Integrating nutrition outcomes into agriculture development for impact at scale: Highlights from the Canadian International Food Security Research Fund

Abstract The Canadian International Food Security Research Fund programme supported research and scaling up of nutrition‐ and gender‐sensitive agriculture innovations from 2009 to 2018. Women and girls were identified as agents of change and were targeted as the main programme beneficiaries. Projects were implemented in 25 countries through multistakeholder partnerships among universities, research institutions, public and private sectors, and civil society groups, reaching over 78 million people, mainly women and children. Approaches specific to nutrition included growing more nutritious crops, improving dietary diversity, value added processing, food fortification, and nutrition education. Scale‐up for impact was achieved through a number of pathways that started with evidence through rigorous research, followed by a combination of elements such as understanding local and regional contexts to identify specific bottlenecks and opportunities for the deployment and adoption of successful innovations, selecting politically effective or influential partners to lead the scaling up process, and investing in long‐term local capacity and leadership building. Overall, the knowledge generated in the programme indicate that well‐designed nutrition‐sensitive agriculture and food‐based interventions can have meaningful impacts on pathways that will lead to better health and well‐being of women and children through improving household and individual access to nutrient‐rich foods. Longer intervention times are needed to demonstrate changes in health indicators such as reduced stunting. This overview paper summarises the programme and showcases examples from studies that demonstrate the impact pathway for nutrition interventions that encompass efficacy and effectiveness studies, value‐added processing, cost effectiveness of interventions, and bringing a proven intervention to scale.


| BACKGROUND
Agriculture is central to human nutrition through its direct contributions to household food consumption, income generation, and women's empowerment (Haselow, Stormer, & Pries, 2016). There is a growing recognition that agricultural development is a strong entry point for efforts to improve nutrition with increased interest from donors and governments to leverage agriculture interventions to maximise nutritional impact. In 2017, it was estimated that 821 million people were undernourished, more than 1.5 billion were affected by micronutrient deficiencies, coupled with a worrying increase in the rate of overweight and obesity, with 38 million children under 5 years of age affected (Food and  Among the Sustainable Development Goals (SDGs) adopted by global leaders, SDG 2 aims to "end hunger, achieve food security and improved nutrition and promote sustainable agriculture" (United Nations, 2015). It identifies the linkages between agriculture interventions, empowering small-holder farmers, promoting gender equality and healthy lifestyles, and tackling climate change. However, pathways from agriculture to improved nutrition are complex, encompassing economic, social, and gender considerations (McDermott, Johnson, Kadiyala, Kennedy, & Wyatt, 2015). Malnutrition is a multidimensional problem that requires multisectoral interventions. Nutrition-and gender-sensitive agriculture provides timely and promising pathways to challenge the global problem of malnutrition.

| CANADIAN INTERNATIONAL FOOD SECURITY RESEARCH FUND
People are considered food secure when they have access to sufficient, safe, nutritious food at all times in order to maintain a healthy and active life (FAO, 1996) [2009][2010][2011][2012][2013][2014][2015][2016][2017][2018] was implemented in two phases supporting applied research to develop, test, and scale up promising food and nutrition security innovations. It invested CA$124.5 million in 39 projects that were selected through competitive calls and implemented in 25 countries by multistakeholder partnerships among Canadian universities and research institutions, the private and public sectors, and civil society groups from low-and middle-income countries. From the beginning, the programme promoted nutrition-based innovations alongside efforts to sustainably enhance food production by small-holder farmers and increase their economic returns. To some degree, all projects addressed nutrition, but 10 projects had specifically identified nutrition related objectives.
During the first phase of CIFSRF (2009)(2010)(2011)(2012)(2013), more than 144 food security-based innovations were developed and field tested through a range of agriculture, food security, and nutrition projects. impacted policy change, and is shaping the dialogue on food security within countries of implementation (Njuki, Parkins, & Kale, 2016).
The key elements that helped to achieve impact at scale during CIFSRF Phase 2 included generating evidence through rigorous research design to address specific challenges; selecting the most appropriate scaling up pathways to reach target populations for nutritional impact; responding to local context; identifying potential bottlenecks and opportunities for large scale adoption; selecting politicallyeffective or influential partners; and investing in long-term local capacity and leadership building (Shilomboleni & De Plaen, 2019).

Key messages
• Well-planned research for nutrition interventions provides reliable new technical and social innovations, which should be tested considering contextual factors that might influence their effective delivery.
• Important to engage with policymakers and the private sector, especially when applying value-added food fortification pathways.
• Scaling up nutrition-sensitive agriculture programming requires multiple strategies and pathways to achieve sustainable results.
• Nutrition interventions that are also gender sensitive and have supportive environment to bring changes in capacity and behaviour of target population are needed.
To highlight results from specific projects that contributed to

