11. The participants were divided into two groups. Group 1 consisted of representatives from Bangladesh, Philippines, Sri Lanka and Thailand while Group 2 was composed of participants from India, Indonesia, Thailand and Viet Nam. (Details of workshop outputs are given in Appendix IV (a) and (b)).
12. Based on the responses to the questionnaires (Appendix 5 presents the questionnaire sent to all the participants) and group discussions, it was evident that a wide array of direct and indirect nutrition interventions were being implemented in the countries represented. Those interventions were largely interdisciplinary in recognition of the multi-factorial nature of the malnutrition problems present in the countries. The meeting noted that a nutrition intervention was any activity which could directly cure or prevent malnutrition. A programme was a cluster of projects and a project was composed of activities within which an intervention is implemented.
13. The meeting recognized that there was widespread malnutrition in the countries represented. To address the problem, there was a need for a multidisciplinary and multi-sectoral response. The countries had also evolved from viewing malnutrition as a welfare or health problem to a development problem as reflected in the wide array of programme, projects and interventions implemented. This evolution was also accompanied by a change in perspective from a sectoral to an intersectoral and rights perspective. However, despite these changes in approaches and perspectives, the potential impact of combined efforts, particularly the integration of nutrition, agriculture and health, lagged behind. In addition, there was a lack of understanding on the intergenerational problems due to undernutrition which caused an uncertain future and risks in health welfare and economics.
14. Food-based strategies like food production (at home, community and school), food fortification of some foodstuffs like rice (with iron), oil (with Vitamin A), hydrogenated fat (with Vitamin A), wheat (with iron), fish sauce (with iodine and Vitamin A), noodles (with iron, iodine and Vitamin D and Vitamin A), sweetened condensed/toned milk (with Vitamin A and D) and salt (with iodine) and dietary diversification, particularly the promotion of nutritious recipes and appropriate food preservation and storage practices, had been implemented across countries.
15. Supplementary feeding of preschoolers and in some countries targeting vulnerable groups under different schemes had also been implemented in all the countries represented. Interventions that deal with food storage and distribution, food quality and safety control were also mentioned.
16. Food subsidies under different schemes had also been implemented along with interventions that aimed to raise incomes like livelihood, small-scale industry and credit assistance.
17. Nutrition information, communication and education that target various stakeholders were identified as an integral part of the overall strategy for addressing malnutrition.
18. For an integrated strategy, public health measures like targeted micronutrient supplementation, promotion of environmental sanitation and personal hygiene (through provision of safe water, proper waste disposal), immunization and deworming were likewise identified.
19. Lastly, in some countries nutrition had been integrated in some sectoral programmemes like those of the agriculture, education, health and other developmental programmemes at the national and sub-national levels. The latter was particularly in line with decentralization which had taken place in some countries.
20. This session closely reviewed the limitations and constraints in the implementation of the different nutrition interventions. The two groups tackled the topic differently. Group 1, recognizing that the limitations vary depending on the intervention, decided to examine each of the interventions in terms of limitations and opportunities (the constraints and opportunities of each of the interventions are shown also in Appendix 4). Group 2 came up with a set of limitations, opportunities and suggestions dealing only with the multi-sectoral nature of nutrition interventions.
21. Group 2 identified major multi-sectoral constraints of nutrition interventions as follows: a) Nutrition objectives and target groups were not integrated into each related sector policy , b) Lack of a nutrition component in each of the related sectoral programmes, c) Policy-makers and planners in agriculture were not sensitized on nutrition issues, d) Lack of multi-sectoral coordination, e) The rigid government system/mechanism did not favor the implementation of multisectoral programmes, for instance, the key performance indicators used in the implementation of good governance does not include this, and f) Weakness of human and institutional capacity on integrating nutrition in the agriculture sector, and g) Lack of nutrition awareness.
22. In terms of opportunities, Group 1 recognized that the growing health and nutrition awareness among various stakeholders, including politicians and local chief executives, present a great opportunity for advocating for nutrition and its integration in agriculture and other sectoral or development programmes. This could also lead to intersectoral participation and collaboration from the national down to the sub-national levels.
