At the International Conference on Nutrition (ICN) held in December 1992, 159 countries unanimously adopted a World Declaration and Plan of Action for Nutrition which stresses the determination of all actions to work together to eliminate hunger and all forms of malnutrition. Participating governments and other concerned parties pledged to make all efforts to eliminate before the end of the 1990s:
They also pledged to reduce substantially within the same period:
The ICN World Declaration on Nutrition recognizes that poverty, social inequality and the lack of education are the root causes of malnutrition and stresses that improvements in human welfare, including nutritional well-being, must be at the centre of social and economic development efforts. The Declaration calls for concerted action by all concerned to direct resources to those most in need in order to enable them to adequately care for themselves by raising their productive capacities and social opportunities. It stresses the need to protect the nutritional well-being of vulnerable groups and calls for specific short-term actions, when needed, while working for longer-term solutions.
The ICN Plan of Action specifies the action necessary for achieving the Declaration goals. It provides a technical framework for developing national plans of action and endorses major policy guidelines which should underlie national and international policies, strategies and activities to improve nutrition. Governments pledged to revise or prepare, before the end of 1994, National Plans of Action for Nutrition (NPANs), including attainable goals and measurable targets, based on the principles and relevant strategies in the global plan.
The major focus of the ICN Plan of Action for Nutrition is on the strategies and actions necessary to reach the overall ICN objectives of ensuring adequate acces by all to the food necessary for safe and adequate diets, promoting health and nutritional well-being for all through sustainable and environmentally sound development interventions and eliminating famine and famine deaths. These strategies and action areas include: incorporating nutrition objectives into development programmes and policies; improving household food security; protecting consumers through improved food quality and safety; preventing and managing infectious diseases; caring for the socio-economically deprived and nutritionally vulnerable; promoting breast-feeding; preventing specific micronutrient deficiencies; promoting appropriate diets and healthy lifestyles; and assessing, analysing and monitoring nutrition situations.
One of the key strategies to emerge from the ICN is to explicitly promote better nutrition through a range of agricultural and developmental policies and programmes by incorporating nutrition objectives and considerations into their planning and implementation. To accomplish this, appropriate sectors of government must have the capacity to analyse the nutritional impact of various policies and programmes and to act upon that analysis. FAO, through its various policy and planning support efforts, will assist Member Governments to develop or strengthen their capacity for incorporating nutrition objectives into development activities. In addition, FAO is ready to assist member countries to implement the Plan of Action by focusing on the following areas: improving nutrition through community development and household food security; assuring food quality and safety; combating micronutrient deficiency diseases; promoting nutrition education; monitoring nutritional status and making better use of nutrition-related information for planning and monitoring.
Most countries have already made good progress in identifying priority problems, reviewing or preparing national plans and establishing intersectoral mechanisms for action. In the light of the outcome of the ICN, however, this basic work should be requested or initiated with a view to reformulating national plans of action to improve nutrition in accord with the goals and objectives of the World Declaration and Plan of Action for Nutrition. These national plans of action should establish appropriate goals, targets and timeframes; identify priority areas of actions and programmes; indicate the technical and financial resources available, and those still needed, for programme development and implementation; and foster continued intersectoral cooperation.
The main objective of these Guidelines is to assist countries in preparing National Plans of Action based on ICN goals and objectives. Given the diversity in National Plans that already exist, it is recognized that the Guidelines must be adapted to existing circumstances. It is hoped that the Guidelines will stimulate the process of developing or revising Plans, using a broad-based and intersectoral approach.
The Guidelines review the processes, how countries might go about preparing a National Plan of Action for Nutrition, discuss the issues, what might be covered by the NPAN. Section II. Processes is addressed to all those involved in the preparation of the NPAN and discusses how to set objectives and define policies, how to determine strategies for meeting the objectives and implementing the policies, how to establish priorities in the light of the identified needs and of the available or required resources, summarizes the main steps involved in the plan preparation process and presents a possible format for the Plan. Section II. Issues: Identifying Intersectoral Activities consists of nine sections covering the nine themes identified by the ICN. Each section is mainly addressed to those considering actions specific to that theme. To this effect, a number of questions are listed to help identify some of the main issues that should be considered in connection with each theme; these questions are not exhaustive and do not go into the detail necessary at national level. Most importantly, they do not provide answers, as these would need to reflect circumstances in each country. Their main purpose is to encourage a thorough assessment of the issues and of the links between them and to promote a broad-based systematic approach.
Member countries have indicated widely different priorities in their need for assistance from the international community to address different aspects of the World Declaration and Plan of Action for Nutrition. FAO is pleased to work with governments in the overall preparation of National Plans of Action for Nutrition and in the development and implementation of programmes and activities to improve the nutritional well-being of all populations.
Who prepares the National Plan of Action for Nutrition (NPAN) and who approves it will vary from country to country. All countries already have experience in preparing general or sector plans on development and presumably, therefore, they will decide for themselves on the most appropriate arrangements for preparing and approving a national Plan of Action.
While these Guidelines are primarily directed to those who will be responsible for preparing the NPAN, they are also addressed to policy-makers, people working in nutrition and other development workers. In any case, the usual functions of the persons or group entrusted with the preparation of the NPAN will themselves vary by country. The responsibility may lie with a task force formed in preparation for the ICN or with the Ministries of Agriculture, Health, Planning or elsewhere. Each country will need some type of intersectoral group to be responsible for overseeing the preparation of the NPAN. This group, which may already exist or may need to be established, may be constituted as a committee, working group or task force, as each country wishes. For the sake of simplicity, such a group will be referred to in these guidelines as “the intersectoral group”.
