandhouseholdfoodconsumption

healthandnutritiontrainingwhenlinkedwithagricultureresultsincreasedhouseholdnutritionintermsofcalorieandproteinintakeandchangeinhealthbehavior

improvednutritionaloutcomesthroughagriculturearepossiblewheninterventionsfrommultiplesectorsareintegratedsuchasacoordinatedapproachofnutritionawarenessandbehaviorchangetrainingwithagriculturalproductionand/orincomegenerationactivities

researchthatmeasurestheeffectsofeachtheseinterventionsaloneversusincombinationonnutritionoutcomesoverasignificantperiodoftimeislimited

Dr.Gauchan,fromtheNepalAgriculturalResearchCouncil(NARC),presentedanoverviewofNepal’sagro‐economyandinsightsontheroleofagricultureinfoodsecurityandnutritioninNepalinhissession‐specifickeynotetalk.HestatedthatNepal’sruralagrarianeconomymakesagriculturethemainsourceofincomeandemploymentandthusisaprimarycontributortothelivelihoodofNepalipeople.Itisakeydriveroffoodconsumptionpatternsinbothruralandurbanareaandanessentialfactorforfoodsecurity

andnutritionbyvirtueofbeingbothasourceoffoodandincome.Agriculturalproductionalsoinfluencesthefluctuationsinfoodpriceswhichinfluenceshouseholdfoodsecurity.Intheory,increasedfoodproductionmayincreasemarketsupplyand,inturn,increasehomeconsumption.Butinpractice,significantamountsoffoodand/orthenutrientvalueofthosefoodsaredisplacedbythetimeitis

FIGURE8

availableforindividualconsumption.Therefore,despitethelinkagesbetweenfoodproductionandfoodavailability,gapsinthispathwayexist.AgriculturalproductivityinNepalislowerthanthecountry’spotentialproductivityasindicatedbyareportonpulseproductionpresentedbyMr.Neupane.Thereportstatesthatthenationalaverageofpulseproductionislessthanhalfofpulseproductionpotential.AmajorreasonforfoodinsecurityinNepalisthelimitedinvestmentinagricultureandagriculturalresearch.Also,smalllandplotsandtheuseofnon‐commercializedfarmingmethods,especiallyamongstpoorerfarmers,contributetolowfoodproduction.

Householdsoftenselltheirproduceinsteadofconsumingitforincome;however,amajorportionoffarmers’incomesareultimatelyspentonfoodpurchases.Otherconstraintsofoptimalproductionispooraccesstoimprovedseedsandalackoffarmers’knowledgeonutilizationofimprovedtechnologies,limitedlandareawithminimaloutput,cropdiseases,pests,poorpostharvestsaswellaslimitedmarketoptions.Duetothegeographicaldiversityin

Nepal,seasonalityisanimportantfactorinfluencingfoodavailabilityandmarketprices.Duringleanmonths(i.e.MaytoSeptember)poorhouseholdsaremostvulnerableandsufferfromhigherratesofundernutrition.Climatechanges(rainfallvariability,temperatureandincreaseincidenceofdiseasesandpests)furtherdriveupratesofundernutritionamongvulnerablegroupsinthistimeswindow.Interventionssuchashomesteadfoodproduction,thepromotionanduseofimprovedtechnology,commercialfarmingandinfrastructuredevelopment(allofwhichwerediscussedduringSession1)havebeenshowntostabilizemarketvariabilityandprice.Dr.Gauchanrecommendedstrengtheningeffortstoensureyear‐roundavailabilityofnutrientrichfoods,andtheneedforexpandingtheuseoftechnologiessuchasoff‐seasonfoodproductionofvegetables,breedingnutrientrichcropvarieties,fortificationduringfoodprocessing,technologyfordetectingfoodcontaminants,improvingtheshelflifeofprocessedfoodproducts,technologyforreducingdrudgeryandpost‐harvesthandlinglosses.However,heacknowledgedthelackofdatadefinitivelylinkingtheseapproachestoimprovementsinagricultureproductionandfoodavailabilityatthehouseholdlevels.RamKrishnaNeupane,fromFORWARDNepal,reportedonastudyshowingthatlegumeproductionandhouseholdlegumeconsumptioncanbeincreasedusinginterventionsthatcombinewiltresistant/tolerantvarietiesoflegumes,croprotation,seeddressingwithfungicidealongwithcapacitybuildingoflegumegrowers(throughtraining,regularvisits,workshopsandawarenessraising).Hesuggestedthataccesstoimprovedseedsandknowledgeatthelocallevelisimportanttocontributetoincreasedproductivity.Although

hisresearchfindingsshowedanincreaseinpulseconsumption,theoverallimpactontotalhouseholddietornutritionalstatusofhouseholdmemberswasnotmeasured.Henotedthatmostoftheincomegeneratedbyincreasedpulseproductionwasspentonimprovingsoilqualityandthehousehold’spersonalhealthexpenses.Healsospeculatedthatnutritionalstatusmightbeimprovediftheincreasedpulseconsumptionaddedtotheoveralldietofhouseholdmembersand/orreplacedfoodsoflessernutritionalvalue.

Dr.LukeCovalitopresentedfindingsfromtheSmallholderIrrigationMarketInitiative(SIMI).Henotedthatthisprojectincreasedsmalllandholderincomes,healthandnutritionthroughtrainingandthecreationofvalue‐chains.KeyfeaturesofSIMIincludedaccesstomicroirrigation,improvedtechnologies,multiple‐usepipedwatersystems,andthedevelopmentofsmallholdercommercialpockets.TheuseoftrainingmethodologycalledtheParticipatoryLearningApproach(PLA),whichincludesliteracyembeddedwithhealthnutritiontraining,wasconsideredespeciallyimportantinimprovingparticipants’healthandnutrition.Theprojectreportedthat15%ofvegetablesproducedbyhouseholdswereconsumedbythehouseholdmembers,althoughfurtherresearchiswarrantedtoestablishifandtowhatextentminimumnutrientrequirementsaremetgivensuchconsumptionlevels.Dr.Covalitonotedthecostbenefitsofcombiningagriculture,healthandnutritiontraining,andrecommendedfurtherresearchtobetterunderstandhowbehaviorchangesduetoincomegenerationimpactonfoodandnutrition.Henotedthattargetinginterventionstoclustersofthepooresthouseholdsislikelytoachievebetterresults.

JoeSandersfromUSAID’sNepalFloodRecoveryProgramexplainedthatintegratedinterventionsacrosssectorslikecommercialagriculture,nutrition,andinfrastructurecanhaveanimpactonfoodsecurityofruralpeople.Inhispresentation,hestatedthatwithoutunderstandingtargetedfarmers’economicsituations,landholdingsize,andpotentialasproducers,foodsecurityprogrammaticinterventionsmaynotbeveryeffective.Inadditiontotraditionalfarmingpractices,aside‐by‐sideinvestmentinimprovedtechnologies,inputsandagronomicpracticesarerequiredtoincreaseoutput,farmers’capitalbaseandlongertermsustainabilityofsuchoutcomes,statedSanders.Suchinvestmentswouldalsoaffectlocalvaluechains,andtheincorporationofnutritioneducationandbehaviorchangetrainingcouldhaveimpactsonhouseholdfoodsecurityoverall.Henotedthatmajorityoffoodinsecurehouseholdsaresmalllandholdersso,thesewouldbeappropriatetargetgroups.TheimpactofcommercialfarmingonhouseholdfoodsecurityisnotwellstudiedinNepal.

DuringSession1,ingeneral,barrierstolinkagriculturetomarketwereidentifiedandsuggestionsweremade.Poorroadconnectivityandinfrastructure,inefficientsmall‐scale

andscatteredproduction,lackofmarketinformation,highpost‐harvestlossesaremanyofthebarriersthatexistbetweenfoodproductionandavailability.Validtestingisrequiredtoidentifywhetherthosebarriersspecificallylieinthepathwaycontributingtopoornutritionaloutcomes.Itwasreportedthattargetedinvestmentsinproductiveinfrastructureshouldbemadeinordertoachievesubstantialimprovementsinagriculturalproductionandcommercialization.

Potentialactorsinthepathwayofagriculturetomarketsuchasretailers,localtraders,agro‐processors,exportersandothersshouldbecarefullyexaminedfortheircontributiontofarmers’economy,foodavailabilityandfoodmarketstability.ItisstillnotclearwhetherNepal’scurrentagriculturalpoliciessupportsthesustainabilityofapproachestoimproveproductionandwhethertheyfacilitatefarmer‐marketlinkages.Internationaltradeandliberalizationoffoodmarketsaswellasexpansionoffoodretail,foodprocessingandmarketingindustriesarebelievedtohelplinkagriculturetomarket,therefore,shouldbeconsiderationswhiledesigningstudies.

Therearestillmanyknowledgegapsinourunderstandingofhowtoreshapeagriculturetoimprovenutritionaloutcomes.Therearenotvalidreportstodescribehowincomefromagricultureproductionisbeingspentandhowandtowhatextentthisimpactshouseholdconsumptionofnutritiousfoods.Relationshipsbetweenincreasedproductionandincreasedmarketavailabilityandimprovedhouseholdfoodsecurityandnutritionneedtobevalidated.

TimewasallocatedforquestionsandanswersbetweentheaudienceandpresentersfollowingSession1.Theaudiencechallengedthepanelaskingwhetherincreasedproductionandconsumptionoflegumespotentiallydisplacesconsumptionofotherstaplefoodsandwhattrulywasthecosteffectivenessoflinkingagriculturetonutrition.GivenNepal’slimitedresources,thepanelurgedtothinkofhowtobestapplylimitedresourcesforoptimalreturns.Studiesneedtofocusonthecomparisonbetweengrowtoeatversusgrowtomarkettoseewhichoneismorecontributorytoimprovedfoodproductionand

nutritionalhealth.Itisalsoimportanttoidentifydemandversussupplypatternsaswellaswhatisactuallyconsumptionversusmarketavailability.Intermsofnutrition,farmerstendtosellproducenotconsumewhattheygrowwhichneedstobeexploredinastandarddesignforitsimpactonnutrition.

Itwassuggestedduringthediscussiontoexplorewhethernutritioneducationtomothersbestassociatedwithchangesinbehavioractuallyhaveanimpactonnutritionoutcomes.Postharvestnutrientlossesareanotherareathattheaudienceprobed.AttheendofSession1,thespeakersandaudiencesexpressedtheirthoughtsoncropprotectionfrominsects,postharvestfoodpreservation,anti‐nutrientfactors,developmentofruralmarketstoimprovefoodsecurityandnutrition,astrategyofmulti‐sectoralandinter‐disciplinaryinterventioncombiningagriculture,nutritionandhealth,andtheneedformoreinclusiveagriculturalgrowthtargetedwithnutritioninterventionsthatempowerofwomenandtargetdisadvantagedgroups.

SESSION2

LINKINGFOODMARKETSAND/ORHOMEPRODUCTIONTOHOUSEHOLDACCESS

ThemainfocusofSession2washouseholds’accesstofoodsthroughmarketavailabilityorhomefoodproductionandapproachestoimprovelinkagesbetweenagricultureandnutritionthroughmarketdynamics.Theruralpoor’saccesstofoodsrichinessentialmicronutrientssuchasfruitsandvegetables,meat,fish,dairyproducts,andbio‐fortifiedstaplefoodsisrestrictedbecauseoflimitedavailability,economicconstraints,lackofknowledgeandinformation,andarelatedlackofdemandfornutritiousfoods.

Agriculturalproductionmayhelpat‐riskgroupsgeneratemoreincomeandhelpmakenutritiousfoodsmoreavailable,affordable,acceptable,andofhigherquality.Onitswayfromfarmtomouth,foodundergoesstorage,distribution,processingandpreparationprocessesthataffecttheavailability,affordability,acceptability,andnutritionalqualityofthesefoodstotheconsumer.Itiscriticaltoanalyzewhathappensbetweenproductionandconsumptionthataffecteconomicandnutritionalvalueofthefoodproduct.

