A review of the effectiveness of agriculture interventions in improving nutrition outcomes

OBJECTIVES: To review the impact of agriculture interventions on nutritional status in participating households, and to analyse the characteristics of interventions that improved nutrition outcomes. DESIGN: We identified and reviewed reports describing 30 agriculture interventions that measured impact on nutritional status. The interventions reviewed included home gardening, livestock, mixed garden and livestock, cash cropping, and irrigation. We examined the reports for the scientific quality of the research design and treatment of the data. We also assessed whether the projects invested in five types of 'capital' (physical, natural, financial, human and social) as defined in the Sustainable Livelihoods Framework, a conceptual map of major factors that affect people's livelihoods. RESULTS: Most agriculture interventions increased food production, but did not necessarily improve nutrition or health within participating households. Nutrition was improved in 11 of 13 home gardening interventions, and in 11 of 17 other types of intervention. Of the 19 interventions that had a positive effect on nutrition, 14 of them invested in four or five types of capital in addition to the agriculture intervention. Of the nine interventions that had a negative or no effect on nutrition, only one invested in four or five types of capital. CONCLUSIONS: Those agriculture interventions that invested broadly in different types of capital were more likely to improve nutrition outcomes. Those projects which invested in human capital (especially nutrition education and consideration of gender issues), and other types of capital, had a greater likelihood of effecting positive nutritional change, but such investment is neither sufficient nor always necessary to effect change.     

Socio-economic inequalities in women's fruit and vegetable intakes: a multilevel study of individual, social and environmental mediators

OBJECTIVE: This study employed a multilevel design to test the contribution of individual, social and environmental factors to mediating socio-economic status (SES) inequalities in fruit and vegetable consumption among women. DESIGN: A cross-sectional survey was linked with objective environmental data. SETTING: A community sample involving 45 neighbourhoods. SUBJECTS: In total, 1347 women from 45 neighbourhoods provided survey data on their SES (highest education level), nutrition knowledge, health considerations related to food purchasing, and social support for healthy eating. These data were linked with objective environmental data on the density of supermarkets and fruit and vegetable outlets in local neighbourhoods. RESULTS: Multilevel modelling showed that individual and social factors partly mediated, but did not completely explain, SES variations in fruit and vegetable consumption. Store density did not mediate the relationship of SES with fruit or vegetable consumption. CONCLUSIONS: Nutrition promotion interventions should focus on enhancing nutrition knowledge and health considerations underlying food purchasing in order to promote healthy eating, particularly among those who are socio-economically disadvantaged. Further investigation is required to identify additional potential mediators of SES-diet relationships, particularly at the environmental level.     

Strategies to promote healthier food purchases: a pilot supermarket intervention study

OBJECTIVE: To pilot the design and methodology for a large randomised controlled trial (RCT) of two interventions to promote healthier food purchasing: culturally appropriate nutrition education and price discounts. DESIGN: A 12-week, single-blind, pilot RCT. Effects on food purchases were measured using individualised electronic shopping data ('Shop 'N Go' system). Partial data were also collected on food expenditure at other (non-supermarket) retail outlets. SETTING: A supermarket in Wellington, New Zealand. PARTICIPANTS: Eligible customers were those who were the main household shoppers, shopped mainly at the participating store, and were registered to use the Shop 'N Go system. Ninety-seven supermarket customers (72% women; age 40 +/- 9.6 years, mean +/- standard deviation) were randomised to one of four intervention groups: price discounts, nutrition education, a combination of price discounts and nutrition education, or control (no intervention). RESULTS: There was a 98% follow-up rate of participants, with 85% of all reported supermarket purchases being captured via the electronic data collection system. The pilot did, however, demonstrate difficulty recruiting Maori, Pacific and low-income shoppers using the electronic register and mail-out. CONCLUSIONS: This pilot study showed that electronic sales data capture is a viable way to measure effects of study interventions on food purchases in supermarkets, and points to the feasibility of conducting a large-scale RCT to evaluate the effectiveness of price discounts and nutrition education. Recruitment strategies will, however, need to be modified for the main trial in order to ensure inclusion of all ethnic and socio-economic groups.     

