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Abstract
Introduction
Implementing nutrition for populations in transition
Thailand’s nutritional development
A new approach is needed
Capacity-building for countries in transition
A proposed direction
A final note
References
Aree Valyasevi and Sakorn Dhanamitta
Aree Valyasevi is the president of the International Union of Nutrition Sciences. Sakorn Dhanamitta is affiliated with the Institute of Nutrition at Mahidol University (INMU) in Salaya, Thailand. Both are former directors of INMU.
Facing a double burden of malnutrition, transitional countries must urgently begin proactive institution-building. A problem- and development-based approach is proposed to guide this process that requires a deep understanding of today’s complex food and nutrition issues and appropriate actions for population change. The concept of “empowerment” should be used as a framework in this capacity-building process, and the experiential learning approach must be a key to its development. Furthermore, effective implementation will require a mechanism for multidisciplinary work. On the basis of Thailand’s experience, this mechanism involves at least three essential elements: (1) a problem- and development-based mission, (2) leadership, and (3) proper training for the country’s nutrition professionals.
Many countries are now in transition. The socio-economic conditions in these countries are changing rather rapidly, and in general they are said to be undergoing transformation into “newly industrialized countries.” The globalization movement, it is believed, helps this process and will continue to lead more countries into this group [1].
Nutritionally speaking, these countries are noted for their double burden of food and nutrition problems, because they often face both undernutrition and overnutrition. In Asia, for instance, many transitional countries still struggle with deficiencies of vitamin A, iron, and iodine. At the same time, their urban populations increasingly face diet-related chronic degenerative diseases, such as obesity, diabetes mellitus, hypertension, coronary heart disease, and cancer [2].
To cope with rapid changes in these countries, this paper proposes (1) an approach to deal with this dual nutritional situation, (2) an empowerment process for institution-building, and (3) a mechanism to create multidisciplinary approaches that are needed for the enhancement of nutrition in these countries.
Before the 1950s, undernutrition was recognized as a disease in Thailand, as it was in most developing countries. It was not uncommon for patients to be brought to physicians because of its complications, such as diarrhoea and pneumonia, rather than because of malnutrition per se. These symptoms were accordingly recognized and cured simply by applying biomedical knowledge. However, these patients were repeatedly hospitalized because of the lack of attention to the underlying causes of malnutrition.
Today, current knowledge undoubtedly pinpoints not only that nutrition is an abstract concept but that it has a very complex nature [3]. Although scientific knowledge has contributed greatly to a global reduction in many nutrition-related diseases during the past 40 years, it is now well recognized that much of this available knowledge remains underutilized, and more emphasis is needed in the area of the implementation of knowledge [4]. This approach is believed to be critical to the enhancement of nutrition in transitional countries. In the following, Thailand’s experience will be used to exemplify this view.
Historically, the breakthrough in Thailand’s nutritional development came when health authorities recognized that the alleviation of malnutrition was beyond the responsibility of the health sector. Concerned nutrition professionals coalesced to form a prime mover group that disseminated information about malnutrition in the country to the public. Good nutrition was advocated as the foundation for human resource development. This movement helped to convince policy makers and national planners that promoting good nutrition was a valuable investment for the nation’s future development.
A national consensus also was reached that malnutrition was multifaceted in origin. Its alleviation required a holistic approach that involved integrating expertise and resources from multisectoral agencies and community participation and involvement. Universities also were recognized for their important roles in research, training, and providing technical and operational support to the implementing agencies. From these combined efforts, the prevalence of undernutrition in Thailand, especially among children under five years of age, has been reduced drastically to only a few percent [5, 6].
To analyse this particular experience broadly, one must recognize that the implementation of successful nutrition actions requires nutrition knowledge and qualified nutrition professionals who can be advocates and who are capable of adopting comprehensive approaches for change. Yet despite our successes, more needs to be done to improve nutrition in Thailand. Despite our success story, in Thailand, as in many other countries, rapid socio-economic changes have had both positive and negative consequences for the population’s quality of life [7].
At this time, it is simply not true that poverty is a major cause of malnutrition in Thailand and in other transitional countries. Even with sound improvements in their economies, many people in these countries still suffer from the consequences of inadequate and inappropriate nutrition-related practices. In Thailand, nutrition professionals recognize that changes in the nature of the problem present challenges that are more difficult than those faced previously. Their biomedically oriented nutrition knowledge and excellent change initiators used successfully in the past are no longer perceived as adequate inputs. A more systematic approach to the problem is needed.
