The Vicious Cycle of Poverty and the Part Nutrition Plays

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Gender and nutrition are intricate parts of the vicious cycle of poverty. Gender inequality can be a cause as well as an effect of hunger and malnutrition. Not surprisingly, higher levels of gender inequality are associated with higher levels of under nutrition, both acute and chronic under nutrition. Gender and nutrition are not stand-alone issues. Agriculture, nutrition, health and gender are interlinked and can be mutually reinforcing. Some experts consider women to be the nexus of the agriculture, health and nutrition sectors.

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Gender and nutrition are increasingly acknowledged by the development community as important cross-cutting issues. Recently, the mutual relationship between the two issues was affirmed, giving rise to various efforts that seek to mainstream gender into nutrition policy and programming.

While diverging interpretations of gender exist, there is a common understanding that women and men should have equal rights and opportunities. Women continue to face discrimination and often have less access to power and resources, including those related to nutrition. This emphasizes the need to apply a rights-based approach to gender programming, with opportunities to leverage complementary rights-based nutrition principles such as the Right to Food.

Notwithstanding, the roles, priorities, needs and use of resources may differ between men and women. The way women and men are affected by nutrition actions may also differ. The tendency is to focus on women when addressing gender, yet this overlooks the influential role of men in closing the gender gap. Both men and women need to be involved in this process, acknowledging their respective roles and needs, and fostering mutual awareness and partnership.

Many development practitioners consider gender to be a complex (and/or delicate) topic. For this reason, nutrition and food security specialists often spend limited time addressing gender dimensions, even though gender-sensitive actions are effective and empowering ways to tackle malnutrition. While addressing nutrition or gender singularly can improve nutrition and livelihoods, a holistic approach can accelerate progress.

Gender and nutrition are increasingly considered to be priority areas of development and mainstreamed by organizations and inter-institutional collaboration platforms. This paper seeks to: Discuss the main linkages between gender and nutrition, highlighting opportunities for increased interaction and also to provide recommendations for improved policies, programming and projects. This information is supplemented by an overview of the gender-sensitive frameworks and/or efforts adopted by and/or underway in organizations and inter-institutional collaboration platforms, as presented in Annex 1.

Linkages between gender and nutrition are present in various areas and act through different pathways, thereby offering multiple opportunities for synergy. Nutrition may be an entry point for addressing more sensitive gender issues through nutrition education, school-based and youth programs and agriculture extension, among others. Careful attention should be given to prevent and monitor unwarranted side effects. The following paragraphs highlight the main opportunities for synergy between gender and nutrition. They do not, however, identify a prescribed list of actions to be uniformly adopted. Translating good intentions and policies into practical design and implementation is complex. What works in one country or region, may not work as well, or even be counterproductive, in another location. Moreover, it is important to recognize that the combined provision of children’s health services, nutrition education for mothers and women’s empowerment interventions has been shown to lead to heightened impact on child stunting. Everyday logistics such as childcare services for working mothers can also have real implications on gender and nutrition outcomes, and therefore warrant special consideration. Targeting women in nutrition interventions as part of the vulnerable population is often seen as sufficiently gender sensitive. The “Do no harm” principle is widely applied, but often narrowed to the recognition that women are already overburdened with household and reproductive tasks e.g. childcare, food preparation, water and firewood collection, etc. and therefore should not be given additional tasks. Targeting women only (and thus excluding men), misses out on a number of opportunities; the same would be true when targeting men only. Public health interventions focus on individuals and physiological vulnerabilities, thereby often ignoring gender among other social considerations.

When targeting households, this problem is implicitly tackled, as the household entity is often shared by men and women. Household members generally share a common goal, namely: the welfare of their household, themselves and their children. By orienting activities towards household food security and nutrition, one can simultaneously address power relations and task/chore distribution, without having to emphasize the subjects as such. This can inadvertently help promote an equal distribution of household tasks between men and women. For instance, men who are involved in breastfeeding promotion and counselling activities will be more likely to appreciate its value.