23. Worsening economic situation and increasing food prices experienced by all countries was changing people’s perspectives from being market dependent to being more self reliant. However, it should be noted that to effectively carry this out an enabling macro environment, particularly formulation of relevant policies, should also be put in place.
24. Group 2 identified several opportunities for future nutrition programmes, namely: a) Several ongoing successful community based integrated programmes existed, b) Cost effective food-based interventions existed (e.g. food fortification), c) International and regional nutrition commitments and programme assistance facilitated by UN Agencies and other institutions, d) Increasing concern of several food industries and non-governmental organizations (NGOs) on nutrition promotion and programmemes, and e) Increasing multisector involvement and public-private partnership.
25. In order to integrate nutrition into policies and programmemes of the two main sectors, i.e. agriculture and health, it was proposed to include the term “food” such that labels like food and nutrition policy or programmeme, food and nutrition security, and food and nutrition education are used which were likely to facilitate the much needed integration.
26. In addressing agenda item 3, the two groups of participants were asked to discuss the following topics, namely: 1) Comment on the two documents distributed to participants, i.e. the 2008 Lancet’s Series on Maternal and Child Undernutrition, and the 1983 FAO manual on Selecting Interventions for Nutritional Improvement: 2) Could agriculture or nutrition programmemes as stand alone programmemes work effectively? 3) What were the key messages to be communicated to advocate for nutrition in the agriculture sector; and 4) To formulate a sample agricultural project proposal that integrates nutrition. Workshop outputs are given in Appendix VI.
27. Both groups 1 and 2 came up with similar comments, that the Lancet’s Series presented new insights on global prevalence of maternal and child undernutrition, and its short as well as long-term effects on health. The document rightly emphasized the lack of political commitment, financial investment, human resources and institutional capacity to deal with the problems of malnutrition. Also, it presented an extensive review of different nutrition interventions. However, the meeting noted that the interventions were mostly health based and there was very limited discussion on food-based strategies.
28. Regarding the second document, the meeting noted that since it is a manual it presented the method and criteria for selecting appropriate interventions for nutritional improvement. The method proposed in the publication was adjudged by the meeting as still relevant and useful for programme planning and management. In using the method, however, there was need for data that could assist decision-making on criteria to be used.
29. The meeting also observed that in the FAO document food fortification, bio-fortification, research, education, and institutional building on nutrition were not given due emphasis. Also, the interventions dealt with the problems of malnutrition during the 1980s, when the double burden of nutrition was not yet a serious problem.
30. The meeting recognized that neither nutrition nor agriculture programmemes could stand-alone and work effectively for nutrition improvement. The participants unanimously agreed that since malnutrition is a multi-faceted problem, the solutions need to be multisectoral, holistic and integrated for a more sustainable strategy, although certain sectors had to play the lead role in improving the nutritional wellbeing of the people.
31. Integration of nutrition could be done in several ways such as including nutrition objectives, including nutrition indicators for monitoring and evaluation, including a nutrition component, and targeting of nutritionally vulnerable groups.
32. Since policy-makers and politicians change their official position frequently, a sustainable advocacy for policy-makers, who are usually not nutrition minded, is urgently required. The meeting identified key messages for advocating the integration of nutrition in the agricultural sector, such as: 1) The importance of agriculture in national development, including nutrition wellbeing. 2) The importance of nutrition for national development. Hence, ensuring that food and nutrition security should be the priority of any sector for sustainable human, social and economic development. 3) The existence of several international commitments on nutrition, food, agriculture (ICN/ WFS/MDGs) such as the first, the third and the seventh goals of the MDGs. 4) Human beings are a country’s vital resource, especially in the agriculture sector: good nutrition results in improved mental performance and increased productivity.
33. Examples of how to integrate nutrition into agricultural policies were likewise shared as follows: 1) Nutritional orientation of agriculture policy, 2) Ensure food and nutrition security from the national level to household and individual levels, 3) Promote nutrition oriented horticultural production, 4) Enhance the production of fisheries, livestock, dairy and their products, 6) Formulate national policy aimed at economic development and nutritional wellbeing of farmers and their families, 7) Strengthen agriculture, food and nutrition extension and education framework and activities, 8) Address gender issues in farming and food processing from harvesting to storage by incorporating women empowerment in policies, and 9) Enhance food security basket (food items required for food security) by including nutritious locally grown foods.