Nutrition education and Mediterranean diet: exploring the teaching process of a school-based nutrition and media education project in Cretan primary schools

BACKGROUND: During the past few decades there has been a gradual abandoning of the traditional Mediterranean diet by the population of Crete and especially among the younger generations. Since this is related to the rapidly increasing morbidity and mortality rates from chronic diseases, the need for educating young people on the principles of good nutrition becomes increasingly important. It is also acknowledged that the epidemiological field needs to focus on studying the implementation process, since this will allow for a deeper understanding of the outcomes. OBJECTIVES: The aims of the present study were to explore the process of implementing an innovation in Cretan primary schools and to identify best teaching practices and principles. DESIGN: In three state primary schools on the island of Crete, 107 children took part in a 30-h nutrition and media education programme. Classroom observations were used to define attitudes towards the programme and teaching methods. Besides baseline and post evaluation, the pupils were also interviewed about 11 months after the end of the programme. IMPLEMENTATION: During observation of the teaching process, emerging issues were the teacher's motivation and interest in the course, his/her preparation before each class, teaching ability and communication skills, the respect and discipline he/she kept and the innovative teaching methods used. In some cases researcher intervention in the classroom could not be avoided. FINDINGS AND CONCLUSIONS: Overall, individual teacher willingness and teaching skills were mainly responsible for the quality of teaching, the variety of educational methods used in classrooms and pupils' interest in the course. Changes in pupils' knowledge and recall of the course were related to teacher enthusiasm but also to researcher intervention. Exploring the teaching and learning process allowed a deeper understanding of the data. It is concluded that attempts to introduce the principles of a Mediterranean diet to children through nutrition education require innovative, enthusiastic and highly motivated teachers.     

Tea or coffee? A case study on evidence for dietary advice

The present paper explores the level of evidence required to justify giving dietary advice to the public. There are important practical differences between the development of public health nutrition guidelines and guidelines for clinical practice. While the gold standard for evidence for clinical practice guidelines is a meta-analysis of a number of randomised controlled trials, this is often unrealistic and sometimes unethical for the evaluation of public health nutrition interventions. Hence, epidemiological studies make up the bulk of evidence for nutrition guidelines. Tea and coffee are an interesting case study in relation to this issue. They are two of the most commonly consumed beverages worldwide, yet there is little dietary advice on their use. The evidence for a relationship between coffee or tea consumption and several diseases is discussed. The available studies, predominantly epidemiological, together with animal and in vitro studies, indicate that coffee and tea are both safe beverages. However, tea is the healthier option because it has a possible role in the prevention of several cancers and CVD. While the evidence for such relationships is not strong, the public will continue to drink both tea and coffee, and will continue to ask nutritionists to make recommendations. It is therefore argued that advice should be given on the best available data, as waiting for complete data to become available could have severe consequences for public health.     

Are research priorities in Latin America in line with the nutritional problems of the population?

OBJECTIVE: Concordance of nutritional research priorities with the related burden of disease is essential to develop cost-effective interventions to address the nutritional problems of populations. The present study aimed to evaluate whether nutrition research priorities are in agreement with the population's nutritional problems in Latin America. DESIGN: The epidemiological profile was contrasted with the research priorities and research produced by academic institutions for each country. Qualitative analysis of research production by type of contribution to problem solving was also conducted. SETTINGS: Nine Latin American countries. RESULTS: Obesity (high body mass index (BMI)) and micronutrient deficiencies (anaemia) emerged as key problems, followed by stunting, breast-feeding/lactation and low birth weight. Wasting in children and women (low BMI) was uncommon. Concordance of ranked research priorities with the epidemiological profile of the country was generally good for nutrition-related chronic diseases, micronutrients and low birth weight, but not for undernutrition, stunting and breast-feeding. Studies on the efficacy and effectiveness of interventions were uncommon. CONCLUSIONS: The present research agenda insufficiently supports the goal of public health nutrition, which is to ensure the implementation of cost-effective nutrition programmes and policies. A more rational approach to define research priorities is needed.     