Physiological factors supplement nutritional vulnerability among adolescent girls and women. Selected nutritional requirements (e.g. iron) are higher among women of child-bearing age than among their male counterparts in order to sustain/compensate biological processes including menstruation, pregnancy and lactation. For example, gender disparities are observed with respect to iron deficiency and iron deficiency anemia due to regular blood loss during menses in girls post-menarche and premenopausal women.

Both pregnancy and lactation considerably augment nutritional needs in terms of dietary quantity e.g. daily caloric needs increase and quality (micronutrient intake, particularly folate/folic acid, iron and iodine). Results from a recent, seminal study on maternal nutrition have indicated that maternal nutrition during early stages of pregnancy contribute more to pregnancy outcomes than later stages of pregnancy, identifying clear implications for nutrition policy and programming. While exclusive breastfeeding is promoted for the first six months of life and continued breastfeeding promoted up to the first two years of life, breastfeeding places an extra time and physical burden on women. In many cases, women do not receive support and/or time compensation to help them breastfeed their children, which may contribute to continued low levels of breastfeeding. Social norms frequently exacerbate the situation with men (and sometimes male children) receiving preferential access to meat and other nutritious foods. This situation is further compounded if the mother is overburdened with tasks, poorly educated, in poor health, as her ability to provide proper infant and young child feeding is compromised. Linkages have been observed between excessive physical activities during pregnancy and poor birth outcomes, namely increased risk of: preterm-deliveries, small-for gestational age and low birth weight. Other landmark studies have shown that suboptimal maternal nutrition and poor infant and young child nutrition, starting in pregnancy through the first two years of life, can lead to largely irreversible effects on growth and development, both physical and cognitive. Further evidence suggests that mothers experience difficulty meeting the increased energy (calories) required of lactation when facing high physical demands (e.g. manual labor in fields).

For these reasons, targeting women in nutrition programs and activities is warranted.

Further insult occurs when pregnancy and lactation coincide with adolescence, as nutritional needs in this phase of the life-cycle compete with the nutritional needs of the foetus and for the production of breast milk. Empirical evidence suggests that adolescent pregnancies increase the likelihood of giving birth to infants of low birth weight, and more broadly speaking, perpetuate the intergenerational cycle of malnutrition. Moreover, the evidence suggests that adolescent pregnancy

Gender and Nutrition Issue paper – DRAFT – FAO 2012 may stunt growth and increase body mass index (BMI) in adulthood, contributing to the double burden of malnutrition whereby under nutrition and over nutrition coexist. These considerations are particularly relevant, as early pregnancies remain common in developing countries. Direct food support to adolescent pregnant girls is discouraged understanding that it may lead to adulthood obesity, whereas the prevention and/or delaying teenage pregnancy to after 18 years old (e.g. via advocacy for legislation, nutrition education and family planning) should be a priority for halting the intergenerational cycle of malnutrition.

A major opportunity is missed if nutrition activities addressing women are only initiated during pregnancy. Pre-maternal nutrition is critically important for two main reasons: a substantial proportion of pregnancies are unplanned and many birth defects/abnormalities occur during the first weeks of gestation. Weight status (underweight and obesity) and micronutrient status (particularly folate, vitamin A, iodine, iron and B12) are among the four key factors that drive pre-maternal nutritional status in women. Underweight during the pre-maternal period impedes weight gain during pregnancy (the main predictor of pregnancy outcomes), increasing the likelihood of preterm delivery and giving birth to small babies. In developing countries, this is often attributed to food insecurity, extremely high physical activity including manual labor, and in some countries, HIV/AIDS. As a result, increased attention to gender can help identify opportunities to reach women earlier, during influential stages of the life-cycle.

Food taboos, preferences and consumption patterns have an impact on the nutritional status and frequently have a gender dimension. These factors should be addressed if they hinder healthy dietary practices (e.g. the tendency of women to eat smaller portions than other household members in some countries). Likewise, there is often a gender dimension to the roles and responsibilities of food collection, preservation, preparation and distribution. Women play a key role in household food preservation/processing (e.g. solar-drying, soaking, fermentation, etc.), appealing to local tastes and preferences, which can also help smooth consumption during lean seasons and support nutrition gains (e.g. sustained consumption of micronutrient-rich fruits and vegetables).