The intersectoral group should provide the necessary framework for promoting and coordinating activities to prepare the NPAN, including the following:
Setting objectives and defining policies
In setting preliminary objectives and defining policies for nutrition, a first step should be to assess existing national plans and national policy objectives in the light of the overall objectives and major policy recommendations agreed by ICN. Not only specific nutrition objectives but also major socio-economic policy objectives should be assessed against the ICN recommendations. To what extent could national policies be expected to explicitly promote better nutrition? While at the level of objectives and policies (as opposed to that of strategies and interventions) incompatibility may be rare, the emphasis and priority suggested by ICN may not always be reflected in national objectives. In particular, they may not be reflected in specific, relevant and effective action.
Commitment to promoting nutritional well-being: Can the government openly and honestly confront hunger and malnutrition? Is the extent of the problem known? To what extent do national and sectoral (agriculture, health, education, etc.) policies and programmes incorporate nutrition objectives? What are these objectives? Are there effective efforts to inform the public about nutrition issues? What do they consist of? Is the infrastructure adequate for the requirements of current actions? Do we know sufficiently well how that infrastructure works? Who, at what level and how many are the key operators in promoting better nutrition (both in the public and private sectors)?
Strengthening agricultural policies: All countries have substantial experience with agricultural policies and interventions whose main objective is increased food production, yet in many countries there are substantial numbers of underfed people. Is insufficient food production one of the reasons or inadequate food handling, processing, storage, distribution or marketing? Given the problem, the causes and the objective of improved food supplies, are there policy changes that might lead to improved production?
Environmentally sound and sustainable development: To what extent have current and past policies addressed or failed to address environmental issues? What lessons may be drawn about the sustainability of development policies so far? What would be required, and at what cost, to do better in the future?
Growth with equity; priority given to the most vulnerable groups: To what extent have ICN objectives been reflected in policies to-date? What constraints are there to their full implementation? How could they be overcome? Are these objectives designed to be potentially beneficial to the economy as a whole as well as humanitarian in their development? Which specific measures have been introduced to reduce discrimination and to improve access of the most vulnerable to basic social services such as health, education, family planning, social security, etc.?
Focus on women and gender equality: Do policies address any factors having a negative impact on the nutritional status of women? Do they provide for the satisfaction of women's special nutrition needs, in particular during pregnancy and lactation? Do they provide for adequate family planning services to reduce the difficulties caused by large families to women, children, the families themselves and society as a whole? Do they address issues that affect adversely the economic, and hence nutritional status of women? Do they ensure that women have sufficient access to information that could lead to improved nutritional status, for their families as well as for themselves?
People's participation: To what extent do nutrition policies genuinely reflect people's priorities? To what extent have local communities been involved in defining priorities and also in planning, managing and evaluating policies and programmes to improve nutrition? Is “people's participation” evident in other areas of human and socio-economic development planning? What is the level of proper nutritional knowledge of the people, and is it adequate to enable them to make informed decisions on nutrition improvement priorities and actions? What actions are needed to ensure that people's participation is an efficient approach to nutrition improvement?
Population policies: Is there a population policy? Is it realistic? Is it effective? Are there adequate planning services within the family and nationally?
Health policies: Nutrition and health are closely related. Questions on health policies relate to many areas that go beyond nutrition improvement. However, the extent to which the Health for All strategy proposed by WHO is being implemented and its impact on nutritional status should be considered. Clearly, reduction of infant and childhood diseases is a critical aspect of improved nutritional status, in addition to significantly reducing morbidity and mortality.
Allocating additional resources: The level of allocated resources is the most concrete measure of perceived priority. What do resources allocated to-date suggest for the perceived priority of nutrition? Is it realistic to expect any substantial improvement in the future? How could additional resources be assured, from national as well as international sources? ICN's recommendations on focusing on Africa and on strengthening economic and technical cooperation among countries are also relevant to the allocation of international resources.
Determining priorities and strategies
The next step is to determine a preliminary set of priorities and strategies in line with the selected objectives and policies. Countries will need to choose those activities which are expected to be the most efficient in meeting their nutrition objectives, while being consistent with national policies. These would almost certainly involve actions related to one or more of the nine themes identified by ICN:
These themes are not all independent of each other; there are many links between them. For example, introduction of an effective food control system aiming to improve food quality and safety might also contribute to controlling micronutrient deficiencies. An even clearer example perhaps is that of the interdependence between household food security and most other themes. Indeed, in many developing countries household food security may well be considered as the central issue for action.
All themes need to be examined while preparing the NPAN. There are only two reasons for not including programmes or projects directly related to a particular theme:
No need. This would be the case if it were decided that there is no call for additional improvement regarding a particular theme, meaning that current activities are adequate and additional efforts and expenditures would not provide significant additional benefits.
No resources. This is a much more likely situation that leads directly to the need for a definition of priorities. As a first step, the objectives and the areas in which it is most important to intervene must be established. Possible actions can then be identified and costed. Subsequently, priorities need to be revised in light of a comparison of the levels of estimated costs and expected resources.
