The scope and consequences of nutritional problems
Factors influencing nutritional status
Development policies and nutrition
Policies and programmes to improve nutrition
1 This article was adapted from Nutrition and development - a global assessment, written by FAO and WHO for the International Conference on Nutrition, 1992.
As we approach the twenty-first century, hunger and malnutrition remain the most devastating problems facing the world's poor. Although the proportion and absolute number of chronically undernourished people 2 has declined worldwide, progress has been uneven among developing countries (Figure 1). For developing regions as a whole, the estimated number of people suffering from chronic malnutrition has declined from 941 million to 786 million people over the past two decades. The challenge facing the international community is to build upon the progress that has occurred and accelerate the processes that improve nutrition.
2 Defined as those people whose estimated daily energy intake over a year falls below that required to maintain body weight and support light activity.
In Asia and the Pacific striking improvements have occurred in the last 20 years, the proportion of the population affected by undernutrition declined from 40 percent to 19 percent. Nevertheless, the highest number of chronically undernourished people, 528 million, live in this region The region with the largest proportion of the population affected by undernutrition, 33 percent, is Africa. The actual number of Africans affected by undernutrition has increased dramatically, rising from 101 million people in 1969-71 to 128 million in 1979-81 and reaching 168 million in 1988-90.
Undernutrition
The consequences of malnutrition are varied and far-reaching undernutrition can retard growth and development, reduce physical activity, impair resistance to infection, increase morbidity and lead to disabilities and death. Approximately 192 million children under five years of age suffer from acute or chronic protein-energy malnutrition During seasonal food shortages and in times of famine and social unrest, this average number increases. The percentage of underweight children under five years of age has declined in the last 15 years, but the absolute numbers have remained fairly stable because of population increases (Table 1).
Micronutrient deficiencies
Lack of specific nutrients within the diet causes serious health problems in many countries (Table 2). Over 1000 million people are at risk of iodine deficiency, often because little iodine is present in local soils. Severe or moderate iodine deficiency during pregnancy or early childhood can lead to neurological or hyperthyroid cretinism, resulting in deaf-mutism, impaired motor coordination, growth failure, severe mental defects and increased rates of abortion and stillbirths.
An estimated 40 million people are affected by insufficient intake of vitamin A. Vitamin A deficiency occurs when fruit and vegetable consumption and, in some cases, fat intake are low. This deficiency is the most common cause of preventable childhood blindness. It may also lead to night blindness, decreased resistance to infections and increased morbidity and mortality rates from various infections, especially diarrhoeal and respiratory infections and measles.
Poor nutritional status in general is associated with increased prevalence of anemia, pregnancy and delivery problems, and increased rates of intrauterine growth retardation, low birth weight and perinatal mortality In adults, undernourishment and anemia, can lead to poor health, can impair productivity because of reduced physical and intellectual performance and can constrain community and national development. Over 2000 million people, primarily women of child-bearing age and young children, are affected by the lack of iron.
Deficiencies of zinc, selenium and other trace elements affect large numbers of people in certain areas. Outbreaks of beriberi, pellagra and scurvy occur in refugee camps and among other deprived populations. Finally, rickets affects significant numbers of children.
TABLE 1
Prevalence and number of underweight children under five years of age, by region.
Prévalence de l'insuffisance pondérale chez les enfants de moins de cinq ans par régions.
Prevalencia y número de niños menores de cinco años con falta de peso, por regiones.
