Comprehensive Report_ENG

‘Integration of nutrition in agriculture and rural development projects’
Final Report
July, 2015
Janine Roelofsen
Nicholus Tint Zaw
Goodnutrition isthefoundation ofhuman well-being.
Beforebirthandthroughoutinfancy,good nutrition allowsbrainfunctioningtoevolve
fullyandimmune systemstodevelopwell.Foryoungchildren,goodnutritionprevents
deathordisease.Ithelpstheirbodytogrowanddeveloptoitsfullpotential.Good
nutrition leadstobetterresultsinschoolandimprovedlearningcapacity.
Laterinlife,itleadstobetter-nourishedmotherswhogivebirthtobetter-nourished
children,andadultswhoaretaller,lesslikelytobeoverweightorgetdiseaseslikeheart
diseaseorcancer.Goodnutritionimprovesworkcapacityandproductivity.
Therefore,peoplewithgoodnutritionarekeytosustainabledevelopment.

Food Security Working Group 2015
2 Integratingnutritionin agricultural andrural developmentprograms.
Acknowledgement
We wouldlike toacknowledge the supportandcontributionsof the followingpeople andorganizations
that made the deliveryof thisreportpossible:
We wouldlike tothankthe teamfromSympathyHand inDelta,ACF’sSUSTAIN programinKayah,
CESVI’steaminthe Dry Zone,and WHH inBogale foryour warmwelcome andsupportto ourfieldvisits.
We greatlyappreciate the kindsupportof NyeingKyaw Kyaw Latt(Boardof DirectorMember,Sympathy
Hand),NangSam Hom (SUSTAIN ProgramManager),HeinZaw Htwe (TownshipCoordinator, CESVI), and
Jana Koerner(Headof ProjectWHH).
We are grateful forthe followingpeopletotake the time tomeetwithus andto provide useful ideas
and suggestions,helpingtoimprove the qualityof the report: AndreaMenefee (NutritionAdvisorSave
the Children), MathewTasker(FoodSecurity,Livelihoods&Social ProtectionAdvisor, Save the
Children),Celine Lesavre(Headof departmentHealthandNutritionACF),JanisDiffert(FoodSecurity
and LivelihoodsHeadof DepartmentACF),ElizabethWhelan (ProgramManagerLEARN Project),Saw
Eden(LEARN Project),Aye Aye Khaine (HealthandNutritionSpecialist), Joy-DestaBrandsma(Senior
Program ManagerMaternal,Neonatal,ChildHealthandNutritionPlanInternational),AdriaanKorevaar
(InterimCountryDirectorCDN), KhinMaungLatt (National Agricultural andForestrySectorCoordinator,
Metta),Saw Sunday(Programme Managerlivelihood,KMSS) andThuraAung(Directorof Programme,
Ratana Ayar).
We wouldlike tothankKhinPaPa Wai,ThijsWissinkandAye Myat Thu fromFSWG for theirsupport
and meaningfulcontributionsandsuggestions.

Introduction
The main aimof thisstudyisto gathergood practicesof integratingnutritionintoagriculture andrural
developmentprojects,andparticularly tocompilegoodpracticesbyFSWG’smembers. Todothis,we
have:(i) done a thoroughliterature reviewof international andMyanmardocuments, (ii) talkedto
nutritionexpertsin-countryand (iii) studiedcurrentprogramsof FSWG memberorganizations.
The researchwas conductedfromDecember2014 to June 2015 inthree phases.Inphase 1, information
was gathered fromliterature sources,fromFSWGmembersandfromnutritionexpertsinMyanmar.In
phase 2, fieldvisitsweredone toFSWGmemberswhichimplementgoodexamplesof how tointegrate
nutrition.Inphase 3, analysis,translationandreportingtookplace.
Methodology
In line withthe ToRand as agreedwiththe researchcommittee,the researchwasbasedona thorough
literature review andaqualitative researchincludingquestionnaires,keyinformantinterviews,focus
groupdiscussionsandfieldvisits (directobservation).
All FSWG membersreceivedaWelcome Questionnairetogatherbasicdata on whatorganizationsare
doinginagricultural andrural developmentandtoknow if theyintegratednutritionintheirprograms.
Keyinformantinterviewswere done with nutritionexpertsfromdifferentorganizationsworkingin
Myanmar. Barrieranalysisinterviewswere done withorganizationswhohadbeentrainedonnutrition,
but whodidnot include nutritionintheirprograms.Furthermore,fieldvisitsandfocusgroupdiscussions
were done withFSWGmemberstogatherpositive case studies.
Limitations
The biggestlimitationwas the lownumberof participants inthe survey.The Welcome Questionnaire
was an easy-to-fill inquestionnaireandwassenda numberof timesbyemail toFSWG memberswhich
onlyledtoaround 10 responses(outof 120 FSWG memberorganizations). Otherpro-activeapproaches
were usedtoincrease the numberof respondents. Eventuallyonly29 responseswerereceived.
It ispossible thatorganizationsor peoplewhoare notinvolvedinnutrition are lesslikelyto respondto a
questionnaire aboutnutrition. And, thatthose organizations/people whoare alreadyintegrating
nutritionorat leastwhoare interestedinnutrition are more likelytorespond.Thismightover-
representthe proportionof organizationsinvolvedinnutrition.
Approach
On the followingpage anoverview of technical termscanhelpnon-nutritioniststounderstandthe
differentterminologythatisfrequentlyusedinnutritiondocuments. Throughoutthe report,aneffort
was made to keepterminologytoalimittoimprove readabilityforawideraudience.

Technical nutrition terms
1,000 day
window
First1,000 daysof a child’slife startingfromconceptiontothe child’ssecond
birthday.
Complemen-
tary feeding
Complementaryfeedingisforinfantsandyoungchildrenafter6monthsoldwhen,
besidesdrinkingbreast-milktheystarteatingsolidfood.The solidfood
complementsthe breastfeeding,whichiswhyitiscalledcomplementaryfood.
Exclusive
breastfeeding
Recommendedforinfantsfrom0-6monthstoonlydrinkbreast-milkexclusively;
meaningnothingelse.Alsonowaterorotherliquids.
Food intake Foodconsumption.
Food security Foodsecurity at the individual,household,national, regionalandglobal levelsis
achievedwhenall people,atall times,have physical andeconomicaccessto
sufficient,safe andnutritiousfoodtomeettheirdietaryneedsandfoodpreferences
for an active andhealthylife.
Lactating Lactating womenare breastfeedingwomen.
Macro-
nutrients
Macro-nutrientsinclude protein,carbohydratesandfat;providingenergyforan
active and growingbody.
Micro-
nutrients
Micro-nutrientsinclude vitaminsormineralswhicheachhave aspecificrole inone
of the processesinourbody;e.g.supportingnervoussystem, supportingeye
functioning,supportingthe heartetc.
Nutrients The word nutritioncomesfromthe Latinword‘nutrire’whichmeansto nourish or
to provide withthe foodneededforahealthylife andgrowth.
A nutrientisa substance thatprovidesnourishment.
Nutritiongap The gap betweenwhatfoodsare grownandavailable andwhatfoodare neededfor
a healthydiet.
Nutrition
security
Nutritionsecurity:‘A situationthatexistswhensecure accesstoan appropriately
nutritiousdietiscoupledwithasanitaryenvironment,adequate healthservicesand
care, inorderto ensure a healthyandactive life forall householdmembers’.
Nutrition-
specific
Interventionsthatdirectlyinfluencenutrition;these includefeedingpractices
(includingbreastfeeding,nutrient-richfoods),eatingroutines,care-givingpractices,
and burdenof infectiousdisease.
Nutrition-
sensitive
Interventionsthataddressunderlyingcausesof malnutrition;theseinclude food
security,foodavailability,economicaccesstofood,resourcesforfeedingandcare-
givingpractices(formothers,households,community-level) oraccesstoand the use
of healthservices,asafe andhygienicenvironment
Stunting To check if a childisstunted(toosmall foritsage),we measure itsheightandthen
compare it to the expectedheightforthatage (heightforage).If a childisstunted,
it meansthata childdidnotget enoughnutritiousfoodoverarelativelylongperiod
and/orhas beensickrepeatedly.Stuntingreflectschronicmalnutrition.
Supplements Dietarysupplementsprovide nutrientsthatmayotherwisenotbe consumedin
sufficientquantities;e.g.micro-nutrientsupplementssuchasirontablets.
Under-weight To check if a childisunder-weight,we measureitsweightandthencompare itto
the expectedweightforthatage (weightforage). Thisindicatormeasuresthe
combinationof recentandlong-termunder-nutrition.
Wasting To see whetherachildiswasted,we can compare itsweighttoitsheight(weightfor
height).Wastingisasignof acute malnutrition;itmeansthata childdidnothave
enoughfoodrecentlyandislosingtoomuchweight.

Table of contents
Acknowledgement..............................................................................................................................2
Introduction.......................................................................................................................................3
Technical nutrition terms....................................................................................................................4
Summary ...........................................................................................................................................6
1. Why should agricultural or rural development programsinclude nutrition?....................................8
Agricultural and rural development programs are needed to improve nutrition .................................8
Food insecurity and malnutrition rates are high in Myanmar.............................................................9
Nutrition improves your program. .................................................................................................13
Myanmar government have joined nutritioninitiatives such as SUN and Zero Hunger challenge .......13
2. What are FSWG member organizations doing in nutrition?..........................................................15
3. What are the barriersfor organizations toinclude nutrition in their programs? ............................17
4. How to integrate nutrition in agricultural / rural development programs?....................................19
Recommendations from literature review......................................................................................19
Recommendations from nutrition experts in Myanmar...................................................................30
Ideas from FSWG member organizations........................................................................................32
Positive case-studies in Myanmar..................................................................................................33
5. Final recommendationsonhowtointegrate nutritioninagricultural andrural development
programs. ........................................................................................................................................43
Annex I. Conceptual framework linking food availability,food security and nutrition...........................45
Annex II. References.........................................................................................................................46

Summary
The FSWG isinterestedtogatherpositive examplesof how tointegrate nutritioninagricultural andrural
developmentprograms.Whyshouldwe integrate nutritioninagricultural andrural development
programs?
There isa misconceptionthatnutritioncan be done byhealthprogramsalone.Healthprograms,
however, cannotimprove foodavailability, norimproveproductionof nutritiousfood, norimprove
people’sincomesotheycanaffordto produce or buysufficientandqualityfood.Toimprove nutrition,
each household would needtohave accessto locallyavailable andaffordable nutritiousfood.Without
that, the foundationof goodnutritionismissing.
We can create awarenessaboutthe importance of healthyfood,butthatwouldonlymake sense if
people couldactuallyaccessthese kindsof foodsyear-round.Toeffectivelyimprove nutrition,we need
agricultural andrural developmentprogramstothinkaboutnutrition.
The foundationof goodnutritionisavailabilityandaccessto sufficient,safe andnutritiousfoodforall
familymembers. Local availabilityof foodisdirectlylinkedtolocal production,local marketsand inrural
areas alsoto food availabilityfromnatural resourceslike forestsandfisheries.InMyanmar,local food
productionisincreasingthroughimprovedpractices,techniquesand(high-yield) varieties.Onthe other
hand,foodproductionandyieldsare threatenedbyclimate change andrelatedwatershortages,
persistentconflictsandemergencies,landrightsissuesandnatural disasters.Inaddition,food
availabilityfromnatural resourcesisdecliningwithdeforestation,landissuesandreducingfishstocks.
These challengesare compoundedbychangesindemandforfoodthatare broughtaboutby growing
populations,increasingincomes andurbanization.Inviewof these challenges,protectionof nutrition,
letalone accelerationof progress,will entail more thanimprovingnutrition&health-relatedknowledge
and practices.To sustainablyimprove foodsecurityandnutritionstatusof Myanmarpeople,anew
focusis requiredtoaddressthe underlyingcausesof undernutrition. The needforinvestmentstoboost
agricultural production,natural resource managementandincrease incomesisundisputable.
In Myanmar,around one out of three childrenunder5yearsoldare stunted (heightforage) andone
out of five childrenunder5are under-weight(weightforage).These ratesare classifiedas‘high’
accordingto WHO standards. Highstuntingandunder-weightmeansthatahighnumberof children did
not getenoughfoodforovera longerperiodof time.
In additiontohamperedgrowth, 75% of under5’s hasiron deficiency(notenoughiron),while 71%of
pregnantwomenand45% of womenof childbearingage have irondeficiency.Ironisneededforoxygen
transportand storage in muscles,improvesimmunity,isrequiredforgrowth,forenergyproduction,for
drug metabolismandpropermental functioning.Withlackof iron,children’sbraindevelopmentand
school performance islowerthanitcouldbe.Lack of ironleadstoreducedphysical andmental
performance,tirednessandhigherchance of gettinginfectionsandillness.
The 5th
leadingcause of deathof children1-12 monthsis beriberi (notenoughvitaminB1).VitaminB1is
neededforenergy production,growthinchildhoodandfertilityinadults.VitaminB1maintainsa
healthyheartandnervoussystem;infantsdie of lackof vitaminB1because theirheartfails.
If people lackenoughfood,theyare hungrywhichiseasyto see andeasyto measure.However,if
people lackironorvitamins,itcan go unnoticed,while the consequencescanbe serious.
Good nutritionisthe foundationof humanwell-being.Before birthandthroughoutinfancy,good
nutritionallowsbrainfunctioningtoevolve withoutimpairmentandimmune systemstodevelopmore
robustly.Foryoungchildren,goodnutritionstatusavertsdeathandequipsthe bodytogrow and