34. The meeting shared examples of success stories in integrating nutrition like the following: in the Philippines, integration of nutrition into agriculture paved the way for the affiliation of the National Nutrition Council (NNC) to the Department of Agriculture (DA). While presently, NNC is with the Department of Health (DoH), its major programme is the Accelerated Hunger Mitigation Programme , a food subsidy programme that utilizes FIVIMS data for targeting food insecure households; Bangladesh has been pushing for the integration of nutrition topics in the primary, secondary and diploma courses in agriculture; in Sri Lanka , food science and nutrition have been integrated in rural finance and SAMURDHI has integrated agriculture and nutrition in its poverty alleviation programmes and lastly, in Thailand, the school milk feeding programmes benefit both farmers and children.
35. The meeting presented two proposals on integrating nutrition in the agriculture sector. Both proposals addressed improvement in maternal and child nutrition through food-based approaches. The first proposal entitled Promotion of home gardens and small livestock production: a sustainable strategy for improving maternal and child nutrition aimed to reduce maternal and child undernutrition through improving physical and economic access to adequate, safe and nutritious foods. The second proposal entitled Addressing the food and nutrition need of women in rural poor districts of SA and SEA countries.The main objective of the project was to improve the food intake and nutritional status of poor rural women through family empowerment, which directly effect the agricultural production of the country. (Proposed projects are given in Appendix VII (a) and (b)).
36. Both proposals identified components that were meant to demonstrate the need for an integrated approach. Hence, food production was combined with some important nutrition components and also included other concerns like increasing income, improving knowledge and skills on food preparation, preservation and storage as well as appropriate caring practices.
37. Intersectoral involvement and collaboration with the agriculture sector taking the lead was also identified as an important step toward effective integration.
38. The meeting also underscored the importance of establishing baseline information to be used for evaluating the impact of proposed projects. It was also deemed necessary that output, outcome and impact indicators be identified against set objectives.
39. The Government of Bangladesh, as reported by A.F. M. Saiful Islam, incorporated an article in the constitution for ensuring the country’s commitment to provide food for all. The country adopted the national nutrition policy, national food policy, national agriculture policy and national environmental policy. Recently the Government tried to finalize the consumer protection policy.
40. Emphasis had been given to producing more food. A number of programmes and projects had been implemented and were being implemented to boost food production to reduce malnutrition in the country.
41. Bangladesh Integrated Nutrition Project (BINP) activities had been completed and now the National Nutrition Project is being implemented. Other activities included updating of nutrition education curriculum in the primary, secondary and diploma levels and conduct of food-based nutrition training and research. Promotional campaigns on breastfeeding, immunization and vitamin A supplementation were likewise implemented.
42. Jai Singh from India shared the latest development in the implementation of the successive Five Year Plans of the country, particularly the Ninth and the Tenth Five Year Plans. These plans had given high importance to achieving food and nutrition security in the country. Now the 11th Five Year Plan (2007-2012) is in operation. There was a separate chapter on food and nutrition security in the Plan document which covered the mandate for the nutrition sector. This was enough testimony to the fact that India was totally committed to achieving food and nutrition security for its people.
43. The National Nutrition Policy of the country was the most comprehensive document which identifies nutrition as a development indicator. This includes among its many objectives achieving food security for the people through increased food production and nutrition oriented horticultural interventions.
44. Micronutrient malnutrition control activities were intensified through a national update, regional advocacy workshops on micronutrient malnutrition, exhibitions etc.
45. India had a strong Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act-1992 and its Amendment Act-2003 to regulate the production and publicity of the milk food substitute industries in the country to protect breast feeding. Complementary to this was the promotion of Infant and Young Child Feeding (IYCF) through advertisement campaigns on breastfeeding and complementary feeding of infants, integrating an infant and young child feeding component in training curricula of Integrated Child Development Services (ICDS) functionaries, conduct of regional workshops and telecast and broadcast of audio-video spots on IYCF.
46. The Food and Nutrition Board strived to coordinate and integrate nutritional concerns in policies and programmemes of concerned sectors so that all concerned sectors had the explicit goal of achieving food and nutrition security in the country. It was also generating nutrition awareness among people.