|
Region
|
Percentage underweight |
Number underweight(millions) |
||||
|
1975 |
1990 |
2005 |
1975 |
1990 |
2005 |
|
|
Continental Africa |
26 |
24 |
22 |
19.7 |
27.4 |
36.5 |
|
North Africa |
20 |
13 |
11 |
3.1 |
3.0 |
2.7 |
|
East Africa |
25 |
24 |
22 |
5.7 |
8.7 |
12.4 |
|
Central Africa |
24 |
22 |
19 |
1.8 |
2.7 |
3.6 |
|
Southern Africa |
16 |
13 |
10 |
0.7 |
0.7 |
0.7 |
|
West Africa |
35 |
32 |
29 |
8.3 |
12.2 |
17.0 |
|
Sub-Saharan Africa c |
28 |
26 |
24 |
17.4 |
25.4 |
34.9 |
|
Americas |
12 |
9 |
8 |
7.8 |
6.8 |
6.2 |
|
North America |
4 |
2 |
1 |
0.7 |
0.3 |
0.2 |
|
Caribbean |
18 |
15 |
14 |
0.6 |
0.5 |
0.5 |
|
Central America |
14 |
12 |
8 |
2.0 |
1.6 |
1.5 |
|
South America |
15 |
11 |
10 |
4.4 |
4.3 |
3.9 |
|
Asia d |
49 |
44 |
41 |
163.1 |
154.7 |
149.3 |
|
Eastern Asia |
33 |
21 |
17 |
47.4 |
25.4 |
18.5 |
|
Southeastern Asia e |
48 |
38 |
32 |
24.6 |
21.6 |
18.4 |
|
Southern Asia |
68 |
62 |
57 |
91.0 |
107.6 |
112.3 |
|
Near East f |
22 |
15 |
12 |
2.9 |
2.9 |
3.1 |
|
Average |
47.5 |
40.8 |
37.8 |
|
|
|
|
Total |
|
|
193.6 |
191.9 |
195.2 |
|
a Underweight is defined as weight-for-age less than minus 2 SD of the WHO reference.b Population projections for 1990 and 2005 are based on the medium variant from the UN.
c East, West, Central and southern Africa, and including the Sudan from North Africa.
d Excluding the countries of the former USSR and the Near East (01 western Asia), for which the data are tabulated separately.
e Including Papua New Guinea and Vanuatu.
f Excluding Gaza Strip and Cyprus.
Diet and non-communicable diseases
The emergence of obesity and various non-communicable diseases, including heart disease, hypertension, non-insulin-dependent diabetes and some cancers may be linked to changing dietary patterns and lifestyles. Dietary imbalances for instance inadequate intakes of dietary fibre or excessive energy intakes have been associated with these diseases. There is concern that the prevalence of diet related non communicable diseases will increase among younger segments of the population as well as the elderly. This would place additional burdens on health services and development.
TABLE 2
Population at risk of and affected by micronutrient malnutrition (millions).
Populations menacées et affectées par des carences en oligo-éléments (en millions).
Población a riesgo y afectada por malnutrición debida a carencia de micronutrientes (millones).
|
Region a
|
Iodine deficiency disorders |
Vitamin A deficiency b |
Iron deficiency or anemia |
||
|
At risk |
Affected (goitre) |
At risk |
Affected (xerophthalmia) |
|
|
|
Africa |
150 |
39 |
18 |
1 3 |
206 |
|
Americas |
55 |
30 |
2 |
01 |
94 |
|
Southeast Asia |
280 |
100 |
138 |
100 |
616 |
|
Europe |
82 |
14 |
- |
- |
27 |
|
Eastern Mediterranean |
33 |
12 |
13 |
1 0 |
149 |
|
Western Pacific c |
405 |
30 |
19 |
1 4 |
1 058 |
|
Total |
1005 |
225 |
190 |
138 |
2150 |
a WHO regions.
b Preschool children only
c Including China
Current understanding of nutritional problems involves awareness of a broad range of complex issues The various influences on nutritional status can be grouped in the categories of food health and care.
Food
By the late 1980s roughly 60 percent of the world's population lived in countries that had more than 2 600 kcal available per person per day. At the same time 123 million people resided in countries where dietary energy supplies 3 were grossly insufficient at less than 2 000 kcal per person per day (Figure 2). The average per caput food supplies in the developing countries increased in the 1980s although at a slower rate than in the 1970s. In sub-Saharan Africa food supplies reached critical levels because of severe drought coupled with civil unrest in some countries. By 1990, approximately 18 million people were affected and in urgent need of emergency assistance.
3 Dietary energy supply (DES) is an estimate of the average daily per caput energy available for human consumption in the total food supply during a given period DES figures do not indicate actual consumption or the distribution patterns of the available supplies.
Stable food availability at the national, regional and household level can bring profound nutritional benefits. Even when the first priority of agricultural development is raising aggregate production of selected food and nonfood commodities, increasing consumption levels of poor households and generating sustainable livelihoods should be explicit goals; otherwise the nutritional benefits may not be attained. Often who produces, what they produce, how they produce and where they produce may be as important as how much is produced.
