Right to food

Health Topics

Author: K. E. Eduljee
One-point-eighty-one million years ago, massive volcanic eruptions deposited a layer of ash. Both Kant and Carruthers agree that my torturing my own cat for fun would be wrong. It feels like there might be something in there, but I like a challenge so I'll knap it anyway. The standing rule is to give a very small test dose initially and to wait for five minutes for any sign of an anaphylactic reaction. But Richard Wrangham is sure Homo erectus was building fires much earlier.

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A full liver cleanse can be helpful in reversing the damage to some extent. You might not know what too much alcohol means as far as your liver health is concerned. From mild scarring to severe inflammation of the liver cells, an excessive intake of alcohol can cause a severely negative impact on the liver. Moreover, if the negative impact of alcohol takes a toll on the liver, the ability to break down alcohol further reduces, thus, causing chronic damage.

So, it is advisable to keep the consumption of alcohol at a moderate pace. A good rule of thumb is one standard drink for women and a maximum two for men per day. Diet , food , health , injury , liver , meals , nutrition , organs , Supplements. In summer, most of us take our workouts a bit more seriously. Many of us have post workout routines that we feel are important for our fitness. From stretches and yoga to meditation and even meals or protein shakes, the things we do after our workouts are just as important as what we do during them.

The post-workout routine is filled with these mental and physical exercises and practices that remain critical to our fitness success. What can we add to our post-workouts for better fitness and for stress relief? Surprisingly, one answer is blogging. Because it combines some of the mental tasks above with habitual practices that make your workouts more productive and help you keep track of the things you want and need to accomplish.

Starting a blog, choosing a domain and website host and designing your site are all pretty easy. Once you get going, blogging can be addictive just like exercise. How does post-workout blogging help improve your workouts? Here are a few ways. Here is an interesting guest post by a good friend of Project Swole. He wishes to remain mostly nameless aside from mentioning his name is Andy , but trust in me he is smart and experienced, and I think this piece will really connect with most Swole readers.

Human beings like habits, as a rule. Good or bad, habits allow us to predict the future — if I do this exactly as I did yesterday , I know what will happen.

Habits equal proven outcomes. Habits provide routine, and for us, routinely provides security. Take, for example, the diabetic cake-shop owner. You get my point. How to Get a Degree in Exercise Science. How to Get a Degree in Physiology. How to Get a Degree in Kinesiology. As a certified personal trainer , you can not only meet these professional goals, but you can also put your outgoing personality, communication skills, and motivational strategies to good use by helping others to realize their true potential and meet their fitness goals through targeted training programs.

Including methods of behavioural modification in training sessions, however, requires competent educators and more time for reinforcement of the necessary skills, both of which make inputs for these approaches more costly. Characteristics of a competent adult educator Base training on sound theory The theoretical basis for planning interventions for changing health behaviours rests on models of behaviour.

The most common theories mentioned in the nutrition education literature are summarised in Table 2. Glanz and Rudd surveyed nutrition education and consumer behaviour professionals both in fields providing information to influence food choice for their opinions on which theories and models were most familiar and useful. Those in both fields selected a few familiar and current theories, but respondents concurred that theories were not all-important as there are frequently gaps between research and practice.

The practical application of these theories is difficult since no single model of behaviour change available today fits all situations. While theories attempt to identify all factors which may influence the outcome behaviour, they are simplifications of reality. Also, different theories are more successfully applied at one stage of learning than at another.

Therefore, it is difficult to use a single paradigm for the whole intervention process. Nevertheless, theory-based nutrition education efforts and the use of theoretical models to help construct training efforts are useful since they permit the educator to methodically incorporate the influence of motivators, barriers, and other influential factors in the planning and implementation of nutrition education efforts.

Eclectic models may be most appropriate. Influences components include the environment, providing incentives and disincentives; situations which provide consequences, or "expectancies"; and skills behavioural capacity , and self-efficacy, the ability to do what needs to be done.

Positive reinforcement is important for this component Bandura, Represents interaction and influence of factors in the social environment as they reflect and modify behaviour.

The stages of readiness include pre-contemplation through contemplation and eventual action. For more complex applications, the transtheoretical across several theories model posits relationships among the stages and processes of change Prochaska, Attitudes and attitudinal assessment of target audience are emphasised. Health Belief Model Weights various factors influencing health behaviour change.

People more likely to change are thought to be the ones who believe they are susceptible to a stated risk which has potentially serious consequences, when the solution offered is likely to decrease the susceptibility or severity of outcome, and the anticipated costs or barriers to participation are outweighed by this benefit.