developitsfull potential.Overthe course of the humanlife-span,itleadstomore effective learningat
school,better-nourishedmotherswhogive birthtobetter-nourishedchildren,andadultswhoare
likeliertobe productive andearnhigherwages.Inmiddle age,itgivespeople metabolismsthatare
betterpreparedtoward off the diseasesassociatedwithchangesindietandphysical activity.Without
goodnutrition,people’slivesandlivelihoodsare builtonquicksand.
Nutritionisintegratedbyaroundhalf of the FSWGmemberswhorespondedtothe survey.However,
thismightnot representthe total numberof FSWGmembersbecause onlylessthanone quarterof all
FSWG membersresponded. Additionally,itmightbe thatorganizationswhodonutritionwouldrespond
while organizationswhodon’tdonutritiondidnotrespond.Thiswouldover-representthe proportionof
organizationsinvolvedinnutrition.Furthermore,onlyafew organizationswereactuallyproviding
examplesof nutritionactivities/objectives.E.g.62% saidtheyhave nutritionasa crosscutting issue but
only4 organizationsmentionedwhattheydid.
Therefore,itislikelythatnotthat manyFSWG are integratingnutritionintheirprograms.Itislikelythat
there isa lot of room to increase nutrition-relatedactivitiesamongFSWGmembers.Withmost
membersalreadyworkingonfoodsecurity,foodavailability,economicaccesstofood,andover half
workingonwaterand hygienicenvironment,itwouldbe mostsuitable topromote nutrition-sensitive
activitiesfirst.Theseare activitieswhichaddressthe underlyingcausesof malnutrition.
The main barriersfororganizationstointegrate nutritionintheirprogramsinclude:lackof
understandingwhatmalnutritionis,how todefine itandhow severe itiswithintheirtargetgroup.Not
manyagricultural organizationsare involvedinnutritionwhichlimitsexpertise in-countryorthe
possibilitiestolearnfromothers.More technical trainingisneededforstaff tobe able tointegrate
nutritionwell;itiseasyto addnutrition-relatedactivitiesbutmore difficulttochoose the mostrelevant
activities whichhave anactual impact.Equallyimportant,communitiesneedtobetterunderstandthe
importance of goodnutrition;otherwise theywill neverrequestsupport.Finally,amainbarrierisno
organizational commitment.
All literature sourcesagree thattargetedagriculturalprogramscanhave a large role in supporting
livelihoods,foodsecurity,dietquality,women’sempowerment,andinachievingscale andhigh
coverage of nutritionallyat-riskhouseholdsandindividuals.Increasingthe availabilityandconsumption
of nutrient-richfoodsthroughahousehold’sownproductionisconsideredtobe a sustainable approach
because the processempowershouseholdmembers,particularlywomen,totake ultimate responsibility
for the qualityof the dietof the householdsthroughtheirownproductionandimprovednutritional
knowledge.
Literature providesawide varietyof ideasandevidenceof effectiveapproaches.Nutritionexpertsand
experiencesfromFSWGmemberorganizationsconfirmandcomplementthe evidencethat isgathered
worldwide. All organizations couldatleastthinkaboutDo NoHarm to avoidprojectsharmingnutrition
security.Agricultural organizationsthatlike to(start) implementnutrition-relatedactivitiesshouldthink
aboutwhat theywantto achieve andwhattheycan’t achieve;e.g.aimtoimprove dietarydiversitybut
not aimto improve anthropometry.The selectedcase studiesshow thatsmall organizationswithlimited
fundingcanhave an importantimpact,because theysetrealisticgoalsof whattheycouldachieve (in
thiscase,change the foodconsumptionpatternof school childrenfromprocessedfoodtohealthy,
nutritiousfood).

1. Why should agricultural or rural development programs include nutrition?
The main reasonwhyagriculture andrural developmentprogramsshouldincludenutrition isbecause
agricultural andrural developmentprogramsare neededtoimprove foodsecurityandnutrition.
Secondly,comparedtootherAsiancountries foodinsecurityandmalnutritionrates are still highin
Myanmar withmillionsof Myanmar’spopulationbeingfoodinsecure and/ormalnourished.Thirdly,
researchhas shownthatincludingnutritioninagricultural orrural developmentprogramsimprovesthe
qualityandthe impactof the program. These are importantreasonswhy itisnecessary,effectiveand
recommendabletoinclude nutritioninagricultural andrural developmentprograms.
Agricultural and rural development programs are needed to improve nutrition
There isa misconceptionthatnutritioncanbe done byhealthprogramsalone.Healthprogramscannot
improve foodavailability,norimproveproductionof nutritiousfood,norimprove people’sincomeso
theycan affordto produce or buysufficientandqualityfood.Toimprove nutrition,eachhousehold
wouldneedtohave accessto locallyavailableandaffordablenutritiousfood.Withoutthat,the
foundationof goodnutritionismissing.
Healthprogramscan create awarenessaboutthe importance of healthyfood,butthatwouldonlymake
sense if people couldactuallyaccessthese kindsof foodsyear-round.Healthprogramscanfindoutwho
isseverelymalnourishedandthenprovidetherapeuticfeeding,vitaminpillsorextrafoodpackages,but
those are costlyactivitieswhichcreate dependenciesaswell.Toeffectivelyimprove nutrition,we need
agricultural andrural developmentprogramstothinkaboutnutrition.
Many FSWG memberorganizationsaimtoimprove foodsecuritythroughtheiragricultural andrural
developmentprograms.The mostcommonlyuseddefinitionof foodsecurityisbasedonthe definition
fromthe 1996 WorldFoodSummit:
Food securityat the individual,household,national,regional andglobal levelsisachievedwhenall
people,atall times,have physical andeconomicaccesstosufficient,safe andnutritiousfoodto
meettheirdietaryneedsandfoodpreferencesforanactive andhealthylife.
Many programs ‘only’focusonensuring sufficientfoodisavailable andaccessible;forexampletheyask
beneficiariesif theyhadenoughfoodinthe past12 months.If the program managesto reduce the
numberof monthsof foodinsecurity(orhunger),thatis a goodachievement.However,lookingatthe
above definition,foodsecurityalsoincludes whetherhouseholdshave accessto safe andnutritious food
for eachfamilymember;isitlocallyavailableandcanpeople affordit?
To ensure foodisaccessible ‘atall times’,we have tolookatseasonalityof foodsandimprove year-
roundaccess by promotingadiversity
of foods.
Finally,the definitionof foodsecurityalsoincludesthatall peopleshouldhave accesstofoodthatmeets
theirdietaryneedsandfoodpreferencesforanactive and healthylife. The dietaryneedsthatpeople
have differdependingontheirage,theirworkorfor example if theyare pregnant.Childrenwhogrow,
people whoare involvedinlabour-intensivejobsandpregnantmothershave higherdietaryneedsthan
otherpeople.Foodsecuritytherefore isonlyachievedwheneachpersonhasthe sufficientquantityand
qualityof foodtheyneedtobe healthyandactive.
Foodsecurityisnot yetachievedif people have justenoughfoodtosurvive.

Whatis the difference between Foodsecurity and Nutritionsecurity?
Foodsecurity isfullyachievedwhenthe availability andaccessto (sufficient,safe andnutritious) foodis
ensured.
Nutritionsecurity isfullyachievedwhen,inadditiontothe availabilityandaccesstofood,all people
actually eat(foodintake) andtheirbodies use (foodutilization) the foodthatisneededforanactive and
healthylife.
Foodsecurityfocusesonavailabilityandaccesstofood;whichisprimaryrelatedtoagricultural
production,home gardening,fruit-trees,livestock,fishing,aquaculture aswell asanykindof supportto
livelihoodswhichwill improve people’sresourcestobuydifferentkindof foods.Agriculturalprograms
therefore playaveryimportantrole inimprovingfoodsecurity,whichhealthprogramscan’t.
Healthand nutritionspecialists onthe otherhand know how to improve actual consumptionof different
foodsandoptimumuse of nutrientsbythe body.To improve use of nutrientsbythe body,the nutritious
dietneedstobe complementedwithasanitaryenvironment,adequatehealthservicesandcare;if
people drinkdirtywaterorare sick,theirbodiesdonotabsorbthe nutrientsverywell,eventhoughthey
mighteat healthyfood.Therefore,toimprove nutritionsecurity,differentsectorshave towork
together.
FAOdefinitionof nutritionsecurity:
Nutritionsecurity: ‘A situationthatexistswhensecure accesstoanappropriatelynutritiousdietis
coupledwithasanitaryenvironment,adequatehealthservicesandcare,inorderto ensure a
healthyandactive life forall householdmembers’.
Agricultural programsare notonlyneeded,butcrucial toimprove nutritionandtoaddressthe
underlyingcausesof under-nutrition.Withoutsufficient,year-roundlocallyavailable safe andnutritious
food,itwill be extremelydifficulttoimprove nutrition.
Annex Ishowsthe conceptual frameworklinkingfoodavailability,foodsecurityandnutrition.
Food insecurity and malnutrition rates are high in Myanmar.
As explainedabove,foodsecurity isfullyachievedwhenthe availability andaccessto(sufficient,safe
and nutritious) foodisensured.Howisthe foodavailabilityandaccessinMyanmar?
Foodavailabilityislinkedtolocal foodproductionandavailabilityof foodinlocal marketsor natural
resourceslike forests. FoodproductioninMyanmarisdevelopingwithupdatedtechniques,new(high-
yielding) varieties,and large-scale agricultural supporttoimprove production.Atthe same time,food
productioninMyanmar isthreatenedbyclimate change andrelatedwatershortages,persistent
conflictsandemergencies, landrightsissues andnatural disastersaffectingagriculture productionand
yields. These challengesare compoundedbychangesindemandforfoodthatare broughtaboutby
growingpopulations,increasingincomesand urbanization.
Particularlysmall-holderfarmersandfarmersinremote areas have more difficultiestoovercome these
challengesastheydon’thave the resourcestopreventormitigate them.Similarly,the poorest
householdswithoutaccesstolandhave difficultytobuyenoughfoodtofeedtheirfamilies.