The mix of staple, secondary and non-food cash crops influences access to food in rural areas. Cash crops can complement food crops and provide income to purchase food. In addition to increasing foreign exchange earnings, cash crops can raise and perhaps stabilize household incomes, either directly or through jobs created on or off the farm. Better production technologies which are often adopted for cash crops may spread to the food crop sector, raising food production as well.
Improvements in dietary intake will not occur if the earnings from new crops are spent on items not related to food. Women's participation in new enterprises and control of the income is important if nutritional benefits are to be realized. When a mother has a controlling hand in household expenditures, children usually receive more benefits.
The full nutritional benefits of commercialized agriculture can only be realized if prices of food in local markets remain affordable and a diversity of food crops is attained. When planners contemplate introducing cash crops or other farm enterprises, the socio-economic effects must be carefully assessed, and counteracting interventions must be made where needed to assure food security, especially for poor households.
Approximately two-thirds of the population of developing countries live in rural areas where crop and animal production, fisheries and forestry are direct sources of food and income. The employment requirements of agriculture may be key determinants of nutritional well-being. The high amounts of energy spent in farming and household activities can be significant. Labor-saving technologies may be beneficial, but in areas of high unemployment they should not be labor displacing. When the wages of landless laborers are irregular and uncertain, the threat of food insecurity may be great In countries where land reforms are needed, the tenants on small farms form another highly vulnerable group.
The benefits of food crops such as roots and tubers, pulses and legumes are often not fully realized because of lack of research to improve production and storage, transport and processing problems. Since these traditional foods are well adapted to local environments, they can reduce the risk of food shortages. Increased cultivation of these crops by small producers could directly improve food supplies for nutritionally vulnerable households. Roots and tubers serve as staples in many diets, while legumes, oilseeds, vegetables and fruits are primary sources of oils, vitamins and minerals.
Improvements in post-harvest management can often significantly increase overall food availability and reduce costs for producers, distributors and consumers. The postharvest operations where major losses are most likely to occur are storage, marketing and food handling in the home. Adequate storage is essential in rural areas, particularly among semi-subsistence farming households which are directly dependent upon stored foods for their food security. It is also important in urban areas where retail food distribution and marketing occur.
Marketing facilities generally improve nutrition because they provide relatively easy access to cheaper and more diverse foods. Adequate transport and marketing facilities and liberal, non-interventionist domestic trading policies are essential for food markets to function well. Producers and consumers should be able to reach markets without excessive expenditures of time or money.
Indeed, reducing marketing inefficiencies and transaction costs may be a more cost-effective method for increasing food availability than increasing production. Such efforts may be relatively simple, for instance, policies on transport licenses can be liberalized or restrictions on movements of food commodities removed.
Health
Good health and sanitation are essential for good nutrition, yet they are beyond the reach of the majority of the world's population. Infectious disease and inadequate diet act synergistically, each aggravating the effects of the other to produce the "malnutrition and infection complex". In malnourished persons, illnesses tend to be more frequent, more severe and prolonged. Nutritional requirements are higher during and following episodes of infection. Chronic infections or frequent acute infections make it almost impossible to maintain adequate nutritional status.
The mechanisms by which infections harm nutritional status include reduced food and water intake resulting from anorexia, diminished absorption and utilization of ingested food, increased nutrient and water losses, increased metabolic demands and therefore higher nutritional requirements, and alteration of metabolic pathways and the intentional withholding of food. Diarrhoeal diseases, measles, acute respiratory infections (ARI), tuberculosis and, more recently, acquired immunodeficiency syndrome (AIDS) have major effects on nutritional status Among the parasitic infestations, malaria, hookworm, ascariasis, amoebiasis and schistosomiasis are most significant for nutrition.
Antenatal care, immunizations and curative services to shorten disease episodes can improve nutritional status. Health services can influence the initiation and establishment of breast-feeding. Growth monitoring of children and follow-up when faltering occurs are important public health actions to prevent undernutrition In addition to improved health facilities, intersectoral and community-based approaches need to be promoted. Developing human resources and strengthening managerial capacity at national and local levels are essential to deal with nutritional problems effectively.