| CIFSRF THEORY OF CHANGE FOR IMPROVED NUTRITION
To understand the complex and varied means through which nutritional challenges can be addressed, a Theory of Change for improved nutrition was created. The Theory of Change for the CIFSRF FIGURE 1 CIFSRF Theory of Change for improved nutrition programme was built using the method outlined by Mayne (2015) who suggests that enhanced capacity change in the target population is brought about through interventions that lead to behaviour change, which in turn improves well-being (Mayne, 2015). Though the construction of the Theory of Change is both intuitive and sufficiently flexible to respond to the wide diversity of projects, it provided a structured framework and link to causality. The components of the Theory of Change are presented in Figure 1 and summarised in Box 1.
The complexity of the Theory of Change demonstrates how investing in agricultural production alone does not necessarily improve nutrition. Leveraging with market interventions, women's empowerment, and Behavior Change Communications to further improve availability of, access to, affordability of, and demand for nutritious foods is important (Ruel, Quisumbing, & Balagamwala, 2018). It also confirms how the complex interaction of food intake, water quality, care practices, disease burdens, sanitation, and health services drive a number of intermediate outcomes that affect nutrition, as do a range of deeper social, economic, and political processes (UNICEF, 2015).  (Verbowski et al., 2018). However, as reported in the paper Effect of enhanced homestead food production on anaemia among Cambodia women and children: A cluster randomized controlled trial, although significant improvements were observed in anaemia rates among children in one of the Box 1: Components of the Theory of Change • Outputs-are practices and integrated models that improve dietary diversity, nutrition education and messages, value-added processing methods, or specific fortification technologies.
• Reach and reaction-in the target population who are intended to receive the intervention's outputs and their initial reaction. The reach group here is food consumers, especially mothers and young children, small-holder farmers and small to medium-sized enterprises.
• Capacity changes-in one or more of knowledge, attitudes, skills, aspirations, and opportunities of those who have received or used the intervention's outputs.
• Behavioural changes-are alterations in actual practices that occur in the target population. An example is the changes in child feeding practices that occur as a result of the improved knowledge from training mothers.
There, typically, is feedback between capacity and behavioural changes.
• Direct benefits-leading to improvements in the state of individual beneficiaries. This includes increased dietary diversity, consumption of nutritious diets by women and children, increased incomes, better use of health services, more productive farming, and women's empowerment.
• Well-being changes-are longer term cumulative improvements such as better health, reduced poverty, and better food security. For example, improved diets should lead to better nutritional status.
• Assumptions-are events and conditions required for causal links to work and lead to desired effects. For example, for change to happen, it is assumed that the target group learns and implements solutions and that there is a positive enabling environment of the underlying determinants of nutrition.
• External influences-are factors not directly related to the intervention but that could contribute to the intended results or minimise their impact. As such, these factors could explain, in part, the success or failure of the intervention.
intervention groups, no improvements were seen in women (Michaux et al., 2019). Although these findings are particularly promising for young children, they do not support the added benefit of polyculture plus diversified home gardens over diversified home gardens alone for women of reproductive age. The authors attribute the difference in impact between women and children to subsequent research that showed anaemia among women in Cambodia was likely not due to nutritional deficiencies (Wieringa et al., 2016) and thus a nutritionsensitive agricultural programme would have little impact on anemia in this population. Michaux et al. highlight the need to have a thorough understanding of the complex and ever-changing causes of food insecurity and undernutrition in a population throughout the design stage and before implementation of a programme. This paper also demonstrates how critical it is to have end-user buy-in (i.e., small-holder women farmers) for the scalability and sustainability of innovative programmes, as attrition was high and mostly due to work-related migration, which was perhaps more attractive than the proposed solution.  building on the success of salt iodization. The paper presents the rigorous research that identified the technology to encapsulate iron into a premix that can be safely added to iodised salt to produce double fortified salt (DFS) as a stable product. After a series of efficacy and effectiveness studies that proved that DFS can successfully address iron and iodine deficiencies among women and children, the authors demonstrate how the innovation from Canada was taken to Indian through transfer of technology to a local manufacturer. They then leveraged India's vast public distribution system, which targets the poor and reaches over 200 million people with essential commodities through its network of 500,000 fair price shops. The paper reports impressive results at scale by working in three Indian states where the government procures the locally manufactured DFS, which reached an estimated 60 million people in 2018. With high levels of iron deficiency in India affecting more than 50% of women and 70% of children, this paper also demonstrates the value of partnerships among researchers, policymakers, private sector, public sector, and the community to achieve a public health goal.

| CONCLUSIONS
The lessons learned from the 39 CIFSRF projects in 25 countries demonstrate that projects with a specific focus on nutrition-sensitive pathways can successfully change behaviours and diets and scale up production and consumption of nutritious foods. This was verified by an independent analysis of selected projects conducted in mid-2018 (Wiggins, Keats, Löwe, & Shaxson, 2018). In the analysis, Wiggins et al. (2018) concluded that the nutrition-focused CIFSRF programmes utilised different pathways to link agriculture interventions to nutritional outcomes. All projects worked towards greater inclusion of women at different stages of the supply and value chains to improve their decision-making control within households. Most projects used a combination of three key strategies to improve nutrition and other health outcomes: dietary diversity and more nutritious crops; food fortification and value added-processing; nutrition education and promotion. In this Supplement, we focus on the premise that nutrition-and gender-sensitive agricultural and food-based interventions have strong potential to improve the nutrition and health outcomes of the most vulnerable in low-income settings, women of reproductive age and young children. Through the Supplement, we show that evidence of a successful intervention must stem from efficacy to effectiveness studies, must consider optimization of technologies and cost effectiveness and that truly scaled-up solutions come from the culmination of these considerations along with strong government, non-government organization, industry, and participant buy-in. Although the results of these studies suggest that longer study durations and even intergenerational evaluations of interventions, may be needed to properly assess and confirm nutrition outcomes such as stunting, these papers add to the growing evidence suggesting that well-designed nutrition-sensitive agriculture and food-based interventions can have meaningful impacts on the health and well-being of women and children.