Furthermore,natural resourcessuchasforestsandfishstockare declining,furtherhamperinglocal food
availability.
The MDG Data Reportof the IntegratedHouseholdLivingConditionsSurveyinMyanmar(2011) states
that the proportionof the populationlivingbelow the minimumlevel of dietaryenergyrequirements is
5% in 2010. With currentpopulation1
of 51.5 M people thatwould meanthat2.6 M people in-country
lack enoughfoodtomeettheirenergyrequirements. Notethatenergyrequirementsare relatedto
macro-nutrients(protein,carbohydratesandfat) whichprovideenergytothe body. Withoutsufficient
macro-nutrientswe donothave enoughenergyandwill feel hungry.
In addition,we alsoneedmicro-nutrients(vitaminsandminerals)whichsupportdifferentprocessesin
our bodies;suchasensuringourheart andnervoussystemisworkingwell oroureyesare functioning
well.People donotfeel hungryif theymissnecessarymicro-nutrients,whichisalsowhyitiscalled
‘hiddenhunger’.However,theymightexperience thatcertainpartsof theirbodyare not workingwell.
In severe casestheymaybecome blind(lackof vitaminA) ortheymayevendie if theirheartfailsto
work(lackof vitaminB1).
The table belowshowsthatinMyanmar, malnutritionisacombinationof bothmacro- andmicro-
nutrients deficiencies.
Myanmar2
Childrenunder5 35.1% stunted(height forage)
7.9% wasted(weigh forheight)
22.6% under-weight(weightforage)
8.6% of babiesbornwithlow birthweight(lessthan2,500 gram)
75% hasiron deficiency(notenoughiron)
5th
leadingcause of deathof children1-12 monthsisberiberi
(notenoughvitaminB1,whichisalsocalled thiamine)
2% are overweight
Pregnantwomen
Non-pregnant
women
Adolescentgirls
71% irondeficiencyanemia(notenoughiron)
45% irondeficiencyanemia(notenoughiron)
26.4% irondeficiencyanemia(notenoughiron)
Adultmen 20.5% are underweight(<18.5 body massindex)
Adultwomen 21.7% are underweight(<18.5 bodymassindex)
Stunting, wastingandunder-weightare the mostcommonindicatorstocheckif a childismalnourished.
Stuntingor ‘heightfor age’; To check if a childisstunted(toosmall foritsage),we measure itsheight
and thencompare itto the expectedheightforthatage (heightforage). If a childisstunted,itmeans
that a childdidnot getenoughnutritious foodoverarelativelylongperiodand/orhasbeensick
repeatedly.Stuntingreflectschronicmalnutrition.
Wastingor ‘weightfor height’;To see whetherachildiswasted,we can compare itsweighttoits
height(weightforheight). Wastingisasignof acute malnutrition;itmeansthata childdidnot have
enoughfoodrecently andislosingtoomuchweight.
Under-weightor ‘weightfor age’; To check if a childisunder-weight,we measure itsweightandthen
compare it to the expectedweightforthatage (weightforage). Thisindicatormeasuresthe
combinationof recentand long-termunder-nutrition.
1 Population census 2014
2 National Plan of Action for Food and Nutrition 2011 – 2016,Myanmar

Most statesin Myanmar showstable ordecreasingstuntingrates3
,exceptforChin,Rakhine andNorth
Shan where stuntingrates are the highestof the countryandalso have increasedto40 - 50%.
The World HealthOrganization (WHO) classifiedthe severityof malnutritioninapopulationof children
as showinthe table below.
Indicator Prevalence
Low Medium High Very high Myanmar
Stunted
(heightforage)
< 20 20-29 30-39 40 35.1%
Wasted
(weightfor
height)
<5 5-9 10-14 15 7.9%
Underweight
(weightforage)
<10 10-19 20-29 30 22.6%
Thisshowsthat inMyanmar stuntingandunder-weightratesare high,while wastingratesare medium.
Highstuntingandunder-weightmeansthata highnumberof childrendidnotgetenoughfoodforover
a longerperiodof time.
In additiontoinfantsandyoungchildren,one outof five adultsinMyanmarisunder-weight,whileiron-
deficiencyiswide-spreadamongwomen,particularlyif theyare pregnant.Pregnantandlactating
womenneedmore nutritiousfoodthanotheradults.If theycannotaccesssufficientandhealthyfood,
theirreserveswillbe depleted,evenmore soif theyhave more childrenclose together.Thiswill not
onlyaffectthe mother,butalsothe children.
Lookingat micro-nutrients,the biggestdeficienciesare ironandvitaminB1(alsocalledThiamin).
Iron deficiencyisveryhighinMyanmar,despite ironsupplementation4
forpregnantwomen, adolescent
girls,andchildren.Ironisneededforoxygentransportandstorage inmuscles,ironimprovesimmunity,
isrequiredforgrowth,energyproduction,drugmetabolismandpropermental functioning.People who
lack ironexperience reducedphysical andmental performance,fatigue,poorcirculation,depression,
decreasedresistancetoinfectionandillness. Irondeficiencyasfetusorchildunderthe age of 2 has
seriousconsequencesand hampersbraindevelopment,whichcannotbe compensatedanymoreafter
the age of 2.
VitaminB1 (or Thiamine) isneededforenergyproduction,growthinchildhoodandfertilityinadults.It
maintainsahealthyheartandnervoussystem. Infantmortality(childrendyingbefore theirfirst
birthday) is highinMyanmar with44.9 childrendying outof 1,000 who were bornalive. The 5th
cause of
deathfor infantsisheartfailure due tolackof vitaminB1.
3 MICS 2009:
4 Iron supplementation is provided by the Health facilities for free (usually pillswith daily rateof iron needed).

Nutrition improves your program.
Optimumnutritionhasawide range of impactswhichwill improve yourprogram andthe livesof the
beneficiaries:
↓sicknessand
deathsof
children
↑brain,body,
socio-
emotional
development
↑school
performance
and learning
capacity
↑ adultheight
↓ overweight
and non-
communicable
diseases
↑workcapacity
and
productivity
Good nutritionisthe foundation of humanwell-being.Before birthandthroughoutinfancy,good
nutritionallowsbrainfunctioningtoevolve withoutimpairmentandimmune systemstodevelopmore
robustly.Foryoungchildren,goodnutritionstatusavertsdeathandequipsthe bodytogrow and
developitsfull potential.Overthe course of the humanlife-span,itleadstomore effective learningat
school,better-nourishedmotherswhogive birthtobetter-nourishedchildren,andadultswhoare
likeliertobe productive andearnhigherwages. Inmiddle age,itgivespeople metabolismsthatare
betterpreparedtoward off the diseasesassociatedwithchangesindietandphysical activity.Without
goodnutrition,people’slivesandlivelihoodsare builtonquicksand.
Researchhasconfirmedthat optimumnutritionleadsto:
1. lesssicknessanddeathsinchildren,2.smarter,healthier,social andstrongchildren,3.better
performance inschool andlearningingeneral.Inaddition,ithasbeenproventhatwhenchildrenhad
optimumnutrition,iteveninfluencesthemwhentheyare adults;4.theywill become tallerand have
lesschance of beingoverweightorgettingnon-communicable diseases(suchasheartdisease) and5.
theywill have betterworkcapacityandare more productive.
If we docommunitydevelopmentwork,andparticularlyagriculture andlivelihoods,we needourtarget
groupsto be healthyandstrong. If people have improvedhealthandnutritionstatusitwill helpto
reduce costsfor healthcare and will improve theirschool andworkperformance. Therefore,including
nutritioninyourprogramswill improve yourimpact.
Myanmar government have joined nutrition initiatives such as SUN and Zero Hunger
challenge
ScalingupNutrition(SUN)
ScalingupNutrition(SUN) isa global movementwhich unitesgovernments,civilsociety,businessesand
citizensinaworldwide efforttoendunder-nutrition.SUN waslaunchedin2010 and Myanmar joinedin
2014. The SUN StrategyincludesaRoad Map to significantlyreduce under-nutritioninparticipating
countries.The SUN movementiscountry-drivenandbuildsonprogressachievedincountry.
Countriesinthe SUN movementare increasingpeople’saccesstoaffordable nutritiousfoodandother
determinantsof nutritional statussuchascleanwater,sanitation, healthcare,social protectionand
initiativestoempowerwomen.Theiraimistocollectivelymeetthe globaltargetsagreedatthe 2012
WorldHealthAssembly(includinga40% reductioninthe numberof stuntedchildrenby2025).
Political commitmentof the participatingcountriesistransformedtoeffective actionbyunitingefforts
across disciplinesandsectors,byadoptingmethodsthathave proventobe effective,bylearningfrom
available bestpracticesandbymobilizingsufficientresourcestoachieve measurable results.

SUN countriesaimtoachieve theirnutritiongoalsthroughtwostrategicapproaches:1.Scalingup
nutrition-specificinterventionsthathave proventobe effective,and2.implementingsectoral strategies
that are nutrition-sensitive.
Nutrition-specificinterventionsare interventionsthatdirectlyinfluence nutrition;these include
feedingpractices(includingbreastfeeding,nutrient-richfoods),eatingroutines,care-giving
practices,andburdenof infectiousdisease.Examplesof nutritionspecificinterventionsare:
adolescenthealthandpre-conceptionnutrition,maternal dietarysupplement,micro-nutrient
supplementationorfortification,breastfeeding,infantandyoungchildfeeding,dietary
diversification,treatmentof severemalnutrition,disease preventionandmanagement,nutrition
interventionsinemergencies.These examplesshow thatnutrition-specificinterventionsare usually
done byhealthprograms,althoughnotexclusively.
Nutrition-sensitiveinterventionsare interventionsthataddressunderlyingcausesof malnutrition;
these include foodsecurity,foodavailability,economicaccessto food,resourcesforfeedingand
care-givingpractices(formothers,households,community-level) oraccessto andthe use of health
services,asafe andhygienicenvironment.Examplesof nutrition-specificinterventionsare:
agricultural andfoodsecurityprograms,social safetynets,earlychilddevelopment,women’s
empowerment,childprotection,education,water&sanitation,healthandfamilyplanning.These
examplesshowthatnutrition-sensitiveinterventionsare done bya varietyof sectors.
Zero hunger challenge
Myanmar’s Ministryof Agriculture andIrrigation(MoAI) andthe UN,withsupport of FAOhave launched
the National ZeroHungerChallenge onWorldFoodDayinNovember2014. The challenge wantsto
ensure thateveryman,womanand childenjoytheirRighttoAdequate Food;thatwomenare
empowered;thatpriorityisgiventofamilyfarming;andfoodsystemseverywhere are sustainable and
resilient.The ZeroHungerChallenge means:

2. What are FSWG member organizations doing innutrition?
All FSWG memberorganizationsreceivedawelcomequestionnairetoparticipate inthe nutritionstudy.
Out of 120 organizations,we received29 filledinquestionnaires,whichisjustunderaquarter(24.2%)
of all FSWG members. Therefore,the resultsbelow mightnotfullyrepresentall FSWGmembers.
Most of the respondingFSWGmembersare involvedinvegetable growing(69.0%) or sustainable
agriculture (65.5%).Agro-forestryandrice production(both58.6%) are alsocommonactivities. Around
half of the respondingorganizationssupportfruit(55.2%),animal husbandry/dairy(51.7%) or agri-
businesses(51.7%).A limitednumberof organizationsare involvedinfish/aqua-culture oragricultural
research(both17.2%).
Only38% of FSWG respondsare involvedinPrimaryHealthCare,while overhalf are doingWASH
(55.2%),Natural Resource management(51.7%),micro-finance orsavinggroups(55.2%) or women
empowerment(58.6%).
As manyas 62.1% of respondingorganizationsconfirmthattheyhave nutritionasa cross-cuttingissue
intheirprojects.However,onlyafewactuallydescribewhattheydo: one organization integrates
nutritionsessionsintheirFarmerFieldSchool sessionsand twointheirhome gardeningactivities.
AnotherorganizationdoesaSchool feedingprogram.
Similarly,62.1%of organizationssaytheydoinnovative nutritionactivities,however these are slightly
differentorganizationsthanthose whohave nutritionascross-cuttingissue;41.4% of organizations
have bothnutritionascross-cuttingissue andhave innovative nutritionactivities.Only nine
organizations describedclearlywhattheirinnovativeactivitiesinclude:one organizationbasedtheir
projectactivitiesonacomprehensive initialassessmentincludingassessingnutritional statusof children
undertwo,micro-nutrientsdeficiencies,foodconsumptionpatterns/dietaryintake/care practices,
barriersand positive deviance,andalsoidentifiedmicro-nutrientrichcropsandassessedwildfoods.The
same organizationalso doesnutritionscreeningtobe able tomeasure the impactof theirFoodSecurity
Livelihood/WASHprogramonnutritional status.A secondorganizationalsodidacomprehensive
assessmentandhasdevelopedBehaviorChange Communication(BCC) strategiesfornutrition,which
are implementedthroughaninnovative approachandFoodSecurity/Livelihoodstaff mainstreamBCCin
theiractivities.A thirdorganizationisinvolvedinraisingindigenouschickeninthe DryZone,while a
fourthorganizationdoesinnovativevegetable productionincontainersforlandlessorlandpoor
households.Anadditionalfourorganizationssaythattheypromote nutritiousvegetablesand/orfruits
insteadof traditionallygrownvegetables. Finally,one organizationisinvolvedinproducingfortifiedrice.
The numberof organizationswithnutritionobjectivesissubstantiallylowerat31.0% and onlyfour
organizationsdescribetheirnutrition-relatedobjectiveswhichtypicallyinclude improve knowledgeon
nutrition,diversifyingdietsand/orimprovingconsumptionof nutrients.One organizationalsonotices
the importance of landsecurityandeconomicinstruments(savinggroups,healthinsurances,rice banks)
inrelationtofoodsecurity.Onlyone organizationmentionsthattheirobjective istotreatmalnutrition
and to addressunderlyingcausesof malnutritionthroughamulti-sectoral approach.
Nearlyhalf of respondingFSWGmembersmeasure (1) foodavailabilityathouseholdlevel, (2)
householdcopingmechanismsduringfoodcrisisand (3) foodconsumptionhabitsinthe household
(suchas HDDS: Householddietarydiversityscore,HFIAS:HouseholdFoodInsecurityaccessscale,
nutritiousfoodormicro-nutrientconsumption).