Nutrimetabolomic strategies to develop new biomarkers of intake and health effects

Correctly assessing the metabolic status of subjects after consumption of specific diets is an important challenge for modern nutrition. Recently, metabolomics has been proposed as a powerful tool for exploring the complex relationship between nutrition and health. Nutritional metabolomics, through investigating the role that dietary components play in the maintenance of health and development of risk disease, aims to identify new biomarkers that allow the intake of these compounds to be monitored and related to their expected biological effects. This review offers an overview of the application of nutrimetabolomic strategies in the discovery of new biomarkers in human nutritional research, suggesting three main categories: (1) assessment of nutritional and dietary interventions; (2) diet exposure and food consumption monitoring; and (3) health phenotype and metabolic impact of diet. For this purpose, several examples of these applications will be used to provide evidence and to discuss the advantages and drawbacks of these nutrimetabolomic strategies.     

Estimate of health impacts of acidifying air pollutants and tropospheric ozone in Europe

Based on combined information available from air quality monitoring data and long-range transport models, European population exposure to SO₂, NO₂ and O₃ has been estimated. This information has been combined with the results of epidemiological studies assessing strength of association between the exposure and health effects to estimate an impact of the pollution on health in Europe. The analysis indicates that a considerable number of health problems, ranging from mild irritation of the respiratory system to increased mortality, can be attributed to short-term peaks of pollution observed in Europe. Chronic impacts of prolonged elevated SO₂ levels on lung function are estimated to occur in close to10 million people in Europe.     

Nutrition education for illiterate children in southern Madagascar--addressing their needs, perceptions and capabilities

OBJECTIVE: A Knowledge, Attitudes and Practices (KAP) study was conducted in three villages of Bekily District in southern Madagascar prior to the implementation of a health education programme with children. The participatory learning concept of the Child-to-Child approach was followed to involve the children in the planning and implementation of the programme, which was covered by the German Agency for Technical Cooperation. DESIGN: To this effect, qualitative research methods such as Participatory Learning and Action techniques (focus group discussions, mapping and matrix ranking, etc.) were applied. SUBJECTS: The survey was conducted between August and December 1999. It involved a total of 55 school-aged children (6-14 years) along with 21 mothers and 34 fathers, representing different ethnic groups and educational backgrounds. RESULTS: The results show that children's KAP related to health and nutrition strongly reflect those of adults. They are not aware of a possible link between bad hygiene and the occurrence of diseases. According to them, diarrhoea or malaria is caused by consuming too large amounts of certain foods. Even if they know about certain elementary hygiene behaviours, they do not practise this in their everyday life. CONCLUSION: A major objective of the health education programme for children should be to tackle the discrepancy between hygiene-related knowledge and behaviour. Through the participatory study approach the children revealed their ability to contribute to the programme development. In using appropriate communication channels, the Child-to-Child health education programme is expected to influence the health behaviours of both adults and children. The health education programme should be combined with a literacy programme to address the children's desire to learn reading and writing.     

Consumer perception versus scientific evidence about health benefits and safety risks from fish consumption

OBJECTIVE: To investigate the gap between consumer perception and scientific evidence related to health benefits and safety risks from fish consumption. DESIGN: Consumer perceptions from a cross-sectional survey in March 2003 in Belgium were compared with scientific evidence based on a literature review. METHOD: A quota sampling procedure was used with age as quota control variable. Subjects completed a self-administered questionnaire including health benefit beliefs from fish, fish content and effect beliefs for nutrients and harmful substances. SUBJECTS: Adults (n=429), who were the main person responsible for food purchasing in the household (284 women; 145 men), aged 18-83 years, from different regional, education, family size and income groups. RESULTS: Fish is predominantly perceived as a healthy food that reduces risk for coronary heart disease, which corroborates scientific evidence. This perception is stronger among women than among men. In contrast with scientific evidence, 46% of the consumers believe that fish contains dietary fibre, whereas less than one-third is aware that fish contains omega-3 fatty acids and that this nutrient has a positive impact on human health. The gap between perception and evidence is larger among consumers with lower education. In general, consumers are better aware of the content and effect of harmful substances than of nutrients in fish. CONCLUSIONS: Despite conclusive evidence about the content and positive effect of omega-3 fatty acids in fish, related consumer awareness and beliefs are poor and often wrong. This study exemplifies the need for nutrition education and more effective communication about the health benefits of fish consumption.     