Priorities will depend on circumstances in each country. But beyond that, it should also be remembered that there is no unique way of assessing those circumstances. Further, people's perceived priorities are determined by subjective, as well as objective, criteria. The intersectoral group might therefore be well advised to ask questions such as:
The interdependence of the nine themes is reflected by the intersectoral issues that the ICN World Plan of Action identified as important for addressing nutritional improvement. Whatever the theme and whatever the specific nutrition intervention chosen, a number of intersectoral issues will need to be addressed. Some main issues are listed below:
Creating, strengthening or increasing activity of institutions to address nutrition-related problems;
Carrying out training on relevant nutrition matters in sectors such as agriculture, health, economics and education;
Using mass media to increase awareness and promote better nutrition;
Strengthening relevant research on identified nutrition-related problems;
Strengthening educational systems and social communication mechanisms to improve nutrition-related knowledge;
Generally, priority actions related to any of the ICN themes would involve a number of these issues. In planning action regarding any particular theme, it is therefore important to consider to what extent this could be coupled with action on other themes. For example, introducing an effective food quality and safety system would include education to improve nutrition knowledge.
A number of countries have already established priorities for actions to improve nutrition, as suggested by the country papers prepared for ICN. In countries that have not done so yet or in countries that may wish to revise their priorities, the intersectoral group preparing the NPAN should consider the following steps:
Based on the ICN country paper and on all other relevant information, identify a preliminary set of priorities for actions to improve nutrition.
Determine the ICN themes which would be involved. Review those themes and prepare a preliminary list of possible actions.
For each preliminary action, consider the intersectoral issues involved. This should be done both within each theme and between themes.
For each preliminary action, assess, approximately, the implications for: (i) field activities and programmes; (ii) institutional requirements; and (iii) costs.
Compare findings with resources actually available or potential and indicate the expected time frame of each activity. Some activities will need to be delayed if adequate resources are not immediately available.
The resources needed to implement the selected activities, in addition to time, include various human, financial and organizational inputs. A detailed breakdown can only be done for a well-defined plan. Resources can come from any combination of the following measures; (i) increasing government revenue; (ii) restructuring the national budget; (iii) restructuring and increasing donor support; (iv) developing the national economy and individual incomes, especially those of the poor. Which, if any, of these measures proves feasible will depend on local conditions.
Sample Outline
Introduction
Linkage to overall national economic and development plan objectives; for example, Medium-term (five-year) economic and development plans, including human development priorities
Priority Concerns
List of measurable goals/targets
Strategy and Actions
Under each strategy area identify actions underway or to be taken and who is responsible (see ICN Plan of Action)
The appropriate strategies form the list below may be included:
Assessing, analysing and monitoring nutrition situations
Incorporating nutrition objectives into development programmes and policies
Improving household food security
Preventing micronutrient deficiencies
Protecting the consumer through improved food quality and safety
Promoting healthy lifestyles and diet
Promoting breast-feeding
Preventing and managing infectious diseases
Caring for the socio-economically disadvantaged and nutritionally vulnerable
For each strategy area selected, list of specific goals with actions
For these areas, consideration of overall implications include: institutional arrangements; training; monitoring and evaluation; research; communication; education, and resources, funding and budget
For each action, list of: responsibilities; obstacles, programmes; resources and funding available; resources needed; implementing agencies; how progress will be measured and evaluated
Description of Follow-up Mechanism
Objectives, policies and strategies should clearly address the nine themes proposed by the ICN Plan of Action for Nutrition in order to identify necessary sectoral activities. This Section addresses specific actions related to each of the nine ICN themes, and outlines some of the main issues that should be considered in connection with each of them. For any theme, the experience to-date should be thoroughly reviewed; this should indicate the need for and the form of any further actions. Some of the questions are quite similar for the various themes but, for convenience, they are repeated in each of the relevant sections.
Five of the themes are considered in greater detail than the rest. Those are the themes more directly related to agriculture and food production, the quantity and quality of food available for consumption, and planning, assessment and monitoring of nutrition. They are:
1. Incorporating Nutritional Objectives, Considerations and Components into Development Policies and Programmes
Factors influencing nutritional well-being fall under the responsibility of many sectors, and all of these factors must be addressed in order to achieve good nutrition and health outcomes. Improving nutritional well-being depends upon improving overall social and economic development and ensuring a more equitable distribution of the benefits of development.
While a population's nutritional status is determined by an array of social, economic, environmental and biological factors, a healthy well-nourished population is also essential for successful social and economic development. Improving nutrition should therefore be seen both as a goal of development in its own right and as a means of achieving it.
Significant improvements in nutrition can result from the incorporation of nutritional considerations into the broader policies of economic growth and development, structural adjustment, food and agricultural production, processing, storage and marketing of food, health care, education and social development. Such policies have an impact on nutrition through food availability and prices, incomes, environmental conditions and health status, care and feeding practices and other socio-economic factors. Development policies and programmes can also have varying impacts on the nutritional well-being of different population groups.
Since agriculture is the major source of income and livelihood for many of the world's poor, this sector represents the greatest opportunity for socio-economic development and consequently offers the greatest potential for achieving sustained improvements in the nutritional status of the world's rural poor. However, as many of the rural poor depend at least in part on off-farm sources of income, implementing agriculture production-enhancing policies may not necessarily enhance their situation. By taking a more comprehensive approach to development, a more equitable distribution and consumption of food can be encouraged, along with increasing the purchasing power of the nutritionally deprived, poor and disadvantaged.
An effective means to improve nutrition is to incorporate food consumption and nutrition objectives in mainstream policies and projects which support and shape the country's development process. These nutrition objectives need to be deliberately built into all development programmes at the planning stage, especially the larger-scale investment and area development policies and programmes to ensure that appropriate resources to improve food consumption and nutrition are channelled to the most malnourished or to those most at- risk.