Session2startedwithakeynotespeechfromDr.MarieRuel,whopresentedmaterialontheconceptofanutrition‐sensitivevalue‐chaintoimproveaccesstonutritiousfoodsinruralmarkets.Thistypeofvaluechainisbelievedtohavethepotentialtoimpactnutrition,buttheconceptisinitspreliminarystageandisnotyetwidelyused.Dr.Ruelnotedthatmicronutrientdeficiencyisaglobalproblemandthepoorareoftenthemostvulnerabletothesedeficienciesbecausetheylackaccesstodiverse,nutrient‐richfoods.Dr.Ruel,basedonworkdoneinAfricaandHonduras,statedthatusingtheconceptofa“nutritionsensitivevaluechain”canprovidecluesforstrengtheningagriculture‐nutritionlinkagesandmaximizingthepotentialforaddednutritionalvaluealongthefoodchain,bymaximizing,conserving,oraddingnutrientsatkeypoints.Identifyingwherethenutritiveandeconomic

valuescanbecreatedinthesupplyside,valuechainfornutritionapproachcanbeusedtoincreasetheavailability,affordability,andqualityofnutritiousfoods.Itcouldenhancetheperception,supplyanddemandofnutritiousfoodstothepoorandcreatetheeconomicbenefitstoat‐riskproducers(seeFigure9).Inadditiontoimprovingnutrition,thisconceptprovidessolutionstodevelopmentchallengesinothersectorssuchasinagricultureaswellastheconceptcanbeusedtoidentifytheproblemsandtodesignandimplementsolutionstoincreasetheavailability,affordability,andqualityofnutritiousfoods.

Inputs into production

Food production

Food storage, processing

Food distribution, transport

Food retail and labeling

MORE NUTRITIOUS/SAFER FOODS AVAILABLE/AFFORDABLE

Examples of actions that can be used to make value chains nutrition sensitive

Increased intake of nutritious/safer foods among the poor

Activities on the supply side

Test, evaluate, adopt solutions to enhance nutrient content & safety along the value chain Activities on the

demand side

Characterize diets, markets & constraints to access to nutritious/safe foods

Develop, test, evaluate new tools to improve knowledge, awareness, and demand for nutritiouand safe foods

Identify bottlenecks and processes where nutrients are lost & opportunities to restore or increase them

FIGURE9

Anexampleofusingapplyinga“nutritionsensitivevaluechain”approachistheadditionofmicronutrientrichproductstotortillaproductioninHonduras.Carrots,sweetpotatoes,spinachandothermicronutrientrichfoodshavebeenaddedtotheproductionprocessandhaveaddedcolorandimprovedmicronutrientcontenttotortillaswhichhaveresultedinanincreaseddemandforandconsumptionofmorenutritioustortillasamongchildrenandpregnantmothers.Astheconceptofvaluechainfornutritionisinitspreliminaryphase,a

lotmoreworkneedstobedonetodetermineitsfeasibilityandpracticalityinthecontextofpovertystrickencountrylikeNepalasincreaseinnutritionvaluemayaccompanyincreaseinprice.

FIGURE10

Nepalissociallyandculturallydiversecountryandadefinitiveassociationexistsbetweensocioeconomicstatusandhouseholdaccesstofood.Differentwealthgroupshavedifferentfoodconsumptionpatternsanditisimportanttoanalyzefoodsecurityandlivelihoodsituationamongthesegroups.Sincewomenarepredominantlyin‐chargeofhouseholdfoodpreparationsanddistribution,targetedinterventionstowomen’sgroupscouldimpacthouseholdbehavioralchangesassociatedwithnutritionoutcomes.Dr.NaomiSavilleusedthe

HouseholdEconomyApproach(HEA)tostudyfoodsecurityandlivelihoodsituationofdifferentwealthgroupsinTerai.Interviewsandmarketsurveyscompletedinthisstudyindicatedthathouseholdexpenditureincreaseswithwealthgroups,andthepoorspendsmoreinfoodandlessinagricultureinputsandeducation.Staplecropproductioncontributesmoretowardsthesourceoffoodconsumptiontothehigherwealthgroups(Figure10,Figure11).Thepoordependonlaborexchangetofulfilltheircalorierequirement.Thusthepooraremorelikelytoworktoaffordfoodandtheirlackofagriculturaloutiseitherduetothelackofknowledgeorresourcesleadingtolimitedfoodproductionandfoodsecurity.

Inadditiontosocialandculturaldiversity,diverseecologicalvariabilityinNepalaffectsfoodproduction,availabilityandconsumptionpatternsamongvariouspopulationgroupsinvariousregions.Thiscausesmorevariabilityinfoodsecurityandmakesfoodsecuritymonitoringcomplexandchallenging.MarikoKawabatafromtheWorldFoodProgrammeillustratedtwodifferentdatacollectionmethodstoassessfoodsecuritymonitoringinNepalinordertoprovidereliableandtimelyinformationforappropriateactiontopreventhumansufferingfromfoodinsecurity.Datacollection(especiallyinformationobtainedseasonallyatthevillagelevel)usingthephaseclassificationapproach(developedbasedontheprinciplesofglobalIntegratedFoodSecurityPhaseClassification(IPC)methodologypioneeredbyFAOinSomalia)bytheDistrictFoodSecurityNetworks(DFSNs)wascomparedandvalidatedagainstcrosscountryhouseholdsurveysdesignedtomonitorfoodsecurityby

FIGURE11

ecologicalbeltorsub‐regionbyseasonandyear.KeyfoodsecurityindicatorsfromthehouseholddataconfirmedthedegreeoffoodinsecurityreportedbytheDFSNsprovidingvalidtoolsforfoodsecuritymonitoring.

BPShresthafromMotherandInfantResearchActivities(MIRA)ontheotherhandapplieddifferentfoodinsecuritymeasurementtoolsinhisstudy,namelytheHouseholdDietaryDiversityScore(HDDS),MonthsofAdequateHouseholdFoodProvisioning(MAHFP)andHouseholdFoodInsecurityAccessScale(HFIAS).ThesetoolsindicatedthatpoorandDalit(definedaslowercaste)sufferedthemostfromfoodinsecurity.Thisstudydemonstratedthatincomegenerationeitherbyagricultureorothermeansimprovesfoodsecurity.

CommunitydevelopmentprogramslikeActionAgainstMalnutritionThroughAgriculture(AAMA)haveshownpositiveresultsintermsofincomegeneration,micronutrientrichfoodavailabilityandknowledgeofhealthandnutritionthathaveimprovedmother’sandyoungchildren’snutritionalstatus.EssentialNutritionActions(breastfeeding,complementaryfeeding,maternalnutrition,nutritionforsickchild,micronutrientdeficiencies),homesteadfoodproduction(VillageModelFarms,homegardensandpoultry),behaviorchangecommunication(counselingandnegotiationsskill,IEC(flipchart,counselingcard,posteretc.)aresomeofthestrategiesthatAAMAimplementedintheFarWesternregionsofthecountry.DebendraAdhikarireportedthatthesestrategieshaveimprovedhomefoodproductionandincreasedknowledgeofappropriateinfantfeedingrequirementsleadingtoimprovedinfantfeedingpractices.

Povertyappearstobeakeydeterminantofhouseholdfoodaccess.Uponincomegeneration,peopletendtospendmoreonnutritiousfoods.Howeverduringthequestionanswersession,participantsexpressedtheirconcernaboutmaintenanceoffoodqualitythroughoutthesupplychain.Theaudiencenotedthatpeopleprefertoeatwhattheyhavetraditionallybeeneatingandchangingdietaryhabitscanbechallenging.PeopleinNepalseemtobemorereceptivetoeatingmorenutritiousrawfoodpreparationsratherthanprocessedfoods.However,itisimportanttogenerateevidencetodeterminewhichaspectsofbehaviorchangeareeffectiveinimprovingdietaryhabits.Thefarmer’sinstinctistogrowtosell.Noorlimitedlandholdingsofthepoorisanissueforthecreationofhomegardens.Themostfoodinsecurehouseholdsareoftenthosewithnoorlittlelandorotherresourcesrequiredforagriculturalproduction;thus,promotingonlyagriculturalinterventionsisnotadequate.Nonetheless,agricultureisthemainmechanismtoincreaseincomeastherearenootherjobopportunitiesintheruralareas.

SESSION3

HOUSEHOLDAVAILABILITY,ACCESSANDUSETODIETARYINTAKEANDNUTRITIONANDHEALTHOUTCOMESOFWOMENANDYOUNGCHILDREN

Theimportantpartoftheagriculture‐to‐nutritionpathwayistoexplorehowdownstreamprocesses,suchasagriculturalproduction,marketaccessandaffordability,andhouseholdfoodavailability,influencedietaryintakeandnutritionandhealthoutcomesinwomenandyoungchildren.Understandingthefoodsupplysystem—fromproductiontoconsumption—enablesonetoexplorethepointsinthesystemthatinfluencetheamount,quality,safety,availability,affordabilityandaccessibilityoffoods,andultimately,thenutritionalhealthofaspecifictargetgroup.Ofcourse,afoodsystemoperateswithinacontextofcultural,socioeconomicandotherfactorsthatalsoinfluencehealthandnutrition.Thesefactorscanpositivelyornegativelyinteractwiththefoodsystemtoinfluencethepopulation’snutritionandhealth.Thusunderstandingthecontextinwhichitoperatesisvitalforunderstandingwhatelementsofthefoodsystemshouldbereshapedtobetterimprovenutritionalwell‐being.Dr.RKAdhikariinhiskeynotespeechhighlightedthedoubleburdenofthenutritionalproblemsinNepalreflectedbyindicatorsofundernutrition(i.e.lowbirthweight,stunting,underweight,wastingandirondeficiencyanemia)andalsoovernutrition(i.e.overweightandobesity).The2011DHSshowsanimprovementinmaternalnutritionandaslightdeclineintheprevalenceofstuntingandunderweightinchildren,however,wastingratesremainedalmoststaticsince2006.Despiteimprovementsinseveralmaternalandchildnutritionstatusindicators,ratesofundernutritionremainalarminglyhighinNepal.Forexample,theprevalenceofanemiainwomenandchildrenisstill35%and46%respectively.Iodinedeficiencyinhighmountainareaspersistsalthoughthehouseholdsusingiodizedsaltinotherpartsofthecountryhavelowlevelsofiodinedeficiency.Breastfeedingisuniversalandbreastfeedingpracticeshaveimprovedsignificantly.ButpoormaternalnutritionstatusandinappropriatecomplementaryfeedingpracticescontinuetocontributetopoorgrowthanddevelopmentinNepalichildren.Moreover,seasonality,workloadofmothers,gastrointestinalinfection,intra‐householdfooddistributionandfoodgiventochildrenalsoinfluencethenutritionalstatusofmothersandchildren.

Asmentionedearlier,dietaryhabitsalsoplayamajorroleofdietaryintakeandriskofundernutrition.Feedingpracticesdifferacrosscommunitiesduetodifferencesinculture,knowledgelevelandsocio‐economicstatus.Over‐dependenceoncerealfoods,withoutnutrient‐densefoods,canleadtohighratesofmicronutrientdeficiencies.Forexample,Dr.PeterAndersonmentionedthatpulseconsumptioncontributeslessthan3%tototalcalorieintakewhilericeconsumptioncontributesmorethan63%.Pulsesareagoodsourceof

micronutrientslikevitaminB2,folate,calcium,potassiumandiron;declinesinpulseconsumptionmaybecontributingtolowintakesoffoodsrichinessentialmineralsandvitamins.Dr.Anderson’spresenteddatashowingadeclineinpulseconsumptioninSouthAsia,andmodeledtheimpactofincreasingpulseconsumptiononimprovingnutrientintake.Themodelsshowedthatadding30gofrice‐beanintaketothedietwouldsubstantiallyincreasefolateintake,aswellaslysine,Ca,K,FeandotherB‐vitamins.Dr.Andersonrecommendedpromotingpulseintake,alongwithfortificationofstaples,toimprovethemicronutrientintakeofthepopulation.