Low back disorders in agriculture and the role of stooped work: scope, potential interventions, and research needs

Low back disorders (LBDs) continue to be a major occupational health problem facing the agricultural workforce. Working in a flexed or stooped posture is one of several workplace factors associated with occupationally related LBDs and is highly prevalent in many agricultural tasks. The purpose of this article is to evaluate the role of stooped work in the problem of LBDs among agricultural workers by examining the epidemiological literature, evaluating the scope of stooped work in agriculture, and examining current and potential intervention approaches. The literature review indicates that the prevalence of LBDs in agriculture worldwide is considerably high and substantially reported. Workers who are exposed to stooped work in agriculture are estimated to be in the 100s of millions worldwide. However, stooped work has not been specifically investigated as an independent LBD risk factor. Plausible biomechanical and physiological mechanisms of how stooped work may lead to damage to the spinal structures are discussed, and this complements the epidemiological evidence of high prevalence of LBDs in agriculture. However, this study also identifies the need to conduct more thorough epidemiological studies that utilize accurate quantitative exposure and outcome assessment techniques for developing more appropriate dose-response relationships in agricultural stooped work. This will provide better means for evaluating current and future interventions for jobs involving stooped work. Various intervention approaches are summarized to control and abate stooped work in agriculture; however, it must be emphasized that any development of ergonomic interventions for stooped work in agriculture must incorporate a participatory ergonomics approach that integrates the opinions and concerns of workers, managers, and ergonomists.     

Increasing fruit and vegetable consumption: success of the Western Australian Go for 2&5 campaign

OBJECTIVE: The Western Australian Health Department's Go for 2&5 campaign aimed to increase adults' awareness of the need to eat more fruit and vegetables and encourage increased consumption of one serving over five years. DESIGN: The multi-strategy fruit and vegetable social marketing campaign, conducted from 2002 to 2005, included mass media advertising (television, radio, press and point-of-sale), public relations events, publications, a website (www.gofor2and5.com), and school and community activities. Campaign development and the evaluation framework were designed using health promotion theory, and assessed values, beliefs, knowledge and behaviour. Two independent telephone surveys evaluated the campaign: the Campaign Tracking Survey interviewed 5032 adults monitoring fruit and vegetable attitudes, beliefs and consumption prior to, during and 12 months after the campaign; and the Health & Wellbeing Surveillance System surveyed 17,993 adults between 2001 and 2006, continuously monitoring consumption. SETTING: Population public health intervention-social marketing campaign in Western Australia, population of 2,010,113 in 2005. SUBJECTS: Adults in the Perth metropolitan area. RESULTS: The campaign reached the target audience, increasing awareness of the recommended servings of fruit and vegetables. There was a population net increase of 0.8 in the mean number of servings of fruit and vegetables per day over three years (0.2 for fruit (1.6 in 2002 to 1.8 in 2005) and 0.6 for vegetables (2.6 in 2002 to 3.2 in 2005), significant at P < 0.05). CONCLUSION: Sustained, well-executed social marketing is effective in improving nutrition knowledge, attitudes and consumption behaviour. The Go for 2&5 campaign provides guidance to future nutrition promotion through social marketing.     