Care
Adequate care and feeding practices require time, attention and support and are essential to meet the physical, mental and social needs of individuals. To assist children and others who may be unable to care for themselves because of disability or old age, resources must be used effectively. The knowledge, attitudes and practices of household members largely determine the nutritional status of the household. An incomplete understanding of the body's nutritional needs and lack of knowledge of how to meet those needs with available foods can lead to malnutrition. Food taboos and fads, inappropriate eating habits, poor food preparation techniques, inadequate understanding of health risks, special dietary needs and physiological states all contribute to poor nutrition. While changes are difficult to make, nutrition education can be an appropriate and effective means of preventing and correcting nutritional problems. Women who are educated are more likely to use health care services and have lower fertility rates and more child-centred care-giving behaviours. With increasing education, women have more influence and skills to manage household resources for their children's health and welfare.
It is only through concerted efforts to reduce social inequity and poverty, the root cause of malnutrition, that lasting solutions to nutritional problems will be found. The poor and disadvantaged are affected most by acute and chronic undernutrition and micronutrient deficiencies. Poor families not only need better incomes, they often live in marginal areas and unsanitary environments, and they lack education and information to improve their nutritional status.
Economic growth and equity
National planners and policy-makers have often failed to give adequate attention to the nutritional implications of development policies. As a result, such policies have not achieved their potential to bring nutritional benefits, and in some cases they can have a negative impact on nutritional well-being. To ensure that nutrition interventions are effective, the context of general and sectoral development policies should be taken into account. A programme to improve food, health or care may be implemented successfully but may fail to show a measurable impact if the general policies are not favorable to nutrition.
National income growth can improve living standards and individual welfare including nutrition in several ways. As real incomes increase, demand for goods and services grows and more jobs become available, enabling more people to meet their needs for food, health care and safe and sanitary housing. However, specific government policies are needed to ensure that the poor and nutritionally vulnerable benefit from economic growth. Macroeconomic policies that discriminate against the food and agriculture sector or that reduce health services can adversely affect nutrition.
The burden of structural adjustment often falls disproportionately on the poor and nutritionally vulnerable. In the long run, however, it is the poor who would suffer most if macroeconomic imbalances were to continue. By making economic and social adjustments simultaneously and improving the targeting of interventions for the poor, "safety nets" can be created. Compensatory programmes (e.g. supplementary feeding, expanded health care, income-generating programmes) may be needed to help relieve the poor when negative effects occur.
In some countries the national income is high but inequitably distributed. In such situations if government spending in the social sector is relatively low, welfare indicators are often worse than those of other countries with similar per caput gross national product (GNP). In other countries, the governments have made strong commitments to providing for basic needs and the welfare indicators are better than their level of GNP would predict, Yet, without sustained economic growth, the impact of redistribution of incomes and assets tends to be limited over time. Finally, there are countries that have promoted economic growth along with a more equitable distribution of income as well as higher investments in developing human resources and skills. There is a strong case in favor of emphasizing equity together with growth as an integral part of a development strategy.
Agricultural policies, trade and the debt burden
Through its influence on development prospects and resource availability, the international trade environment can affect nutritional well-being in many countries. Foreign exchange earnings, employment and GNP are all affected by barriers to international trade, Trade liberalization, particularly in agricultural products, can have a favorable impact on the food security of developing countries overall. In countries that subsidize domestic production, agricultural imports are often relatively low, and when production exceeds domestic needs the surplus is sold abroad. This may constrain the volume and value of exports flowing from other countries, as an oversupply in the world market leads to depressed prices.
For developing countries that are primarily food importers, the industrialized countries' agricultural policies can provide food at low prices, as well as food aid. The availability of cheap food may allow the pursuit of programmes that increase access to food, particularly among urban populations, as well as relieving immediate balance of payment problems to some extent. However, if food self-sufficiency and trade-oriented self-reliance and rural development are the long-term solutions to a developing country's food problems, the impact of these policies is not positive.
Domestic prices are depressed when developing countries set farm prices in relation to world prices which are unduly low because of producer and export subsidies. In those circumstances, the profitability of investment in domestic agriculture decreases, productive resources are diverted to other less competitive sectors and the adoption of technologies and other measures to improve productivity is delayed. The long-term effect is perpetuation of dependence on imported food, which contributes to general deficits.
The external debt burden of the developing countries is critical. The ratio of debt servicing to exports remains at a high level for developing countries as a whole. There is a net outflow of debt-related resources from developing countries to creditors, which totaled US$ 242000 million in the period 1983 to 1989. Severe external constraints, e.g. shrinking markets for their products, prevent many developing countries from coping with their debts. Some limited debt rescheduling and even reductions have taken place recently, but the overall impact has been small.