47. The ICDS was the most important nationwide nutrition programmeme which aimed to improve the nutrition and health status of 0-6 year old children, and pregnant and lactating women. The Government of India had taken a decision to implement the programme nationwide in its 11th Five Year Plan (2007-2012).
48. The Department of Food and Public Distribution had a well planned Food Distribution System through fair prized shops. It also had a Targeted Public Distribution System for the Below Poverty Line (BPL) families and Antodaya Anna Yojana for the poorer among the poor. It also had an Annapurna Scheme for poor and uncovered senior citizens of the country. All these programmemes ensured food security at the household level.
49. The Country also had a Consumer Protection Act as well as Prevention of Food Adulteration Act to protect consumers and to enforce food safety laws in the country.
50. Hardinsyah from Indonesia reported that regarding the first ICN recommendation, namely, incorporating nutritional objectives, consideration, and components into development policies and programmemes, the Government of Indonesia (GOI) had made significant progress. The progress included 1) incorporation of nutrition objectives, considerations and components into the five year (midterm) national development plan; and 2) the formulation of intersectoral National Food and Nutrition Plan and action documents of 2001-2005 and 2006-2010. A lot of progress had also been achieved in relation to the first and the second ICN recommendations, such as improving household food security, and protecting consumers through improved food quality and safety.
51. Some efforts were also pursued in order to reduce problems of food security, undernutrition, and poverty in Indonesia. These included improving food production and food diversification; improving food supply and food intake, and food safety; strengthening food fortification (wheat flour fortification with iron, zinc and folic acid; and salt with iodine), formulating food and nutrition standards and guidelines, strengthening food and nutrition surveillance, revitalizing Posyandu (integrated health posts), feeding programmes, community empowerment through family nutrition awareness programme; micronutrient supplementation, immunization, strengthening the nutrition referral system and therapeutic malnutrition, and health school programme.
52. Despite these efforts, Indonesia, with a population of about 225 million, still faces food insecurity, poverty and undernutrition problems. The availability of food in terms of energy and protein increased. Household food intake improved during that period as shown by an increase in the desirable dietary pattern score (DDS) of household food intake. In terms of undernutrition, the prevalence of underweight among under-five children remained at about 28 percent. However, the prevalence of iron deficiency anemia (IDA) among pregnant women and under-five children decreased, as well as subclinical vitamin A deficiency.
53. The poverty incidence decreased very slowly, from 18.2 percent in 1999 to 16.9 percent in 2007. This partly explained why the prevalence of underweight remained stagnant. Other identified contributory factors included limited budget, lack of local government commitment to nutrition, lack of infrastructure, and high dependency of target groups on charity programmes (cash transfer, rice for poor, complementary foods for poor children under-two) that weakened the social capital of the community. There was still a demand for quality programmes and effective efforts in both social and economic sectors through a community empowerment approach to rapidly reduce undernutrition in Indonesia.
54. Maria Antonia G. Tuazon from the Philippines shared the latest developments in the implementation of the Medium Term Philippine Plan of Action for Nutrition (MTPPAN) as follows: 1) The MTPPAN 2008-2010 had been reviewed, updated and approved for implementation by the National Nutrition Council (NNC) Governing Board. Outlined in the MTPPAN were the continuing efforts to address under-as well as overnutrition, specific micronutrient deficiencies and some non-communicable diseases (NCDs).
55. The MTPPAN, as in the past, recognized the need for an integrated, holistic approach as reflected in the mix of interventions that had been identified for continued implementation. It also presented a mechanism that raises nutrition as a priority and widened and deepened the agenda for improving nutrition involving various stakeholders across sectors and from the national down to the local level.
56. One of the flagship programmemes under the MTPPAN was the Accelerated Hunger Mitigation Programmeme, a food subsidy programmeme that attempted to reduce hunger and malnutrition in the Philippines.
57. Chandrani Piyasena from Sri Lanka informed the meeting that the National Nutrition Policy for Sri Lanka was updated recently and strategic approaches for implementation of the proposed policy had been drafted accordingly. Food and nutrition security at the household level had been identified as a key area in the strategy to ensure safety of foods and food-based approaches for nutritional wellbeing. Further, integration of nutritional objectives into national development and other relevant policies were being advocated. It had been planned to set up a core group consisting of Ministries of Samurdhi (Poverty alleviation), Agriculture, Finance, Fisheries and Livestock to facilitate nutrition programmeme implementation.