The impact of a school-based nutrition education intervention on dietary intake and cognitive and attitudinal variables relating to fruits and vegetables

OBJECTIVE: To assess the impact of a school-based nutrition education intervention aimed at increasing the consumption of fruits and vegetables. DESIGN: The intervention programme increased the provision of fruits and vegetables in schools and provided a range of point-of-purchase marketing materials, newsletters for children and parents, and teacher information. Curriculum materials at age 6-7 and 10-11 years were also developed and utilised. Evaluation was undertaken with groups of younger (aged 6-7 years) and older (aged 10-11 years) children. Methods included 3-day dietary records with interview and cognitive and attitudinal measures at baseline, with follow-up at 9 months, in intervention and control schools. SETTING: The work was undertaken in primary schools in Dundee, Scotland. SUBJECTS: Subjects comprised 511 children in two intervention schools with a further 464 children from two schools acting as controls. RESULTS: Children (n=64) in the intervention schools had an average increase in fruit intake (133+/-1.9 to 183+/-17.0 g day(-1)) that was significantly (P<0.05) greater than the increase (100+/-11.7 to 107+/-14.2 g day(-1)) estimated in children (n=65) in control schools. No other changes in food or nutrient intake were detected. Increases in scores for variables relating to knowledge about fruits and vegetables and subjective norms were also greater in the intervention than in the control group, although taste preferences for fruits and vegetables were unchanged. CONCLUSIONS: It is concluded that a whole school approach to increasing intakes of fruits and vegetables has a modest but significant effect on cognitive and attitudinal variables and on fruit intake.     

Factors to consider in Micronesian food-based interventions: a case study of preventing vitamin A deficiency

BACKGROUND: Many factors need to be considered in a food-based intervention. Vitamin A deficiency and chronic diseases, such as diabetes, heart disease and cancer, have become serious problems in the Federated States of Micronesia (FSM) following the decreased production and consumption of locally grown foods. However, agricultural and social conditions are still favourable for local food production. AIM: To identify key factors to consider in a Micronesian food-based intervention focusing on increased production and consumption of four major Micronesian staple foods: banana, breadfruit, giant swamp taro and pandanus. METHODS: Ethnographic methods including key informant interviews and a literature review. RESULTS: Pacific and Micronesian values, concepts of food and disease, and food classifications differ sharply from Western concepts. There are few FSM professionals with nutrition expertise. Traditional foods and food cultivars vary in nutrient content, consumption level, cost, availability, status, convenience in growing, storing and cooking, and organoleptic factors. CONCLUSIONS: A systematic consideration of the factors that relate to a food-based intervention is critical to its success. The evaluation of which food and cultivar of that food that might be most effectively promoted is also critical. Regional differences, for example FSM inter-island differences between the staple foods and cultivars, must be considered carefully. The evaluation framework presented here may be relevant to Pacific Island and other countries with similar foods where food-based interventions are being planned. An ethnographic approach was found to be essential in understanding the cultural context and in data collection and analysis.     

Evaluation of the Food and Agriculture Organization's global school-based nutrition education initiative, Feeding Minds, Fighting Hunger (FMFH), in schools of Hyderabad, India

OBJECTIVE: To assess the efficacy of the Food and Agriculture Organization's global school-based nutrition education initiative, Feeding Minds, Fighting Hunger (FMFH), in improving nutrition-related knowledge levels of schoolchildren. DESIGN: Adopting the cluster randomisation technique, five schools each in experimental and control groups were randomly chosen from the member schools of a voluntary organisation. Repeated measures of knowledge levels were carried out at three points in time to assess pre-, post-intervention and retention of knowledge gained during the intervention. Children from experimental schools were given nutrition education by teachers in the classroom setting using FMFH material. SUBJECTS/SETTINGS: Schoolchildren (n=358 in the control group and n=312 in the experimental group) of grades VIII and IX from schools in Hyderabad, India.Results: The classroom-based intervention resulted in a significant improvement (P<0.01) in nutrition knowledge levels of schoolchildren in the experimental group. Significant improvement in knowledge was also observed in the control group. The effect size indicated that the improvement in knowledge levels of schoolchildren in experimental schools over control schools was medium (d=0.40), indicating the efficacy of the FMFH programme in improving nutrition-related knowledge. No significant decrease (P>0.05) in knowledge levels was observed after 2 months, indicating retention of the knowledge acquired through the intervention. CONCLUSION: The FMFH programme provides an opportunity for schoolchildren to learn more about nutrition through their teachers in a classroom setting if the lesson plans are adapted to the local circumstances. Furthermore, it has the potential to make nutrition education interactive, effective and sustainable.     

