My winter began in Kathmandu last week where I attended the 6^th Annual Scientific Symposium on Agriculture- Nutrition Pathways organised by Feed the Future Innovation Lab for Nutrition. I have attended the Annual event 3 years in a row and this year was extra special as the event also was celebrating 25 years of Nepal’s Progress in Nutrition. What makes this event unique is that it attracts students and young researchers in equal numbers as persons from academia, policy makers and programme implementors in the field of agriculture- nutrition research relevant to Nepal.

To set the scene let me share some data on Nepal.

• Nepal which has prevalence of 35.8% of stunting in U5 children has shown an average Annual Rate of Reduction from 2001-2016 of 3.1% which is remarkable but not sufficient for the country to meet the WHA targets which will need to be accelerated to 4.3%. The Multi Sector Nutrition Plan 2 (MSNP2) which will be implemented between 2018-2022 is the second phase of an integrated effort which brings multiple sectors together to achieve the acceleration.
• Nepal is one of the countries which has demonstrated tangible political commitment by a 100% increase in spending on nutrition specific activities with other countries like Madagascar and Mauritania.
• This country has demonstrated huge successes with specific interventions like Vitamin A Supplementation, iron and folic acid supplementation for pregnant women, chlorhexidine for new born cord care at scale. Common to these advancements has been the female community health volunteers (FCHV) about 50,000 of them, who are the face of the health system to every household in Nepal.

The symposium covered a multitude of topics – from the country’s policy environment and efforts to reduce undernutrition, new technologies in testing for and improving food safety and evidence on the linkages between diet, nutrition and health.

This piece is not an attempt to capture all that transpired – I present what made an impression on me and left me thinking at the end of the sessions.

The success of the Vitamin A supplementation programme in Nepal is well known. The programme began in the early 1990’s and now reaches 2.6 million children every 6 months through the FCHV. The programme is now fully funded by the Government of Nepal and has averted 88,000 deaths of preschool children till date. A few reasons for success have been noted which include

• The programme was implemented in a phased manner and persons who were associated with its initiation were those with experience of working in the government, so they were aware of the constraints and advantages of government systems.
• The government had ensured that a buffer stock of 1 year was available from the very beginning and continued to be maintained so that there were no stockouts.
• What was started in a campaign mode was turned into a routine activity through the FCHVs and was accompanied by mini surveys to assess coverage and understand people’s perception of the initiative. This won the trust of people and established the programme as an important one in the minds of people.

Despite its successes some important concerns were raised. The recent MICS does not show an increase in consumption of Vitamin A rich diet, regardless of the level of food security. Some questions were raised if it is time to review the programme as near universal coverage has been achieved and clinical cases of Vitamin A deficiency are being reported less.

The story of Salt Iodisation to me was a compelling piece of history which has had lasting impacts on the people of this mountainous country which produces no salt. It is a story of collaboration across countries, across sectors to ensure that this very critical commodity reaches every household. The recognition of endemic goitre as a public health programme was as early as 1965 where goitre prevalence rates were reported to be as high as 55%, in children and adults older than 13 years. Various interventions were begun with support of the Indian government from where all the iodised salt is supplied. A survey in 1998 showed that only about 50% of households consumed salt with adequate iodine and a little over 80% of households had salt with any iodine in them. Achieving universal salt iodisation was set as a national goal in 1998 and the Iodized Salt (Production, Sale and Distribution) Act was passed. With sustained regulatory efforts and information campaigns involving branding of iodised salt, more than 90% of households are now reported to use refined salt and nearly 90% of households have salt with adequate iodine as per the 2016 National Micronutrient Survey.

Furthermore, the symposium brought attention to various aspects of the food system. The aspect of achieving dietary diversity in the country was presented by numerous researchers. Related to this were papers which looked at dietary patterns; the relationship between extra income in households and spending patterns on food and how behaviours can be changed on food intake in households. Attention was drawn in numerous posters and presentations to increasing consumption of ultra-processed foods- commonly called junk foods or unhealthy snacks.