Population growth
Providing for increasing numbers of people is a critical challenge in many developing countries, especially those where the population is expected to double in the next 20 to 25 years, To address population growth and migration successfully, more equitable economic development must be promoted and better access to education, health and family planning services should be provided, Many countries address high fertility levels through programmes to reduce the number of births and lengthen the intervals between pregnancies. Breast-feeding, especially when exclusive, favors pregnancy spacing and maternal health, Services for nutrition, maternal and child health and family planning will be more successful if linked and integrated.
Environment pressures
The increasing number of people places pressures on the natural resources upon which survival depends. Every year, at least 11 million hectares of tropical forests are cut down. The loss of arable land through soil degradation is almost as widespread, Between five and seven million hectares of cultivable land are lost each year, most of it in the developing world. The long-term integrity of food supplies is jeopardized by poor land-use practices, threats to fish and other wildlife, excessive use of fuel and energy sources, urban growth and pollution of air and water. There is increasing concern about food contamination and water pollution resulting from unsafe and overly intensive agricultural production methods.
Environmental degradation results in dwindling stocks of fuelwood, the principal energy source for cooking in most developing countries. Women and children in many countries must spend significant amounts of time and energy walking long distances to collect fuelwood.
In their daily struggle to survive, the rural poor adopt strategies that affect soil, woody biomass, pastureland and water, and their decisions about resource allocation may determine whether government actions to promote sustainable development succeed. Much environmental degradation arises because the rural poor are forced to employ damaging cultivation and pastoral practices. By increasing access to resources and technologies or providing alternative earning opportunities, environmental policies can address these basic issues.
The overall objective should be to create conditions in which it is more profitable to conserve resources than to destroy them. Sustainable production systems should be developed for various types and qualities of land and water resources, such as low- and high-potential agricultural lands, forests and fisheries. The need for sustainable technologies for marginal lands is an area that has largely been neglected by researchers in the past. Greater integration of nutritional, health, economic and environmental considerations is needed. For example, to reconcile environmental concerns with the need to increase food supplies and other agricultural commodities, alternative agricultural systems and technologies may need to be developed. Environmental concerns may create increased pressures for introducing new barriers to trade for products perceived to be "environmentally unfriendly". Other environmental issues such as possible global warming and loss of genetic resources need to be addressed to avoid adverse effects on nutrition over time.
Urban growth
By the year 2000, it is expected that 51 percent of the world's population will live in urban areas. Urban households tend to be better nourished than rural families; they have more varied diets and better access to health and other social services. However, there are urban and periurban groups who are poorer, more vulnerable and more malnourished than their rural counterparts. Breast-feeding is less prevalent and of shorter duration in urban areas, and increased bottle-feeding, poor housing, inadequate water supplies and waste disposal and poor food hygiene heighten the risk of diarrhoeal diseases, In cities, life-styles and dietary patterns change and efforts should be made to prevent new behaviors that have been linked to diseases.
In cities, people rely almost entirely on purchased food, much of it commercially prepared. They are more vulnerable to economic factors affecting commercial food markets, since they spend a high proportion of their budget on food and are dependent on wage labor. Currently many countries meet the needs of the city population by importing foods and subsidizing their prices, undercutting the domestic producers. This may be another motivation for rural people to move to cities, especially if food producers must sell at inadequate prices and farm incomes are kept low.
Strategies and actions to improve nutrition need to be developed according to the particular needs, resources and circumstances of each country. Nonetheless, the following common areas of action for protecting and promoting nutritional well-being have been identified.
Improving household food security
Household food security depends on the ability of the household to produce or procure enough food to ensure an adequate diet for all its members at all times. Farmers living on marginal lands, landless or temporary laborers, pastoralists, small-scale fishermen and forestry workers and the urban poor are most vulnerable to food insecurity. They may experience chronic, seasonal or transitory food shortages. The food supply at both the national and the household level must be sufficient and reasonably stable throughout the year and from one year to another.
Protecting consumers through improved food quality and safety
Food-borne diseases due to pathogenic bacteria, viruses, parasites or intoxication's caused by chemical contaminants are widespread, Food-borne diseases cause loss of income and work output and increased medical care costs. A country's reputation for poor food quality may result in a decrease in trade and export earnings, as well as in tourism if foodstuffs are contaminated. Proper food control measures also help to reduce food losses and assure a healthy diet. To ensure that food is safe and that food quality is maintained during production, handling, processing and packaging, an effective food quality control system is necessary.