Further, those with high self-efficacy, such that they feel they can do what needs to be done to improve the situation, are most likely to change Rosenstock Does not reach those who are at risk but do not see themselves as such, due to denial or lack of information. Does not include non-health-related reasons for behaviour i.

The focus on individual determinants can lead to victim-blaming. Social Action Theory Based on the information processing theory, people are assumed to choose the alternatives which provide them with the most "good" outcomes and the fewest "undesirable" outcomes. Examines people's intentions to behave a certain way and assigns a probability of certain actions based on intentions, influence of others, etc.

Azjen and Fishbein Useful for explaining food-related behaviours over which people have control. Acknowledges the real world in that it considers social influences on certain behaviours.

The more options that are identified along the continuum from intention to desired outcome, the better the predictive value of the model. Follow a four step approach: First the instructor models or demonstrates new responses and action patterns.

Second, guided, and increasingly independent practice in those thoughts and behaviours is provided. Feedback on the appropriateness and accuracy of responses is provided. Finally, trainee behaviours are reinforced by support and encouragement. Gradually the new habit or skill may have naturally reinforcing consequences which provide further rewards. Develop motivational techniques to market messages Without motivation to act on a specific message, information is useless.

The educator must find out what factors motivate people to change their health behaviours, provide information that will motivate them, and deliver it in a context which promotes change. Training that motivates and reinforces the confidence of the nutrition educator, as well as training that includes techniques which improve these skills in counselling is helpful Parlato, Green, Fishman, Some questions answered through qualitative investigative techniques which contribute to developing motivational approaches and messages are listed in Table 3.

Qualitative methods such as focus groups and surveys help to provide data needed to develop motivational techniques to personalise the audience assessment. Lopez used focus groups with low-income women to determine, develop and instrument measuring the effects of certain psychosocial influences on eating in this population. Questions potentially answered through focus groups and surveys of target groups What motivates and reinforces the health behaviour in question?

What are the barriers negative motivators to improved health behaviour? Who considers themselves at risk? How aware of the consequences of the behaviour are members of the population? How deterred by consequences are they? Select appropriate methods of education and communication for target groups Effective education and communication techniques that are derived from marketing and the behavioural sciences are often appropriate and effective for changing nutrition-related behaviours at the community level Parlato, Green, Fishman, ; Cabanero-Verzosa, ; UNICEF, This is called social marketing.

Nutrition communication has been most effective when several steps are taken Parlato, Green, Fishman, First, a limited number of specific behaviours significantly affecting the target group's nutritional status are selected.

Second, small behaviour changes that provide a viable choice within the time and cost constraints of the household and community are targeted. Third, messages tailored for each of the groups of people that influence the intended beneficiary are employed using communicators and language that are meaningful to each group. These messages must be conveyed with enough salience and for a long enough time that the ideas enter into "normal" conversations in the target group and are eventually adopted as behaviours.

Finally community involvement in message development and pretesting is also helpful. Social marketing seems to be an effective communication technique, regardless of the information one is conveying, since it emphasises getting the message to the consumer rather than to the communicator.

In this case, the consumers are both the nutrition educators as trainees , and the target population. When applied to nutrition education, using the social marketing perspective requires that trainers prepare nutrition educators who are particularly knowledgeable about their audience and involve them in finding solutions to problems of inadequate nutritional practices.

Nutrition educators should be able to: Supervised practice in the use of these techniques is also helpful. Familiarise nutrition educators with the use of social marketing techniques in crafting programmes Social marketing refers to a process of delivering highly appealing audience-specific messages. It draws on insights from marketing and advertising. It requires finding out what people need and want, and then developing a programme based on those appeals Novelli, ; Ngo, The objectives of social marketing include disseminating new data and information on healthy eating practices to individuals, offsetting the negative effects of a practice or promotional effort by another organization or group, and motivating people to move from intention to action in implementing sound dietary practices.

Social marketing incorporates the influence of the audience's motivators and reinforcers into planning nutrition education campaigns.

Not all steps involved in planning a social marketing programme involve nutrition education. However each step helps define the appropriate nutrition information and best choices of communication to use to reach goals Young, Steps for planning a social marketing campaign are listed in Table 4 Ngo, Trainers of nutrition educators should introduce these steps in training sessions. Social marketing has been used for planning and implementing a variety of community nutrition initiatives in the United States including Project LEAN, Pawtucket Heart Health Programme Lefebvre, , Stanford Five-City Project Farquhar, , Giant Foods' campaigns to promote heart health and decrease cancer risks, and a campaign to increase breast-feeding by limited income mothers Bryant et al, Steps involved in planning a social marketing campaign 1.