Experience to date: Has any attempt been made so far to introduce nutrition improvement objectives into overall development plans? If so, why? How was it done?
Is there anything else that we would like to know before we can take specific action?
What should be incorporated?: The nutritional objectives that should be incorporated into development policies and programmes need to be clear. It would not be sufficient to refer, for example, to “improvement of nutritional status”. Precise nutritional objectives will vary between countries, as they will need to reflect local circumstances. As much as possible, however, they should target the most vulnerable groups. Probably they will also be closely related to a number of the ICN action-oriented themes.
In particular, objectives related to the improvement of household food security should be introduced into most countries' development policies and programmes. Assessing, analyzing and monitoring nutrition situations should also be reflected into most development programmes, even though it does not represent a nutritional objective in itself. Finally, the themes listed below would be expected to be reflected in many development policies and programmes:
Where should it be incorporated into?: Agriculture policies, in particular those which incorporate nutrition objectives, can have pronounced beneficial effects on nutrition outcomes through their impact on the level and fluctuation of income of nutritionally at-risk households, food prices, women's labour demands and time allocation, and the nutrient content of foods made available. Agricultural development, however, has often been concerned more with raising aggregate production of selected crops than with increasing consumption levels of poor households or generating sustainable livelihoods. Thus, some social groups may fail to benefit from an overall increase in food production due to their poverty and consequent lack of access to food, or to other constraints. Many examples exist of countries with “adequate” food supplies, whose populations still suffer from serious malnutrition.
The effects of the agriculture sector on nutrition go far beyond the matters of food production and supply, and nutrition considerations can be influential in the design and selection of a variety of agriculture policies and programmes. The ultimate role of the agriculture sector should be seen as producing livelihoods and improving nutrition, by the production, processing and marketing of agricultural products not simply by producing crops and commodities alone. The implications that who produces how much of what, and how they do it, may be as important as how much is produced. Similarly, how food and other commodities are processed and distributed is also important. This is because the nutritional impacts of the agriculture sector are mediated through a number of mechanisms other than food availability. These include employment opportunities and incomes, prices, time constraints, labour demands and energy expenditures, environmental and living conditions, gender issues, and a variety of social factors. Depending upon the circumstances, there will be “winners and losers” associated with most policy options; and from a nutrition planning perspective the need is to determine who will actually benefit, and to what degree, from given agricultural policies and to try to ensure that such benefits are directed to the poor and malnourished. Similarly, a safety net for the “losers” would have to be put in place.
Other important areas where government policies can have a major impact on nutrition levels are listed below:
Macro-economics: prices, wages, taxation, exchange rates, national debt, structural adjustment, economic growth, income, foreign trade.
Health: primary health care; health and nutrition education; control of communicable diseases; food safety; differential access to health and nutrition services.
Population: levels and patterns of growth; family planning; family allowances; migration.
Environment: conservation of natural resources; environmental sanitation.
Urbanization: geographical spread of job opportunities; comparative living conditions between urban and rural areas; food price levels.
Education: school-based feeding and health programmes; levels, patterns, gender differences in school attendance.
Policies on almost any of the issues above are unlikely to be determined by nutrition considerations alone. Their main tasks in the introduction of nutritional considerations into development policies and programmes will be:
To ensure, to the extent possible, the adoption of realistic policies and programmes;
To assess the impact of development policies, or policy changes, on nutritional well-being, in particular among the most vulnerable groups;
To sensitize policy-makers on any adverse effects;
Where there are major adverse effects on nutrition to ensure, if not the withdrawal of the policy, at least the adoption of appropriate compensatory measures.
Which issues should determine incorporation?: Which nutritional objectives should be incorporated into which development policies will depend on the national setting. Nutritional objectives are not the only candidates for introduction into overall development planning; population, equity, health are just a few others, although of course they often interface with nutritional objectives.
Planners need to be certain that the introduction of specific nutritional objectives is really necessary, that it would be both effective and efficient and that nutritional objectives will be met within an acceptable time frame and without unnecessary expenditure of resources. Resources and costs represent major issues that need to be addressed. For example, changes in subsidies, price levels, wage levels, and many other have financial implications. These have to be thought out in detail and then decided whether costs are acceptable and whether and how they could be met on a sustainable basis. Non-financial (often political) costs also need to be thought out carefully before deciding whether an intervention will be acceptable and sustainable.
How could incorporation be ensured?: Institutional arrangements and intersectoral cooperation are important in ensuring that nutritional objectives are incorporated into development policies and programmes. It would be a responsibility of the intersectoral group to sensitize policy-makers on the advantages and drawbacks that specific policy measures may imply for nutrition. To this effect, the intersectoral group should develop appropriate indicators to monitor the impact of policies and programmes incorporating nutritional objectives.
2. Improving Household Food Security
Household food security refers to the ability of the household to produce or buy sufficient safe and good quality food to meet the dietary needs of all its members. Inadequate household food security is most often the result of poverty. Addressing household food insecurity therefore implies making food more accessible to the poor. This is primarily achieved through increasing or improving household food production, income generation and income transfer. Specific actions to improve household food security may be grouped into the following categories:
Before however considering further actions, experience to date should be reviewed along the lines suggested below:
How well do we know the patterns and levels of household food insecurity in the country;
What criteria do we use for assessing patterns and levels of household food insecurity;
What do we know about the patterns and levels of household food insecurity by:
cause.