NeenaJoshi,ofHeiferInternational(HI),providedpreliminaryevidenceshowingthatcommunitydevelopmentinterventionscanimprovethelivelihoodofpoorandundernourishedcommunities.HIusesacomprehensiveapproachthatprovideshouseholdswithsmallanimals,mentorsthemtoincreaseincomeandassetownership,trainsthemonsavingandlendingschemes,andprovideshealthandnutritioneducation.PreliminaryresultsfromanHIstudyshowedimprovementsinchildren’sweightinheightintheTeraibutnotinthehills,butthestudydesignanddurationwerenotadequatetoevokecausalattributiontotheprogram.HIis,however,conductingalongtermfollow‐upoftheproject’sbeneficiaries,andwillreportontheirfindingsinthefuture.Dr.KeithWest,fromJohnsHopkinsSchoolofPublicHealth,summarizedanextensivebodyofevidenceonnutritionstatusandinterventionscontributedbytheNepalNutritionInterventionProjectSarlahi(NNIPS),whichhasbeenoperatinginNepalsince1987.NNIPShascompletednumerousrandomizedcontrolledtrials(RCT)toevaluatetheimpactofnutritionalinterventions.Thefirstofthese,NNIPS‐1,showedthatpreschoolvitaminAsupplementationreducedchildmortalityby30%.ThiswasfollowedbyNNIPS‐2,whichshowedthatweeklyvitaminAorβ‐carotenereducedmaternalmortalityby~40%.NNIPS‐3showedthatmaternalironandfolicacidsupplementationimprovedbirth,anemia,andinfantandchildsurvival.NNIPS‐4evaluatedtheeffectsofdailyiron/folicacidand/orzinconmortality.Finally,theNNIPScohortfollow‐upsassessedthelong‐termhealtheffectsofmicronutrientinterventions.Thesestudiesalsoprovideddatashowingthatmultiplemicronutrientdeficienciesco‐existamongwomeninruralNepalandthesupplementationtrialsimprovedhealth,functionandsurvivalamongthemostvulnerablegroupssuchasinfants,childrenandwomen.TheNNIPSstudiesalsorevealedimportanthouseholdbehaviorandeconomicinfluencesondietsandhealthrisksofchildren.Women’semploymentandaccesstocashwasfoundtobeacriticalfactorinraisingeffectivedemandforamorenutritiousdiet.NNIPSstudieshavealsoshownthatearlyinitiationofbreastfeedingreduceinfantmortality,thatdietaryadequacyinchildrendependonwithwhomtheyeatmealsand,thisinturn,canmarkedlyinfluencedietandnutritionalstatus.NNIPSfindingsconfirmedthatprovidinganincomeaccompaniedwithhealthandnutritioneducationcanimprovehouseholdnutrition.TheNNIPSstudieshaveprovidedawealthofevidence‐basedresultsthathaveandcancontinuetoinformnutritionandpublichealthpolicyandprogramdecisionsinNepal.

ThediscussionfollowingSession3presentationsnotedthelackofrandomizedtrialsusingfoodsratherthansupplementstoevaluatefood‐basedinterventionsonnutritional

outcomes.Recommendationsfromthediscussionweretoevaluatetheroleofbio‐fortificationonnutrientintakeandstatus,theeffectsofhouseholdbehaviorchangeonnutrition,andtherisksoftheenvironmentalexposures(suchasaflatoxinandpollution)ongrowthandnutritionalwell‐being.ParticipantsrecommendedfutureresearchinNepalshoulduseonlyvalidateddatacollectionandmeasurementtools,identifyasetofcommonindicatorsthatcouldbeusedinbothagricultureandnutritionalsurveystofacilitatelinkages,enableinter‐sectoral“cross‐talk”andimprovefoodsecuritymonitoring.ProductionofstaplesandinstitutionalizationofthemarketingwasalsosuggestedtobeanapproachtofightfoodinsecurityinNepal.Inaddition,thediscussionhighlightedtheneedforresearchonpost‐harvestprocessestominimizefoodandnutrientlosses,andonfeasiblewaystomeasureindicatorsofhouseholdincomeandconsumption.

SESSION 4

IDENTIFYING,DEFINING,MEASURINGLINKAGESANDEVIDENCEGAPS

Day2ofthesymposiumwasaparticipatorydiscussiontoelicitandprioritizeresearchgaps,identifystudydesignandvariablemeasurementissues,andidentifyresearchcapacitybuildingpriorities.

Priorityresearchdomainsfocusedon:

Improvingthedietaryintake(quality&quantity)ofpoor/malnourishedwomen&children

Nutritionalgoalsinthehome Dietaryfactorsinthehomethatimprovenutritionalconditions Contextualfactorsthatinfluencedietaryadequacy Homefoodproduction,storageandprocessingfactorsthataffectdietaryadequacy Marketfactorsthataffecthomefoodsecurity Agriculturalfactorsthataffectmarketprices,availability,andhouseholdaccess

Thediscussion,ledbyDr.SharadOntaandDr.KeithWest,drewonnationalexpertsincludingNPCMember,AthmaramPandey,Dr.ChetRajUprety,Dr.HariK.Upadhyaya,Dr.IndiraSharma,Dr.KedarP.Baral,Dr.LuciaRusso,Dr.RobinHouston,Dr.ShubhNarayanMahato,JoeSanders,Dr.KirkDeardern,M.R.Maharjan,ShabnamShivakoti,Dr.NaomiSaville,PoojaPandey,SabaMebrathu,SophiyaUprety,Dr.SubarnaKhatry,Dr.Y.B.ThapaandDr.RamChandraBhusal.

Researchgapswereidentifiedundereachresearchdomain.Underthefirstresearcharea,‘improvingdietaryintakeofpoorandmalnourishedwomenandchildren’,discussantsidentifiedtheneedforamorebroadanddistilledunderstandingoftheunderlyingdeterminantsoflineargrowthamonginfantandyoungchildren.Whilematernalnutrition,thequalityandquantityofa

child’sdietandinfectionareknowntoinfluencelineargrowth,interventionsaddressingthesefactorshaveproducedlessthanoptimalchildgrowth,suggestingotherfactorssuchasenvironmentalenteropathiesmightmitigatethegrowthenhancingeffectsofdietonchildgrowth.Non‐Nepalspecificliteraturesupportscorrelationsbetweenstuntingandfactorssuchasmaternaleducation,improvedaccesstohealthcare,maternalhealthandoptimalfeedingbehaviors[5].Butfurtherresearchisneededparticularlyfocusingonmycotoxinandotherenvironmentalexposuresonguthealthandtheirassociationwithchildgrowth.DHS2011datashowsthatstuntingrateshavedecreasedfrom49%to41%,anditisworthexploringthesedatafurthertoidentifypotentialfactorsassociatedwiththisdecline.However,inequalitiespersistacrossagro‐ecologicalzonesinNepal,wherestuntingprevalenceratesamongchildrenresidinginmountainandhillareasare15%to43%higherthanthoselivingintheterai[1].

Therewasagreementthatresearcheffortsshouldfocusonpopulationsinthelowerwealthquintileswhichharborthehighestratesofundernutrition.Therewasalsoagreementabouttheneedtobetterunderstandthedeterminantsofthehighratesofanemiainwomenandchildren,andtherolethatfood‐basedapproachesandfortificationshouldplayinbringingdowntheserates.ResearchconductedinIndiahasshownthatironfortifieddriedmilksignificantlyloweredtheproportionofanemiachildrenrelativetocontrols(19.8%versus50%)among24‐36montholdchildren[6].ResearchisrequiredtodetermineifasimilareffectcanbeachievedinNepalesechildren.Nepal,however,hasfirmevidenceonthebenefitsofmaternaliron‐folicacidsupplementationindecreasingoverall

anemiaprevalenceinwomen,improvingbirthweightsandchildcognitivefunctionandimprovingchildsurvivalthrough7yearsofage[7‐11].ThesefindingshavebeentranslatedintopolicyandnationalprogramsareinplaceinNepal.Nevertheless,despitesignificantreductionsinanemiaamongstwomen,rateshavestagnatedoverthepastyearandprevalenceofanemiaremainsat35%nearlyhalfofchildrenunder5(46%)areanemicdespitedewormingeffortsandscaleupofmicronutrientpowderprogramswarrantingfurtherresearch.

Finally,thedeterminantsofsevereacutemalnutrition(SAM),thecausesofsevereproteinenergymalnutrition(PEM)andmicronutrientdeficienciesamongstthisagegroupwereallidentifiedasareasoffocusthatwarrantedabetterunderstanding.

Anotherpertinentpointofdiscussionunderthisresearchdomainwastheneedforfurtherexaminationoftheinterplaybetweennutritionandinfection(includingenteropathies).Animalandhumanresearchsuggeststhatwhenconfrontedbyincessantmicrobialchallenge,nutrientsmaybechanneledtomobilizeanear‐continuousimmuneresponseattheexpenseofgrowth.Furtherresearchisneededinthisarea.

Inadditiontotheimmediateconsequencesofundernutritionandspecificmicronutrientdeficiencies,moreworkisneededtounderstandthelong‐termeffectsoftheseconditionsoncognition,schooloutcomesandadulthealth.Finally,investigatingintergenerationaleffectsofpoormaternalnutritionisanimportantresearchpriority,especiallyasitrelatestobirthsize,andsubsequentinfantandchildmalnutrition.

Underthe‘nutritionalgoalsinthehome’researchdomain,apriorityresearchareaishowcommunitiesunderstandandapply(ornot)nutritioninformationandmessagingatthehouseholdlevel.Suchresearchrequiresstudyingthecomponentsofbehaviorchangecommunication,andhoweacheffectsfoodpurchasingdecisionsanddietarybehavior.Anotherimportantresearchgapisidentifyinghowtoovercomehouseholdinformationgapsinnutritionacrossdifferentsocio‐economic,gender,ethnicityandcastegroups.Similarresearchgapsonhygienebehaviormessagingalsorequireattention.

Discussionsonthethirdresearcharea‐‐‘Dietaryfactorsinthehomethatimprovenutritionalconditions’‐‐identifiedtheneedforimprovingourunderstandingofdeterminantsofintra‐householdfoodallocationanditsrelationshipwithdietaryintake.Studiespublishedmorethan10yearsagoprovideevidencethateatingfromasharedplate,andwhoachildsharesfoodwith,caninfluencetheamountandqualityoffoodayoungchildconsumes.Inaddition,muchremainstobelearnedabouthowcommonlyusedcookingandfoodpreparationmethodsinfluencethenutrientcontentofcookedfood.Bothoftheseareaswarrantmoreresearch[12,13].

Theimportanceofunderstandingthegendergapanddiscriminatorypracticesthatexistatthehouseholdandcommunitylevelthatultimatelyhavebearingonnutritionoutcomeswashighlightedunderthe‘contextualfactorsthatinfluencedietaryadequacy’researchdomain.Tounpackthisrelationship,questionssuchas“howdoesincomegenerationamongstwomeninfluencedietaryadequacy,purchasingpatterns?”wereposedaspotentialareasforfurtherresearch.Othermarginalizedgroupssuchasindigenouspeopleswereidentifiedaspopulationswhosedietaryintakeanddietarypatternsneededtobestudied.GroupssuchastheMadheshisandDalits,especiallythoseinthemountainsandhighhills,havenotbeenstudiedatgreatlengthandperhapslessonscanbelearnedfromthesegroupswithregardtospecial,nutritious,indigenousfoodsandfoodpreparationmethodsused.Theroleofalleviatingpovertyinimprovingnutritionwasalsorecognizedasabroadareaofresearchthatwouldinformtheagriculturetonutritionpathwayasoneoftheprimaryaimsofagriculturalinvestmentsandinterventionsistoimproveeconomicreturnsfromagriculturalproduction.Agrowingareawithinprogrammaticworkistheinvestmentinprogramsthatprovidehomeandkitchengardeninterventionstocontributetomeetingthehouseholds’dailydietary(anddietarydiversity)needs.Theseinterventionsoftentargetwomenandprovideeducationongardeningtechniquesandoccasionallyprovideseedstopromotehomeproductionoffoods.Thisemergingprogrammaticfocuswithanaimtoimprovenutritionstatusestablishedthenextresearchdomain:‘homefoodproduction,storageandprocessingfactorsthataffectdietaryadequacy’.Animportantpointofdiscussionwithinthisdomainwastheneedtodeterminemicronutrientcontentoflocallyavailablecrops,vegetablesandfruitsgrownathome.Commonlypromotedfoodsforhomeandkitchengardensincludegreenleafyvegetableslikespinachandorangefleshvegetables.Poultry‐raisingforeggsaswellasgoat‐raising,assourcesofanimalprotein,arealsofrequentlypromotedpractices.Whileevidencesupportsimprovedintakeofmicronutrientrichfoodsanddietarydiversityofparticipantsinhomefoodproductionprograms,rigorousevaluationsthatstudyimpactofsuchprogramsonnutritionstatusinwomenandchildrenisstilllacking[14].Soilqualityofthesehomegardenswasalsodeterminedtobearesearchtopicofinterest.Soilqualitycanaffectbothsoilproductivityandnutrientcontentandnutrientbioavailabilityofcrops.Ithasbeenshownthatinsubsistencefarmingwheresoilqualityislow,thecontentofproteinandanti‐nutrientsislowerthaninmediumtohighproductivitysoil.[15,16]

Marketdynamicsandtheireffectsonaccessofhouseholdtofoodcontinuetobeanimportantlinkacrosstheagriculturetonutritionpathway.Discussionsonthedomain,‘marketfactorsthataffecthomefoodsecurity’,capturedopportunitiesforfurtherstudyincludingtopicssuchashowtoengagetheprivatesectortocontributetochangesinhouseholdconsumptionanddietarypractices,determinantsoffoodpurchaseandconsumption,documentingincentivesforagriculturalproductionofindigenousfoodcropandwhetherthisprovidesadequatemotivationoffarmerstoproducethesecrops,householdpurchasingpowerandpatterns,thecost‐effectivenessofgrowingandmarketingcertainnutritiouscropsandlastlymarketdemandforhighvaluecrops.