Some 38% of organizationsdo (4) growthmonitoringof children(weight,length) and(5) monitor
breastfeedingpractices.Only21%of organizationsmeasuresdiarrheaprevalence.
To conclude;FSWG memberorganizationsare involvedinavarietyof projectsthatare interestingfrom
a nutritionperspective astheycoverdifferentfoodgroups:vegetables,fruits,crops,forestproducts,
meat,and fish.Asmanyas 62% saytheyhave nutritionasa cross-cuttingissue,62% doesinnovative
nutritionactivities,while31%has nutritionobjectives.Nearlyhalf of organizationsmeasurerelevant
nutritionindicatorssuchasfoodavailability,copingmechanismsduringfoodshortage andfood
consumptionhabits.
These figureswouldsuggestthatnutritionisintegratedwitharound half of the FSWGmembers,
howeverthere are afewthingsto keepinmind.Firstof all,onlylessthanone quarterof all FSWG
membersrespondedandfilledinthe questionnaire.Itmightbe thatorganizationswhodonutrition
wouldrespondwhileorganizationswhodon’tdonutritiondidnotrespond.Thiswouldover-represent
the proportionof organizationsinvolvedinnutrition.Furthermore,onlyafew organizationswere
actuallyprovidingexamplesof nutritionactivities/objectives.E.g.62% said theyhave nutritionasa
cross cuttingissue butonly 4 organizationsmentionedwhattheydid.
Therefore,itislikelythatthere is a lotof room to increase nutrition-relatedactivitiesamongFSWG
members. Withmostmembersalreadyworkingonfoodsecurity,foodavailability,economicaccessto
food,andover half workingonwaterandhygienicenvironment,itwouldbe mostsuitabletopromote
nutrition-sensitiveactivities first.These are activitieswhichaddressthe underlyingcausesof
malnutrition.

3. What are the barriers for organizations toinclude nutritionintheir
programs?
Barrieranalysisinterviewswere done with fourorganizations,bothnational andinternational.Similarto
the welcome questionnaire itwasdifficulttofindrespondentsandsome didnotwantto participate.It
mightbe that some organizations/staff didn’twanttoparticipate inthe surveybecause they don’tdo
any nutrition-relatedactivities orhave anyexperience orknowledgeonnutritionatall.Thiswas
confirmedbyone of the barrieranalysisinterviews;the participantsaidthattheyare notaware of
malnutritionintheirtargetarea,thattheydon’tknow muchabout nutrition,thatit’sa healthrelated
issue andthat not manylivelihoodorganizationsare involvedinnutrition.
Althoughthe numberof organizationsissmall,theirresponsesgive some insightsintothe actual
barriersthat organizationsface. Organizationswhoreceivednutrition training(eitherbyLEARN orby
FSWG) butwhodid notinclude nutritionintheirprogramwere selected.
Participantswere asked about their perceptionof how seriousmalnutritionisinMyanmar or intheir
target area.
In general,participantshadthe impressionthatmalnutritionisamoderate issue formostpeople anda
seriousissue forcertaingroups.Some perceivedthatnoadultsintheirtargetareawere malnourished
althoughforchildrenitwasrecognized.Others thoughtthatnoadultsor nochildren intheirtargetarea
are malnourished,butalsoaddthatthis isbecause the communitycannotdefinemalnutrition. One
participantstatesthatsince theyare notexperts,itisdifficulttotrulysayif malnutritionisaproblemor
not.
Lack of understandingwhatmalnutrition isorhow to define it,how tomeasure it,aswell as
understandingof the severityof the probleminMyanmarisan issue.Therefore,itisimportantto
explainclearlywhatmalnutritionisandhow manypeople (adultsandchildren) are affectedin
Myanmar. Thisshouldbe done at communitylevel aswell asstaff level.
Participantswere asked about the efficacyof nutritionprograms: ifthey thoughtthat by including
nutritionintheir programs,the qualityoftheir program wouldimprove. Or ifby includingnutrition,
beneficiarieswouldhave improvedtheir foodsecurity andwell-being.
Participantsagreedthatincludingnutritionwouldimprove the qualityof theirprogramsanditwould
alsoimprove the beneficiaries’foodsecurityandwell-being. The participantswe spoke showedthat
theyhad goodunderstandingthatnutritioncanonlybe improved if the programwouldinclude nutrition
objectivesandwould addressactual problemsthatleadtofoodinsecurityormalnutrition. Some
participantsmentionedthataddingnutritionwould actually verywell fitwiththeircurrentworkon
improvingfoodavailability,especiallythe projectsonfarmingandhome gardening.
Selectedparticipantshadgoodunderstandingof the differencebetweenfoodsecurityandnutrition
security.Goodunderstandingof the difference betweenfoodavailability,foodaccessandfood
utilizationandconsumption.Furthermore,theywere aware of the importance of differentsectors
that are neededtoimprove nutrition.Theyagreedthatincludingnutritionwouldimprove the
qualityof theirprogram.
Note that those organizations/people thatwouldhave lessgoodunderstanding mighthave declined
our requesttoparticipate inthe barrieranalysis.

Participantswere asked if manyagricultural organizationsaremainstreamingnutritionintheir
programs.
Participantscommonlyagreedthatonlyafew organizationsare reallymainstreamingnutritionin
agricultural programsandthat onlybiggerorganizationsworkonnutrition. One participantsaidthat
evenafterreceivingnutritiontrainingnotmanyorganizationsadoptedit. Theymentionedthatmost
agricultural programsfocuson foodavailabilityandaccess(foodsecurity).
Participantsthoughtthatnotmany agricultural programsmainstreamnutrition,evenaftertraining.
Participantswere asked if they thoughtthat their organizationwouldbeable to implementnutrition-
related activities,consideringtheirknowledge,staff,and resources.
Participantsagree thatsome nutrition-relatedactivitiesare easytoimplement; forexample conduction
awarenesstraining,formingwomensupportgroups,organizingcookingdemonstration,supporting
home gardenor animal breedingwithmore nutritiousfoods. Some participantsthinkthatitismore
difficulttochoose the rightactivitiesorto choose andmeasure nutritionindicators.Tobe able todo it
well,additional technical personswhoknow aboutnutritionwouldbe needed. Itseemsthat
organizationsonlyhave afewstaff whocouldimplementnutrition-relatedactivitiesandsome even
have no staff at all.All agree thatmore intensive trainingisneededaswell asaccesstoIEC materials.
Participantscommonlyagree thatitisfairlyeasytoimplementseveral nutrition-relatedactivities.
Theythinkitis more difficulttoselectthe rightactivitiesandtotrulyhave an impacton nutrition;to
do that,theirteamswouldrequire more trainingoraddnutritionstaff totheirteam.
Participantswere asked about anycues for action
Participants were notconvincedthattheirtargetcommunitiesaskfornutritionactivities,exceptmaybe
for home gardenactivitiesandanimal husbandryfortheir children’snutrition.Forthe international
organizationthe HQoffice didnotinclude nutritionintheirstrategy,therefore,nutritionhadnotbeen
promotedbythe management.
To promote inclusionof nutrition,itisimportantthatcommunitiesclearly know the causesand
effectsof malnutritionotherwisetheywill notrequestsupporttoimprove nutrition.
It ismore likelythatthe managementof organizationssupportsthe inclusionof nutritionif
organizationshave includednutritionintheirstrategyorpolicydocuments.
Participantswere asked about positiveandnegative attributesto includenutrition
Participantsknowwhere togetadvice onnutrition;LEARN,WHOand MoH were mentioned. Similarly,
participantsalsoconfirmedtheyare able toattendtrainingsonnutrition.Fundingfornutrition is
accessible through3MDG and LIFT funding.Interestingly,whenaskedif the participantswouldliketo
add nutritiontotheirprojects,theyall confirmedthattheywouldlikethat.
Participantsare positive aboutaddingnutritiontotheirprojects andhave several ideashow tostart.
Furthertechnical supportisneededaswell asimprovedexpertise andstaff withinthe organization.
Thisis more likelytohappenif there isanorganizational commitmenttoinclude nutrition.

4. How to integrate nutritioninagricultural /rural development programs?
Recommendations from literature review
An additional investmentof US$ 8 billionperyear globallywouldreduce the numberof under-weight
childrenby10 millionandof hungrypeopleby201 millionby20505
. Note that agricultural production
mightsolve the problemof scarcityof caloriesorenergy(hunger) butnotthe problemof scarcityof
access to nutritiousanddiversediets.A new emphasisonmakingagricultural systemsandfoodand
agricultural policiesmore nutrition-sensitive iscalledfor.
All literature sourcesagree thattargetedagriculturalprogramscanhave a large role in supporting
livelihoods,foodsecurity,dietquality,andwomen’sempowerment,andinachievingscale andhigh
coverage of nutritionallyat-riskhouseholdsandindividuals. Increasingthe availabilityandconsumption
of nutrient-richfoodsthroughahousehold’sownproductionisconsideredtobe a sustainable approach
because the processempowershouseholdmembers,particularlywomen,totake ultimate responsibility
for the qualityof the dietof the householdsthroughtheirownproductionandimprovednutritional
knowledge.
Belowanoverviewof approachesandactivitiesthathave proventobe effective aswell aslessons
learnedtoimprove programquality.
Food-basedapproaches
Food-basedapproaches6
–asthe name says- meanto solve foodinsecurityandmalnutritionwith food,
as opposedtomedicines,ready-to-use-therapeuticfood(RUTF’s) orpills. Inthe case of Myanmar – with
highnumbersof stuntedandunder-weightchildren –childrenlackedfoodforalonger-periodof time
and thissuggeststhatthere isa structural problem. Structural problemsshouldbe solvedbystructural
solutions;improvingyear-roundaccesstonutritiousfood.
Severelywastedchildren(acute malnutrition)needtherapeuticfeeding.Also,pregnant/ lactating
womenwhoneedhigherthannormal amountsof nutrientsneed supplements. However,these
treatmentsshouldnotbe usedtosolve all nutritionproblemsbecause of severalreasons:theyare
expensive,theycreate dependencies, andthey cannotreachall people whoneedit (somepeople
cannot accesshealthcare but alsono governmentororganizationcouldaffordtoreachall people).
Equallyimportant,theymightreplace healthyandexistingfeedingpractices.
The advantagesof food-basedapproachesare thattheyare:affordable,sustainable andlongerterm,
have social,cultural,economicand environmental benefits,andare local and nottop-down.
5 Lancet series #3, nutrition-sensitiveinterventions and programs,June 2013
6 Improvingdiets and nutrition:food-based approaches,FAO 2014

Settingthe right goals and objectives
As explainedearlierinChapter1,there isa cleardifferencebetweenFoodSecurityandNutrition
Security. Foodsecurityis achievedif all people have accesstosufficient,safeandnutritiousfood.
Nutritionsecurity isone stepfurtherinthat besidesaccess,people actually choose toeatandtheir
bodiesactually use the foodtheyneedtolive ahealthyandactive life.
To improve nutritional status,we need toensure people’sbodiesuse the nutrientstheyeatwell.This
meansthat inadditiontoeatinghealthyfood,theyneedto have accessto cleanwater,have good
hygiene andsanitation,andhave accesstohealthcare (to cure diseaseswhichhampernutrientintake)
as well.
Therefore,nutritionalstatus(suchasheight,weight)can only be improvedif we addressall these issues
together.
Dependingonourprogram,we have to thinkwhichgoal we can achieve:
Program Goal
Agriculture Improve year-roundavailabilityof sufficient,safe andnutritiousfood
Improve year-roundaccesstosufficient,safe andnutritiousfood
Agriculture plusnutrition
education
Improve dietarydiversityscores
Improve dietaryenergysupply perperson(kcal)
Improve share of dietaryenergysupplyfromnon-staples
Agriculture,nutrition
educationpluswashand
healthprograms
Improve nutritionalstatus,suchase.g.:
- Reducedstunting
- Reducediron-deficiencyanemia
- Reducedinfantberi-beri (vitaminB1deficiency)
The table showsthat agriculture isthe foundationonwhichthe otheractivitiesbuild;withoutyear-
roundavailabilityof sufficient,safe andnutritiousfood,we cannotimprove people’sdiets.
The above table alsoclearlyshows thatif we ‘only’doagriculture withoutanynutritioneducationor
otherrelatedactivities;we willnotbe able toreduce stuntingratessubstantially.Thisissomethingthat
isshownagainand again inresearchand literature.
Therefore,eachprogramandorganizationhasto decide forthemselveswhattheywanttoachieve.
Evenif you prefertofocuson agriculture alone,youcanthinkaboutwaysto improve year-roundaccess
to foodand waysto increase adiversityof foodsources.Thatwouldbe your(important) contributionto
improvingnutrition.
To furtherimprove the impactof yourprogram, youmightconsiderlinkingwithanorganizationwhois
involvedinhealth,washandnutrition.

