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Sir: I write in response to Hélène Delisle's commentary in World Nutrition last month. I congratulate Hélène and her colleagues for their efforts and commitment to strengthen capacity for nutrition by establishing a competency-based nutrition training at both undergraduate and postgraduate levels in Francophone Africa. In many under-resourced countries, especially in sub-Saharan Africa, the need for strengthened capacity in nutrition cannot be overemphasised. This is even more so in French-speaking Africa where indeed this capacity is very poor.

I would also like to stress the need for networking between Francophone Africa and Anglophone Africa, where I live and work, to strengthen capacity. I am sure there will be much synergy in this. At the Kwame Nkrumah University of Science and Technology where I work, we are starting an MPhil programme in human nutrition and dietetics. There are other programmes being run in Ghana and many other English-speaking African countries. We also need to ensure that other health professionals have skills and competencies to deal with nutrition issues. For instance doctors and nurses should be trained to treat children with severe malnutrition. Continuous professional development programmes will help in achieving this, but in the long term there is the need for integrating nutrition training in training programmes for nurses, pharmacists and doctors. Working together is indeed the best way forward.

Nutrition and development

If I may, I would like also to make some general points, in tune with all that Hélène says. Nutrition is truly central to development, and hence the high levels of malnutrition in Africa over the years explain the poor progress in economic development. As Hélène points out, well over one-third (38 per cent) of under-5 African children were stunted in 2010 and the prevalence of anaemia is highest in Africa, with nearly a half (47.5 per cent) of under 5 children, and two-thirds (67.6 per cent) of women, affected. Vitamin A, iodine and iron deficiency disorders continue to affect many children and women across sub-Saharan Africa.

What is even more worrying is the rate at which non-communicable diseases are increasing, and threatening the very fabric of African societies, while nothing much is being done to avert this. The statistics on the prevalence of obesity, diabetes, cardiovascular diseases and many cancers are staggering. The consequences, in terms of mortality and disability-adjusted lost years, and for economic growth and development, are dire. From my experience, many who are suffering from chronic diseases in Ghana, my country, are unaware of their status. There are people with diabetes or hypertension who do not know it until complications set in or until they suddenly die. It is common to hear stories like this: 'For the past week he'd been complaining of feeling exhausted and out of breath and this morning he suddenly fainted, was rushed to the hospital and pronounced dead'. Meanwhile this person probably had been living with say hypertension for two years, totally unaware of it.

In my own May 2012 column, I wrote that in spite of undernutrition and chronic diseases associated with overweight and obesity, Africa is faced with a third disease burden: HIV/AIDS. Malnutrition is aggravated by HIV/AIDS and by tuberculosis and vice versa. Over 33 million people globally are HIV-positive, and about two thirds of these are from sub-Saharan Africa. Therefore, the double burden of undernutrition and chronic diseases is made a triple burden by the HIV-AIDS pandemic as this afflicts Africa.

Competency is crucial

What is the way forward? Hélène raises many issues, which I totally agree with. Some of these pertain to the whole nutrition profession, whereas others are specific to Africa. Regulating the profession is crucial. Otherwise we will continue to have non nutritionists implementing nutrition programmes. In my few months of returning to Ghana after many years studying abroad, I have met agriculturists, biochemists, food scientists and the like with almost no skills and competencies in nutrition, doing research and implementing programmes in nutrition. I have also come across nutritionists who cannot do much because they have some training but this was not competency-based. Regulating the profession is what will ensure that any person who is called a nutritionist has certain core competencies and skills that nutritionists are supposed to have.

These competencies need to be identified and be used as the standard across Africa, whether Francophone or Anglophone. They include skills and understanding for nutrition assessment skills, management of severe malnutrition and nutrition-related chronic diseases, prevention of moderate malnutrition, implementation of nutrition programmes; and applying the public health nutrition cycle and principles in assessment, implementation, monitoring and evaluation of nutrition programmes. Nutritionists also must be equipped with competencies to work multi-sectorally and to integrate nutrition research and interventions into existing programmes. All these were discussed during the World Nutrition Rio2012 congress in April. Indeed in Africa competency is a need and a must.

An important issue also raised is whether public health nutrition should be practiced as a discipline within public health or within nutrition. In sub-Saharan Africa, seeing and practising public health nutrition as a specialisation of general nutrition gives a better standing or recognition to the profession due to the poor regard of nutrition as a whole within public health. Like Hélène says, I expect that professional nutritionists trained at undergraduate level are able to work in various settings – community, clinical and private. Specialisation can be done at the postgraduate level.

Protecting African food systems

Clearly also, encouraging food diversity, and promoting locally available foods that have formed part of Africa's food systems for many decades, is essential. This will help prevent obesity and related chronic diseases that have come about largely due to changes in dietary patterns towards more processed, high energy-dense fast and other highly processed foods and more sedentary ways of life. Even in wealthy countries, transnational and other big industries are powerful, influential, rich and difficult to regulate. How can we deal with these giants in many African countries where in addition to the above, industry is also a major employer? To ensure regulation of giant transnational corporations engaged in the production and marketing of the ultra-processed foods, we need nutritionists with skills in advocacy and lobbying and ability to work cross-sectorally.

At Rio2012 I raised some other challenges that affect nutrition on the continent. I stated that there are very few nutrition policies; and so policy-makers in Africa do not hold people accountable for what is being done and not done. Nutrition is not a high priority in Africa, lack of respect for nutrition as a science is still an issue. Other health professionals often do not see why they need training in nutrition, for instance in how to manage children with severe malnutrition. Another problem is funding. Although there are now so many opportunities for funding in nutrition with the Millennium Development Goals and the Scaling Up Nutrition (SUN) initiative, we all know that over-dependence on external funding is dangerous: there are always strings attached, and external funding is not sustainable. Simple solutions and programmes to increase exclusive breastfeeding and improving complementary feeding will have significant impact, and are not expensive. Governments need to generate internal funding for programmes. Leadership for nutrition is a challenge and hence building capacity for nutritionists is crucial.

These challenges are fundamental and need to be addressed even as we seek to solve the capacity and competency needs. I am also sure that some of these areas above should form part of the training for nutritionists so that the cadre of trained nutritionists are able to function effectively in the broad social, cultural, economic and political environment.

Please cite as: Annan R. Competencies. We need to work together in Africa. [Letter] World Nutrition, July 2012,3, 7: 328-331. Obtainable at www.wphna.org