Their role in food preparation goes well beyond knowledge of recipes and cooking techniques; it also encompasses access to water, fuel/wood and cooking utensils. Furthermore, women tend to be knowledgeable about food that was grown locally and consumed in the past, even if this knowledge is not always appreciated. These food items are often healthy and affordable since they are produced locally. Women who possess this knowledge should be encouraged to share it with others, passing it down to younger generations, in support of sustainable diets. Nutrition programs should foster such information exchange, where feasible.

Broadly speaking, information should be collected on how men and women are affected by and address nutrition issues. Women are often seen as victims of certain situations, including nutritional shortfalls. While women may have experienced hardship concerning gender equality in the past, treating them as victims does no justice to either women or men. It can instigate negative outcomes, such as inciting jealousy among men, turning men away from nutrition issues and actions, and/or stigmatize nutrition activities as “women’s business”. Rather, men and women should both be involved and empowered to take action that can improve the nutritional situation.

Recent events such as the food prices crisis of 2006-2008 have reasserted the role of agriculture in addressing malnutrition, which has since triggered a number of efforts to maximize the nutritional impact of agriculture policies, programs and interventions. In addition to the pivotal role women play in local food culture, they are actively engaged in food production and rural economies, accounting for 43 percent of the agricultural employment in developing countries. A program evaluation from four Asian countries indicated that agricultural training combined with nutrition education empowered women in their ability to offer healthy diets to their families through Gender and Nutrition Issue paper – DRAFT – FAO 2012

Homestead gardening, while being associated with improved nutritional status. Farmer Field Schools are another practical example of how agricultural development can be both gender-and nutrition-sensitive and complementary to other health-based nutrition interventions. Gender and nutrition are often mainstreamed in Farmer Field Schools, including Junior Farmer Field Schools.

There are plans to standardize this approach as part of greater efforts to maximize positive nutritional impact through agriculture. At field level, women and men participate in meetings and training with a focus on good agricultural practices to increase production. They are equally engaged in selecting topics for the trainings, managing field groups and organizing field activities. Good nutrition practices, gender roles and gender equality are discussed in concert with agricultural techniques, enabling women to exchange ideas and tips with other men. The acceptance of women as knowledgeable farmers is a source of empowerment. In addition, women assume managerial roles at these schools (e.g. presidents, treasurers) with the same frequency as the men. These schools not only directly empower women, but they also enable men to change their view on women. This spirit of partnership is likewise exhibited at Junior Farmer Field Schools; in fact, gender equality is a more “natural” aspect of daily life among youth in school environments. The knowledge, attitudes and practices promoted at these schools are at least partly transferred to the parents and caregivers further reinforcing positive change.

While enhancing agricultural production is one lever used to address malnutrition, it does not automatically improve nutrition. Agriculture also provides a source of income to 70-80% of the people in developing countries, who suffer from hunger. Improving nutrition empowers people and helps them generate income given linkages between nutrition, cognitive development, educational attainment and productivity. Some income-generating activities are targeted to women, recognizing that women tend to spend a larger portion of additional income and other resources on household nutrition, health and education. This suggests that the entire household may benefit from improved nutritional status, if the woman of the household exercises decision-making power on income with two critical caveats. First, there will be little or no effect on the nutritional status of the target population if nutrition is not explicitly addressed by the income-generating project/intervention. Secondly, cases have been reported where men demand their wives to hand over income or take over agriculture production activities as soon as they become lucrative. Efforts, subsequently, need to be taken to monitor and mitigate adverse effects. Such experiences demonstrate that the empowerment of income-generating activities does not confer equal benefits to all when gender considerations are overlooked.

People may spend additional income on non-food items. Even if they spend it (partially) on food, they may not make healthy food choices in absence of basic nutrition knowledge. The latter is becoming a worldwide problem with the prevalence of obesity on the rise. Today, there are more people overweight than underweight. The prevalence of non-communicable diseases, which are often related to (over)nutrition, is increasing simultaneously, generating immense costs for public health systems. Furthermore, female obesity is related to additional complications during pregnancy like maternal hypertension and gestational diabetes.