Improve knowledge of and access to storage facilitiesand saving & loan groups
Storage facilities(suchasrice granaries) helphouseholdstoovercome the leanseasonandimprove
year-roundaccesstofood.The storage facilitiesensurethatfarmersdonotneedto sell straightafter
harvestwhenpricesare low. Also,combiningastorage witha saving/loangroupsuchas a Rice Bank
helpsfarmerstoaccesslow-interestloansintimesof need. Additionally,farmerscanuse the affordable
loansto purchase farminputsas well. Post-harvestsupport,including foodprocessingand
transportationmightfurtherincrease the price farmersgetfortheirprojects.
Improvedpricesandreduceddependence onhigh-interestloans,freesuphouseholdmoneytogrowor
buynutritiousfoods.Properstorage andprocessingcanimprove foodsafetyaswell.
Productionsurplusesare oftenlostasa resultof poor harvestingpracticesandinadequateprocessing,
packaging,storage andpreservationtechniques.Postharvestlossescanbe especiallyhighformicro-
nutrient-richfoods,whichare highlyperishable andlose substantialamountsof vitaminCand
carotenoids(pre-vitaminA) afterafewdays.Strategiestoreduce postharvestlossesthatare low-cost
and appropriate forsmallholdersdoexist.Forexample,solardryingof carotene richfruitsand
vegetables(e.g.mangoes,pumpkinsandorange-fleshedsweetpotatoes) canpreservevitaminA levels
for upto 6 months.Simple solardryingcanbe usedforgreenleafyvegetables,whichare typicallyhigh
iniron andpossiblyvitaminC.
Improve home garden practices
HelenKellerInternational(HKI)7
hasbeenable toimprove householdgardenpractices indifferent
countries. Inmostrural areasin Asia,home gardeningisalreadycommonpractice;however,the
gardensdo notofferadequate nutritiousyear-roundproducts.HKIhasclassifiedthree categoriesof
householdgardens:‘traditional’,‘improved’and‘developed’.
Traditional gardens Are seasonal,oftenmaintainedonscatteredplotswithafew traditional
fruitsandvegetables.
Improvedgardens Are maintainedonfixedplotsthatproduce more varietiesof fruitsand
vegetables,butonlyduringcertaintimesof the year.
Developedgarden Are maintainedonfixedplotsandproduce adiversifiedvarietyof fruits
and vegetablesthatare available year-round.
Usingcategorieshelpstosee if yourbeneficiarieshave improvedyear-roundaccesstonutritiousfoods.
The model encouragesboththe improvedanddevelopedgardens,butpromotesandassistshouseholds
to ultimatelyestablishthe developedtype of garden.HKIcombinesthe home gardensupportwithsmall
animal husbandry(poultry).The reasontoinclude animal husbandryisbecause the bio-availabilityof
micro-nutrients(suchasvitaminA andiron) islowerfromplantfoodsand higherfromanimal sources.
7 Contribution of homestead food production to improved household food security and nutrition status;lessons
learned from Bangladesh,Cambodia,Nepal and the Philippines.

The model worksbyprovidingtechnical assistance,training,agricultural suppliesandmanagement
supportto primarilywomenfarmersfrompoorhouseholds.
A village modelfarmisestablishedinthe targetcommunitytoserve asa continuouscommunity-based
resource forthe supplyof seeds,seedlings,saplingsandchickstoparticipatinghouseholds fortheir
year-roundfoodproduction.Thesealsoworkasfocal pointfordemonstratingagricultural methodsand
providingtraining,aswell astocoordinate women’sgroupsof producersandlinkthemtohealthand
agricultural servicesaswell astomarkets.
The majorityof HKI programs are implementedwith3to4 yearsof support,afterwhichsuchsupportis
withdrawnandthe communitytakes over.
In additiontoyear-roundaccesstonutritiousfood,HKIalsomanagedtoimprove dietarydiversity
scores,increase householdincomeaswell asimprove nutritionalstatus(reducedchildanemia) withthis
approach.Theymanagedto achieve thatbyspecificallyencouragingmicro-nutrientrichfruitsand
vegetables,increaseyear-roundproductionof poultryandeggs,improve consistentconsumptionof
fruits,vegetablesandanimal source foods.Thesewere combinedwithbehavioral change
communicationtoensure optimal care,feeding,hygieneanddisease preventionpracticesandto
stimulate demandforprimaryhealthservices.
Improve animal production
Animal source foods(ASFs),particularlymeatof awide variety,fish,fowlmeat,milk,eggs,snails, worms
and othersmall animalssupplynotonlyhigh-qualityandreadilydigestedproteinandenergy,butalso
readilyabsorbable andbio-available micro-nutrients.The inclusionof ASF’sinthe dietpromotesgrowth,
cognitive function(brainfunction),physical activityandhealth,andisparticularlyimportantforchildren
and pregnantwomen.Evenmodestamountsof meatandotherASFsinthe dietfroma varietyof
sourcescan greatlyimprove the overall nutritionandmicro-nutrientstatus.
ASF’shave proventosubstantiallyincrease test-scoresof school children;withgreatesteffectfrom
meatand still agood effectfrommilk.Milkconsumptionwasfoundtoimprove bothweightgainand
growthin the stunted children andyoungerchildren. Supporttohouseholdanimal productionwith
nutritioneducationleadtoreduceddiarrheainfections,respiratoryinfections,pneumoniaandstunting.
Animal source foodsare richersourcesof specificmicro-nutrients,particularlyiron,zinc,riboflavin,
vitaminA,vitaminB12 and calciumthanare plantfood. Note thatmeat andmilkhave differentnutrient
mix and therefore,milkcannotsubstitute meat. The relativelyhighfatcontentof animal source food
increasesitsenergydensity,whichisveryuseful inyoungchildrengiventheirsmall gastricvolume
(small stomach).
While the positiveimpactonnutritionisclear,there are some difficultieswith raisinganimals.Animals
needgrazingland,water,feedandimmunizations,whileveterinarycare isnotwidelyavailableinrural
areas.
Successful/innovative programsincluded:trainingandutilizationof community-basedwomenanimal
healthworkers.These womenveterinarianstrainlocal womentotake care of animals,provide simple
treatmentsforminorconditionsandcarryout immunizations.

Anotherproblemwithrearinganimals,includingfish,forconsumption,isthe needforpreservationof
the meat topreventspoilage inthe absence of refrigeration.Smokingandsolardryingare common
optionsforproducingsafe,shelf-stableproductsundercontrolledconditions.
Anotherinnovative optionthathasbeensuccessful istosolardry rabbitor chickenmeat to produce
fingerfoodssuchas chipsthat can alsobe powderedtoadd itto weaningporridge.Weaningmixescan
be soldfor income generation.
Small freshwaterfishprovide animportantsource of protein,iron,zinc,(pre-formed) vitaminA andare
an excellentsource of calciumwhenconsumedwhole. The small fishcanbe soldfreshorindriedform;
it isusuallyrelativelyaffordable andhasalongshelf life.Wheneatenwhole,itcanmake a major
contributiontofoodsecurityanddietqualityimprovement.One studypresentedthatsmall fishcan
preventandcontrol irondeficiencyanemiainadolescentgirls.
Promoting varietal diversity(growingmultiple varietiesofa crop)
There isa growingbodyof evidence suggestive of anassociationbetweengreatercropdiversity,
improveddietarydiversityandimprovednutrition.
Somethingthatisnotoftenlookedintoisthe manyindividual varieties(orcultivars) thatare available
withinone crop,forexample rice.Differentvarietiesof the same crop speciescanvaryconsiderable in
termsof nutrientcomposition.Knowingif ahouseholdconsumedrice Xtimesinthe pastweekisone
thing;knowingthata householdhasconsumedXvarietyof rice Xtimesinthe past weekissomething
else entirely.Understandingwhichvarietiesare beingconsumedandwhichare not increases
understandingof nutrientintake.
Householdswhichgrowmultiplevarietiesof acrop were foundto eatthiscrop more frequentlyaswell;
possiblybecause of continuousavailabilityorthe fact thatmore varietiesmeansthatmore tastes
(adultsandchildrenalike)canbe pleasedatonce.
Improving crop diversityin rice producing countriesin South-East Asia
Most areas where rice isgrownhave dry seasonsduringwhichnon-paddycropscan be harvested.
Facilitatingthe cultivationof dryseasoncropscan be especiallyimportantinareaswhere rice mono-
croppingiscommon.In some regions,cultivationof lentils,peasandotherpulseshasdeclinedpartly
because rice isa more lucrative crop,butalsobecause the growingseasonof pulse cropsislongerthan
that of rice,and because manypulsesrequire more inputsandmaintenancethanrice crops.
Introductionorreintroductionof nutritious,low-input,short-durationcropsmight,therefore,
appropriate forimprovingthe availabilityof andaccesstoa more diversifieddiet.Mungbeansare high
inprotein(andparticularlylysine whichisalimiting aminoacidinmostcereal grains) andalsohighin
iron,B vitamins,folate,vitaminCanda numberof othernutrients.Recentimprovementsinthe
nutritional contentof mungbeans,andintheirpestanddisease resistance andmaturationcycle could
facilitate theirreintroduction.Additionalsellingpointsinclude ashortproductioncycle (around60
days),minimal moisture requirementsandimprovedsoilfertilityvianitrogenfixation.