Identify the problem 2. Segment the audience 3. Target the audience 4. Position the "product" 5. Design the "product" 6. Implement and assess effectiveness When individual instruction and interaction is less feasible and messages are directed to the general public, such as in social marketing, nutrition education message conveyed via mass media must adhere closely to sound principles of communication in order to be effective.

Some characteristics of successful messages for bringing about health behaviour change in populations are summarised in Table 5 McAlister et al. Use appealing and appropriate instructional methods in training Personal contact is an effective way to influence dietary behaviour, so face-to-face presentations, demonstrations, and counselling are helpful in nutrition communication.

Educators are able to do more effective nutrition counselling on the individual or group level if they have been exposed to these techniques and see them during training. Instructional methods that are appropriate for the audience of trainers must be selected. Frequently a combination of methods is appropriate. Matching method with specific training needs will help to maximise both method and training effectiveness. Table 6, adapted from Pont , describes a variety of common instructional methods and some of their distinguishing characteristics.

Pont points out that research indicates that "learners retain about: Individual and group skills that are important include active-listening, asking questions, and using appropriate language and gestures.

Communication and teaching methods important for working with individuals and groups are listed in Table 7. Working with individuals is more time consuming, but in that extra time the trainer or nutrition educator can potentially provide instruction based on a more thorough understanding of that member of the target population.

Groups can be an efficient way of reaching several people with similar learning needs and interests that capitalise upon social supports and reinforcement by peers. Techniques for managing group dynamics are useful tools. Often a combination of group and individual instructional methods are most effective for nutrition educators Parlato, Green, Fishman, Trainers should use these techniques in training and include them as part of the curricula devised for nutrition educators.

Passing these skills on to the public successfully will result in an audience more capable of critically evaluating information and suggestions set before them, and appropriately applying recommendations in a variety of conditions. Both trainers and nutrition educators need to develop their own critical thinking skills if they are to be effective at teaching these to nutrition educators and the public, respectively. Several references are now available for teaching such skills, and these should be incorporated into training sessions Plavacan et al.

Know and use the "tools" of nutrition education Knowledge of the country's available "tools" for nutrition education is also essential in helping to keep messages consistent and to provide broad guidelines with which to work. Different subject matter areas within food and nutrition such as food preparation, purchasing, budgeting, medical therapies, prevention of deficiencies, improving nutritional status are usually so interrelated that it is possible to teach beginning with a point of individual interest, and eventually convey the message specifically targeted to the population at risk Brink, Having standard tools for reinforcement of these messages allows basic information to be conveyed, while also responding to interests in other areas of interest to the population.

Use up-to-date instructional technologies The potential for new computer-based technologies to increase and improve access to information by parts of the population in industrialised and developing countries, where much of the population is far away from a city or information centre, is tremendous. Other technologies can also enhance teaching world-wide. Table 8 shows some up-to-date instructional technologies.

They include distance learning by radio and TV, and computer-assisted technologies, among others. The training of instructors in the use of new technologies needs to be thorough enough for them to use them in their own teaching.

Provision of backup resources, such as clearly written instructional manuals that include directions for troubleshooting, are useful. Summary of Instructional Technologies to use in training nutrition educators Technology Pros Cons Nutrition education example Radio Widely available Not interactive Targeted messages to hard-to-reach audiences in developing countries; public service announcements Television TV Widely available Need broadcasting capabilities; not easily portable; not interactive Public TV programmes, public service messages Videotape Entertaining if short, can be specific to training needs Need television; expensive to make; tape sizes must match VCR to show in different places; not interactive Videos made by organisations with specific, targeted message i.

Many external, practical factors limit the application of technologies in training of nutrition educators, including unwillingness on the part of instructors to use them, lack of money, skills or facilities, or lack of back-up technical support.

Small, mundane details must be attended to and can be quite disruptive if ignored: With the advent of more recent distance learning technologies, the geographical location of trainees and means of access to them are also considerations. Table 9 provides some ideal conditions and brief comments regarding different training lengths. Training sessions often need to be compressed into several days of intense instruction. It is easy to become bored if the teaching styles are monotonous.

Incorporating discussions and hands-on exercises can help to break up long blocks of time and lessen fatigue. Table 10 contrasts the pros and cons of centralised, on site, and distance learning locations. Plan field experiences to bring training to life After some initial instruction, it is helpful to provide field experiences that offer the opportunity for relevant interactive and hands-on experiences for trainees.

They also provide the instructor with a chance to observe and evaluate trainees in a setting outside of the "classroom". Planned experiences may relate to any of the topics already covered or those coming in the future. Such experiences will help build a high level of competency and comfort with all material and techniques in trainees.