Governments can advise consumers and the food industry about good agricultural, manufacturing and food-handling practices, measures to minimize food spoilage and actions to avoid contamination. Education in hygienic handling and processing of food is needed. Simple precautions can do much to keep food safe in the home, small shops and eating places. Education and training, backed up by well enforced codes of practice, can achieve similar results in the food industry.
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GENERAL STRATEGIES TO ACHIEVE HOUSEHOLD FOOD SECURITY · Adopt overall development strategies and macroeconomic policies that create conditions for growth with equity · Accelerate growth in the food and agriculture sectors and promote rural development that focuses on the poor · Improve access to land and other natural resources · Provide credit for poor households · Increase employment opportunities · Create income transfer schemes · Stabilize food supplies · Improve emergency preparedness planning · Provide emergency food aid and strengthen the coping mechanisms of households |
International standards protect the health of consumers and ensure fair trade practices; they should be part of national and international food security systems. In building their institutional capacity to implement comprehensive food quality programmes, low-income countries can receive assistance in the development of infrastructure and advice from international agencies and countries with existing practices. The standards of the Codex Alimentarius Commission can be used as models for developing legislation and regulations.
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ACTIONS TO IMPROVE FOOD QUALITY AND SAFETY · Create comprehensive legislation, regulations and standards and effective inspection systems · Promote good manufacturing practices and strengthen food control procedures to meet basic standards of hygiene incommercial food handling and preparation · Educate consumers regarding hygiene and sanitation as well as food laws, regulations and standards · Establish food and nutrition labelling regulations and guidelines for advertising so consumers can make more informed decisions · Integrate food quality and safety concepts into government-sponsored, nutrition-related programmes · Monitor national incidence of food-borne diseases and contaminants · Construct infrastructure to provide adequate water and basic sanitation in homes and retail food outlets · In agriculture, promote safe use of pesticides, fertilizers and veterinary drugs as well as proper practices for postharvest storage, chemical use, handling and transport |
Preventing specific micronutrient deficiencies
With concerted efforts, the virtual elimination of iodine and vitamin A deficiencies and the substantial reduction of iron deficiency within this decade are attainable goals. Strategies and activities to tackle specific micronutrient deficiencies need to be formulated and implemented within the context of national plans to improve nutrition. Preventing micronutrient deficiencies involves public health measures and legislation to improve water quality, sanitation and food hygiene and promotion of essential services such as immunization programmes, control of endemic diseases, maternal and child health and primary health care programmes as well as health education and information.
Improving dietary diversity by stimulating the production and consumption of micronutrient-rich foods is the fundamental, sustainable approach for overcoming micronutrient deficiencies. In rural and urban areas there is great scope for improving direct household supplies of micronutrient-rich foods. Food and agricultural planning can promote the increased availability of micronutrient-rich foods, and targeted nutrition education programmes can help increase their consumption.
Food fortification can add micronutrient, particularly potassium iodate, vitamin A and iron, to common foods. However, in developing countries the cost of fortification and the enforcement of relevant legislation can be problematic, especially where there are multiple small-scale producers. While supplementation with iodized oil (given orally or by injection), vitamin A (given in high-dose capsules or oral dispensers) and medicinal iron can be effective in some circumstances, this should only be considered as a temporary measure until long-term solutions can be implemented. Supplementation programmes are often expensive and unsystematic, and coverage may be poor. Frequently, the key target groups are different for each micronutrient, and operational constraints are severe.
Promoting appropriate diets and healthy lifestyles
Excessive or unbalanced diets, often coupled with inadequate physical exercise, stress, excessive alcohol consumption and smoking, contribute to poor health and lead to the increased incidence of diet-related non-communicable diseases including obesity, hypertension, stroke, cardiovascular disease, diabetes mellitus and some cancers.
Promoting healthy diets involves motivating people and creating opportunities for behavioral change while recognizing individual preferences, life-styles and time constraints. Strategies include nutrition education and dietary guidance for the public; training of professionals in health and agriculture; creating guidelines for food services; and involving consumer groups and food industries in the endeavor. These efforts can reverse the trends of increased diet-related non-communicable diseases. They can also have implications for farming, industrial and social policies and international trade.