Finally,thesymposiumparticipantsdiscussedtheresearchdomain:“agriculturalfactorsthataffectmarketprices,availability,andhouseholdaccess”.Knowledgegapsidentifiedincludedtheroleoflivestockandfisheryversustypicalagriculturalinterventionsinpotentiallyimprovingnutritionwithinhouseholds,whatmarketoutletsexistandperfusionofagriculturalproduceinmarkets.Additionalgapsincludedtheneedtoexplorehowtoimproveproductionofstaplecropsacrossecologicalzones,howthere‐designofsomeagriculturaltoolshaveimpactedtimeconstraintsandworkloadoffarmers,howtoimproveproductionofspecializedcropsacrossecozones,whethertechnologiesandcertainseedvarietiescanbeusedacrossecologicalzonesandifso,whethertheseagriculturalapproachescanbescaledup.Acrucialcontributortoimprovedandsustainedagriculturalproductioniswater.Issuessurroundingsustainedwatermanagementapproachestosupportagriculturalproductionandpracticeswerediscussedandidentifiedasareasforfurtherresearch.Giventhesymposium’sfocusonultimatelyimprovingnutritionstatusofwomenandchildren,theroleofmedicinalherbsandoilwerediscussedaspotentialalternativecropinterventionsthatcouldpotentiallycontributeordetractfromdietquality.Theroleofbio‐fortificationofcropswasraised–itspotentialandfeasibilityinNepalanditsefficacyforimprovingnutritionstatus.Beyondagriculturalproduction,issuesfocusedonhomesteadpostharvestfoodlossandfoodpreservationmethodstomaintainnutrientintegrityoffoods.Theseareasrequirefurtherstudy.Auniquetopicthatemergedoutofthisdiscussionwasthepossibilityofdefining,creatingandmeasuringthenutritionaleffectsofa“nutritionfriendly”farmingsystem.TheuseofappropriateresearchdesignsandmethodssurfacedasanoverarchingdiscussionareathroughoutDay2.Acallwasmadefortheuseofmixmethodstostudytheagriculture‐to‐nutritionpathwayandtoquantifylongtermgains(orlosses)ofagricultural

investmentstoaccelerateimprovednutritionoutcomes.Severalparticipantsurgedresearcherstofocusonprogramandimplementationresearch–the“how”ofprogramsandthealsothetrueimpactofprograms.Howareprogramseffectiveinimprovingnutrition?Howisresearchtranslatedintoeffective

programming?Leroyetal.states“themainconstraintslimitingtheeffectivenessoftheseprogramsincludeproblemsofdesignandintegrationoftheirdifferentcomponents(especiallyoftheirnutritionpackage);thelackofconceptualization,frameworkofanalysis,anddocumentationoftheirpathwaysofimpact;thelackofmeasurementandunderstandingoffacilitatingfactorsandconstraintstoimplementationandsuccess;andtheiroftenweakmonitoringandevaluationdesigns”[4].Theuseofquantitativemethodstoaccuratelymeasureresults,aswellasqualitativemethodstoexplainwhycertainbehaviorchangecommunicationmethodsworkorwhyhouseholdsconsumemoreofacertaincrop,forexamplewerestronglyencouraged.Moreover,deconstructingwhatnutritionspecificornutritionsensitiveinterventionswasbroughtupasanimportantconsiderationgiventhehighuseofsuchterminologyindevelopmentcircles. Takingthisdiscussiononestepfurther,questionsthathadpolicylevelimplicationswereraised.Whataretheproblemsintranslationandimplementationatthepolicylevel?Gapanalysesconductedontheidentificationoftheknowledgeofpolicymakersthemselvesontheagriculture‐nutritionpathwaywasputforthasawaytofacilitatetranslationofresearch.Thislackofinformationwasexpressedbythesymposiumattendeesasnotspecifictopolicymakersalonebutalsoagapthatexistedforsmallholderfarmersandmechanismsforeffectivecommunicationoftechnologicaladvanceswithinagriculture,marketdynamicandnutritionresearchitselfwassuggested.Concernswereraisedaboutlimitedgovernmentsupporttoresearch.Oneparticipantpointedoutthatcurrentlyonly3%ofthecountry’sGDPgoestoagriculturethusitmaynotberealistictothinkthatmuchresearchcanbeproducedwithsuchabudget.However,representativesfromtheNationalPlanningCommission(NPC)statedtheyhaveindeedbeguntoprioritizeresearchthatinformsthispathwaythroughtheireffortsinconsideringatechnicalassistancegrouptoreviewresearchthatwouldcontributetotheimplementationofthemulti‐sectoralnutritionplan.Governmentrepresentativesrequestedresearcherstosimplifyresearchfindingsandinturn,researcherscalledforaforumwheretheycouldinteractwithgovernmentrepresentativestoshareNepalspecificand/orNepalrelevantresearch.Tothisend,asuggestionmadewasforsuchaquarterlyorhalf‐yearlymeetingtobeheldbetweenresearchersandtheconcernedpolicymakers.Additionally,itwassuggestedthatlocalresearchbepublishedininternationalbutespeciallyNepalijournalstoestablishareliabledatabasetodrawformthatcanhelpinformpolicyandimplementationdecisions.Thecreationofamonitoringandevaluationsystemsatthepolicyleveltooverseeimplementationofmulti‐sectoralpoliciesseekingtoaddressnutritionandresearchfindingsbeingtestedinsmallerpilotstudiespriortogoingtoscalewasalsosuggested.

Ultimately,capacitybuilding–themeasurethroughwhichnationalresearchagendaonthistopiccouldbeachievedwasaddressed.Itwasacknowledgedthatthereareconstraintswithregardstothenumberoftrainednutritionistsand/orresearcherswithstrongmethodologicaltraininginNepal.Atrainedmulti‐disciplinaryteamthathadbeenrecommendedbytheopeningspeakersonDay1ofthesymposiumandbyaudienceonDay2requiresinvestmentbydonorsandGONtoresearchandacademicinstitutions.Audiencemembersstressedtheneedforrigorousresearchdesignsandmethodologiesthatpolicyandprogrammingdecisionsarefirmlybasedonevidenceandnotonspeculationanduntestedassumptions.Therefore,prioritycapacitybuildingareasshouldberesearchmethodologies,surveymethods,datamanagementandanalysis.Itwasalsothoughtthatsuchatrainedworkforcecouldassistinsettingupandmonitoringsurveillancesystems.Anotherareaforcapacitystrengtheningistrainingpolicymakersontheuseofevidenceinpolicyformation,programdesignandtheevaluationofgovernmentprograms.

NEXTSTEPS

TheNutritionCRSP“Agriculture,FoodSecurityandNutritioninNepal‐TakingStockandDefiningPriorities”symposiumco‐hostedbyJohnsHopkinsBloombergSchoolofPublicHealthandtheDepartmentofCommunityMedicineandPublicHealth,IOMwasoneofthefirsteventsofitskindtobringtogethertheresearchcommunityprimarily,aswellasgovernmentofficialsandprogramimplementerstotakestockoftheresearchthatexistsinNepalcurrentlyacrosstheagriculturetonutritionpathway.ThepresentationsandpostersshowcasedduringtheeventwerebynomeansrepresentativeofallresearchconductedinNepalthatwouldinformthispathway.However,basedonthepresentationsprovidedduringDay1,themoreglaringgapthatsurfacedwasthattherewaslittleresearchthatlinkedacrossallthreedomainsandeventheresearchthataddressedmorethanonedomaindidnotalwayscapturestronglinkagesbasedonmethodsusedoroutcomesmeasured(Figure12).

FIGURE12

Basedondiscussionsthattranspiredthroughoutthesymposium,thesymposiumorganizingcommitteeidentifiedthefollowingpriorityactionsasrecommended“nextsteps”fortheNepalresearchcommunity:

Formacross‐disciplinaryworkinggroupcomposedofestablishedresearchersfromeachrelevantsector—agriculture,economics,marketing,foodsecurity,dietaryintake,publichealthandnutrition—toidentifythekeyresearchquestionsthatneedtobeaddressedinthenext3,5and10yearstoinformtheagriculture‐to‐nutritioncausalpathway.Eachsectoralexpertcouldprioritizeresearchinhis/herdomain,butconsensusshouldbeachievedoncross‐disciplinaryresearchandresearchthataddresseslinkagepointsacrosssectors.Securingdonorsupportforboththisinitialprocess,butalsoforfundingtheresearchprioritiesrecommendedbytheworkinggroup,shouldbeprioritized.

Conductefficacy(i.e.underoptimalconditions)andeffectiveness(underreal‐lifeandprogrammaticconditions)researchonpromisingandrelevantinterventions.Inaddition,aresearchagendaforunderstandinginterventiondelivery,reachanduptakeisneeded.Thisissometimesreferredtoas“implementationresearch”orunderstandingtheconditionsnecessaryforeffectivelarge‐scaleprogramimplementation.

Establishcommunity‐basedsurveillancesitesinthemajoragro‐ecologicalzonesinNepalto(i)providelongitudinalmeasuresoftrendsandchangesovertimeinfoodavailability,accessandutilization,andrelatethemtohouseholdfoodsecurity,dietaryintakeandnutritionandhealthstatus,and(ii)generateempiricalevidenceaboutintegratedagricultureandotherfoodandnutritionprograminterventionshaveaneffectonnutritionandhealthoutcomes.ThisshouldbeapriorityareafortheNutritionCRSP.

Organizeabi‐annualorannualforumforpolicymakersfromtheNPC,MoACandMoHPandresearcherstodiscussandtranslateresearchfindingsthatpertaintoimprovementofnutritionstatusthroughamulti‐sectoralapproach.

Organizeanannualscientificsymposiumor“evidencesummit”tofacilitatetherapidsharingoffindingsandinnovativesolutions.