Examples of such field experiences include trainer-observed instruction by nutrition educators in groups local clinic or with individuals home visit. Options and pros and cons of different training lengths Training Frequency Ideal Conditions Comments Consecutive days Full but not long days i.

If travel is required, consecutive days may be the only option Once a week Several hours weekly over consecutive weeks Provides opportunities for practice in between sessions and reinforcement of material through follow up in subsequent sessions Initial training with follow up sessions Short initial training with regular, on-going supervision and evaluation Allows for ongoing guidance and learning after main, initial training.

Provides opportunities for practice between training sessions Table Obvious inappropriate behaviours, such as cultural biases, prejudice, poor communication, judgmental and condescending attitudes, need to be discussed if individuals possessing these characteristics were not screened out while selecting potential nutrition educators.

Pre-existing value judgements by nutrition educators may have an impact on client interrelationships and can affect the way they communicate nutrition messages to individuals. This applies to issues involving some of the more obvious and sensitive possibilities for discrepancies between nutrition educator and audience, including class, race, and gender. The inculcation of self-direction in learning and practice is a requirement of a good adult educator, and also a reflection of good in-service training and education.

A nutrition educator who can separately assess each teaching situation and adjust the experience accordingly, as well as critically evaluate the success of each contact and revise future efforts accordingly, is one who will be well-equipped to take on the task of facilitating nutrition behaviour change in a target population. Evaluate training efforts Classify the type of outcomes desired Outcomes can be regarded as cognitive knowledge , behavioural response to information , health anthropometric, biochemical and clinical measurements, morbidity and mortality statistics and system institutionalisation, in that a message is incorporated in the content of other development messages and projects.

These need to be explicitly stated. The specific parameters for success, or the size of effects may change in magnitude or specification over time. Edwards, Mullis and Clarke describe several issues in evaluation research as important to consider for a thorough and comprehensive evaluation of nutrition education programmes.

First, evaluation efforts should be flexible and interactive, and be used throughout the development of a new programme so that findings can be used to change future programme and subsequent evaluation procedures.

Second, assessing qualitative data as well as quantitative data provides useful information, for example instructor and participant perceptions of course materials and instructional strategies.

Integrating measures of process and performance reveals clues to explaining performance data. A closer look at process includes evaluation measures of a programme at each level of the organisational structure i. Measure short-term effects Trainee competence with respect to knowledge processes and skills must be assessed both during and after training, to evaluate the overall effectiveness of the training and the achievement of the individual. Evaluation of the trainee should be based on the objectives of the training session - what the trainee must know to function effectively in the field.

Paper and pencil evaluations by pre- and post-tests, quizzes and practicals, as well as evaluation by observation, such as requiring presentation or hands-on demonstrations, are both usually needed to assess the abilities of each trainee. Mid-course evaluations can provide immediate feedback and it is often helpful to build-in some test at the end of each training session.

Also, participant feedback following training sessions provides valuable information for the planning of future sessions, and it should be solicited. Measure long-term effects Evaluation of trainees immediately following the programme is both necessary and useful.

Long-term evaluation measures the "true" effectiveness long-term outcome of the training effort against the long-term goals and objectives of the larger intervention. These may be changes in knowledge, attitudes, or behaviour.

Evaluation methods must be appropriate for the goals and objectives of the programme. Regardless of the type of outcome desired or the time frame for its accomplishment, long-term evaluation must include baseline measurements on the same population, or some acceptable proxy for it. In interpreting results, secular trends and other possible factors contributing to behaviour change measured during the time of the intervention must be considered.

Humans change their behaviour for many reasons. For example, measures may indicate that nutrition educators were successfully trained and performed their tasks well, but behaviours in the population did not change as expected in the given amount of time. Many uncontrolled variables, such as a sudden recession, might prevent learners from putting principles into practice because of lack of money. Today it is nearly impossible to credit any one message or circumstance for doing this.

In less industrialised settings with a dearth of public health efforts, a single intervention's effects may be much easier to quantify. Reformulate and improve training based on results Short- and long-term evaluation results are useless if they are not used to improve training programmes in the future. Analysis of both process and outcome evaluation together provides the most information with which to locate and revise contributors to less than desirable outcomes.

Training programmes for nutrition educators After the nutrition educators have been successfully trained and have demonstrated that they are knowledgeable, competent and skilled, more specific areas of expertise must be acquired before they are ready to go into communities to teach. This section addresses these more specific issues. Base programming on knowledge of food, nutritional needs, and problems of the population and sub-groups by employing needs assessments and other techniques At the outset, the population most in need of nutrition education needs to be identified, and nutrition educators need to know how to do this.

Such needy groups often include infants and young children, pregnant and lactating women, and the elderly. Populations may also be targeted by risk factors for disease i.