While there are more obese women than men, men react differently to a high food intake and face higher health risks when overweight as compared to women. Women and men may have differing lifestyles, which may also contribute to varying unequal risk patterns between the two genders.

Prevention or treatment methods should thus be differentiated for men and women, to the extent possible.

Legal frameworks and/or specific rights-based principles related to nutrition may mutually enable and enhance the above-mentioned gender/nutrition linkages. “Renewed investment in adolescent

Gender and Nutrition Issue paper – DRAFT – FAO 2012 girl and maternal nutrition will contribute significantly to the progressive realization of the rights of the girl child and of the adolescent mother in the context of the Convention on the Rights of the

Child and Convention on the Elimination of All Forms of Discrimination against Women, as well as making important contributions to achieving Millennium Development Goals.” The

Right to Food also addresses gender and nutrition issues by fostering participation and accountability and empowering right-holders (women and men alike) to actively engage in their own development.

It recognizes adequate food as a fundamental right of all human beings in pursuit of freedom from hunger. In order to leverage these rights, awareness-raising activities and/or campaigns should be conducted, targeting both right-holders and duty-bearers, and thereby cultivating a culture where gender- and nutrition-related rights are demanded by right-holders. Human rights violations gender-based violence) and access disparities/discrimination should be carefully monitored with claim mechanisms in place to facilitate recourse. Integrated training and/or workshops present an opportunity to review ongoing and planned gender and nutrition activities with a human rights lens.

In view of the previously discussed opportunities for increased synergy between gender and nutrition, the following recommendations have been articulated to help improve nutrition policies, programming and projects. These recommendations are classified according to the primary audience for which they are intended notwithstanding some cases where there is inherent overlap.

Incorporate a gender analysis as part of the regular, nutrition situation analysis, analyzing the needs, priorities and roles of men and women. These analyses should collectively inform project design, formulation, planning and implementation.

The completion of gender and nutrition analyses does not necessarily require separate tools and/or human resources for gender and nutrition, respectively. Rather, gender and nutrition questions and considerations can be integrated into one tool and/or exercise that might be devised and/or undertaken by one specialist.

Incorporate gender considerations at all levels, framing such efforts as an opportunity to improve effectiveness and nutritional impact. Including gender considerations enhances impact on both women and men, thereby improving the impact of the project as a whole.

Promote nuanced targeting strategies in nutrition policies, programming and project activities, recognizing that there is more to gender than just gender parity or targeting women. Targeted support enhances the effectiveness of nutrition projects as long as it is gender-sensitive. Women may be targeted as part of the vulnerable group in view of their special vulnerabilities, but men should also be reached to help address their needs as well as those of women. In some cases, this may be achieved by targeting food security and nutrition support to households to emphasize common goals and partnership. Targeting youth is also recommended for a number of reasons.

First, good nutrition early in life is a basis for good health at later phases as well as for the health of the next generation. Secondly, gender equality is often more accepted among youth. Thirdly, young people may transfer their knowledge, habits and benefits related to gender and nutrition to their parents and/or other adult members of the community. [Also applicable to policymakers]

Include the promotion of balanced distribution of household tasks between men and women in nutrition programs and actions. While childcare is frequently provided by women, nutrition interventions may encourage fathers to acknowledge their responsibility and play a role in childcare. This will, in turn, enable women to have more time to contribute to household income and nutrition. When childcare services are accompanied by sufficient supply of nutritious and diverse foods and nutrition education/behavior change activities, nutrition outcomes are likely to be greater.

Address gender considerations for each activity, at every stage of an intervention. Both female and male members of target groups and stakeholders should be involved during the formulation and implementation phases, identifying the most pressing needs, developing messaging and communications strategies, and ultimately, advocating and delivering the message/service/ action. This should be backed by a structured, systematized and participatory monitoring and evaluation framework and system, whereby sex and age disaggregated data is collected. A certain amount of flexibility should be maintained in the program design so as to enable unexpected gender issues to be addressed, which may emerge through monitoring.