APPENDIX

SESSION1‐ABSTRACTS

1.1HOUSEHOLDCONSUMPTIONOFGRAINLEGUMESINNEPALTERAI:ASTUDYONIMPACTOFIMPROVEDTECHNOLOGIES.RKNEUPANE,NSTHAKUR,PJHA,DNPOKHAREL,BPMAHATOANDRASAH.FORWARDNepal,BharatpurChitwan,andNARCSinghdurbarPlazaKathmandu,Nepal.Emailaddressofcorrespondingauthor:rk_neupane57@yahoo.co.uk

Background:Grainlegumesplayimportantrolesinthenutritionofthepoorersectorsofsocietywhocannotaffordexpensiveanimalproteinfoodsintheirdailydiets.However,againstasteadydecliningtrend,dailydietaryintakeofpulsesvariesacrossruralhouseholds,andlittletodatehasbeendocumentedontheimpacttechnologyinterventions,suchaswiltresistant/tolerantvarietiesofpulses,croprotationandseedtreatmenthavehadonhouseholdlegumeconsumption.Aims:ToestimatethechangesindailydietaryintakeofpulsesbyruralTeraihouseholdsasaresultoftechnologyinterventions.Methods:Householddietaryintakesurveyswereconductedbeforeand36monthsafteraprojectinterventionthatintroducedwilttolerant/resistantvarietiesoflentil(LensculinarisMedic),chickpea(CicerarietinumL)andpigeonpea(CajanuscajanL.Millsp)alongwithcroprotationandfungicidalseeddressingoptionsintofourdistricts‐Banke,Bardia,DangandKanchanpur,locatedinthemidandfarwesternterai.Atotal30householdswererandomlyselectedfromeachprojectareaofthefourdistricts(totalN=~120).Asemi‐structuredquestionnairewasdeveloped,pretestedandusedandachecklistwaspreparedforfocusgroupdiscussions(FGD).Secondarydataonareaandproductivityofpulsesinprojectdistrictswereobtainedfrompublishedreportsoflineagencies.DatawereanalyzedusingSPSS.Results:Theaverageproductivityoflentil,chickpeaandpigeonpeaincreasedbyabout15,59and48%respectivelyoverthebaseyear.Householdconsumptionofpulseswashigherafterprojectinterventioninallfourdistricts.Averageconsumptionofpulsesbeforeprojectinterventionwasonly2kg/capita/annumandtheconsumptionlevelincreasedto13.5kg/capita/annumafterprojectintervention.Thelevelofconsumptionvariedbylandholdings.Householdswithmorethan2haoflandshowedanaverageconsumptionof19.7kg/capita/annum,whileonly7.5kg/capita/annumwerereportedfromhouseholdsowninglessthan0.5ha.Afterprojectintervention,productivityincreasesofpulseswerehigherinsmallerthaninlargerfarms.However,thecashneedsofsmallerfarmerscompelledthemtoselltheproduceinmarket,resultinginlowerhouseholdconsumption.Conclusion:Technologyinterventionislikelytoimprovepulseproductivityatthehouseholdlevel.Increasesindietaryintakeofpulseshavebeenrecordedirrespectiveofhouseholdsizes,althoughfarmerswithlargerholdingstendedtoincludemorepulsesintheirdailydiets.

1.2EFFECIENCIESINLINKINGAGRICULTURALDEVELOPMENTWITHHEALTHANDNUTRITIONTRAININGINNEPAL.L.COLAVITOANDM.PARIYAR.InternationalDevelopmentEnterprises,Kathmandu,NepalEmailaddressofcorrespondingauthor:lcolavito@idenepal.org

Background:USAIDsupportedapilotprogramforhealthandnutritiontrainingforpregnantwomenandmotherswithchildrenlessthan5yearsold(2006‐9)thatwerefrom14,161targetedhouseholdsfromtheSmallholderIrrigationMarketInitiative.

Aims:Toassessthebenefitsoflinkinghealthandnutritiontraininginimprovementsinhealthandnutritionalindicatorsandcosteffectiveness.

Methods:ComparisonfromrandomizedbaselineandannualimpactsurveyswereconductedfortargetedHHsandforcontrolgrouphouseholds.ControlgroupsincludedbothSIMIprojecttargetedhouseholdsthatdidnotreceivethehealthandnutritiontrainingandcontrolhouseholdsthatdidnotbenefitfromSIMIorsimilarprojects.

Results:Theprogramshowedstrongstatisticallysignificantbenefitsfromlinkingagriculturetrainingandhealthandnutritiontrainingforavarietyofmeasuresforimprovedhealthandnutritionincludingincreasedcaloriesconsumed(329perday),increasedproteinconsumption(7.5gperweek),moremeals(2.5perweek),andsubstantialdecreasesintheincidencesofdiarrheaandpneumonia.Theprogramachievedtheseresultsatanadditionalcostofabout$50perHHs.

Conclusions:Theresultsshowstrongbenefitstolinkingagriculturedevelopmentandhealthandnutritiontrainingprograms.Thebenefitsincludetheabilitytochangebehaviorashouseholdsareincreasingincome,increasedconsumptionthroughincreasedincomesandagriculturalproductivityofnutritiousfoods,andhouseholdsinvestingmoreforbetterhealthcare.Theprogramalsoshowedthecosteffectivenessofaddinghealthandnutritiontrainingtoanongoingprogramthathadalreadysociallymobilizedcommunitiesforagriculturaldevelopment.

1.3HIGHIMPACT.INTEGRATEDAPPROACHESFORIMPROVEDFOODSECURITYANDNUTRITIONOFRURALPOOR.JOESANDERS,COP,USAID/NepalFloodRecoveryProgram.Emailaddressofcorrespondingauthor:joesanders@fintrac.comProblem:FoodinsecurityandmalnutritionarehighestintheFarWestregionofNepal,where82percentofhouseholdsinprogramworksitesaresubsistencefarmerswithhighfoodinsecurity.Objective:Improvetheaffordability,accessibility,andavailabilityofnutritiousfoodtoruralhouseholdsthroughintegratedcommercialagriculture,nutrition,andinfrastructureinterventions.Conceptualframework:Themultifacetedcausesofpoverty,foodinsecurity,andmalnutritionmustbeaddressedbyapproachesthatrecognizetheinterrelationshipsbetweenincomegeneration,foodproductivity,andconsumption.Improvedagriculturalproductivityandcommercializationcandramaticallyincreaseincomes,butcomplementaryinvestmentsinothersectorsarealsorequiredtosustainimpactsandaddressoverallfoodsecuritypriorities.Descriptionofimplementation:Commercialagricultureparticipantscontributesmallplotsoflandtoademonstrationfarmingprogramthatprovidestrainingandcost‐sharedfinancialassistancetopromotehigh‐valuevegetableproductionandimprovedagriculturaltechnologies.Nutritionandhygieneparticipantsfocusisonnutritiousfoodproductionthroughhomegardening.Bothcomponentsprovidetrainingatthehouseholdlevelinenhancednutritionactions,hygiene,andsanitation.Nutritionalimpactismeasuredbothintermsofchangesinfoodconsumptionandbyindicatorssuchasbodymassindex,prevalenceofbreastfeeding,anddietdiversity.Productiveinfrastructureprojectsthatprovidedirectbenefitstoprogramparticipantsarealsosupported.Outcome:CommercialAgriculture:7,536farmers(35%women)assistedon1,780hectares;843shallowtubewellsinstalled;800%increaseinland’seconomicproductivity;320%increaseinhouseholdincomes;225,000person‐daysofsurplusemploymentgenerated.NutritionandHygiene:5,960farmers(75%women)assistedon147hectaresofhomegardens;240modellatrinesand1,715improvedcookingstovesinstalled.ProductiveInfrastructure:131infrastructuresbenefiting837,726people;improvedtransportationaccessfor128,881households;165,106person‐daysoftemporaryemploymentgenerated.Program’simplications:Integratedinterventionsacrosssectorsdeepenimpactsandstrengthensustainability.Understandingfarmers’economicsituations,landholdingsize,andpotentialasproducersiscrucialtodesigningappropriatefoodsecurityinterventions.Co‐investinginimprovedtechnologies,inputs,andagronomicpracticeshelpsmaximizeoutputsandestablishesastrongcapitalbaseforfarmers.Demonstrationfarmingmodelsensurestrongcommitmentsfromfarmers,facilitateplanning,andprovideafirmbasisforestimatingprojectoutcomesandeffectsonthelocalvaluechain.Substantialimprovementsinagriculturalproductionandcommercializationcannotbeachievedwithouttargetedinvestmentsinproductiveinfrastructure.Nutritionawarenessandbehaviorchangetrainingislesseffectivewithoutcoordinatedassistanceinagriculturalproductionandincomegenerationactivities.Adoptionofimprovedagriculturaltechnologiesandnutritionpracticesrequiresanintensivetrainingprogramwithfrequentandconsistentmessagedelivery.

2.1APPLICATIONOFTHEHOUSEHOLDECONOMYAPPROACHFORASSESSINGFOODSECURITYANDDESCRIBINGLIVELIHOODSINNEPAL.SAVILLENM1,AKHTERN1,SHRESTHABP2,MANANDHARDS2,OSRIND1,COSTELLOA11

CentreforInternationalHealthandDevelopment,InstituteofChildHealth,UniversityCollegeLondon,UK.2MotherandInfantResearchActivities(MIRA),GPObox921,Kathmandu,Nepal.

Emailaddressofcorrespondingauthor:n.saville@ucl.ac.uk

Background:Improvementofnutritionalstatusthroughbehaviourchangeisonlypossibleifnutrient‐richfoodsareavailableandhouseholdsabletoaccessthem.IntheplainsdistrictofDhanusha,Nepalduring2006,weconductedaHouseholdEconomyApproach(HEA)studyasformativeresearch.Aim:tounderstandthefoodsecurityandlivelihoodsituationofdifferentwealthgroupsinthedistrictsoastodesignbehaviourchangestrategiesthatcouldbepromotedthroughcommunitymobilizationthroughwomen’sgroups.Methods:Weconducted60communityrepresentativeinterviewsand210in‐depthinterviewswithdisaggregatedwealthgrouprepresentatives.Foreachofour60VillageDevelopmentCommitteeclusters,detailedinformationonfoodproduced,marketandotherlinkages,commodityprices,resourcemaps,historicaltimelinesandseasonalityofproduction,migration,labourandmarketpriceswereobtained.Eachwealthgroupwasdescribedintermsofassetscoresandlivelihoodactivities.Wealthgroupinterviewsprovidedestimatesofincome,expenditureandfoodsourcesfora‘typicalhousehold’inthatgroup.Fromannualestimatesofkilosoffoodfromdifferentsources,kilocalorieaccessperpersonperhouseholdinthatwealthgroupwasestimated.Results:Foodproductioninthedistrictishighandmicronutrient‐richvegetables,fruitandanimalfoodsareavailableyearroundexceptinthemonsoon.‘Hungryseasons’precedericeharvests(Sep/OctandMarch/April).Thelandlesspoorestrelyonfoodpurchaseandagriculturallabourexchangetomeettheirbasicfoodneeds,makingthemvulnerabletofoodpriceandlabouravailabilityshocks.Middle/better‐offgroupsgrowstapleandnon‐staplefoodsforconsumptionandsale,andarevulnerabletoshocksaffectingproduction.PoorergroupsrelyonmigratorylabourtoIndia,plusdaily‐wagedlabour,whereasmiddle/better‐offrunbusinesses,haveregularjobsandremittancesfromArabcountriesandMalaysiaforcashincome.Thepoorborrowonunfavourabletermsinordertoaccessjobsoverseas.Quantitativeincomeestimatesweredifficulttostandardisebetweeninterviewsanddidnotmatchexpenditure.Conclusion:TheHEAprovidesrichdetailonlivelihoodpatternsthatmayhelpdesignappropriatenutritionalinterventions.However,indiverseagriculturaleconomiesquantitativeestimatesofkilocalorieintakeandhouseholdincomemaybelessreliable.