What has been done so far about improving household food security? For each major activity, consider:
Assessment
Lessons What were the main lessons drawn:
about community participation.
Compared to five years ago, in what ways is the situation on household food security better? worse?
Is there anything else that we would like to know before we can take specific action?
After reviewing experience to date, the issues discussed below should be considered:
Are land ownership systems efficient? Are they considered as reasonably equitable? Is there room for reform aimed to improve access to land and water? Who would benefit? What would be the expected effects on agricultural production? On incomes? What would be the constraints? How could they be overcome? Would it be worthwhile?
Are the levels of prevailing producer prices a serious obstacle to raising production (are they too low)? Are they an important contributor to food insecurity at household level (are they too high)? In either case, how could the situation be improved? What might be the side effects? Are they acceptable? How could certain staple food prices be stabilized?
Are credit facilities and saving schemes adequate for the needs of small farmers, such as the purchase of inputs, starting up small businesses and income-generating activities? Who is mobilizing farmers' groups for credit or savings schemes; is this being done effectively and how could it be improved? Which are the main problems: availability; accessibility; high interest rates? What is the experience with loan repayment levels? How could loan repayment improve? To what extent could groups act as guarantors? How could women be given equal access to credit with men? Should credit funds increase? How could any increase be financed?
To what extent has equal access by women to agricultural inputs, credit and savings, and extension services been promoted? How could this be improved or better promoted?
In addition to increasing access to credit, are there other practical ways of helping increase productivity? How could we facilitate access to inputs or to services such as extension? How could we reduce post-harvest losses? How could extension services be improved? Could we quantify the expected benefits and costs?
To what extent should crop diversification be encouraged? Could we quantify, even approximately, the benefits, both nutritional and financial, and the costs? How could we ensure that there is a proper balance between food and cash crops? What would it involve?
Which are the main constraints of the marketing system? To what extent do sub- optimal marketing arrangements prejudice household food security? How could the situation be improved? Better food control? Better infrastructure? More competition? What would be the costs and constraints?
Could agro-industry help improve household food security? How? Who would be the main beneficiaries? What are the constraints to its development? Demand? Expertise? Funds? How helpful would agro-industry be to international trade?
How could employment opportunities be increased among those who need them most (perhaps those unemployed or underemployed, informal sector workers, female heads of household and others)? Introduction of labour-intensive public work programmes? How beneficial would that be, in particular for household food security? How sustainable? What would the costs be? How could they be met? Would there be any positive side-effects such as training or skills acquisition? How useful would these be? How best could food for work programmes be applied?
To what extent would it be feasible to increase employment in the rural areas by encouraging the private sector to provide more job opportunities there, in both the agricultural and non-agricultural sector? How efficient would this be? How acceptable? How sustainable? How beneficial? How expensive?
Would food-related assistance programmes be useful? Under which form would they be most efficient? Targeted distribution or subsidies for those foods consumed mainly by the poor? Are these foods nutritionally adequate? How expensive would the schemes be? How sustainable? Could they be accompanied by other measures to gradually reduce dependence on assistance?
To what extent could stabilization of food supplies be achieved through stockholding of strategic food security reserves? How expensive would it be? How could costs be lowered by reducing dependency on such reserves? Improved agricultural production, processing and marketing? Better developed food trade or aid arrangements? How expensive would these be? How reliable? To what extent international early warning and other information systems would also help?
How could we make it easier for households to cope with emergencies and reduce their dependence on outside help? Household and community food storage? Group savings and credit schemes? Diversification of income and employment sources? Improved marketing infrastructures? Rehabilitation measures? What would all this involve? How helpful could it be? How expensive?
How could we develop cost-effective indicators to measure household food security and to assess the progress of appropriate programmes in promoting household food security?
How could we best promote nutritional education to encourage the selection of a safe and adequate diet, and improved food production, processing, storage and handling techniques, especially at household level? Also, how could we best sensitize men and women on the benefits of limiting household size and on the advantages of family planning?
How could we reduce any adverse impact of structural adjustment programmes on the poor and especially on their household food security? Which compensatory measures would be best suited to alleviate the hardship?
3. Protecting Consumers through Improved Food Quality and Safety
Food that is both of good quality and safe is essential for satisfactory nutrition and the protection of consumers. But the interests of consumers are not always perceived to be the same as those of food producers, manufacturers and traders. The introduction or improvement and the implementation of an adequate food control system are therefore issues that would need to be considered in the preparation of virtually any comprehensive National Plan of Action for Nutrition. Key areas for potential interventions to promote food quality and safety include: food legislation; education of the food industry and consumers; and infrastructure development.
Experience to date: Before considering possible action on food quality and safety, national experience to date should first be reviewed.
What has been done so far about improving the situation regarding food quality and food safety? For each major intervention consider:
Assessment
Lessons What were the main lessons drawn:
about community participation.
Compared to five years ago, in what ways is the situation on food quality and safety better? worse?
Is there anything else that we would like to know before we can take specific action?
Food legislation: Realistic food legislation is a central element of an adequate food control system. Food legislation should therefore be appropriate for the conditions prevailing in the country; it should also be enforceable. Food legislation should address the issues listed below:
Does existing legislation cover all the issues above?
If any issues are missing, which are the reasons? Omission? Are they not applicable? Should they be included?
Should legislation cover anything else? What?