Conduct qualitative and quantitative baseline assessments of target group Baseline assessments of the target population with respect to their food and nutrition problems, needs, and attitudes, are crucial to developing a nutrition education campaign which will change behaviour and improve health. Knowledge of the audience is critical for health messages. Such information is used widely today in social marketing as well as in product-focused messages by marketers.

Qualitative methods of needs assessment include using focus groups and surveys, or compilation of information on knowledge, attitudes, and practices of the target group. Quantitative assessment tools include anthropometric measurements, such as height and weight plotted on growth charts , morbidity and mortality statistics, information on dietary intake, and information on biochemical and clinical measures of nutritional status from screening tests or surveys.

Identify factors to be changed in the target population Identify barriers to better dietary habits and better health Once the population needing help is identified and characterised through the use of qualitative and quantitative methods, the next step the nutrition educator takes is to identify major factors affecting food habits that can be changed. In addition to lack of knowledge, other factors influencing nutritional status and dietary habits usually include economic, cultural, and social factors, individual preferences, lifestyles, and time constraints.

Nutrition education cannot address all of these problems or overcome all of the barriers they create Parlato, Green, Fishman, Therefore realistic objectives that stand a chance of success must be chosen.

Be aware of factors affecting local food supply as well as individual dietary behaviours For solving some problems, the nutrition educator's knowledge of diet-related factors affecting health should also include knowledge of the local food supply and of the health and education sectors.

Nutrition educators must be aware of all the aspects of food-getting that may be affecting health: Their knowledge must also include a broad range of factors affecting the food supply, in addition to individual dietary behaviours. Specific information describing the food and food habits of the target population should also be available to nutrition educators. This information is summarised in Table Knowledge of local food and foodways useful to nutrition educators What Includes Nutritional value of foods Food tables as relevant to country , charts, computer programmes, etc.

Relevant questions may involve issues about whether any of these compromise the nutritional value of the food such that they should be changed Food safety and hygiene General information on foodborne illness and pathogens most likely to affect target audience Selecting foods for sustainability and good nutritional and economic value Need knowledge of indigenous food supply what is available and at what cost ; seasonal trends affecting cost; how to best store foods to make them last longer and keep nutritional value Knowledge of production and marketing of foods "Foodways" Knowledge of how the food is produced, processed, distributed, regulated, marketed, etc.

Other factors that influence food and nutrition-related behaviours include values, attitudes, social and cultural norms, perceived social pressure, a sense of personal competency and control, and perceived rewards and other motivators that may result from following the recommended behaviour.

Barriers to consumer education include, among others: Individuals with experience and insights about the target population's views on these issues, levels of understanding, and conflicting cultural beliefs or messages, may be helpful in identifying these factors and useful in training. Use the media effectively Rules of thumb for appropriate use of the media to communicate the message are included in Table 5.

Local media channels used most frequently by the target population should be considered within budgetary constraints.

The use of "mini-media", such as church bulletins, worksite publications, and bulletin boards at various organisations, can also be very useful in reaching individuals where they work and play, although they are often underused in public health programmes Lasater, In-service education of nutrition educators should be accompanied by back-up assistance for communicating, disseminating and marketing their messages.

One way to help them is to identify local channels of communication, such as local media radio, TV, newspaper , some basic community action skills including locally appropriate methods of contacting key leaders in the field and political figures with whom it may be helpful to network.

Develop support strategies Look within the community to develop support for interventions Apply interventions with, rather than to, a community or group. This implies developing supportive structures in the community. Sophisticated health education efforts involving many aspects of the community have been well reported in the literature Pirie et al. Looking to the community for involvement is advantageous because communities can provide both valuable human resources and sources of support among the target audience that cannot be simulated or equalled by external efforts.

The nutrition educator needs to know how to select and implement appropriate support strategies for education and communication efforts. These include skills in mobilising social support, using home gardening, school meals, and otherwise involving the community through organisations and community leaders.

Reach audiences beyond health systems in places that are familiar Adult learning theories emphasise the advantage of working in a relaxed, trusting, mutually respectful, informal, warm, and collaborative climate, which supports efforts to reach people in their day-to-day comfortable, relevant settings.

This is what is meant by a "supportive environment". Educating people where they work, live and play rather than just within health systems must be considered. Such settings include households, local communities, schools, worksites, markets and shops, and recreational and cultural settings which are closer to the point at which food choices are actually made. The United States' "5-A-Day" Campaign for increasing the consumption of fruits and vegetables targeted people in a work setting and has made use of the particular attributes of this environment for a nutrition education campaign Sorenson, Know and choose appropriate networks and contacts for nutrition education Develop skills for long term collaboration and institutionalisation of programmes into community life Community interventions seek to change organisations and environments as well as individuals.