Generally, nutrition education has been effective when behaviour modification, rather than information diffusion, has been the goal. Social learning, social marketing and educational entertainment strategies for mass communication have improved nutritional status among low-income groups and others. In terms of cost-effectiveness, nutrition communication compares favorably with other nutrition interventions. Maintaining nutrition communication programmes over a long period is essential to sustain meaningful behavioral changes.
Formal and in-service training to teach health professionals, teachers, agricultural extension workers and other community workers to become effective communicators is crucial. Relevant school curricula and materials, teacher preparation, modification of the school environment and cooperation between schools, parents and the local health and social services are essential elements of nutrition education. Nutrition and health education in schools can have positive effects on entire households.
Preventing and managing infectious diseases
Poorly nourished persons are more susceptible to many infectious diseases, and the prevention of infection and management of these diseases involves reducing their incidence, duration and severity. Early and adequate curative treatment at home or in clinics for acute respiratory infections, diarrhoea, malaria and childhood and parasitic diseases helps prevent malnutrition.
Environmental health programmes that lead to safe water, safe waste disposal and adequate housing can reduce morbidity from various water- and faeces-borne infectious diseases. Water- and food-borne diseases are important causes of diarrhoea, as are many other infections due to bacteria, viruses, mycotoxins and parasites.
The accessibility, acceptability and adequacy of health services strongly influence whether people will utilize and benefit from them and whether people will alter their behaviour to improve their health. Community-based health care ensures the community members' active participation in the planning and implementation of their own health care, generates health awareness, mobilizes the community and successfully prevents infections through environmental changes and modification of harmful health practices. Community-based growth monitoring and prevention activities coupled with effective immunization programmes can be particularly important in the management and control of infectious diseases.
Caring for the socio-economically deprived and nutritionally vulnerable
Households and communities must be able to give the time, attention and support required to meet the physical, mental and social needs of children, the elderly and other family members. Each family member's knowledge, motivation and role within the household including his or her time constraints and control of resources, need to be considered in designing and implementing nutrition interventions.
In communities, adequate organization and caring capacity is an important determinant of the nutritional status of vulnerable groups and community efforts to address their own problems need to be encouraged and supported. Increased attention to new community care structures may be needed as urbanization and other social forces alter traditional patterns of family and community care. For instance, care is provided through voluntary and social welfare organizations. Other mechanisms include feeding programmes food subsidies and social security systems.
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STRATEGIES TO ENHANCE SOCIETIES' CAPACITY TO PROVIDE CARE · Recognize the effectiveness of traditional support systems in reducing workloads, providing economic assistance increasing knowledge and offering emotional support · Design and implement national programmes for breast-feeding protection and promotion, e g baby-friendly hospital approaches and training programmes · Form child care centres, work groups, cooperatives or informal networks for sharing tasks · Develop appropriate technologies and improved infrastructure to reduce the demands on women's time and efforts · Ensure that women have access to the resources and the education they need to care for themselves and their families · Through legislation, strengthen women's rights to property and income, and provide social security for women wherever possible · Provide Job and skills training for the disabled to prevent dependency · Promote family and community organizations that help people to cope with their disabilities · Enlist international agencies to help refugees and displaced persons meet their basic needs and become self-reliant |
Policies to improve care for nutritionally vulnerable individuals, such as infants, young children, mothers the disabled and the elderly, are needed. The implementation of such policies often requires strengthening of community, national and international capabilities and institutions.
Analyzing and monitoring nutrition situations
Information related to nutrition is needed for a variety of purposes, such as identifying chronic nutritional problems and causes; predicting and detecting short-term or acute nutritional problems; targeting population groups for both short-term relief efforts and longer-term policy and programme development; and monitoring changes and evaluating the impact of interventions and development programmes.
Efforts to assess and monitor nutritional status and other nutritionally relevant factors must be cost effective, timely and directed towards specific goals such as preparation of development plans and budget decisions. Generally, the most practical approach to nutrition monitoring is to use a minimum number of indicators and to focus on those that lend themselves to regular assessment.
During food crises, timely commitment of resources for public works and food distribution is required. Often, the most important early warning signals are based on forecasts of food availability and price indicators. While assessing the food security status of specific households may be difficult, monitoring changes in food prices is relatively simple and can be a useful indicator in many national early warning systems.