How have our food standards and other regulations been developed? How do they compare with the recommended international standards of the Codex Alimentarius Commission and agreements such as the International Code of Conduct on the Distribution and Use of Pesticides?
Are legislation arrangements sufficiently flexible to respond readily to changing circumstances?
Are the powers of enforcement officers defined sufficiently well?
Are enforcement officers able to exercise fully their powers? If not, what constraints are there? Organizational? Financial? Insufficient commitment either by the officers themselves or by other authorities?
In what way could food legislation be improved? What would be the constraints? Juridical? Organizational? Financial? Training? How would we deal with each?
Education of the food industry and consumers: While appropriate food legislation and law enforcement measures are necessary, much can be achieved in improving food quality and safety levels through the education of the food industry and of consumers.
Which are the main themes that we feel consumers should become more sensitized about? Food handling practices? Recognition of spoiled food? Microbiological contamination, its sources and ways of reducing it? Appropriate cooking methods?
How could this be achieved? Special education programmes? Coupling with other programmes?
How could consumers be made more aware of food laws, regulations and standards? How could they be made more aware of ways available to them for exercising their rights?
How could farmers be sensitized to good agricultural practices such as safe use of pesticides, fertilizers, chemicals, veterinary medicines etc.
How could industry become fully familiar with existing food laws, regulations and standards?
How could industry, and in particular key people in factories, become sensitised to the importance of adequate food handling and preservation practices?
How could we ensure that they have the means to apply that knowledge?
How could we ensure that street food vendors meet at least certain basic standards? How could we arrange for their education?
How could health and education workers be best used to propagate messages and methods related to the improvement of food quality and safety?
How could we best respond to the needs of the especially vulnerable because of economic, health or age constraints, or whatever other reason?
Infrastructure development: An adequate food safety and quality control system requires appropriate infrastructure for carrying out food inspection, food sampling and laboratory analysis. Clearly this implies the need for resources, both human and financial.
What implications would the proposed food control system have for infrastructure?
How would the system be administered?
Are there sufficient numbers of trained food inspectors, analytical chemists, microbiologists and other food scientists available? If not, how could they be obtained? What would be the implication for costs and time?
Are there adequate laboratory facilities available?
How would the costs be met?
4. Controlling Micronutrient Deficiencies
Micronutrient malnutrition usually refers to iodine deficiency disorders (IDD) vitamin A deficiency and iron deficiency anaemia (IDA). Micronutrient interventions are usually grouped into the following: improving the production and consumption of micronutrient-rich foods; food fortification; supplementation; and public health measures. Priority should be given to food-based strategies that are long lasting and sustainable. When other approaches are deemed necessary for short-term measures, these should be complemented by simultaneous food-based activities.
Experience to date
How well do we know the patterns and levels of micronutrient adequacy in the country?
What do we know about the composition of the diet?
What are the levels of micronutrient malnutrition in the country?
What do we know about the patterns and levels of micronutrient deficiencies by:
relationship between levels of calorie and protein intake and levels of micronutrient intake.
What has been done so far about improving the micronutrient situation? For each major intervention, consider:
results.
Assessment
Lessons What were the main lessons drawn about:
community participation.
The ICN World Declaration and Plan of Action for Nutrition have endorsed the following goals concerning micronutrient malnutrition by the year 2000:
What actions have been undertaken so far to meet these goals? How do we assess progress towards each goal? What problems have been experienced in implementing action? To what extent do we think we can overcome such problems now? how?
Is there anything else that we would like to know before we can take specific action?
Improving production and consumption of micronutrient-rich foods
Increased dietary intake of iodine, vitamin A and iron is the most sustainable and effective way of preventing and controlling deficiencies of these micronutrients.
Is the production of micronutrient-rich foods at satisfactory levels?
Is the consumption of micronutrient-rich food at satisfactory levels?
How do we measure “satisfactory”?
What is required in order to increase consumption of micronutrient-rich food? Is it better availability of that food? More such food produced? Or better distributed? Is information needed on the importance of consuming micronutrient-rich foods? Changes in dietary preferences and cultural practices?
Is there enough suitable land? Is there potential for increasing meat or fish production or for using these products more efficiently? Is the land being used efficiently? Is the land divided equitably?
Do workers have access to land for cultivating gardens? Are community and family gardens being developed and actively encouraged?
Should changes in distribution systems be required, what would be the implications?
Should changes in dietary preferences be required, are they feasible? How? What would be the implications in terms of information and consumer education? Are they likely to have undesirable side effects? Are nutrition education campaigns in place?
Is micronutrient deficiency mainly a chronic or an acute problem? The prominence to be given to a strategy aiming to improve dietary diversity should partly depend on the answer.
Fortification: The addition of potassium iodate to salt or other common foods; vitamin A to fats, oils, sugar or salt; and the addition of iron to wheat, rice or salt are common fortifications aimed at combating deficiencies of iodine, vitamin A and iron.
Do we know which of these interventions above would be appropriate? If yes, which? Why? If no, why is fortification not appropriate? If all of them are appropriate, is it really fortification that is required, or is the problem more related to low food intake overall, in which case food supplementation may be a better short- term approach?
Are we confident that fortification would be efficient? Among the target population, are the consumption patterns of the food which would be fortified in line with the required levels of micronutrients?
Are the processing and distribution of the food to be fortified fairly centralized, or are a large number of manufacturers and traders involved (possibly increasing the complexity of the operation)?
What are the implications for legislation? Is it possible to sort them out within an acceptable time frame?