The nutrition educator must keep in mind that his or her work is in a long time frame since the aim is for permanence in community life. The goal is community improvement over the long run Parlato, Green, Fishman, Therefore the nutrition educator needs to develop skills that permit collaboration with a range of different organisations and disciplines over a long time. Influence and seek co-operation with community leaders and pro-established networks Community leaders and networks are often effective channels for promoting solutions to nutrition problems.

Community involvement and commitment should therefore be sought at various levels. The accomplished nutrition educator uses the influence of community members, such as officials, elders, group leaders, and community health volunteers, as well as contacts with "higher ups" in the community who can make efforts work more smoothly, and without whose co-operation the efforts may be difficult or impossible.

For example, the Pawtucket Heart Health Programme in the United States turned to the community for volunteers and was able to staff many programmes with these resources. It also formed alliances with organisations including the local Department of Parks and Recreation, which provided facilities for unique opportunities in the campaign Lasater, The Thailand vitamin A project integrated many influential people from all parts of the community and used them as channels in their efforts to reach village residents with their messages.

Some of these channels included: Other agencies may share concern about the target population and may be ripe for collaboration. Sharing outreach efforts, facilities, channels of communication, and even education campaigns, are opportunities for using resources more efficiently and perhaps increasing effectiveness. Ensure that specific knowledge needs for the task at hand have been imparted Content as well as process are important in nutrition education.

After assessment and targeting of those in need of nutrition education, some information and skills need to be transmitted. The subject matter detail that is necessary depends on the prior skills and knowledge of the nutrition educators who are trainees, and also the task at hand.

While providing more facts in training does not increase effectiveness as educators, more knowledgeable educators may have more credibility with their audience and should be included in the training as appropriate. Other considerations Before launching in-service training programmes for nutrition educators, careful consideration needs to be given to the circumstances for which nutrition education is an appropriate intervention.

What causes of malnutrition can be remedied by nutrition education? Clarify goals of intervention Before embarking on nutrition education or training endeavours, the context and rationale for efforts need to be established. The following questions must be asked and answered: What factors contribute to the inappropriate or inadequate nutrition knowledge and food practices?

Is the goal of the programme to increase nutritional knowledge, or to provide skills for making healthy dietary decisions to maximise nutritional status, or both of these? Nutrition education can rarely remedy malnutrition alone Nutrition education is an appropriate intervention only when a lack of food and nutrition knowledge, attitudes, or skills, harm the health or well-being of the individual or those she or he is responsible for.

When factors other than lack of nutrition knowledge cause poor nutritional status, these also need to be addressed. Informational or educational efforts to combat undernutrition are ineffective unless they are culturally relevant and geared to the target group's interests.

What are some other causes of malnutrition and how can they be addressed? Many of the problems related to the ill effects of improper nutrition are due to economic and social inequalities. For example, among the poor in developing countries, undernutrition is a problem that is often due to inadequate food supply, limited purchasing power, poor health conditions, and incomplete nutrition knowledge Berg, Problems of poorly nourished populations in developing countries are multifactorial and include disease, lack of education, poor education, other circumstances associated with poverty, and unequal distribution of food resources, not only within society but within families, as well as lack of nutrition knowledge.

Abundant research shows that in situations of poverty, where food inadequacy exists, food-assistance programmes must precede educational interventions. Thus, it is especially important in developing countries to integrate nutrition education into broader programmes that encompass agricultural and food availability issues. Nutrition education must also be appropriate for the biological, cultural, economic, social, and cognitive contexts in which the programmes operate.

When undernutrition is present, the causes may sometimes include not only insufficient economic resources to purchase adequate diets, or inappropriate food distribution in the family, but also psychopathology. This is particularly likely in affluent countries. Infants who fail to thrive and adolescents with eating disorders often come from disturbed families. Status of women The status of women also has an impact on the effectiveness of nutrition education, especially in developing countries.

In developing countries women have multiple social and economic roles, long working hours, and less access to education and nutrition than males Brown, Yet it is they who are responsible for the alimentation of their families.

Gender discrimination and violation of women's rights deny many women education, health care, and good nutrition. Economic and political instability Developing countries must currently make "structural adjustments" in the economy, and austerity measures, which have a great social impact on food availability, may be implemented to cope with economic instability Bradshaw et al.

The latest international statistics on the effect of different social indicators, including level of nutrition, present a bleak picture, especially in poorer countries experiencing economic crisis, such as Mexico, certain other Latin countries, and Eastern Europe. Political conflict and wars increase already existing inequalities. Violence in Croatia and Bosnia, in several countries in Africa, and in the countries making up the Former Soviet Union have also increased malnutrition.