The role of foreign direct investment in the nutrition transition

OBJECTIVE: To examine the role of foreign direct investment (FDI) in the nutrition transition, focusing on highly processed foods. DESIGN: Data on FDI were identified from reports/databases and then compiled and analysed. A review of published literature on FDI into the food sector was conducted. SETTING: The nutrition transition is a public health concern owing to its connection with the rising burden of obesity and diet-related chronic diseases in developing countries. Global health leaders are calling for action to address the threat. Highly processed foods often have considerable fat, sugar and salt content, and warrant closer examination. RESULTS: FDI into food processing, service and retail has risen rapidly since the 1980s, mainly from transnational food companies (TFCs) in developed countries. As FDI has risen, so has the proportion invested in highly processed foods for sale in the host market. FDI has proved more effective than trade in generating sales of highly processed foods, and enables TFCs to cut costs, gain market power and obtain efficiencies in distribution and marketing. The amount of FDI targeted at developing countries is increasing; while a disproportionate share enters the larger developing economies, foreign affiliates of TFCs are among the largest companies in low- and low- to middle-income countries. The effect of FDI is to make more highly processed foods available to more people. FDI has made it possible to lower prices, open up new purchasing channels, optimise the effectiveness of marketing and advertising, and increase sales. CONCLUSION: FDI has been a key mechanism in shaping the global market for highly processed foods. Notwithstanding the role of demand-side factors, it has played a role in the nutrition transition by enabling and promoting the consumption of these foods in developing countries. Empirical data on consumption patterns of highly processed foods in developing countries are critically needed, but since FDI is a long-term investment vehicle, it is reasonable to assume that availability and consumption of highly processed foods will continue to increase. FDI can, however, bring considerable benefits as well as risks. Through its position 'upstream', FDI would therefore be an appropriate entry-point to implement a range of public health policies to 'redirect' the nutrition transition.     

'The bigger the better'--mothers' social networks and child nutrition in Andhra Pradesh

OBJECTIVE: It is hypothesised that mothers' social networks can positively affect child nutrition through the sharing of health knowledge and other resources. The present study describes the composition of mothers' networks, examines their association with child nutrition, and assesses whether health knowledge is shared within networks. DESIGN AND SETTING: Cross-sectional data for mothers of young children from Andhra Pradesh (south India) were combined with existing data from the Young Lives study, in which the mothers were participating (n = 282). RESULTS: The composition of social networks varied between urban and rural areas, with urban networks being larger, more female, more literate and with a greater proportion of members living outside the household and being non-family. There was a positive association between child's height-for-age Z-score and mother's network size and network literacy rate. The association with network literacy was stronger among the poorest households. Women commonly reported seeking or receiving health advice from network members.CONCLUSION: Big and literate social networks are associated with better child nutrition, especially among the poor. The dissemination of health knowledge between network members is a plausible way in which social networks benefit child nutrition in India. Further research into the underlying mechanisms is necessary to inform the development of interventions that channel health information through word of mouth to the most excluded and vulnerable families.     

