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PROCEEDINGS

Agriculture,FoodSecurityandNutritioninNepal‐TakingStockandDefiningPriorities

NUTRITIONCOLLABORATIVERESEARCH

SUPPORTPROGRAM:

SCIENTIFICSYMPOSIUM

March21‐22,2012

AUTHORS:

SUDEEPSHRESTHA

SWETHAMANOHAR

ROLFKLEMM

RAPPORTEURS:

DIPLAVSAPKOTA

AKRITISINGH

RAMANSHRESTHA

SUDEEPSHRESTHA

DISCLAIMER:Theauthors’viewsexpressedinthispublicationdonotnecessarilyreflecttheviewsoftheUnitedStatesAgencyforInternationalDevelopmentortheUnitedStatesGovernment.

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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 

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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 

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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.

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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

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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

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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.

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Organizeabi‐annualorannualforumforpolicymakersfromtheNPC,MoACandMoHPandresearcherstodiscussandtranslateresearchfindingsthatpertaintoimprovementofnutritionstatusthroughamulti‐sectoralapproach.

Organizeanannualscientificsymposiumor“evidencesummit”tofacilitatetherapidsharingoffindingsandinnovativesolutions.

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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)

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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)

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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

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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

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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.Heralliedforresearcherstocontinueintheireffortswhilstfulfillingallethicalobligationstotheirsubjectsandthelargerresearch,programandpoliticalcommunities.

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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].

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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]

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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

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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.

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

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NEXTSTEPS

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

FIGURE12

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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.

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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.

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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.

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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.

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SESSION2‐ABSTRACTS

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.

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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.

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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.

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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.

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SESSION3‐ABSTRACTS

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.

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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.

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

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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.

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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.

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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.

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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

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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 

57

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 

58

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 

59

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    

60

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 

61

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