Political strife in Haiti, Somalia, Iraq, Cuba, and Chechnya may have led to food shortages, and under- and malnutrition in vulnerable groups. Education to improve food choices and handling under conditions of war may alleviate some of the impact on nutritional status as limited knowledge may contribute to the undernutrition seen in these circumstances, but undernutrition rarely yields to nutrition education efforts alone.

Developing countries Environmental influences on nutritional status differ in degree between industrialised and developing countries, but are evident in both Scrimshaw, For example, the effects of poverty on child development, links between anaemia and decreased levels of mental and motor development, the positive effects of supplemental nutrition programmes on child development, and the ill effects of poor nutrition and concurrent illness on school performance, are present in both poor and rich countries Pollitt, Ill-effects of malnutrition are well substantiated Poor early childhood development, low productivity, violations of human rights and women's rights, and abject poverty all combine with lack of nutrition education to cause malnutrition in populations.

Evidence for the deleterious effects of inadequate food is substantial. Foster and Rosenzweig reported that intakes of food energy had adverse effects on productivity in the Philippines, India and Pakistan. Khurana reported an association between malnutrition and lack of basic literacy skills among children in India. But in many developing countries, in addition to dietary inadequacy, nutrition-related feeding problems exist in early childhood development.

The ill effects of improper nutrition early in life are many, and may sometimes be irreversible. Myers , analysing the situation in Latin America, concluded that intellectual development, personality, and social behaviour were all severely impaired by lack of good nutrition.

Glewwe and Jacoby indicated that nutritional deficiencies in early childhood in Ghana were associated with delayed primary school enrolment. Nutrition education must be included as part of the solution Prognoses of the nutritional status of populations around the world are not so negative that we should surrender to a future of malnutrition.

He indicated that now the means were at hand to end mass undernutrition, preventable disease and widespread illiteracy among the world's children. Experts agree that if we are to address these problems, nutrition education must be included as part of overall development efforts. Risks of malnutrition cannot be addressed by nutrition education alone, but nutrition education is appropriate, and can be effective, in situations where food is available but food practices are inappropriate or uninformed from a nutritional standpoint.

Frequently, such lack of knowledge is only part of the problem, and therefore for nutrition education to be most efficient and effective, it should be delivered along with programmes that provide the other components that are lacking.

The UNESCO "Education for All" conference Fordham, called for enhancing the learning environment through early childhood care and education about health and nutrition. In in Lisbon, Portugal, education specialists from 51 countries concluded that systematic and continuous social and familial action, beginning in early childhood and continuing until maturity were necessary to tie together pre-school education, health, nutrition, and social service programmes in to effective intentions.

Others have also emphasised the need to sustain nutrition education in the context of overall promotion of maternal and child health Dwyer, ; Wallace, Industrialised countries In highly industrialised countries such as the United States and Western Europe amongst others, efforts to provide information to consumers so that they can make informed choices have been popular. In these countries, chronic degenerative diseases that have been linked to diet are more prevalent than undernutrition as causes of malnutrition USDHHS, Individual choice contributes to malnutrition through chronic disease In these countries the choices of individuals, rather than insufficient incomes for purchasing adequate diets, make up most of the malnutrition problem.

Many long-standing lifestyle factors, in addition to dietary patterns of excess, contribute to ill health and me development of chronic degenerative diseases that are common in those countries.

These diseases include coronary artery disease, hypertension, non-insulin dependent diabetes mellitus, obesity and alcoholic liver disease National Research Council, Innovative, experience-based teaching techniques are also needed. For example, Fletcher and Braner report that an effective way of teaching children about nutrition is for them to prepare their own foods and to instil awareness of ethnic and cultural influences on food choice.

Institutional arrangements and resources for nutrition education The institutional arrangements for nutrition education and training already in place within a country vary.

Usually it is necessary to build programmes on these bases. Lead responsibility for each aspect of nutrition education should be clear whatever the institutional arrangement. Both efforts sponsored by international and bilateral organisations country to country may be involved, and these may include not only governmental but non-governmental organisations as well.

When the government is involved, in some countries, one institution or sector is designated as responsible for training. In other countries, responsibility is shared by several sectors e. The degree of centralisation of control over programmes also varies. Responsibility may lie with a centrally located group or less highly centralised structures may exist. Finally institutional structures may include only a single discipline or multiple disciplines.

Know organisational resources Those who wish to develop in-service training in nutrition education must be familiar with the organisational resources and channels for communicating within these structures for developing training programmes.