2.2HOMESTEADFOODPRODUCTIONCONTRIBUTESTODIETARYINTAKEAMONGCHILDREN6‐23MONTHSOLDINKALIALIDISTRICT,FARWESTTERAI.DPADHIKARI1,PPANDEYRANA1,DDAVIS1,NSHARMA1,HBCHAND2,RKNEUPANE1.1HelenKellerInternational,NepalCountryOffice,Chakupat‐Patan,Lalitpur,P.O.Box3752,Nepal;2HelenKellerInternational,NepalFieldOffice,Dhangadi,Kailali,NepalEmailaddressofcorrespondingauthor:dadhikari@hki.org

Issues:LimitedproductionandvarietyoffoodsandknowledgeabouttimelyintroductionofcomplementaryfoodandageappropriatefeedingpracticesarethekeyissuesaffectingthenutritionalstatusofchildrenandmothersinFar‐WesternNepal.Objectives:Toimprovenutritionalstatusofpregnantandlactatingwomenandchildrenlessthantwoyearsofagebyaddressingakeydeterminantofmalnutritionandincreasinghouseholdfoodproductionintheprojectdistricts.Conceptualframework:Knowledge,skills,technicalandmaterialinputs,andcommunitymobilizationleadtoimprovedavailabilityandincreasedconsumptionofnutritiousfoods.Programdesignanddescription:TheUSAIDsupportedActionAgainstMalnutritionthroughAgriculture(AAMA)Project,wasdesignedtoincreasefoodavailabilityanddiversificationthroughhomesteadfoodproduction(HFP)in4632householdswithpregnantwomenandmotherswithchildrenundertwo.BeneficiariesreceivedtraininginHFP,seeds/seedlingsandpoultrychicks.Processevaluationmethods:Acommunity‐based,bi‐annuallotqualityassurancesamplingsurveywasconductedusinga24hourrecallquestionnaire(WHO,2010)forassessingtheinfantandyoungchildfeedingpracticesusingthesevenrecommendedfoodgroups;recordedbyagegroupandconsumption.SPSSversion18.0wasusedtoanalyzedata.CrosstabulationandbivariteanalysiswereusedtoassesstheminimumdietarydiversityinrelationtotheHFPexposurestatus,andmotherswhoknewtimelyintroductionofcomplementaryfood,ageappropriateamountandfrequencyoffeeding.Results:Vegetablevarietiesincreased(3.8±1.9inJanuary2009,4±2.3inAugust2010,8±3.6inFebruary2011and7±3.1inAugust2011)andtheaveragevegetableproductionwithintheprevioustwomonthsincreasedfrom74kg/HHatbaseline(January2009)to175kg/HH(February2011).InAugust2011,mid‐monsoon,theproductiondroppedto123kg/HH.ThemeaneggproductionHH/weekincreasedfrom2.4eggsperhouseholdinAugust2010to5.7inAugust2011.Dietarydiversity,includingconsumptionofvitaminAandironrichplantsourcesandeggs,wassignificantlyhigheramongchildren6‐23monthsfromHFPinterventionhouseholds(p<001).Dietarydiversityofchildrenage6‐23monthswassignificantlyhigheramongthosewhosemothersknewwhentointroducecomplimentaryfeeding(71.7%)thanthosemotherswhodidn’tknow(36.7%).Dietarydiversityofchildrenage6‐23monthswassignificantlyhigheramongthosewhosemothersknewaboutageappropriatefeedingfrequency(82.0%)versusamongthosewhosemotherdidn’tknow(42.7%)(p<001).Programimplications:ThesefindingsdemonstratethatimprovedHFPandknowledgemayleadtoimprovedinfantfeedingpracticesandadditionaldemonstrationstudysitesarewarranted.

2.3FOODSECURITY,FOODPRICEANDINCOMETRENDSINDHANUSHADISTRICT,NEPALBETWEEN2005AND2011.SHRESTHABP2,AKHTERN1,MANANDHARDS2,OSRIND1,COSTELLOA1,SAVILLENM1.1CentreforInternationalHealthandDevelopment,InstituteofChildHealth,UniversityCollegeLondon,UK.2MotherandInfantResearchActivities(MIRA),GPObox921,Kathmandu,Nepal.Emailaddressofcorrespondingauthor:b.shrestha@mira.org.np

Background:Householdfoodsecurityisdeterminedbyavailability,accessandutilisationoffood.AlthoughtheTeraiisNepal’s‘breadbasket’,thepoorlackaccesstofoods.Hence,inDhanushadistrict,MIRA/UCLmonitoredfoodsecurityandrelatedfactorsbetween2005‐6and2011aspartofprospectivesurveillanceofhouseholdswithrecentlydeliveredwomen.Aims:Ourobjectivesweretounderstand:a)howhouseholdfoodinsecuritywasexperiencedinrelationtoanxietyabout‐,insufficientqualityof‐andinsufficientquantityof‐food;b)whowasaffectedbyfoodinsecurity;andc)whetherthefoodpricecrisisaffectedfoodsecurity.Methods:Weused3standardizedmonitoringtoolswithrecentlydeliveredwomenbetweenSeptember2006andJune2011.‘HouseholdDietaryDiversityScore’(HDDS)‐and‘MonthsofAdequateHouseholdFoodProvisioning’(MAHFP)‐datawerecollectedfromSep2006toJun11in>35,000households.‘HouseholdFoodInsecurityAccessScale’(HFIAS)datawerecollectedin4,084householdsSept2006toMay2007andin11,039householdsNov2009toJune2011.Wemonitoredfoodpricesfor66itemsin48‐53marketsinDhanushain2005‐6,2008,2009andcompared2006and2008ratesfordifferentincomes.Results:AllfoodinsecuritymeasuresimprovesteeplywithassetquintileandDalitssufferworst.ComparingNov‐June2005‐6,2009‐10and2010‐11foodinsecurityindicatorsimprovedforasfollows:HFIAS3.8,2.4,1.9;anxietyaboutfoodaccess63%,41%,34%;insufficientfoodquality52%,36%,31%;insufficientfoodintake24%,15%,11%;HDDS4.3,4.5,4.8foodgroups;MAHFP10.2,10.4,10.5months;moderately/severelyfoodinsecure39%,24%,19%andinthepoorestquintile70%,53%,48%.Householdswithaccesstoremittanceincomesincreasedonaverage36%,48%,52%andinthepoorestquintile16%,31%,32%.Incomeratesincreasedby33%forlabor,26%forsalariedjobsand22%frombusinesses2006‐8.Foodpricesincreased32.6%2005‐8and25.2%2008‐9.Conclusion:Although48%ofpooresthouseholdsinDhanushastillsufferfoodinsecurity,foodsecurityhasimproveddespitethefoodpricecrisis.Effectsofpriceincreasesseemtohavebeenbufferedbysalaryincreasesandincreasingaccesstoremittanceincomes.

2.4VALIDATINGDISTRICT‐LEVELASSESSMENTWITHSURVEYDATA:EXAMPLEFROMTHENEKASP,WORLDFOODPROGRAMMEEmailaddressofcorrespondingauthor:Mariko.Kawabata@wfp.orgFoodsecurityinNepalischaracterizedbyahighvariability:notabledisparityisfoundwithinrespectiveregionsanddistricts,aswellasamongdifferentpopulationgroups,whichmakesthefoodsecuritymonitoringcomplexandchallenging.TheNepalFoodSecurityMonitoringSystem(NeKSAP)employsdifferentdatacollectionmethodstoassessandmonitorthefoodsecuritysituation,deliveringreliableandtimelyinformation.ThepresentationillustrateshowthedifferentdatacollectionmethodscomplementeachothertoachievethebestresultunderpracticallimitationsinvolvedinfoodsecuritymonitoringinNepal.TheNeKSAPemploystwokeydatacollectionmethods:phaseclassificationapproachbytheDistrictFoodSecurityNetworks(DFSNs);andrepeatedcross‐sectionalsurveys.TheDFSNs,formedbystaffandrepresentativesfromdistrict‐basedorganizationsandinstitutions,assessandmonitorthefoodsecuritysituationintheirrespectivedistrictsbasedonstandardizedfoodsecurityphaseclassificationapproach.TheinformationisdisaggregatedtoVDC‐levelandupdatedbyseason(quarterly/bi‐annually).Householdsurveyisconductedacrossthecountry,designedtomonitorthefoodsecuritysituationbyecologicalbeltorsub‐regionbyseasonandyear.InformationgatheredbytheDFSNsisvalidatedusingtheNeKSAPhouseholdsurveydatathroughexaminingthedegreeofhouseholdfoodsecuritybyrespectivefoodsecurityphaseasclassifiedbytheDFSNs.EvidenceshowsthatkeyfoodsecurityindicatorsfromthehouseholddataconfirmthedegreeoffoodinsecurityreportedbytheDFSNs.

3.1NUTRITIONINTERVENTIONSTHATIMPROVECHILDANDMATERNALHEALTHANDSURVIVAL:FINDINGSFROMTRIALSINTHETERAIOFNEPAL(EXPANDEDABSTRACT)KEITHP.WEST,JR.,SUBARNAK.KHATRY,PARULCHRISTIAN,ROLFD.W.KLEMM,JOANNEKATZ,LUKEMULLANY,STEVENC.LECLERQ,JAMESM.TIELSCH.TheNepalNutritionInterventionProject‐Sarlahi(NNIPS),CenterforHumanNutritionandDepartmentofInternationalHealth,JohnsHopkinsBloombergSchoolofPublicHealth,Baltimore,Maryland,USA21205Emailcorrespondingauthor:kwest@jhsph.edu

Background:Nutritionaldeficienciesstemfromadietchronicallyinsufficienttosupporthealthanddevelopment,includinghostdefensestoinfectionandotherenvironmentalstresses.Pregnancy,infancyandearlychildhoodareperiodsofgreatestriskofdeficiencywithpotentialshortandlongtermhealthconsequences.Communityresearchcanrevealthehealthimpactofsupplementingorimprovingthedietinapopulationandprovideabasisforpreventiveprogramsandpolicies.Methods:TheNepalNutritionInterventionProject‐Sarlahi(NNIPS)waslaunchedin1988byJohnsHopkinsUniversityandtheNepalNetraJyotiSangh,withUSAIDsupport,toconductmicronutrientdeficiencypreventionresearchthatwouldinformhealthpoliciesandprogramsinNepal.SarlahiDistrictwaschosenbasedonitscomparabilitywithnumerousfeaturesintheTerai.Keyfindingsfromthefollowingfieldtrialsandassociatedstudiesaresummarized:NNIPS‐1(1989‐92,n=28,630)assessedtheefficacyofperiodic,high‐dosevitaminAinreducingpreschoolchildmortality;NNIPS‐2(1994‐7,n=44,646women/22,189pregnancies)assessedtheimpactofprovidingarecommendeddietaryallowance(RDA)ofvitaminA,eitherpreformedorasbeta‐carotene,towomenonaweeklybasisbefore,duringandafterpregnancyonmaternalandinfantmortality;NNIPS‐3(2000‐1,n=4926pregnantwomen)evaluatedagainstacontroltheeffectsofantenatalsupplementationwithiron,iron+folicacid,iron+folicacid+zincora14‐nutrientsupplementonbirthsize(allgroupsreceivinganRDAofvitaminA);afollow‐upstudyofthesethreecohorts,fundedbytheGatesFoundation,in2006‐8(n=~55,000childrenandmothers)examinedlong‐termeffectsofearlylifeinterventionsonchildren;and,NNIPS‐4(2001‐6,n=41,276)studiedtheefficacyofdailyzinc,ironorbothinreducingmorbidityandmortalityinchildren1to35monthsofage.Results:NNIPS‐1revealedthatvitaminAcouldreducepreschoolchildmortalityby30%[17]which,withsimilarfindingsfromatrialinJumla[18],providedevidenceforNepal'svitaminAprogramwhichhaspreventedatleast120,000childdeathsinthepastdozenyears.TheNNIPSfollow‐upstudyalsofound,byages15‐23years,thatvitaminAhadreducedhearinglossassociatedwithmiddleearinfectionby42%[19],attributedtoareductioninseverityofinfection.VitaminAgivenatbirthmayalsoreduceinfantmortality.InBangladesh[20],India[21]andIndonesia[22],newbornvitaminAhasbeenshowntolowermortality<6monthsofageby~20%,aninterventionbeingpilotedinNepal.