How would we deal with unfortified imports (legal or illegal)? Legislation, monitoring and enforcement implications?
Are there any technical problems to overcome in the fortification process: incorporation and stability of the nutrient, flavour, taste, textural changes of the food? Has the acceptability of the fortified food been tested? What is the shelf-life of the fortified product?
How would the necessary equipment (feeders, blenders) be obtained? Locally, imported?
Can existing food science and technology personnel cope? Is there any need for specialized training of technicians?
Is the food industry willing to cooperate? If it is reluctant, how could its attitude be changed? Education? Financial inducements?
How could we ensure that the nutrient is always available where and when needed? Can we ensure that the fortified food is accessible to the most vulnerable population groups?
Are we satisfied that fortification would not prove too disturbing for the existing food processing and distribution process?
How would we monitor the continuous and correct use (no under or overdosing)?
How would we monitor changes in food consumption patterns that may affect the intake levels of the nutrient?
What would be the cost involved? Is the process of fortification sustainable, considering cost and other factors?
Who would bear the cost: government, industry, the consumer? Are we confident that those expected to bear the cost would do so? Are there likely to be undesirable consequences (lower investments in other social sector interventions, protests, lower consumption of the foods involved)?
Supplementation: The main forms of nutrient supplementation involve iodized oil (given orally or by injection), vitamin A (given in high dose capsules or oral dispensers) and medicinal iron. Supplementation however is only appropriate as short-term assistance to a well-defined target group.
Are there any population sub-groups for which supplementation may be required as short-term assistance? Which? Why?
How well defined are these sub-groups (women of reproductive ages? infants? young children? the elderly? refugees or displaced persons?)
What are their specific needs? Have those needs been measured, or are they just presumed to exist?
Are we sure that the problem is so acute and urgent that supplementation would be appropriate?
Are we sure that we can match the acuteness and urgency requirements with appropriately massive and prompt interventions?
Where would we get the necessary supplies from? How would they be delivered? How would they be distributed? How would we ensure that the target population (and only the target population?) gets them?
Is there sufficient support from the authorities (national, local) to ensure the success of the operation?
Are the proposed beneficiaries aware of the problems? What are their likely attitudes to the proposed assistance?
Are we confident that the assistance would continue for as long as needed? If this is not guaranteed, should we still initiate the intervention, or not?
What parallel measures are we introducing to reduce the period over which supplementation would be needed? Will we be creating an on-going expectation for the supplements? Has an end-point to supplementation been defined and accepted by authorities?
How can we ensure that supplementation does not prove counterproductive by giving the false impression that the basic causes of micronutrient deficiency are being tackled satisfactorily? How can we ensure that there is no consequent diversion of resources that might have otherwise been available for interventions which are either more sustainable, or more long-lasting?
Are we starting at the same time long-term food-based measures to achieve a sustainable solution to the problem?
Public health measures: Micronutrient deficiencies can also be addressed through public health measures, both directly and indirectly. For direct interventions, existing public health programmes (immunization, family planning, maternal and child health, breast-feeding, food safety, nutrition education) may be used as vectors for the delivery of micronutrients to the target population. Indirectly, public health measures can alter the environmental conditions associated with an increased need for micronutrients (diseases).
Which is the target population for each of the existing public health programmes? Is this target population compatible with that for any proposed intervention against micronutrient deficiencies?
To what extent could public health programmes assist in the delivery of micronutrients? What would such assistance imply in terms of logistics? Would there be any legislation requirements?
What would be the costs involved? Would the public health approach be at least as efficient (or low cost/benefit) as any alternative?
Are there likely to be any undesirable side effects (reduced efficiency, alienation of the authorities, operators, target populations …)? Would the programme become a permanent measure? Would the delivery of supplements create a perceived dependency on non-food substances for nutritional well-being?
5. Assessing, Analysing and Monitoring Nutrition Situations
Assessment, analysis and monitoring is an essential element of activities aimed at improving nutritional well-being. Such information 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; monitoring changes; on-going programme management and evaluating the impact of interventions and development programmes.
In preparing a national plan of action, provision should be made for an information system able to address issues such as those enumerated above. Virtually any intervention should have a built-in mechanism for monitoring and assessing performance against objectives and hence introducing appropriate changes. Indeed, the action plan itself should be prepared on the basis of information suitable for defining priorities. In general, this will include indicators of nutritional problems by various population groups; indicators for subsequent monitoring will often be the same.
Efforts to collect and analyse nutrition information must be cost-effective, timely and directed toward specific goals such as the development of plans, programmes design and management and budget decisions. Ideally, information and analysis will lead directly to defining policy options, and indeed, data should be restricted to that needed for this purpose.
Some basic considerations in selecting and implementing methods for assessing, analysing and monitoring nutrition situations are:
Existing data collection systems and existing data should be drawn upon as much as possible. In many countries, growth monitoring programmes accumulate much data which could be used. Price monitoring is part of many routine statistical systems and may be used for monitoring trends in household food security. Nutritional measurements may be added to routine household surveys.
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.
Ideally, information should be provided on the number of people currently affected by specific types of malnutrition, as well as those likely to become so (“at risk”). Additional information and analysis of location and selected socio-economic factors, such as income source, access to services and programmes, is useful.
It is important to follow trends in the selected indicators and population groups over time, so that improvements or deteriorations can be noted and the effectiveness of policies and programmes evaluated.
Information is needed on the implementation and cost-effectiveness of programmes aimed at resolving particular nutritional problems or targeted at a particular group or geographical areas.