Some key points which emerged were

• Dietary diversity is as dependent on location as wealth, income and education put together with decreasing dietary diversity across the years, perhaps can be correlated with a decrease in consumption of Animal Source Foods.
• One study showed that almost 90% of households, both urban and rural, reported purchasing sugar sweetened beverages and/or snacks and sweets; another study showed that a very high percentage of children below the age of 2 had consumed such foods in the past 24 hours. These findings need attention with findings of NDHS 2016 showing 22% of women of reproductive age and 1% of children under 5 are overweight or obese.
• The importance of dietary quality was emphasised by a study which showed that good dietary quality over a period impacted positively on child development and that diets must include more than just animal source foods.
• The method of measuring dietary diversity currently i.e. as Dietary Diversity Scores needs to be reconsidered as it does not capture the full picture-one of the papers presented looked at diets based on patterns as diets vary based on agroecological zone largely in addition to other factors. 

Technology in various forms and ranging from simple to complex featured strongly in discussions. Simple solutions like hermetic bags to store maize to prevent dampness and mycotoxin contamination, solar panel dryers for maize, cool rooms created with household air conditioners to store vegetables till they can be taken to the market after harvesting and floating gardens to grow  vegetables in ponds even in dry seasons were shared with improvements significant enough to consider uptake on a larger scale where applicable. There was a study shared on the choice of lab testing techniques to measure levels of aflatoxin - this study was done as part of the USAID-supported Aflatoxin (AflaCohort) Birth Cohort Study in Banke, Nepal which has brought attention to this widespread problem. Use of mobile phone technology to send messages to mothers, watch videos, enter real time data in surveys and as part of monitoring systems replacing old fashioned means of sharing information also featured in discussions frequently.

An interesting panel discussion on Evaluations of Agricultural and Nutrition Interventions threw up some points to ponder:

• How can programmes achieve immediate behaviour change and sustain the behaviour change even after the interventions cease? Opportunities to return to intervention sites to see if behaviours are sustained in the long term are rare - one such evaluation was presented which returned to look at what was retained well after the intervention ended. This evaluation showed that some behaviours at household level were retained and that sustaining impact depended on other programmes which complemented the initial intervention and strong local governance to create an enabling environment.
• The importance of evaluations to be done with quality and rigour was emphasised with transparency to report null findings - ‘Be brave, be honest’ was the call.
• The importance of going beyond statistical significance was stressed- it is important for findings to be looking at:
  • The significance of findings for the child- the mother - i.e. the biological significance and
  • The significance for policy makers who are defining the national agenda
• A word of caution was given to pay attention to methodology when planning an evaluation and when comparing studies - when findings from two studies with different methodologies are being compared it is important to interpret carefully.
• The need for costing studies was emphasised - it is important to have sufficient information to make choices with scarce resources.

The symposium ended with a session where some of the prominent researchers and specialists presented what they thought was necessary for Nepal to achieve the SDGs. Emphasis was laid on ending child marriage and preventing adolescent pregnancies to improve Adolescent and Women’s nutrition. This is truly an important observation - women’s nutrition often gets subsumed (but neglected) within the larger discussion on Maternal and Child Health.

The importance of social safety nets to ensure that the poorest can benefit from the overall development in the country was stressed. It was pointed out that new interventions often increase inequity - the disadvantaged often do not take to new interventions easily unless supported to do so.

The process of development of MSNP2 by the Government of Nepal in collaboration with UN and external development partners was applauded and an appeal made to the Government that support for research must be continued; there is need for evidence on how to scale up proven interventions. The need for longitudinal studies was raised by many researchers in the event.

Nepal is one of the focus countries for ENN in Asia - we will be following the progress of MSNP 2 implementation and the symposium gave me an opportunity to identify some very interesting posters and presentations for publication in Field Exchange and Nutrition Exchange in the coming months. A great way to end the year for me looking back at some of the achievements of Public health programmes in this country. Wishing all readers, a joyous festive season and a wonderful start to 2019.