NNIPS‐2reducedmortalityrelatedtopregnancybyanaverageof44%witheithermaternalvitaminAorbeta‐carotenesupplementation[23].Maternalsupplementationalsoreducednightblindness[24]andmaternalmorbidity[25]buthadnooveralleffectoninfantmortality[26].At9‐12yearsofage,however,thefollow‐upstudyrevealedgreaterlungcapacity(byspirometry)amongchildrenborntovitaminAsupplementedmothers[27],likelybyimprovingfetallungdevelopment[28].Therewerenoeffectsonbloodpressureorcognitionofoffspring.EpidemiologicalfindingsrevealedmaternalnightblindnesstobeamajorriskfactorformaternalvitaminAdeficiency,undernutrition,morbidityandmortalityduringandlongaftertheendofpregnancy[29,30].DuringNNIPS‐3,motherswerefoundtobelow‐to‐deficientinmultiplemicronutrients15,raisingconcernthatmulti‐nutrientsupplementsmaybeneededduringpregnancyorlactationintheabsenceofdietaryadequacy.However,thetrialshowedvariedeffects:Folicacidalonehadnoeffectonbirthweight[31]butsignificantlyreducedpreterminfantmortality[9].Addingironreducedanemiainthisiron‐deficientsetting,andriskoflowbirthweightby16%[32].Addingzinctothesupplementreversedeffectsofiron.Themultiplemicronutrientsupplementalsoreducedriskoflowbirthweight,by14%,comparabletothatseenwithfolicacid‐ironalone[9],butconveyednosurvivaladvantageforinfants[32].Longerfollow‐upstrengthenedthecaseforantenatalfolicacid‐ironsupplementuse:Byage6‐8yearsofage,childrenborntofolicacidsupplementedmotherswere~40%lesslikelytohaveabnormalkidneyfunction(bymicroalbumintocreatinineratio)andearlybiomarkerindicationsofmetabolicsyndrome[33].Morestrikingly,childrenborntomothersreceivingironwithfolicacidinpregnancyweremorelikelytosurvivethepreschoolyears[10]andperformbetteroncognitivetests[34].Theseeffectswerenotseenwithamultiplemicronutrientsupplement.Itisunlikelythatfoodbasedapproacheswill,inthenearfuture,assureadequatedietaryintakesofbioavailableiron,indicatingthatantenatalfolicacid‐ironsupplementationremainastandardofcareforachievingmaternaladequacyinthesenutrientsinNepal.NNIPS‐4standsasoneoftwocommunitybasedtrials(theotherinZanzibar)thatassessedeffectsofdailyzincorironsupplementationonchildsurvival.InNepal,dailyzincsupplementusehadnoeffectoninfantmortalitybutexertedanon‐significant20%reductioninmortality>12monthsofage[35].However,becausebothtrialsinNepalandZanzibarwerecomparableindesign,underlyingrisksandeffectestimates,datafrombothwerepooledtorevealasignificantoverallmortalityreductionof18%[35].Whiletheevidenceismarginaltopromoteuniversal,dailyzincsupplementationforchildsurvival,thefindingsareconsistentwithknowneffectsofzincinreducingprevalence,severityandsubsequentincidenceofdiarrhea,andemphasizeitsimportanceintreatingdiarrhea[36].Twoepidemiologicalstudiesreveallikelybenefitsof(a)earlyexclusivebreastfeedingand(b)theimportanceofguidingmealconsumptionpatternstoassureadequateintakesbychildrenathome.Inthefirst,adose‐responserelationshipwasobservedbetweenthenumberofhoursinwhichbreastfeedingwasdelayedandriskofneonatalmortality,suggestingthat19%ofallneonataldeathsinruralNepalcouldbeavertedbyinitiatingbreastfeedingwithinthefirsthouroflife[37].Inthesecond,ananthropologicalstudyshowedthattheoddsoftoddlersconsumingavarietyofnutritiousfoodswas1.5to12timeshigherifthechildhadsharedaplatewithanoldersiblingratherthaneatalone[38].Sharingaplateatmealtimewithanolderfemalewasmoreadvantageoustothechildthanwithanoldermale.

Conclusions:Communityresearchcanprovideevidencefornutritionprogramdecisions:PreschoolvitaminAsupplementationcontinuestoprotectlives,sightandhealthofchildren.SupplementationshouldcontinueuntilsuchtimethatadequatedietaryvitaminAintakeandstatusinthepopulationisassured.AmaternaldietadequateinvitaminAwilllikelyhelpreducesriskofmaternalmortalityinNepal,helpcontrolriskofnightblindness.Pregnantandlactatingwomenshouldbeaskedaboutnightblindness,providedlowdosevitaminAifpositive,andofferedgeneraldietaryandhealthcareguidance.Amongothernutrients,antenatalfolicacidandironassuresasubstantialpublichealthimpactforbothmotherandchildinNepal,forwhichthereispresentlynoadequatedietaryalternative.Amultiplemicronutrientsupplementmaynotaddfurtherpublichealthbenefit,forwhichmoreresearchmaybeneeded.Zincsupplementationisacriticaladjuncttreatment(withoralrehydration)fordiarrhea,andcouldreduceunder‐fivemortalityifintakeisincreaseduniversally,preferablythroughfoodbasedstrategies.Immediateandexclusivebreastfeedingcanlikelyreduceneonatalmortality.And,foodbasedstrategieswillneedtoalsoguideintrahouseholdmealpracticestoassuredietaryadequacyinyoungchildren.

3.2GROWTHANDHEALTHOFRURALCHILDRENIN3DISTRICTSOFNEPAL:EFFECTOFACOMMUNITYDEVELOPMENTINTERVENTION.LCMILLER*#,RSHRESTHA^,MLOHANI#,PSINGH#,PSUBBA^,DTHAPA^,SNMAHATO#,NJOSHI#*TuftsUnivSchofMedicine,Boston,MAUSA;^NepalTechnicalAssistanceGroup,Kathmandu,Nepal;#HeiferInternational,Kathmandu,NepalEmailaddressofcorrespondingauthor:LMiller1@tuftsmedicalcenter.orgBackground:Morethan50%ofchildreninNepalaremalnourished.Economicgrowthandpovertyreductionarenotalwayssufficienttoimprovethehealthandnutritionalstatusofchildren.Becausechildhealth/nutritionarevitalcornerstonesofcommunitydevelopment,HeiferNepalconductedalongitudinalrandomizedcontrolledtrialtoevaluatetheeffectsofitsprogramsontheseimportantoutcomes.Aims:(1)systematicallyassesseffectsofHeiferactivitiesonchildhealthandnutritionalstatus;(2)delineatecharacteristicsoffamiliesandchildrenaffectingthese(andother)outcomes.Studydesign:6communitiesin3districtsofNepal[Chitwan/Nawalparasi(Terai),Nuwakot(hills)],werepair‐matchedforspecificcharacteristicsandthenrandomlyassignedtoreceiveHeifercommunitydevelopmentactivitiesatbaseline(INT)orat1year(CON).Atbaseline,6,12,18,and24months,a125‐itemquestionnaireaddressingfamilydemographics,SES,diet,andchildhealth/nutritionwascompletedineachhousehold,alongwithchildgrowthmonitoring.Results:By12months,2903individualsin430householdswereenrolled,including528children6mo‐8yrs.INTandCONcommunitieswereequivalentforbaselineand12monthsSES,householdsize,land/animalownership,andchildnutrition/health,butthereweremarkeddifferencesbetweenTeraiandhilldistricts.At12months,TeraiINTgrouphadimprovedchildweight(p=.04),height(p=.05),andreducedsickdays(p=.01),aswellasincreasedhouseholdincome(p=.004),animal(p=.04)andlandownership(p=.04)comparedtoCON.SignificantimprovementswerenotedinsanitationpracticesinINTgroupat12months(p<.01).Childhealthandnutritionstronglycorrelatedwithage.Conclusions:Significantimprovementsat12monthsinmanyindicatorswerenotedinTeraibutnothillsINTvs.CON.Familyclusteringandotherhouseholdcharacteristicslikelyaffectoutcomesofcommunitydevelopmentinterventions.Extendedfollow‐upwillbeimportanttofurtherunderstandfactorsaffectingchildoutcomesandidentifyspecifictargetsforimprovement.

3.3IMPACTSOFCHANGESINGRAINPULSE(LEGUME)CONSUMPTIONONMICRONUTRIENTSUPPLYOFRURALWOMENINNEPALANDNORTHINDIA.PANDERSEN,DepartmentofGeographyandRKChandyo,CentreforInternationalHealth,UniversityofBergen,Norway.Emailaddressofcorrespondingauthor:Peter.Andersen@geog.uib.noBackground:AnimportantfoodsystemchangeinSouthAsia,isthereductionofpulses(legumes)inthedietsoverthelastfourtofivedecades,duetostagnantagriculturalproduction.Thereasonsforstagnantpulseavailabilityincludelowpriorityinresearchanddevelopmentandagriculturalincentives,anddepletionofsoilmicronutrientsandrhizobiumduetoagriculturalintensification.Thepercapitaconsumptionofpulseshasdeclinedbymorethanhalf.Forruralandpoorpeople,pulseshaveprimarilybeenreplacedbystaplegrains,notbyanimalsourcefoods,leadingtoreducedmicronutrientdensity.ThepaperisbasedontheFOSRINprojectwhichstudiedricebean(Vignaumbellata)inparticular.Aims:Pulsesareoftenseenasasourceproteinforpoorand/orvegetarianpopulations.Weinvestigatetheroleofpulsesinpreventionofmicronutrientsufficiency–“hiddenhunger”.Methods:Dietaryrecallsof800ruralwomenofreproductiveageinNepalandNorthIndia,wereanalyzedusingtheWorldFood2program.Thedietaryintakeswerecomparedtorecommendedintakevaluestopredictgeneraldeficiencyproblems.Contributionsofdifferentfoodgroupswereassessed.Results:Staplegrainsprovidedabout80%oftheenergy,ricealone62%.Majordeficienciespredictedwerelysine,Ca,K,Fe,vit.A,C,D,folateandB12;theintakesofFeandfolatewereparticularlyinadequateforpregnantwomen.Thepredicteddeficiencies,combinedwiththenutrientdensityofpulsescomparedtostaplegrains,definesthewindowofopportunityforpulses.Themajorcontributionsofpulseswerelysine,Ca,K,FeandBvitaminsotherthanB12.Conclusion:Pulseshaveacentralbutnotsufficientroleinpreventionofhiddenhunger.Thepolicyimplicationsofthestudyincludesifinterventionsshouldbeenrichmentofrice,substitutionwithotherstaples,supplementationorcomplementaryfooditems,includingpulses.

3.4CORRELATESOFINFANTANDYOUNGCHILDFEEDINGPRACTICESINCHEPANGCOMMUNITY.SUBEDIN,1POUDELS,2RANAT1ANDPAUDELAK3.1NepalPublicHealthFoundation,2KarnaliIntegratedRuralDevelopmentandResearchCenterNepal,3DepartmentofCommunityMedicineandPublicHealth,InstituteofMedicine,TribhuvanUniversityEmailaddressofcorrespondingauthor:subedi.narayan@gmail.com

Background:Infantandyoungchildfeeding(IYCF)practicesdiffersincommunitiesduetodifferenceinknowledge,healthserviceutilization,culture,andothersocio‐economicfactors.TheobjectiveofthisstudywastoexploreknowledgeandpracticeofChepangmothersonIYCFandtheircorrelates.Methods:AcrosssectionaldescriptivestudywasconductedinChepangcommunityofMakawanpurdistrict.Quantitativemethodologywasusedinwhich360mothersofundertwoyearagechildrenwereselectedrandomly.Logisticregressionanalysisofselectedchildfeedingindicatorswasdonetofindtheirassociationwithsocio‐economicandhealthrelatedfactors.Results:Feedingpracticesofmotherswerefoundbetterthantheirknowledgelevel.About35%hadknowledgeaboutearlyinitiationofbreastfeeding.Exclusivebreastfeedingandintroductionofcomplementaryfoodsattheageofsixmonthswere81%and90%respectively.Literatemotherswerefoundinitiatingbreastfeedingearlythantheilliterate(OR=2.61,95%CI,1.59‐4.27).Growthmonitoringserviceutilizationwasfoundtohavesignificantassociationwithexclusivebreastfeedingpractices(OR=2.75;95%CI,1.30‐5.78).Feedingdiversecomplementaryfoodswasfoundtobeassociatedwithaveragemonthlyfamilyincomeanddurationoffoodsufficiency.Conclusions:FeedingpracticesinChepangcommunitywereassociatedwithhealthandsocioeconomicdeterminants.Someofthefeedingpracticeswerefoundgoodhowever,mealfrequencyforthechildren9‐23monthsofageandfeedingdiversefoodsforchildren6‐23monthswerefoundlowerwhichneedstobeimprovedthroughnutritionawarenessprograms.Qualitativestudiesareneededfurthertoexploretheculturalfactors.