Soybeanforlocal consumptionisanotheroption;theycanbe encouragedamongsmallholdersto
diversifyproductionandcapture positive rotationeffects.Theyare highinproteinanda goodsource of
poly- andmono-unsaturatedfats,aswell asof omega-3fattyacids(‘goodfats’).
Mustard is alsoan alternative:inaddition tohavinghighlynutritiousandedible leaves,thisplant’shardy
oilseedscouldincrease fatintake.Mustardisappropriate formanyrice-basedfoodtypologies,
particularlythose thatare rain fedandhence droughtprone.
Note that the introductionorreintroductionof food mustbe accompaniedbysocial marketingand
educationeffortstoencourage consumption.Populationsmightnotbe opentonew crops or new foods,
eventhose thatare nutritiousandpractical.Investinginagricultural extensionservicesandnutrition
educationservicesiscrucial.
Integratedhorticulture/aquaculture projects
Integratedhorticulture/aquaculture projectsare one wayto improve householdaccesstoanimal source
foods,fruitsandvegetablesatthe same time.Additionally,inmanyareasof South-eastAsia,theyfit
intotraditional productionstrategieswe well.Integrationof the home lot,garden,livestockand
fishpondhave beenpromotedinVietnamsince the 1980s. The livestockorpoultrypensare situated
nearor overthe pondto provide animmediate source of organicfertilization.Gardensincludeboth
annual and perennial cropsforyear-roundfoodprovision,aswell asproductsformarketand garden
waste may be usedforpondfertilization.The promotioninVietnam isbelievedtohave hada positive
impacton the country’snutritionoutcomes,whichshowedmarketimprovementsintermsof
consumptionof animal source foods,fruitsandvegetables.
From a nutritionperspective,thesestrategiesare exemplaryinthattheyaddressdeficitsinASF’sand
fruitsandvegetablessimultaneously.Evenasmall amountof haemiron(foundonlyinanimal source
foods) consumedwithameal where mostof the ironisnon-haem(plant-derived),willenhancethe
absorptionof the ironin the meal.The additionof asmall amountof fishormeat (e.g.30 g) to a meal
containingnon-haemironwill resultinmuchgreaterabsorptionof iron.If thismeal containsvitaminC-
rich fruitsor vegetables,ironabsorptionwill be furtherimproved.InSouth-eastAsia,whereiron
deficiencyanemiaisespeciallypronounced,suchprojectspresentculturallyacceptable andviable
opportunitiestoincrease the dietaryavailabilityof ironandotheressential micro-nutrients.
Improving poultryproduction
Farmersstruggle withextremehighlossesof small ruminantsandpoultrytodiseases.A solutionsuited
to smallholders,especiallythose facingbudgetconstraints,istoincrease the productivityof existing
local animals.Introducingimprovedhousingand supplementaryfeedingthroughimprovedextension
servicescango a longway to reduce highlossesamongsmall ruminantsandpoultry.
In areaswhere lossesare high,farmersmightallow the majorityof eggstohatchinorder to maintain
the flockas an assetbase,ratherthan to use themfor consumption;thusreducingthe opportunityto
improve dietaryintake. If poultrymortalityratescanbe reducedthroughimprovedhousingand
supplementaryfeeding, asopposedtosimplylettingchickensforage,the consumptionof eggsmight
increase.Froma nutritionperspective,improvingeggconsumptionincreasesthe intake of protein,fat
and vitaminA.

Forestry inimproving foodsecurity and nutrition
Forestsandtreescan make a bigcontributiontoimprovingdietsandnutritionalquality,byadding
varietytodiets,improvingtaste andpalatabilityof staple foodsandprovidingessentialvitamins,protein
and calories. Forestsprovidealarge range of edible foods,suchasseeds,fruits,leaves,roots,
mushroomsandgums;theyare habitatfor wildanimals,insects,rodentsandfish;theyprovidefodder
for livestock;andtheyprovidefuel woodforfoodprocessing.There hasbeenincreasedrealizationthat
local people dependonforestsandtreestomeetimportantneedssuchasfoodandincome.Inequality
inownershipandaccessto productive resources,suchasland,causespoorhouseholdstorelyeven
more on forestproductsforincome andnutrition.
Examplesof contributionsof forestsandtreestoimprovednutrition:
- Leaves:wildleavesandleavesfromplantedtreescanbe excellentsourcesof vitaminA andC,
proteinandmicro-nutrientssuchascalciumand iron.
- Fruits: wildfruitsare especiallygoodsourcesof mineralsandvitamins,andsometimescontribute
significantquantitiesof calories. Agro-forestrytreessuchasguava or mangoare importantsources
of vitaminCto manyhouseholds.
- Seedsand nuts: In additionto the calories,oil andprotein,theyare alsoimportantforthe absorption
of vitaminsA,D,E and K.
- Roots and tubers:a large varietyof forestplants(climbers) canprovide carbohydratesandsome
minerals.
- Mushrooms:mushrooms,gatheredwildfromforestsandwoodlands,are muchlikedinmany
cultures,andare addedtosaucesand relishesforflavoring.Inmanycases,theyprovide substitutes
for meat.
- Honey: isan excellentsource of sugarandis an importantingredientfortraditionalmedicines.
- Gumsand sap: Sap isfrequentlytappedforbeveragesandisoftenhighinsugarsand minerals.Gum
isusedas a foodsupplementandcanalsobe a goodsource of energy.Bothhave medicinal uses.
- Animal foods from forestsand farm trees:wildanimalsandfishare otherimportantforestfood
products.Forestedareas,mangrovesandstreamsprovide ahabitatformanywildanimal speciesand
fish. The range of speciesconsumedincludesbirds,eggs,insects,rodentsandotherlarger mammals.
Collectionandsalesof forest-derivedproductscanbe an importantincome source aswell,whichcan
provide part-time,seasonal,orfull-timeyear-roundemploymentdependingonthe product.
Bio-fortificationoffood
Bio-fortification,throughconventional plantbreeding,canimprove the nutritional contentof the staple
foodsthat poorpeople alreadyeat,andprovide acomparativelyinexpensive,cost-effective,sustainable
and long-termmeansof deliveringmicro-nutrientstothe poor.New varietiesof staple foods(suchas
rice) are beingdevelopedthatare highiniron,zincand/or pro-vitaminA. These foodscannothave too
highconcentrationsof micro-nutrientsbecause peopleeatthemdaily.Therefore,theycan’tbe the
single solutiontosevere deficiencies.However,the canbe one componentof a largerstrategyto
eliminatemicro-nutrientdeficiencies,suchasvitaminA and irondeficiency.
Researchoniron fortifiedrice andbeanshasbeenpositive andshowedfavorable agronomicqualitie s
includingequal/higheryieldsandgreaterdiseaseresistance anddroughttolerance. Challengesonthe

otherhand mightbe that industrial fortifiedfoodscanbe more expensive.Tobe successful,the farmers
needtoadopt the fortifiedseeds,andthe consumersneedtoacceptthe final product.
It isgood to keepthisoptioninmindandorganizationsmightwanttotestthese new varietieswhen
theyare available inMyanmar.Iron-fortifiedrice isbeing promotedbyMyanmarConsumersUnion.A
countrystrategy and productionplanforfortifiedrice wasdevelopedinFebruary2015.
A pilot project;optimized feedingrecommendationsandin-home fortificationtoimprove iron
status in infants and young children.
Anemiaisa widespreadpublichealthproblem(alsoinMyanmar) thataffectsparticularlyinfantsand
youngchildren.Nutritionhasanimportantrole inaddressingthiscondition,andintegratedfood-based
strategiescanbe adoptedto improve complementary feedingpractices. A pilotproject8
wasdone to
compare childrenwhowere fedrecommendedcomplementaryfeedingwithchildrenwhowere fed
recommendedcomplementaryfeedingplusSprinkles(micro-nutrientpowderusedathome).
Recommendedcomplementaryfeedingpracticesforchildren between6and 23 monthswhichwere
promoted inthe project:
- timelyintroductionof animal source foods(meat,egg,dairyproducts),beans,freshfruitand
vegetables
- discourage togive the childrenblackteawhichpreventsthe absorptionof iron
- increase consumptionof iron-richfoods
- dailyconsumptionof fruit,vegetables,cereals,milk
- guarantee a balanceddailydistributionof mealsandsnacks
Nutritioneducationwasdone throughlocal existinghealthworkerswhowere trained oninfantand
youngchildfeedingpractices.The healthworkersthenwouldadvice the mothersonamonthlybasis
usinginteractive approachessuchascookingdemonstrationsandgroupdiscussions.
In the groupdiscussionsothercommunitymembers(suchaselderlywomenormothers-in-law)would
be welcomesaswell since (young) mothersmightfinditdifficulttochange a commonpractice
particularlywhenitcomestofeedingchildrenandfamily. Also,inthe groupdiscussionsany
misunderstandingsorproblems aswell aspotential solutionscouldbe discussed.
To promote mothersfeedingtheirchildrennutritiousfood,locallyavailablefoodwas promotedand
preparedusinglocal householdutensils. The mothersreceivedthe lessonsonhow tofeedtheirchildren
inbook formwithpictures.The same pictureswere usedduringthe nutritioneducationsessions.
A child’snutritional statusisstronglycorrelatedwiththe mother’seducation.If the mother hasdifficulty
readingor interpretingnutritional recommendationsprovidedinwrittenformitisveryunlikelythatshe
will complywithrecommendations.Incontrast,the powerof a picture,designedtorepresent
commonlyusedfoodsandtools,helpstounderstandthe messagemore clearly.
Assessingif motherswouldindeedfeedtheirchildrenthe preferredfoodwasagaindone withapicture
bookletinwhichfoodandfoodpreparationpictureswere combinedtoshow recommendedand
standardizedamounts/portion sizes.Motherswere askedtosimplytick,onadailybasis,the food
consumedbythe child.
8 Optimized feeding recommendations and in-home fortification to improveiron status in infants and young
children in the republic of Tajikistan:a pilotproject,Marina Adrianopoli,INRAN and WHO

Withinthisstudy,one groupof childrenreceivedSprinkles(micro-nutrientpowderwhichcanbe added
to foodat home) while the secondgroupof childrendidnot getthose.All childrenwereanemicatthe
start of the study (100%). The studyfoundthat the numberof children withiron-deficiencyanemia
droppeddramaticallyafter3monthsalreadyto40% (onlyimprovedfeedingpractices)and to10%
(improvedfeeding practicesplusSprinkles).Afterone year,the numberof anemicchildrenwas35%
(onlyfood-based) and20%(foodandSprinkles) respectively.Itwasnotedthatmotherswhodidnot
receive Sprinkleswere betterfollowingthe recommendedfeedingpractices.
An importantconclusionfromthe studyisthatin-home fortificationisanappropriate intermediate
solutionwhenthere isariskof micro-nutrientdeficiency.However,micronutrientpowdersare notfood,
and cannotbe consumedwithoutfood;thusthe use of effectiveandaffordable food-based
recommendationsusinglocallyavailablefoodsshouldbe stronglyencouraged.
Improve targeting / beneficiaryselection
1. Includinghouseholdswithpregnant/ lactatingmothers,children under the age of two and
adolescentgirlsin nutritionprogramsis effective andhas highreturn rates.
Interventionsfocusingonchildrenduringthe first1,000 daysof life (fromconceptiontoachild’ssecond
birthday) have highreturnratesbecause of theirimportance inenhancingeconomicproductivitylaterin
life,throughhigherschooling,higher-payingjobs,andoverall improvementof physical,cognitiveand
reproductive performance.
Most nutritionprogramsandstrategiesfocusonimprovingnutritionof childrenduringtheirfirst1,000
daysof life;itisalsocalledthe 1,000 day window of opportunity.If achildisunder-nourishedduringthis
time,ithas missedthisimportantopportunityandthe effectswillbe irreversible.
To improve nutritionof childrenduringtheirfirst 1,000 days,we needtoensure theirmothersalsohave
goodnutritionsince theyare the mainfoodproviders(whenpregnantandwhenbreastfeeding).To
improve the mothers’nutritionstatus,itisimportanttostart before theyactuallybecome mothers.
Therefore,itisgoodto include adolescentgirlsinthe programas well.
2. Womenare key mediatorsbecause of their role inintra-householdresourceallocation,family
nutritionandchildnutrition.
Impact onnutritionismore likelywhenagricultural interventionstargetwomenandinclude women’s
empowermentsuchasimprovingtheirknowledge andskills. Programsimprovingwomen’ssocial status,
power,control overresources,andreduce women’stimeconstraintsare importanttoimprove
nutrition.
3. Targeting householdswithmalnourishedchildren?
A disadvantage of targetingorsupportingmainlyhouseholdswithmalnourishedchildrenisthatitmay
create an incentive forafamilytokeepa childmalnourished.While suchabuse ispossible,verifyingor
disprovingthe extentof suchbehaviorisdifficult.Thisformof targetinghasalsothe disadvantage of
onlyreachingchildrenwhoare malnourishedalready,ratherthanbeingpreventative.Insteaditmight
be betterto targethouseholdswithincreasedrisk;targetthe mostnutritionallyvulnerable households.