Countries in transition are moving from the stage of nutrition survival to the stage of nutrition promotion. They are currently facing drastic changes in family structures and lifestyles that greatly affect their food and nutrition behaviours and practices. In responding to new challenges, nutrition professionals need to understand the numerous complex linkages between a broad array of factors to formulate effective action strategies [8]. Hence, new approaches for change must integrate knowledge from the basic, health, and social sciences and related experiences. The integration of multidisciplinary knowledge and related experiences is necessary to develop sufficiently comprehensive approaches and means to improve the nutrition and health of populations. In other words, a problem- and development-based approach should be one guiding light for proactive nutrition actions capable of coping with the complexity of nutrition conditions in Thailand and other countries in transition.
Tentatively, the recommended approach should include at least the following activities:
» the development of the understanding and a raising of awareness of the nature, causes, and consequences of nutrition problems in a country (this especially involves basic biology, the biological underpinnings of interventions, and the psychological and sociocultural aspects of food and nutrition);» the institutionalization of ongoing epidemiological assessment, including monitoring, surveillance, and evaluation;
» the development of nutritional requirements and dietary guidelines for individuals and populations;
» active programme planning and implementation (i.e., design, management, and evaluation);
» the implementation of community nutrition and comprehensive community-based programmes;
» ongoing public education (especially nutrition education for behavioural change);
» advocacy through network linkages and public policies [9].
To cope with complex and dynamic food and nutrition systems in transitional countries, appropriate human resource development will be most critical. Since it is likely that there will be no one solution to these complex situations, nutrition professionals must be expert in utilizing available contextually based knowledge and experiences to find possible solutions to continuously emerging circumstances.
With this mission, it will be necessary for effective nutrition professionals first to develop a good foundation in key disciplinary areas, such as one of the basic, health, or social sciences. This foundation should be guided by specialists from each subject so that linkages between subjects and nutrition issues may be forged. What is important is that nutrition professionals have a deep understanding of the fundamentals of the field: what the problems and questions are, why the issues are difficult, and what knowledge is available to help. A superficial understanding of such fundamentals will diminish the effectiveness of interventions.
Secondly, successful nutrition professionals in transitional countries often are expected to be generalists rather than specialists. Their fundamental knowledge is useful only if it can help improve operating situations. Thus, it is necessary that they be capable of functioning well in inter- and multidisciplinary ways. To develop human resources for nutrition with these capacities remains a challenge because of its comprehensive nature and the required interaction of knowledge and action. This issue requires much more attention by leaders in the field of food and nutrition.
We suggest that the popular concept of empowerment be used as a framework for capacity-building. We believe that sustainability should be the ultimate goal of significant development at all levels. According to this concept, an empowering process is possible when all involved determine that the key actors are, in the end, those within the “target” country. Furthermore, if a major element of successful nutrition policies and programmes is the integration of knowledge and action, the experiential learning approach must be adopted [10]. To apply this concept in practice, the empowerment of nutrition professionals in transitional countries is suggested.
To begin an effective capacity-building process, more advanced countries are encouraged to assist countries in transition with fundamental knowledge and experiences through education, research, and training. This can be done by working together as a team to exchange bodies of theoretical and practical knowledge developed to improve nutritional well-being. During this first phase of collaboration, professionals from more advanced countries may be effective in mentoring local professionals because of their more systematic experiences in selected areas. At the same time, a few highly qualified local professionals should be sent aboard for special training in well-respected institutions to acquire first-hand experience in an advanced field. This phase can be expected to take at least three to five years.
For the second phase, local professionals who receive advanced training should return to their respective countries but continue to work with professionals from advanced countries, so that knowledge can be effectively put into practice. This period can be as short as two years. In its third phase, leadership should be transferred to local professionals, with only a few expatriates left to finish necessary tasks. After that, further collaboration should continue based on mutual benefits to both parties.
According to past experiences in Thailand, this approach to capacity-building creates a good foundation for human resource development within a country in approximately 10 years. Empowering and team-oriented investment benefits the “target” country and its neighbours and is cost-effective. With current communication technologies, this process might be accomplishable at a much faster pace and its coverage might reach regional levels through effective networking systems.
A mechanism for multidisciplinary work
Although a multidisciplinary approach has long been recognized as an essential element in the nutritional development of Thailand, we also recognize that assembling a team that works harmoniously in a multidisciplinary fashion is a demanding task. We have learned that simply involving many disciplines does not automatically create an environment that sustains a multidisciplinary approach in the application of nutrition knowledge and experiences. Mechanisms helpful for creating such an atmosphere must be developed actively. Some essential elements to help ensure the creation of effective mechanisms that are based on the authors’ direct involvement in multidisciplinary work in Thailand over the past 20 years are discussed in the next section.