Information about the implementation and cost-effectiveness of programmes aimed at resolving particular nutritional problems or targeted at a particular group or geographic area is important. An appropriate institutional capacity is central to nutrition monitoring. Many countries are establishing food and nutrition information systems, generally starting with data on food availability and childhood undernutrition. Often, with the use of established data sources and information systems, a more multifaceted system can be developed in accordance with a country's priorities and resources.
Food security is assessed at the global level with two objectives to advocate the allocation of resources to address hunger and malnutrition; and to alert donors of impending food crises. These assessments are based on various sources such as FAO's food balance sheet procedures and the Global Information and Early Warning System for Food and Agriculture (GIEWS).
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DISPLACED PERSONS FACE SEVERE NUTRITION PROBLEMS Often the worst problems of protein-energy malnutrition (PEM) and micronutrient deficiencies are found among refugees and other displaced persons. Increasingly, drought and other environmental hazards, as well as internal or International social upheavals, cause people to flee their communities, Monitoring of areas that are especially vulnerable to food shortages and of populations considered to be nutritionally at risk is essential. The total number of refugees dependent upon international assistance has Increased rapidly over the past two decades. The Office of the United Nations High Commissioner for Refugees (UNHCR) estimated that there were 2.5 million refugees at the end of 1970 while there were 8 2 million ten years later. By 1992, the total number of assisted refugees had risen to an estimated 19 5 million. Because of increasing difficulties, more refugees remain for longer periods of time in conditions of at least partial food aid dependency. Host countries may not be in a position to take responsibility for immigrants, and international organizations lack sufficient resources to provide full rations to meet their nutritional needs. Only the development of international policies, arrangements and resources can address these tragic situations. |
MEETING THE NUTRITION CHALLENGE
Governments, non-governmental organizations, local communities, the private sector and the international community, including international organizations, can contribute to meeting the nutrition challenge. Three main types of action can be developed: first, nutrition objectives and actions can be incorporated into national, sectoral and integrated development plans and the necessary human and financial resources can be allocated for achieving these objectives; second, specific nutritional interventions can be developed which are directed at particular problems or groups, and third, community-based actions for nutritional assessment of problems and the implementation of appropriate measures can be initiated.
Governments are involved primarily through sectoral activities, especially in the fields of agriculture, health, education and social welfare. Ministries could seek to enhance the nutritional impact of their policies, programmes or projects. Each country needs to evaluate its own experiences and processes of intersectoral cooperation and to strengthen them as necessary, in the light of their needs and resources.
Non-governmental organizations often foster innovative activities at the grassroots level. However, there are problems of replication of NGO projects and the need for generating a wider impact. NGOs should strive for full integration in the national system and cooperation with others.
Consumer organizations can initiate a dialogue with the food industry and distribution network agents Most food and agricultural production is carried out by private farmers. The contribution of private industries in ensuring good food processing, food quality and safety and nutritious products as well as in supporting research in nutrition is significant. Although the government is responsible for legislation regarding the quality and safety of food and its labelling, marketing and advertising, the implementation and monitoring of these measures are primarily in the hands of the private sector and consumers. Discussion among the government, consumers and private industry is essential and cooperation is required for sustainable improvements.
Through UN agencies and bilateral organizations, the international community can support national efforts to address nutrition problems. Development assistance can be a powerful vehicle for attaining nutrition objectives, but amounts have remained disappointingly small relative to the need, and the extent to which aid will be allocated for poverty alleviation is not yet clear. Also, the efficiency of distributing aid and its effectiveness could be enhanced.
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PRINCIPLES FOR INCORPORATING NUTRITION INTO NATIONAL DEVELOPMENT · Pursue policies, for sustainable economic and social development, with emphasis on growth with equity · Promote local community participation · Strengthen technical and managerial capacities both at the community level and at intermediate levels of government · Focus on human resource development and training · Improve the status of women · Foster intersectoral action and partnership among agencies · Incorporate nutritional objectives in sectoral policies and programmes · Enhance the role of consumers and consumer education · Ensure commitment on the part of governments and the international community |
The challenge to alleviate hunger and malnutrition is formidable, but the goal is attainable through concerted action by governments, local communities, NGOs and the private sector. What is needed is a mutual commitment to improving human welfare and the recognition that nutritional status is a fundamental indicator of development. The present trend towards grassroots democracy offers a precious opportunity for people to participate fully in development and to take initiative towards improving their nutritional situations.
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