Improving nutritionthrough multi-sectoral approaches
The World Bankcompareddifferentpathwaystoimprove nutritionstatus,show inthe table below.
These resultsare inline with earlierpartsof the reportwhichalsoshowedthateconomicgrowthor
improvedincome orimprovedaccesstofoodwill notautomaticallyleadtoimprovednutritionstatus.
Still itisinterestingtocompare the differentpathwaysandtonote that empowermentof women
throughtargetedagricultural interventionshasstrongevidence of improvingnutrition.
Pathway Strength of the pathway
Increase macro-
economicgrowth
overall
Modesteffect.Doublingpercapitaagricultural income isassociatedwith
an approximately15-21% decline instunting onaverage,whichwould
resultinveryslow andunevenprogressinreducingundernutrition.
Increase accessto food
by higherproduction
and decreasedprices
Modesteffect.Of the countriesmeetingthe MDG1 targetto halve
hunger,fewerthanone-thirdare ontrack to meetthe MDG1 targetto
halve undernutrition,demonstratingthe limitedtranslationof national-
level grainavailabilitytonutritional improvements.
Increase household
income throughselling
agricultural products
Variable effects.Onaverage,income povertyandundernutritionare
correlated,butincreasesinhouseholdincome donotnecessarilyleadto
improvednutritional statusof itsmostvulnerable members.Increasing
women’sincome hasstrongerpositive effectsonnutritional status.
Existingempirical evidence showscommercializationbasedoncashcrops
has limitednutritional effectsonvulnerableindividualsinproducer
households.
Increase nutrientdense
food productionfor
householdconsumption
Some evidence.The bestevidencetodate isfoundfromincreasingsmall-
scale productionof nutrient-dense foods.Nutritioneducationenhances
dietaryconsumptionandthe potentialforconsumerdemand.
Empower women
throughtargeted
agricultural
interventions
Strong evidence.Over50% of the reductioninchildunderweightfrom
1970-1995 is attributable toimprovementsinwomen’sstatus.In
agricultural activities,increasingwomen’sincome andreducingwomen’s
time andlabourconstraintsappearto be especiallyimportanttoimprove
nutrition.
Eventhoughthese pathwaysalone mightnotleadtoimprovednutrition,theymaycontributean
importantpart to improvingnutrition.Forexample:improving livelihoodsandincome hasonlyamodest
effectonmalnutrition.Atthe same time,improvinglivelihoodsandincome helpstocreate choicesfor
poor households;includingthe choice toproduce or buynutritiousfood.Thisisveryimportant.
In summary:people needincome tomake healthychoicesandtoacquire nutritiousfood,but only
improvingincome doesnotautomaticallyleadtoimprovednutrition.If we wantpeopletomake these
healthychoices,we needtointegrate nutritionintoourlivelihoodprograms.Andif we wanttoachieve
evenmore;if we wantto improve nutrition,we needtoaddressall issuesthathampernutrition.
As explainedearlier(forexample onpage 16: settingthe rightgoal for yourprogram), althoughour
program mightnotimprove nutritionstatus, we mightwantto improve foodavailabilityorfoodsecurity
as an importantsteptowardsimprovingnutrition.

Global NutritionReport2014 – Actionsand accountabilitytoaccelerate the world’sprogress on
nutrition.
The Global NutritionReport2014 providesrecommendationsatglobal level andcountrylevel.They
state that people withgoodnutritionare keytosustainabledevelopment andtherefore,theyadvocate
for inclusionof nutritionindicatorsinthe Sustainable DevelopmentGoal targetsfor20309
. They also
recommend focusingagreatershare of investmentstoimprove underlyingdeterminantsof nutritionto
have largerimpacton nutritional outcomes.Todothat, it isimportantto provide more guidance onhow
to designandimplementthese approaches.
The report calculatedwhichtargetsare neededinfoodsecurity,water,educationtoachieve the
worldwide targetof reducingnumberof stuntedchildrenby40% by2025 (thisisequivalenttoa level of
about15% of stuntingin2025). To achieve thatgoal,the followingunderlyingdeterminantsare needed:
98% hasaccess to improvedwatersource,75% has access to improvedsanitationfacility,98% of
femalesenrolledinsecondaryschool,2905 kcal dietaryenergysupplypercapita,and48% of dietary
energysupplyfromnon-staples.
Governmentefforts,lessonslearned:improvementofnutritionstatus of childrenunder5, growth
of school-agedchildrenand adolescentsduringthe period ofrapid economicgrowth in China.
Chinamanagedto reduce stuntingratesinthe countryside from40.3% in 1990 to 12.6% in2009. The
medianheightof variousage groupsof school-agedchildrenandadolescentsincitiesare close tothe
reference usedbythe WHO.Atthe same time however,micronutrientintake(iron)didnotimprove and
iron-deficientanemiawasnotreduced.Furthermore,chronicdiseasessuchasobesity,hypertension,
and diabetesrapidlyincreased.
These resultsare linkedtoimprovedandmore balanceddietsinrural areasof Chinaand a worse dietary
patterninurban areas.With the rapideconomicdevelopmentinChina,people enjoyabetterincome
and standardof living.Moneyforfoodisbasicallysecure,butthe dietarypatternhasbecome
unbalancedandnutritionhasturnedoutto be the most importantfactorleadingtothe rapidincrease in
majorchronic diseases.
Anyimprovementinnutritionisthe outcome of the concertedeffortsof the government,especiallyin
agricultural development.Agricultural productionisthe basisforthe availabilityandsufficientfoodand
income inbothurban and rural areas of China,and the applicationof policiesfavorable tofarmerssince
2000 has stimulatedthe improvementof nutritionof rural poorchildren.The Chinesegovernmenthas
combinedagricultural productionwithrural developmentandfarmers’livelihoodstogetheras‘3 Agri’in
national planning.Thisincluded:tax exemptionforagriculture,directsubsidiesforgrowinggrains,risk
fundsforgrain purchasingat a protectedprice,construction plansfornew villages,subsidiesforrural
householdsonelectricappliances,tuitionfeewaiversandfree textbooksuppliesforrural schools,
subsidiesforthe pooresthouseholds,pensionsforrural elderly,meal subsidiesforrural boarding
schools,publichealthservices.The numberof extremelypoorpeoplefellfrom94.23 million(10.2%of
rural population)in2000 to 35.97 millionin2009. Agriculture is,therefore,considerednotonlyinterms
of productionoryield,butalsoasthe integrationof rural developmentandfarmers’wellbeing,whichis
extremelyimportantinrelationtothe improvementof nutrition.
9 The SustainableDevelopment Goals arethe post-2015 development goals,replacingtheMDG’s which run until
2015.The SDG’s includedevelopingand developed countries.

Recommendations from nutrition experts in Myanmar
A varietyof nutritionexpertswere interviewed,mostlyfromthe NGOsector. These includedAndrea
Menefee –NutritionAdvisorSave the Children,Matt – Tat Lan managerSave the Children,Celine
Lesavre – Head of departmentHealthandNutritionACF,JanisDiffert –FoodSecurityandLivelihoods
Headof DepartmentACF,ElizabethWhelan –ProgramManager LEARN Project,Saw Eden – LEARN
Project,Joy-DestaBrandsma–SeniorProgramManager Maternal,Neonatal,ChildHealthandNutrition
PlanInternational.
Recommended activitiesor approachesfor organizationsinvolvedinagricultureorfoodsecurity to
includenutritionincludedthe followingmainsuggestions:
General recommendations:
- Importantnot to force organizationstodonutritionbutratherencourage /motivate first
- Importantto provide sufficientstaff trainingandsupport
- For programs whichmainstreamnutrition;thinkaboutwhattodoand whatnot to do (e.g.aimfor
improveddietarydiversitybutnotforimprovedanthropometry).Inotherwords,itisimportantto
carefullythinkwhatyourorganizationcanandcannot achieve ordo.
- At leastthinkaboutDo NoHarm; try to avoidthat your projectactivitiesare harmful tonutrition
- Importantto thinkabouttargeting;focusonwomen,adolescentsandchildrenupto5 yearsold
- Agricultural programstypicallyfocusonmaincrops;change into a more holisticapproachtofood
and aimfor a sustainable andvalue addedfoodsystem.The problemisthatthiswill require more
expertise.
- If your organizationaimstoimprove nutritionstatus,be aware thatyouhave to considerthe
differentneedsindifferentsectorsthatinfluence nutrition.
Recommendationsfornutritionassessments:
- Importantto do a thoroughneed assessmentwhichincludesthe differentaspectsof nutrition,taking
intoaccount the local contextandlookingatpeople’sknowledge,attitude andpractices.
- Importantto do a thoroughneedassessmenttoknow whichneedsordeficienciesneedtobe
addressed;thenpromote locallyavailablefoodswhichare relatedtothese needs.
- Importantto assessthe real barriersforpeople toadoptnutritionrecommendations.
Recommendationfor nutrition-relatedactivities
- Nutrition-relatedactivitiesdonotalwaysmeanthatwe have to add on additional activities;
sometimeswe candesignourcurrentactivitiesdifferentlysothattheybecome nutritionsensitive.
For example,if we supportagricultural production,notonlyconsidercashcropsbut alsoconsider
nutritiouscrops.
- It isimportantto considergenderandknowingthe role andresponsibilitiesof menandwomenin
nutrition-relateddecisions.
- Considersettingupabreastfeedingroomif youdoa cash for workproject
- Considersettingupvillage childcare nearfarmfields
- Considerpromotingwildfoods toimprove year-roundfoodaccesstonutritiousfoods
- Importantto thinkaboutthe influential peopleinthe communitysuchasthe elderly;theyinfluence
the pregnantor youngmothers andcan have a bigimpact oncommunitymembers.Theymightnot
be interestedinflip-chartsbutmore interestedinshowsandperformances.

Recommended nutrition-relatedindicatorsforagricultural programsinclude:
- Yields of differentfoodgroups
- HouseholdDietaryDiversityScore (HDDS)
- Individual DietaryDiversityScore (IDDS)
- Foodprices
- Proxyindicators:e.g.consumptionof vitaminA richfoods
- % of motherswhoexclusivelybreastfeed
- % of beneficiariesthatbenefitfromnutritionandfoodsecurityactivities
For some indicators, detaileddescriptionsexist online of how tomeasure andcalculate them;including
the HDDS andIDDS.
For the more technical indicators(e.g.stunting) supportmightbe neededfromnutritionadvisors.
Before selectingindicators,itisimportantthatfield staffsare clearwhytheyneedtocollectthem.
Recommendationsonwhere or how to train staffon nutrition:
- Hire a nutritionconsultant
- LEARN isfor LIFT implementingpartners
- LEARN hasdevelopedafacilitatorsmanual fornon-nutritioniststodonutritiontraininginthe
community(EnglishandMyanmar),including:3foodgroups,nutritiousfoodsinmarket,what
plantsto growin home-garden,micro-nutrients,1000 dayswindow,basicnutrition,home
hygiene andsignsof malnutrition.LEARN hastaughtLIFT IP’sand theyare able to do these
trainingsinthe community.The manual includesIECmaterials,flip-chartstoryandgames. The
manual couldbe spreadto interestedorganizations,alsothose whoare not(current) LIFTIP’s.
- Importantnotice withregards totraining:shouldbe done atmanagementandfieldlevel
because managersare typicallyinvolvedindesignof new projectsandmake the decisionto
include nutritionornot.
- SUN (Scalingupnutrition) will be involvedinsharingknowledge andinformation, evidenceand
learning,involvinggrassrootslevel andgovernmentlevels.

Ideas from FSWG member organizations
FSWG memberorganizationsprovidedtheirideasandcurrentapproachesof how to integrate nutrition
inagricultural or rural developmentprograms.These include:
- Nutritionawarenessandtrainings,home andschool gardens,differentiationof agricultural
production.
- Capacitybuildingof fieldteams.
- Diversifyfoodsources,improveproductionof micro-nutrientrichandenergy-dense food.
- Address seasonalityof accesstofood.
- Target women/caregiversandempowerthem.
- Sensitize beneficiariesonnutritionaspectsandonhygiene,InfantYoungChildFeedingpractices.
- Include relevantassessmentstoproperlydesignactivitiesinordertoaddressmalnutrition.
- Incorporate indicatorstotrack nutritionimpact,orat least,impacton dietaryintake andfood
diversityathouseholdsandindividual level.
- Distribute school feeding,care forimprovedhealthandsupportorganizationalplan.
- Publishabookon nutritionvaluesof Myanmarvegetablesandfoods,sothatpeople canselect
suitable foods.
- Notassume that nutritionwill improve forall familymembersjustbyincreasingincomeor
agricultural production.Investinunderstandingknowledge,attitude and practicesof nutritionand
addressnutritionasa topicin itself.
- Give special focustothe 1,000 day window andnursing/pregnantwomen.
- Special foodsupportprogramforchildrenunderfive yearsoldwhoare notgoingto school.
- Include livestockactivities(chicken,goat,duck,cow formeat andmilk) andfisheryactivities.
- Include nutritionrelatedactivitiessuchasnutritiousfood,cookingdemonstrationandnutrition
progressstatusdocumentforchildren.
- Improve farmersandconsumersawarenessonsafe andnutritiousfood.
- Produce healthyandsafe foodthroughsustainableagriculturalactivities.
- Supportaddedvalue forlocal vegetable andfoodproducts.
- Integrate homesteadgardenwithtraditional livestock.
- Supportrice seedbankand animal bank.