A problem- and development-based mission
Multidisciplinary work is easier if a team is brought together for a specific problem- and development-based mission. For instance, upon the recommendation of Thailand’s National Economic and Social Development Board, the Institute of Nutrition at Mahidol University (INMU) was established in 1977 to strengthen the planning and implementation of the National Food and Nutrition Development Plan. Consequently, INMU’s main purpose became the development and implementation of activities in research, training, and graduate food and nutrition education. For research this included the investigation of existing food and nutrition problems, the development of appropriate technologies and communication methods, and the provision of technical assistance and consultative services. Furthermore, the training of professionals involved in national and international nutrition programmes remained a priority. Because of its mission to be involved directly in the nation’s nutritional development process, to a certain extent INMU has been encouraged to employ multidisciplinary approaches to its work.
Leadership
Multidisciplinary approaches become feasible when scientists from diverse disciplines recognize common needs and jointly search for effective ways to integrate them. Therefore, leadership is critical for bringing people together within a multidisciplinary framework and managing a team. Professionalism can be an obstacle; a team leader should be sensitive to this issue and take responsibility to maintain the best possible environment. In addition to having a sound vision, the team leader must be convinced of the efficacy of this approach, possess an appropriate personality (be positive thinking and have the ability to work well in groups), have self efficacy and a firm commitment to the mission, and be highly motivated to achieve the team’s goals.
INMU’s research activities have concentrated on two dimensions: food and nutrition. In the former instance, INMU conducts food research in the fields of biochemistry, toxicology, microbiology, and food science and technology. Its nutrition research focuses on physiology, community and human nutrition, nutrition education and communication, and the behavioural sciences. A leader is needed to balance these two dimensions and draw them together in developing a multidisciplinary approach. The leader must guide the team to recognize the existing biophysical, epidemiological, sociocultural, and economic circumstances of population groups and their role in determining food consumption and allied nutrition behaviours. Moreover, all must agree that improving national nutrition requires the contribution of academic exercises (knowledge) and comprehensive field experiences (action) that are relevant to the nation’s policies. This consensus allows for the improved design and implementation of appropriate research projects and intervention programmes.
Training
To improve the nutritional condition of countries in transition, proactive roles are required of nutrition professionals. Their training should be broadly based in the various areas of understanding essential for programme implementation and multidisciplinary in practice. These are prerequisites to the identification and effective analysis of problems and to the resolution of persistent national nutrition problems. Proper training is and will be an essential element for successful nutrition implementation. Within its limitations, INMU offers a series of graduate education and training programmes for national and international participants that follow these principles. Its national offerings centre on programmes for a master of science in nutrition and a doctorate in science (nutrition). Internationally, INMU provides training in a master of science degree programme in applied food and nutrition for development (offering both theoretical and practical experience in the application of the food, nutrition, social, communication, and behavioural sciences) and in a master of community nutrition programme in collaboration with the University of Queensland, Australia. INMU assists students in their fieldwork and thesis writing.
Upon requests from other countries, special training courses also have been conducted: for instance, a policy seminar for high-level policy makers or planners, a workshop for high-level planners, and a three-month training in community nutrition, as well as special need-based training for selected individuals. These activities have helped maintain INMU’s close collaborative partnerships with many institutions at the national and international levels and have contributed to its continued learning processes.
Disciplinary and interdisciplinary breadth and integration are definitely required for countries in transition if they are to deal effectively with the complex and multiple nutritional issues they face. Comprehensiveness of knowledge is necessary; however, it will be worthless if such knowledge cannot lead nutrition professionals to effective action, which is urgently needed in these countries. The integration of knowledge and action for the improvement of the nutritional well-being of populations is a fundamental and challenging issue for this field.
To strengthen nutrition professionals who are faced with the double burden of undernutrition and overnutrition, a proactive and empowering institution-building process should be considered. The experiential learning approach is crucial for this process, because it bridges and integrates knowledge and action. Furthermore, multidisciplinary work is an effective way to solve the complex problems faced by nutrition professionals in these countries in transition. Mechanisms are needed to ensure that this concept can thrive at this time of change.
Action needs to be taken now for better institution-building for research and advanced training in countries in transition. Strategically speaking, lessons learned from these countries will benefit countries with both more and less complex nutritional situations. The lessons learned should help prevent future problems and promote solutions when preventive action is too late. It is now known that “a world without borders” will bring speedy changes to every corner of the earth. Nutrition professionals will need to know how to help populations successfully adapt to change and how to do this better and faster. Those who work in isolation will be less likely to make a significant change in today’s and tomorrow’s world. Nutrition professionals must work together and with diverse disciplines to best use the limited energy and resources available to us. The complexity of issues we face requires everyone to be proactive in his or her learning process in this time of rapid change.
Nevertheless, all nutrition professionals must be clear that research and advanced training are only a means to improve nutrition. One must be careful not to mistake the means for an end.
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