Establish and operationalize specific mechanisms to ensure increased farmers’ income from agricultural production leads to better nutrition. Focusing on agricultural production alone can adversely impact nutrition as well as gender, whereas mainstreaming nutrition in agriculture can emphasize gender indirectly. Agricultural interventions should promote time- and labor-saving techniques and technologies, improve access to safe water and energy as well as improve and/or introduce food processing and storage, which all have gender aspects.

Build on the local context, adapting gender policies as needed. A gender policy containing a set of general principles accepted by all can provide a general framework for projects and programs.

Since gender roles are culture and context-specific, additional work is needed to reflect these roles and cultural consideration in gender policies to be most meaningful.

Promote gender-sensitive elements in integrated/multi-sectorial nutrition policies, programs and actions. Moreover, explore and successively use the way these components influence each other.

Support equal rights and access to employment, land and other resources/services such as: Right to Food and other human rights; equal access to education; reproductive health and family planning; women’s access to land, financial services, extension, technology and markets among other areas. [Also applicable to specialists and practitioners]

Advocate for equal representation of women and men in decision-making positions e.g. designing and developing laws, policies and programs. This may require lobbying efforts as well as the establishment of quotas for policy-making positions. Equal involvement and participation in rural and national institutions will lead to better nutrition for all.

Gender and nutrition have multiple dimensions and are highly context-specific. Ideally, the pathway towards improved food and nutrition security – for all – should be a gender-equitable process. In recent years, considerable progress has been made with regard to prioritizing gender and nutrition in policies, programs and projects though these efforts have largely treated gender and nutrition as two distinct topics. Greater attention is needed for operationalizing opportunities to combine the two. The above recommendations are a preliminary attempt to bridge these two areas in support of gender-sensitive nutrition policies, programming and projects as a means to increasing nutritional impact.

Nutrition can offer opportunities to address otherwise sensitive issues regarding gender roles.

Mainstreaming gender in nutrition within the field of agriculture is a critical aspect of strengthening gender and nutrition linkages in recognition of their substantial contribution to agriculture production and their central role in household food collection, preservation/processing and preparation. The inclusion of gender-sensitive approaches in primary health care, water and sanitation, social protection and education are equally paramount, and may be achieved through multiple entry points. Furthermore, mainstreaming gender in nutrition offers opportunities to integrate agriculture and health approaches. This will require increased collaboration and coordination between and within organizations working in the field of gender and nutrition so as to exploit existing complementarities and comparative advantages, and to apply a holistic approach.

Mainstreaming gender in nutrition can only be accomplished if accountability is taken at all levels.

Not only should higher management in relevant organizations regularly update and ensure implementation of gender and nutrition policy, but also staff members should be made accountable for gender and nutrition priorities in their respective areas. Governments and other implementing partners should also be encouraged to incorporate gender and nutrition into their regular work, programs and projects, to the extent possible. Nevertheless, some of most needed support goes beyond formal, sophisticated organizational structures and results-based frameworks. Facilitating household logistics such as making childcare services available at household and/or community levels is critical, with increased accountability also needed between household members to achieve a more balanced distribution of reproductive tasks among men and women.

Many members of the international nutrition community have developed and are implementing policies, strategies and action plans with a focus on gender and nutrition. Most members of the UN family (e.g. FAO32, WFP33, IFAD34, WHO35 and UNICEF36 among others) and organizations such as the

European Union (EU)3 and IFPRI38 have developed and implemented gender policies, work plans and strategies, and are making efforts to promote gender equality and women’s empowerment in nutrition programs and projects. Similarly, inter-institutional bodies and mechanisms have followed suit. These bodies are particularly well-positioned to promote mainstreaming gender in nutrition in view of their multi-stakeholder reach, and in some cases, multi-sectorial focus.