Positive case-studies in Myanmar
Four positive case-studiesare selected;representingdifferentareasinMyanmarand differenttype of
organizations.The firstgoodexample isfromalocal CBO and the two othersfrom internationalNGO’s.
1. School garden project in Delta – by local CBO
The selected projectinvolvedschool-basedgardeningin5local schoolsin5 villages.
Purpose ofthe project andwhat couldbe achieved?
The purpose of the projectwasto change the foodconsumptionpractice of children andtheirfamily
froma foodsafetyperspective andtoincrease gardeningpracticesnotusingchemical fertilizer.
The projectindeedsucceededinchangingthe foodconsumptionpractice:afterthe project,the food
choice and selectionof school snacksamongstudentschangedbecause of the foodsafetyeducation
activities.Some food/snacksellershadtochange theirproducts;insteadof processed/Chinese snacks
the childrenwantedtraditional Burmesesnacksmade from‘real’food.The noodle selleralsochanged
the preparationof the sauce and currentlyusestraditional sauce liketamarindsauce.
Afterthe project,people improvedthe seedselectioninvegetablegardening,alsoconsiderednutrition
and foodsafetywhenselectingsnacks/mealsinschool andathome.Childrendeniedfastfoodinschool
or at home and demandedtheirparentstoprovide more fruitsandvegetables.
Childrenandtheirfamiliesgainednew knowledgeonfoodsafetyandunderstoodhow it affectstheir
health.
The communityonlydidlimitedhome gardeningbeforeandtheyusuallyboughtvegetables/fruitfor
consumption.Throughthe projecthowever,technical knowledge how todohome gardeningwas
disseminatedtomore people andwhenpeoplesaw the school gardentheywantedtogrow one
themselves.Inone village withlackof goodsoil,the people placedgoodplantingsoil inplasticbagsto
grow vegetables.Thistechniquewasnew tothemandwas spreadby the community.
The projectwas visitedtwotothree monthsafteritfinished,andthe childrenwere verywellable to
recall the nutritioneducationtheyreceived;three foodgroups,nutritionvalue,unsafe foodandits
negative effectonhealth,aswell asthe practical lessonsonvegetable growing.
How was the project able to achieve these changes?What kindof activitiesdidyou do andhow?
Activities Description
1. Community Awareness Raising
Contact the TownshipEducationOfficertoexplainaboutthe project activitiesandto get approval.Hold
a communitymeetingwithcommunitymembers inthe villageandexplainaboutthe projectactivitiesand
objective – including Parents and Teacher Association and Senior Students.
2. School Garden committee
FormSchool GardenCommittee withParents&TeacherAssociation,HeadmasterandSeniorStudent who
take the main responsibility to take care of the garden and management of the funds gained from
gardening activities.
3. Good Agricultural Practice Training

Arrange trainingoneachschool withsupportfromVegetableandFruitResearchandDevelopment Center
(CFRDC) on good agricultural practice and how to cultivate vegetable.
4. Seeds Selection
In school, discuss the seed selection with the committee including seed selection of nutrient-rich
vegetables(onemonthafterthe projectstarted).The followingtypesof seedswereselected: Ladyfinger,
Pumpkin, Egg plant, Rosella, Carrot, Watercress, Bitter guard, Tomato, Long bean, Other green leafy
vegetable (HinNuNwe).Afterthe selectionprocess,the projectteamdid the procurementof the seeds
with the school garden committee.
5. Set-up School Garden
Make landselectionwhich isclose toschool andeasyto getwater.Made agreementwith headmasterto
share the school “Exercise Time”todo school gardeningactivitieswithsome active memberfromP&TA.
Made fence for school garden to prevent animals entering and destroying the plants.
Seedplantingwas doneinone sessionwithallstudentsthroughdemonstrationonhow to plantandgrow
a seed,forit to become a small plant.Everystudentwho was interestedtogrow a home gardenin their
house received those small plants from the school garden. Regular watering on school garden was
conducted by some active committee members and students during “Exercise Time” of schooling.
6. Education Activities
Since the first month of the project, the education and awareness promotion activities on food and
nutrition were started. The reason why the project focused on children for the Behavioral Change
Communicationwastopromote awarenessondisadvantagesof chemicalfertilizer,foodgroup&nutrition
value of foodandhowecologyissupportsincechildhoodsothattheycanpractice thiswhentheybecome
an adult.
a. The veryfirsteducation sessionwas conductedineachprojectvillageschool on“FoodSafety”. The
ConsumerProtectionAssociationof Myanmar was requested toconductthat sessionandittook2
hoursto coverhowfoodsafety isharmful inMyanmar–especiallyindailyfoodswhatwe consume
and in school snack market. Pamphlets and CD on food safety were shared.
b. After a month, another education session was conduct in all project areas on Nutrition – 3 food
groups and nutrition value in food. One nutrition staff from WHH was asked to conduct the
education session and to disseminate pamphlets to participants. This included a quiz and game
session toselectvegetablestowhich foodgroup. Pumpkineating wasalsopromoted throughthis
educationsessionand thereforeitwas putinthe school gardenasthisis veryrare inthisarea.The
education session messages were discussed during the seed selection process when the team
talked about seed selection with the committee and the students.
c. The thirdtopiccoveredbythe educationactivityisthe ecosystem,environmentandfood,forwhich
the project invited one environment specialist who is also working as one of the chair parsons of
Sympathy Hand Organization.
d. After three educationactivities, the organization had the chance to attend the LEARN training on
basic nutrition and got the field manual for education sessions and the LEARN video clip on 1,000
days. Those were used for the last education session including Quiz for 1000 days.
e. Apart from this kind of education activities, the project also did an Essay Contest in three project
schools on World Food Day on Our School Garden.
Positive:

- The educationonthree foodgroupswithquizand gameswasmentionedbythe childrenasfun.
Also,3 monthsafterthe projectfinishedtheywereable tomentionwhichfoodbelongedto
whichgroup.(Thissessionwasdone byWHH.)
- The childrenalsolikedthe essaycontestinschool.
- The childrensharedthe newknowledge withtheirparentsandaskedtheirparentstocook
accordingto the differentfoodgroupsandnotjustfast foodwhichisunhealthy.
- The childrencame up withgoodsuggestionssuchassellingthe vegetablesfromthe school
gardenand use it forthe school or for foodneededinschool events.
Lessons learned:
- School gardensitself are notverysustainable;hybridseedswere used forthe home gardens and
there isno systemsetupto earn moneybysellingvegetablestobuynew seedsnextyear.
Betterto setup a systemor to thinkaheadhow to make itsustainable.
- There wasno specificpersonresponsible totake care of the gardenduringthe daysthat there is
no school andespeciallybefore harvesting.Withthe gardenbeingbeside the road,some people
justtook the vegetableswiththem.Goodtohave one personcommittedtotake care of the
garden,possiblysupportedbysome incentivebasedonthe time they actuallyspendonthe
garden.
- Timingof school gardenactivities;overlappedwithexamperiodatschoolswhichmade itmore
difficulttoimplementalthoughstudentswereveryactive inbotheducationandgardening.
- School gardensleadtolessownershipandthe committee memberswere notveryinterestedin
the activitiesastheydidn’tbelieve itwouldbringphysical incentives/benefitsforthem.The
projectteammightneedtodo bettersensitizationonthe projectobjectivesandactivities.
- The pamphletsandCD was disseminatedtothe whole communitywhichhelpstopromote and
spreadthe awareness.The projectactivitieshoweverfocusedonlyonstudentsandschool,so
theyhad limitedreachtothe community.Maybe considertodobothschool gardenand also a
communitydemoplotnexttime.
- Althoughthe TownshipEducationOfficerapprovedthe project,some schoolheadmasterswere
not interested.Toimplementthiskindof projectagain,itwouldbe goodto getthe approval
official letterfromthe TownshipEducationOfficertohelpdeal withthe school headmaster.
- Due to bad weather,all seedswere lostjustafterplanting.
Eventhoughthere are some lessonslearnedtoimprove sustainabilityandtoimprove the project
further,the projectitself wasable tomake some goodchangesforthe childrenandpossiblytheir
families.The childrenenjoyedthe activities,are interestedtocontinue themandlike tolearnmore.
The projectclearlyshowsthatby workingtogetherwithotherspaysof.Itisa cleverideatoinvite
expertsfromdifferentorganizationstoensure qualityof informationandtechniques.Also,itisa
goodway of learningmore;withincommunitiesandwithinthe staff team.
The projectalsoshowscreative waysto use andbuildonexistinglocal systemssuchasusingthe
school’sexercisetime orcombiningthe nutrition education sessions withthe monthlyreligious
sessionsatthe monasterytoreach more people.
The project’saimwas veryclearand focused; changingthe foodconsumptionpractice of children
and increasinggardeningpracticesnotusingchemical fertilizer. Thissmall projectisconsidereda
goodexample forothersmall organizationsof how toachieve changesinfoodconsumption
patterns.

2. Non-timber Forest Products survey in Delta – by an INGO
Purpose ofthe project andwhat couldbe achieved?
The Non-TimberForestProductSurvey wasdone toidentifygoodsourcesof foodandnutritioninthe
wildsforthe purpose of increasingnutrientintake aswell ashouseholdincomes.
The participatorywaythissurveyisconductedisa good example andmightbe useful forother
organizationsparticularlyinareaswhere people face seasonalfoodshortage orwhere agricultural
developmentismore challenging. Furthermore,the methodology of the surveyisverystraightforward
so itis easyto copyand alsonot so expensive,whichmakesitdoable forsmallerorganizationsaswell.
Therefore,thissurveyhasbeenselectedas apositive case study.
Throughthe survey,targetbeneficiaries identifiedediblewildplantsandfishspeciesconsumedbylocal
people inthe surveyarea.The resultof the surveywasa listof edible foodsincludingpictures,names,
descriptionsaswell aslocationsof where tofindthem.The foodswere dividedinthree categories,
dependingontheirusage for:foodconsumption,incomegenerationormedicinal use. The foodnames
were presentedinthe local language,Burmese,EnglishandLatinname.
How was the project able to achieve these changes?What kindof activitiesdidyou do andhow?
Activities Description
1. Selectingparticipants
In eachvillage,three communitygroupswere selected:the local eldersgroup,awomengroupanda
school teachersandchildrengroup.The elderscontributionwasveryusefulbecause of theirlongtime
presence inthe areaand particularlythe menknew verywellthe existingnatural resourcesof plants,
fishesandtrees.The womenwere veryfamiliarwiththe natural resourcesusedforhousehold
consumptionandwere alsogoodpractitionersof medicinal plants.
2. Participatoryexercise toidentifywildfoods
To start the participatoryexercise,the surveyteamfirstexplainedwhatNon-TimberForestProductsare
and whywe wantto identifythem.Then,the surveyteamshowedthe communitygroupaposterwhich
had differentpicturesof Non-TimberForestProducts(NTFP) anddiscussedwiththe participantswhich
onesare existingin placesneartheirhomes,inpaddyfieldsorvillagesurroundings.
The groups discussedthe followingtopics: natural vegetation(trees) growninthe area,edibleplants
that are collected,medicinal plantsthatare available,andmarine species(fish) thatare caught.The
groupsalsodiscussedaboutwhichproductsare soldand can provide income aswell asideas for
possible incomegenerationactivitieswithwildproducts.
Furthermore,the surveyteamshowedthe mapof each village onGoogle Mapsandmade sure the
participantscouldlocate theirvillage onthe map.Thenthe teamcopiedthe map intoa new sheetto
prepare forresource mapping.The participantsthenmarkedpossiblelocationof specificNTFPproducts
on the map.
Eventually,the survey teamandgroupmemberswentaroundthe village tosee the natural trees,edible
plants,medicinal plantsandfishspeciesasdiscussedinthe meetings.All availableNTFPswere recorded
as photo-images.

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