58. A series of rural development initiatives were currently in operation. Amidst several adversities and increased violence, Sri Lanka was still able to achieve some of the Millennium Development Goals.
59. According to the Food Balance Sheet published by the Department of Census and Statistics (2000-2005) it was shown that there was an increasing trend in the production of rice, vegetables, milk, meat and fruits over the last five years. Accordingly, per capita availability of calories and proteins (g/day) had increased. This generally implied an improved food security situation even though it did not necessarily translate at the household level. Inequity in household food distribution, insufficient knowledge, inappropriate feeding and caring practices added to the problem of the nutrition security of individuals.
60. Inappropriate infant and young child feeding practices, especially the short duration of exclusive breastfeeding and inappropriate complementary feeding still persisted. Inadequate knowledge and time constraints on the part of caregivers were major contributory factors for poor feeding practices rather than economic hardships.
61. Nutrition in transition was clearly found in Thailand as reported to the meeting by Visith Chavasit. Problems of undernutrition, stunting, wasting and even micronutrient deficiencies as well as iodine deficiency had declined significantly. Meanwhile overweight, obesity and related NCD in all age groups were increasing. In addition, an increase in the number of the aging population would be the country’s burden in the next decade. Food safety still remains as a public health problem in the country due to inefficient quality management within the food chain. Unsafe foods did not only cause food-borne disease problems that affect consumers, but is also a problem in exporting foods, which makes up a large share of the country’s income.
62. In fact, the term “Nutrition” was not directly mentioned in the 10th National Economic and Social Development Plan of Thailand, however, the term “Good Health for all” was instead described in the plan. The term “Good health” included both physical and mental health. Nutrition was therefore merged in many programmemes of the Ministry of Public Health, which involved different vulnerable groups.
63. At least five nutrition programmes were conducted at the Department of Health, Ministry of Public Health including (1) Waist Measurement Concerns among Thai People, (2) Healthy Thai Menu for all Thai People, (3) Healthy Eating Habits among Thai Children, (4) Healthy Eating Habits among Thai Adults, and (5) Iodine Deficiency Disorder (IDD) Control Programme.
64. Several nutrition inventions were continuously implemented within the mentioned programmes, e.g. breastfeeding promotion, extension of maternity leave period, appropriate complementary feeding, supplementation of iron in pregnant women, food fortification, national nutrition survey, national food consumption survey, promotion of eating more fruits and vegetables, promotion of doing more exercise, and food hygiene. Public-private partnership was one of the effective strategies for successful implementation of nutrition intervention in the country, especially on food fortification. To target significant emerging problems, certain interventions were included in the key performance indicators of the Ministry of Public Health, i.e. quality of iodized salt and waist measurement.
65. The country’s food and nutrition policy would be prepared this year and monitored by a newly established “National Food Committee” chaired by the Prime Minister. The committee will be responsible for planning and monitoring of food security, food safety, food quality and nutritive value, and food education for the whole food chain in order to assure the country’s food and nutrition security which included provision of safe, good quality and nutritious foods for all age groups during normal and emergency situations.
66. Truong Hong Son informed the meeting that in Viet Nam, the Malnutrition Control Programmeme under the Ministry of Health, for a long time, had been implementing health related activities. The recommendations put forward in the Lancet series which had analyzed in detail the consequences of maternal and child undernutrition would be applied in the future in choosing community nutrition interventions.
67. However, it was recognized that the health sector could not cover all factors since many factors affect malnutrition. One of the other major sectors to be involved was agriculture. The role of agriculture was important in ensuring nutrition security for all people, especially for children. Therefore, specific interventions would include long-term solutions like how to increase labour productivity and how to produce higher quality products as well as how to respond to disaster situations.
68. The National Strategy in Nutrition of Viet Nam (2001-2010) would be revised and adjusted for approval by the Government for the period 2011-2020. Strategies for achieving food security needed to be developed by the Ministry of Agriculture and Rural Development. The cooperation of the health sector and agriculture sector was necessary at all levels from national to province, district and village level.