The Committee of World Food Security (CFS) is an intergovernmental body that was established in 1974 to serve as a forum for the UN system to review and follow-up food security policies. It refers to the UN Standing Committee on Nutrition (SCN) on nutrition-related issues, the official forum for harmonizing nutrition policies and programs. Both have convened a number of (special) sessions, whereby gender and nutrition linkages were explored. In the final report from the 37th CFS session, concrete actions to improve women’s health, educational and nutritional status were identified as prerequisites to achieving food and nutrition security – for all. Furthermore, member states are urged to support equal participation and increased access (e.g. to land, extension, health services, education and credit) to women, encourage their leadership and advance human rights.

In 2010, more than one hundred stakeholders endorsed the framework for the Scaling-up Nutrition movement, which seeks to address the persisting high levels of under nutrition and accelerate action in the context of MDG1. SUN focuses on the first 1000 days (from conception until two years old) and encourages participating governments to promote nutrition- and gender-sensitive development.

The gender dimension and women’s empowerment in policies and actions to scale-up nutrition is one of six key themes of the SUN strategy, currently under development40. Moreover, the appointed

High Level Task Force on Food Security and Nutrition, the G20 Development Group Food Security Pillar and UN REACH partnership actively contribute to the SUN movement.

The UN Renewed Efforts against Child Hunger and under nutrition (REACH) is a partnership between

FAO, WHO, UNICEF and WFP, established in 2008, to address under nutrition, particularly the reduction of stunting among children under-five years old. It promotes a child-centered, holistic approach by facilitating multi-sectorial action among the partner agencies and other stakeholders. It builds on the political commitments pledged through SUN and is considered to be a vehicle for advancing country level action. REACH acknowledges the importance of maternal nutrition and has given increased attention to gender-sensitive strategies and programming.

Pre-existing gender inequality and nutrition insecurity may be aggravated during and/or as a result of emergency situations. Emergencies are almost always characterized by high levels of acute malnutrition, with women, girls, boys and men facing different nutrition risks, and thus warranting differentiated responses. The Global Nutrition and the Global Food Security Clusters play a lead role in emergencies, starting with the Consolidated Appeal Processes, where a working group on gender is formulated. Furthermore, the inclusion of gender marker scores in humanitarian funding appeals became a mandatory requirement earlier this year. These measures are reinforced by the policy statement issued by the United Nations Inter-Agency Standing Committee (IASC) in 1999, which stipulated the following requirements for providing humanitarian assistance in emergencies: member organizations formulate and apply specific strategies to integrate gender issues, collect and analyze data from a gender perspective, build capacity for gender programming, develop reporting and accountability mechanisms that ensure attention to gender. It also published a Gender Handbook in Humanitarian Action in 2006, with complementary Guidelines for Gender-based Violence Interventions in Humanitarian Setting reasons why gender matters when improving global nutrition Women are crucial: We simply cannot end malnutrition if we don’t invest in women, and not just because of their hugely important role as mothers. Women are critical to food and nutrition security due to the enormously important and myriad roles they play in agriculture, in their communities as workers and as producers.

Recognize inequality: Of course we have to recognize that there are multiple competing demands on women, especially the poorest. What’s needed is a supportive system to allow women to make the choices that work best for them and their families. Sometimes this goes to the heart of complex and unequal power relationships in the family and the social and economic status of women in the poorest communities.

Breastfeeding powers the next generation: As the mother goes, so goes the child. Improving rates of exclusive breastfeeding is one of the best, most cost-effective solutions to ensure child survival and set the foundation for lifelong health. Successful breastfeeding promotion relies on tapping into ‘influencers’ in a woman’s life: doctors, mothers-in-law, celebrities or media. It is important for breastfeeding to be promoted as the norm.

Covert breast milk substitute promotion happens everywhere: An egregious tactic used to market infant formula is using medical professionals, especially pediatricians and nurses, to ‘prescribe’ or push formula onto mothers. I had it just happen to me when I gave birth to my second child here in the US a month ago. I was encouraged by doctors and nurses to ‘supplement’ my breastfeeding with formula on my baby’s second day of life. Medical professionals often don’t realize that their well-meaning advice can undermi

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