Imposition of in-service training in nutrition education by international organisations with little or no involvement by groups within the country is unlikely to succeed. Co-operation at the government level will make some aspects of training easier than efforts relying unilaterally on voluntary groups.

Countries where interdisciplinary teams have already been formed with a mutual interest in nutrition i. Thailand, with Ministries of Health, Agriculture and Education working together may have systems in place for training and delivery of education which can be used. Large government organisations typically have specified procedures for training staff, which may be necessary and useful to incorporate into training plans if funding is to be obtained from the government agency. For example, in the United States, the Nutrition Education and Training NET Programme was established to support the training of nutrition educators of school age children Ullrich, , and training is built into the mission of the Co-operative Extension service organisations at the Federal and State level.

These organisations exist to translate research information into practical terms, and to bring it to people in target groups who would otherwise not have access to it. In planning and training, nutrition interventions can be linked to other health and socio-economic development programmes.

Investigate other organisations with and interest in nutrition education It is also useful to investigate the willingness of other government, industry and volunteer organisations to cooperate in developing in-service training.

They may have aims which overlap with or involve nutrition education. Monetary or in-kind assistance may also be available for nutrition education training programmes from these sources if their goals and objectives are consistent with those of these funding organisations. Conclusions Plan carefully Thorough and thoughtful planning for training of nutrition educators improves the likelihood that desirable outcomes will result. In the best of all worlds there would be time, money, facilities, willing and capable volunteers, good channels of transportation and communication, co-operative government, and well-established organisational structures in which the trainer could operate.

In the real world, this is often not the case and many barriers exist that cannot be overcome even by the most careful planning. Nevertheless, careful planning, coupled with the flexibility to modify plans to overcome barriers, is likely to achieve more than unplanned efforts. Tailor context to learners' experiences The content of training sessions should be partially determined by the experience of the selected nutrition educators.

While subject matter must be provided to prepare credible educators, educators must also be prepared to communicate their messages effectively.

Recommendations Special considerations applicable to developing countries The guidelines for in-service training of trainers and nutrition educators apply both to industrialised and developing countries.

However, there are some practices which are especially important for furthering nutrition education efforts in developing countries. First, it must be recognised that in developing countries, economic resources for health are limited. However, it is also true that existing resources are not used to their full potential World Bank, More attention to planning and management may be helpful in this regard. Planning can provide better utilisation of a programme, and effective management assures that the programme is efficiently administered and prevents a crisis management approach.

In-service training of nutrition educators must adequately address questions of planning and management, including the manner in which the training is to be conducted, and the larger societal effects. General guidelines, especially appropriate for in-service training of trainers and nutrition educators in developing countries include the following.

Political attitudes and social traditions affect the way people nourish themselves, as does the way a society conceptualises nutrition-related issues. Trainers and nutrition educators, as planners and administrators, must use information provided by local respondents.

Often health professionals and government administrators are unaware of, or unable to, provide information about the local situation.

Generally, most highly educated professionals, including physicians and health workers, are concentrated in the urban areas Phillips and Verhasselt, The in-service training of rural nutrition educators presents special challenges since so few trained personnel are available. An effective way to increase the probability of a programme's success is to invite and encourage the participation of community leaders and teachers. Determining the most important issues to be addressed may assist in finding a proper balance between what is urgent and what is important, and in mobilising efforts.

Maximum impact is determined by attending to highest priority issues and lowest cost by using all available resources effectively. Many developing countries are multilingual, and much scientific and technical information is not available in the indigenous language.

Ideally, the training of trainers should be provided in the language in which recipients are most likely to learn. Trainers should know those languages and adapt the level of language used to match the characteristics of the learners. Illiteracy, or lack of understanding of language used in teaching, may also be a problem of the target group.

Audio-visual technology and aural messages can be used to present or reinforce the message. Training of nutrition educators should recognise the heterogeneity of messages and the existence of varying opinions and find a way to resolve these incongruities without providing false or misleading information. Pre-recorded relevant information can be projected or sent to the trainees. Distance education is also useful for reinforcing face-to-face training, using radio, television, and pamphlets mailed to recipients.

Distance education is also useful for updating nutrition educators. This support system ensures that the programmes can be sustained. Wray in Perry, Marketing strategies for the registered dietitian. What should be next for nutrition education? Training guide in lactation management. Understanding attitudes and predicting behavior. Social foundations of thought and action. What can be done? Lessons from World Bank Experience. Reduction of mortality in rural Haiti through a primary health care programme.

New England J Medicine, Borrowing against the future: Social Forces, 71 3. Challenging adults to explore alternative ways of thinking and acting.

Chapter 4: Population and Human Resources