Socio-economic pathways to diet: modelling the association between socio-economic position and food purchasing behaviour

OBJECTIVES: To examine the association between education level and food purchasing behaviour and the contribution of dietary knowledge to this relationship; and the association between household income and purchasing behaviour and the contribution made by subjective perceptions about the cost of healthy food.DESIGN AND SETTING: The study was conducted in Brisbane City (Australia) in 2000. The sample was selected using a stratified two-stage cluster design. Data were collected by face-to-face interview from residents of private dwellings (n=1003), and the response rate was 66.4%. Dietary knowledge was measured using a 20-item index that assessed general knowledge about food, nutrition, health and their interrelationships. Food-cost concern was measured using a three-item scale derived from principal components analysis (alpha=0.647). Food purchasing was measured using a 16-item index that reflected a household's purchase of grocery items that were consistent (or otherwise) with dietary guideline recommendations. Associations among the variables were analysed using linear regression with adjustment for age and sex.RESULTS: Significant associations were found between education, household income and food purchasing behaviour. Food shoppers with low levels of education, and those residing in low-income households, were least likely to purchase foods that were comparatively high in fibre and low in fat, salt and sugar. Socio-economic differences in dietary knowledge represented part of the pathway through which educational attainment exerts an influence on diet; and food purchasing differences by household income were related to diet in part via food-cost concern.CONCLUSIONS: Our findings suggest that socio-economic differences in food purchasing behaviour may contribute to the relationship between socio-economic position and food and nutrient intakes, and, by extension, to socio-economic health inequalities for diet-related disease. Further, socio-economic differences in dietary knowledge and concerns about the cost of healthy food play an important role in these relationships and hence should form the focus of future health promotion efforts directed at reducing health inequalities and encouraging the general population to improve their diets.     

The Public Health Nutrition workforce and its future challenges: the US experience

OBJECTIVES: To describe the US public health nutrition workforce and its future social, biological and fiscal challenges. DESIGN: Literature review primarily for the four workforce surveys conducted since 1985 by the Association of State and Territorial Public Health Nutrition Directors. SETTING: The United States. SUBJECTS: Nutrition personnel working in governmental health agencies. The 1985 and 1987 subjects were personnel in full-time budgeted positions employed in governmental health agencies providing predominantly population-based services. In 1994 and 1999 subjects were both full-time and part-time, employed in or funded by governmental health agencies, and provided both direct-care and population-based services. RESULTS: The workforce primarily focuses on direct-care services for pregnant and breast-feeding women, infants and children. The US Department of Agriculture funds 81.7 % of full-time equivalent positions, primarily through the WIC Program (Special Supplemental Nutrition Program for Women, Infants, and Children). Of those personnel working in WIC, 45 % have at least 10 years of experience compared to over 65 % of the non-WIC workforce. Continuing education needs of the WIC and non-WIC workforces differ. The workforce is increasingly more racially/ethnically diverse and with 18.2 % speaking Spanish as a second language. CONCLUSIONS: The future workforce will need to focus on increasing its diversity and cultural competence, and likely will need to address retirement within leadership positions. Little is known about the workforce's capacity to address the needs of the elderly, emergency preparedness and behavioural interventions. Fiscal challenges will require evidence-based practice demonstrating both costs and impact. Little is known about the broader public health nutrition workforce beyond governmental health agencies.     

Responding to the crisis in sub-Saharan Africa: the role of nutrition

In the chapter dealing with education and health, the report of the influential Commission for Africa prioritises basic health systems, HIV/AIDS, malaria and tuberculosis. In contrast, nutrition is given less than half a page and is reduced to parasite control and micronutrient support. Such neglect of nutrition is hard to understand in the context of increasing hunger and malnutrition across the continent. Sub-Saharan Africa is the only region in the world where the proportion of underweight children has stagnated and the absolute numbers have actually increased in the last decade. It has been pointed out that if current trends continue sub-Saharan Africa will achieve the Millennium Development Goal for child mortality around 2115 - one century after the target date. Quite clearly those concerned with nutrition need to more powerfully advocate the role of nutrition in lifting Africa out of the spiral of poverty. The present paper argues that to achieve this requires an understanding not just of the critical role of nutrition for health and development (both individual and national), but also of how recent global changes are interacting with changes in food production and supply, other determinants of maternal and child health, and the role and capacity of the state to tackle malnutrition in Africa. It concludes by suggesting some responses that nutritionists could now be making.