TITLELISTINGSFORPOSTERPRESENTATIONS

IMPROVEMENTOFWOMEN’SLIVELIHOODS,INCOMEANDNUTRITIONTHROUGHCARP‐SIS‐PRAWNPOLYCULTUREINTERAI,NEPAL.SunilaRai,MadhavK.Shrestha,NabaRajDevkota.InstituteofAgricultureandAnimalScience,Rampur,Chitwan,NepalEmailaddressofcorrespondingauthor:madhavshrestha1954@gmail.com

RICESEEDBUSINESSMODELINGANDFOODSECURITY:ACASESTUDYOFKAVREPALANCHOKANDRAUTAHATDISTRICTSOFNEPAL.MeghBahadurNepali1,*,SudeepGautam2,SabitaMohiniAmatyaShrestha2andSanjeevAdhikari21,2SocioeconomicsandAgriculturalResearchPolicyDivision,NARC,Khumaltar,NepalEmailaddressofcorrespondingauthor:mbnepali@yahoo.com

HEALTHANDHUMANDEVELOPMENTNEXUSINNEPAL.MukeshKumarMishra*,VinodMishra1,FarhatN.Siddiquie2.*BhopalNIMSCollege,Lalitpur,Nepal,1Departmentofsociology,TribhuwanUniversityNepal2DepartmentOfClinicalNutritionandDietetics,Emailaddressofcorrespondingauthor:Mr.callmishra@gmail.com

LISTOFPARTICIPANTS

NAME DESIGNATION INSTITUTION

1 MS. AKRITI SINGH SR. NUTRITION COORDINATOR SUAAHARA

2 MS. ALINA MAHARJAN BOARD MEMBER IOM/NPHF

3 DR. ARJUN KARKI VC PAHS

4 MR. ARUN UPRETY BNMT

5 MR. ASHOK BHURTYAL NATIONAL PROFESSIONAL OFFICER WHO

6 MR. ATMA RAM PANDEY JOINT SECRETARY NPC

7 MR. BAL GOPAL BAIDYA SR.RESEARCH ASSOCIATE NEW ERA

8 MR. BASUDEV SHARMA DRISHYAVOLOKAN

9 MS. BASUNDHARA SHER. COLLEGE

10 MR. BED MANI DAHAL ASST. PROFESSOR KATHMANDU UNIVERSITY

11 MR. BHIM SHRESTHA R.MANAGER MIRA

12 MR. BHIM SUNUWAR DRIVER NTAG

13 DR. BIBHUSAN SHRESTHA DOCTOR KUSMS

14 MR. BIJAY K. SINGH CONSULTANT RENAISSANCE SOCIETY NEPAL

15 MR. BIJU K. SHRESTHA PROGRAM DIRECTOR NPCS

16 DR. BIKRAM SHRESTHA MEDICAL DOCTOR KUSMS

17 MS. BIMALA MANANDHAR MIRA

18 MR. BINESH MAN SAKHA SENIOR SCIENTIST NARC (PRP)

19 MR. BINOD KHANAL STUDENT IAAS,RAMPUR,CHITWAN

20 MR. BIRENDRA YADAV ASST. PROFESSOR BPKIHS DHARAN

21 MR. CHARLES ENCISO DIR. OF PROGRAMMING/TRANING PEACE CORPS

22 DR. CHET RAJ PANT VICE CHAIRMAN NNJS

23 DR. CHET RAJ UPRETI PRINCIPAL SCIENTIST NARC

24 DR. CHOP LAL BHUSAL NHRC

25 MR. DARRELL DEPPET CHIEF OF PARTY EIG/WINROCR

26 MR. DAVID C. ATTEBERRY MISSION DIRECTOR USAID

27 MR. DEBENDRA ADHIKARI M &E MANAGER HKI

28 DR. DEBENDRA GAUCHAN SENIOR SCIENTIST NARC

29 MR. DEEPAK THAPA PROGRAM MANAGER NTAG

30 MR. DHANANJAYA POUDYAL FREELANCER

31 DR. DHARMA MANANDHAR PEDIATRICIAN MIRA

32 MR. DURGA PRASAD PAHARI FACULTY IOM

33 MS. DUSHALA ADHIKARI MEMBER PHI

34 MS. ELISA FACCHINI INTERN USAID EIG

35 DR. GAJANANDA BHANDARI DIRECTOR NPHF

36 DR. GERALD SHIVELY PROFESSOR PURDVE UNIVERSITY

37 MR. HAN KANG DEPUTY DIRECTOR USAID

38 MR. HARI KOIRALA PROGRAM SPECIALIST USAID

39 DR. INDIRA SHARMA PROFESSOR T.U. PADMA KANYA CAMPUS

40 MR. JOE SANDERS USAID‐NFRP FINTRAC

41 MR. JYOTI SHRESTHA COORDINATOR MIRA

42 DR. K.K. LAL AGRONOMY EXPERT R.S NEPAL

43 MR. K.P ACHARYA TECHNICAL MANAGER NTAG

44 DR. KALPANA TIWARI NUTRITION SPECIALIST NTAG

45 MR. KAMAL SHRESTHA M&O SPECIALIST USAID ‐NFRP

46 DR. KANTI LATA BHANDARI CHAIRPERSON IRHDTC/NEPAL

47 DR. KEDAR P. BARAL PROFESSOR PAHS

48 DR. KEITH WEST PROFESSOR JOHNS HOPKINS

49 MS. KENDA CUNNINGHAM RESEARCHER IFPRI

50 MR. KIPP SUTTON AGRICULTURAL OFFICER USAID

51 MR. KIRK DEARDEN DCOP HKI/SUAAHARA

52 MR. KUMAR SANJEL NTAG

53 MR. LILA B. THAPA SENIOR PUBLIC HEALTH OFFICER CHD/DOHS

54 MS. LUEIA RUSSO COORDINATOR ISAS

55 MR. LUIS GUZMAN FOREIGN SERVICE USAID

56 MR. LUKE COLAVITO COUNTRY DIRECTOR IDE

57 MS. LYNN LEDERER CHIEF OF PARTY SUAAHARA

58 MR. M .R MAHARJAN DIRECTOR MI

59 DR. MADAN PARIYAR PD/M &E DIRECTOR IDE NEPAL

60 DR. MADHAV K. SHRESTHA PROFESSOR IAAS/RAMPUR

61 DR. MADHU DIXIT DEVKOTA PROFESSOR IOM

62 MR. MADHUKAR B.SHRESTHA SENIOR PROGRAM MANAGER HKI

63 MS. MANASA THAPA THAKURATHI ASSOCIATE PROFESSOR PADMA KANYA CAMPUS

64 MR. MANDIP RAI PROGRAM OFFICER FAO

65 MS. MANDIRA TAMRAKAR ASSOCIATE PROFESSOR PADMA KANYA CAMPUS

66 MS. MANJITA SHRESTHA NTAG

67 MS. MANODHARA SHAKYA ASSOCIATE PROFESSOR PADMA KANYA CAMPUS

68 MS. MARIE RUEL IFPRI

69 MS. MARIKO KAWABATA HEAD FSMAV WFP

70 MR. MEGH BAHADUR NEPALI T.OFFICER NARC

71 MS. MONA SHARMA SENIOR OFFICER WINROCK INTL'

72 MR. MUKTI SANJEL DRIVER NTAG

73 DR. NABA RAJ DEVKOTA PROFESSOR IAAS,RAMPUR,CHITWAN

74 MR. NANDA PRASAD SHRESTHA LIV. EXPERT RNS/FAO

75 MS. NAOMI SAVILLE TECHNICAL ADVISOR MIRA/UCL

76 MR. NARAYAN SUBEDI PROGRAM MANAGER NPHF

77 MR. NAVEEN PAUDYAL P.O. NUTRITION UNICEF

78 MR. NAVIN HADA AG. SPECIALIST USAID

79 MS. NEENA JOSHI SENIOR PROGRAM MANAGER HEIFER INTERNATIONAL

80 MS. NICOLE MENAGE REPRESENTATIVE WFP

81 MS. NIRMALA PANDEY AG. FOOD SECURITY COORDINATOR HKI

82 MS. NIRMALA SHARMA PROG.DEV. COORDINATOR CARE

83 DR. P. MISHRA SECRETARY MOHP

84 MS. PASCASIE ADEDZE NUTRITION ADVISOR USAID

85 DR. PATRICK WEBB Dean of Academic Affairs, Friedman School Tufts University

86 MR. PETER ANDERSEN ASSOCIATE PROFESSOR UNIVERSITY OF BERGEN

87 MS. POOJA RANA DIRECTOR OF PROGRAM HKI/SUAAHARA

88 MR. PRADEEP DIXIT DIRECTOR AFFAN

89 MR. PRADIUMNA DAHAL NUTRITION SPECIALIST UNICEF

90 MS. PRAGYA GARTAULLA LECTURER NEPAL INSTITUTE OF HEALTH SCIENCES

92 MR. PRAMOD G.C ASST. PROFESSOR BPKIHS

93 MR. PRAMOD KOIRALA DFTQC

94 MR. PRAVEEN BAIDYA DCOP WINROCK INTL'

95 MS. PREETI SUBBA M&E OFFICER NTAG

96 MS. PUSHPA SHRESTHA PROGRAM OFFICER WFP

97 MR. RADHA KRISHNA PRADHAN PROGRAM DIRECTOR NPC

98 MR. RADHA SHYAM CHAUDHARY NUTRITION COORDINATOR USAID/NFRD (FINTRAC)

99 MR. RAJAN PAUDEL LECTURER IOM

100 MR. RAJU KANDEL CONSULTANT CHEMONICS

101 DR. RAM CHANDRA BHUSAL

VALUE CHAIN/MARKETING SPECIALIST CEAPRED

102 MR. RAM GUPTA USAID/NFRP

103 DR. RAM K. CHANDYO RESEARCHER IOM

104 MR. RAM KRISHNA NEUPANE PROGRAM DIRECTOR FORWARD NEPAL

105 MR. RAM KUMAR NEUPANE HFPC HKI

106 DR. RAMAN SHRESTHA M & E OFFICER NTAG

107 MR. RAMESH K. ADHIKARI PROFESSOR IOM

108 MS. RITA PRADHAN NTAG

109 DR. RIWAAJ LAMSAL DOCTOR(MED.OFFICER) SAHARA HOSPITAL

110 MR. ROBIN HOUSTON DCOP NFHP

111 DR. ROLF KLEMM JOHNS HOPKINS

112 MR. RUDRA SHARMA PLANNING OFFICER NATIONAL PLANNING COMMISSION

113 MS. RUPA MAHARJAN NTAG

114 MS. RUPA PANDEY(THAPA) ASSOCIATE PROFESSOR

NEPAL INSTITUTE OF HEALTH SCIENCES

115 DR. S.K KHATRY DIRECTOR NNIPS

116 MS. SABA MEBRAHTU CHIEF NUTRITION UNICEF

117 MS. SABNAM SHIVAKOTI MOAC

118 MS. SAHARAH MOON CHAPOTIN USAID

120 MS. SARAH NISCHALKE UNIVERSITY COLLEGE

121 MS. SHANDA STEIMER DIRECTOR USAID

122 DR. SHARAD ONTA PROFESSOR IOM

123 MS. SHARADA PANDEY SPHA MOHP

124 DR. SHIBA KUMAR RAI HON. MEMBER NPC

125 DR. SHIDDI GANESH SHRESTHA PROGRAM DIRECTOR

DIRECTORATE OF AG.EXTENSION

126 MS. SHIKHA BASNET FREELANCER

127 MR. SHREERAM NEUPANE LECTURER GOLDENGATE COLLEGE

128 MR. SHROCHIS KARKI D.PHIL. STUDENT OXFORD UNIVERSITY

129 MR. SHUBH MAHATO COUNTRY DIRECTOR HEIFER

130 MS. SOPHIYA UPRETY PROGRAM OFFICER WFP

131 MR. STEVE LECLERQ FIELD DIRECTOR/JHUREP NNIPS/JHU

132 MS. STUTI BASNYET USAID

133 DR. SUDEEP SHRESTHA FELLOW JHU

134 MS. SUMI DEVKOTA CONSULTANT DAI

135 MR. SUMIT KARN NPC NS/CHD

136 MS. SUNEETHA KADIYALA RESEARCH FELLOW IFPRI

137 DR. SUNILA RAI ASSOCIATE PROFESSOR IAAS

138 MR. SURYA P. PAUDEL SR. LIVESTOCK OFFICER MUAC

139 MS. SUSHILA RISAL MOH LIAISON OFFICER NTAG/CHD

140 MS. SWETHA MANOHAR RESEARCH ASSOCIATE JHSPH

141 DR. TIRTHA RANA FREELANCER

142 DR. TRISHNA SHARMA DOCTOR

143 MR. TUYU NARAYAN PACHHAI IEC OFFICER NTAG

144 MR. Y.B.THAPA TEAM LEADER FNSP

145 MS. ZARIN A .PRADHAN M&E USAID EIG

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