To improve the effectiveness and efficiency of monitoring, it should be built into a project or intervention from the beginning, rather than adding on after implementation has begun.
In considering whether to obtain any new information, address the following questions:
6. Preventing and Managing Infectious Diseases
Poor nutrition increases vulnerability to infectious diseases and deteriorates prospects after infection; similarly, infection contributes to malnutrition. This interaction between malnutrition and infection is responsible for the severity of a number of infections and for the high mortality associated with diarrhoea and respiratory infections, especially measles. It is also a contributing factor to increased incidence of growth faltering, protein-energy malnutrition, low birth weight and micronutrient deficiencies, especially of vitamin A and iron. Addressing either malnutrition or infection could therefore be expected to have a positive impact on the other also. The list of possible interventions below is designed to assist in developing a joint approach towards the two issues. Before however considering the interventions, it should be noted that:
Malnutrition and infection need to be reduced by as much as possible not just because of their influence on each other, but also as distinct constraints to human welfare.
Although malnutrition and infection interact, they are not usually the main cause of each other. Either is much more likely to have been caused by poor economic and social factors. Improvements in nutritional status or the incidence and consequences of infection are difficult to sustain unless socio-economic conditions also improve.
After reviewing experience to date, consider the feasibility of actions such as those proposed by the ICN Plan of Action for Nutrition and listed below. Consider also the extent to which activities could be jointly implemented (for example, jointly promoting birth- spacing, breast-feeding and good weaning practices):
The importance of breast-feeding for the survival, health and nutrition of the child, for maternal health and for child spacing is well documented. Recommendations to promote breast-feeding include: encouraging exclusive breast-feeding from 4–6 months with only gradual introduction of supplementary food up to at least 24 months; organizing information campaigns about the benefits and management of breast-feeding; supporting “baby-friendly hospitals” enforcing sound infant feeding practices; assisting the formation of mother-support groups; training health and other care providers on breast-feeding; ensuring that mothers are able to exercise their right to breast-feed their children adequately, independently of their employment situation, as provided by ILO conventions and regulations; ensuring that the International Code of Marketing of Breast Milk Substitutes is enforced.
In applying such recommendations, it is important to first review experience to date and then consider issues such as those listed below:
Are any major changes from prevailing practices implied? What are the reasons for the existing practices? Which would be the constraints in effecting change?
To what extent would legislation need to be introduced or modified? Would it be practical?
How could information, education and communication be best organized? How effective are they likely to be? How could community support be best obtained? What would it involve?
To what extent is breast-feeding prevalence constrained by the mother's work commitments? Is introduction of measures to help working mothers breast-feed necessary? Would such measures have a major impact on breast-feeding practices? Would they penalize women's employment prospects? If so, how could this be overcome?
Are breast milk substitutes a major problem? If so, how could we best try to solve it? Communication? Legislation? Both? Are there any important vested interests that we have to address?
8. Caring for the Socio-economically Deprived and Nutritionally Vulnerable
Ensuring that others receive adequate nutrition is one important practical aspect of caring. If those assisted are socio-economically deprived and nutritionally vulnerable such assistance becomes even more meaningful. Infants and young children form an especially important group of nutritionally vulnerable individuals. Other groups include the elderly, the disabled and those too poor to provide a satisfactory diet to themselves. Addressing however the issue of caring is often interpreted not only as providing for those being cared for but also as assisting those who do the caring. At family level, this usually implies mothers and other women. After reviewing experience to date, the following issues should be considered:
Beyond breast-feeding, what other arrangements are feasible to ensure that infants and young children receive adequate diets? What are the constraints to sound weaning practices? Insufficient information? Mothers' vulnerability? Economic difficulties?
What should be the main characteristics of appropriate information campaigns?
To what extent might improvements in women's economic and social status positively affect their caring capacity, as well as their own welfare?
What improvements are practical? Increased access to land ownership or to facilities such as education, training, credit, family planning services? Motivation of adult males to assume an increased share of caring responsibilities? What would be the legislation implications? To what extent should such interventions form part of a National Plan of Action for Nutrition, rather than of a broader plan for social and economic development?
How could care at community level be strengthened? How efficient would that be?
9. Promoting Appropriate Diets and Healthy Lifestyles
A healthy lifestyle is also an important contributor to good nutrition both directly, since it should include an adequate diet, and indirectly, since it reduces the risk of diseases which affect nutritional status adversely. Promoting adequate diets and lifestyles is therefore important and is largely a matter of information and education. Application of the new knowledge may however be more difficult. Although information and education are important, vast segments of the world's population do not always have a real choice over the way they eat and live. An overall objective should be to improve the economic, environmental, social and cultural conditions that influence people's behaviour in relation to diet and other aspects of lifestyle. Those considering interventions to promote better diets and lifestyles might first review experience to date and then address issues such as those listed below:
What evidence is there that nutritional status is adversely affected by diets and lifestyles over which people have realistic alternatives?
How serious are any such problems?
Do they mainly affect the economically better-off, or are they more or less independent of economic status?
Is the main cause insufficient knowledge or are there are other important contributing factors?
How could information and education aimed to promote better diets and lifestyles be combined with interventions in areas such as:
caring for especially vulnerable groups.
To what extent could better diets be promoted through interventions in areas such as:
introduction of nutrition objectives into overall development programmes.
Have any national dietary guidelines been developed? If not, would they be useful? How could they be developed?
Is the market for appropriate food products large enough to justify the introduction of fairly comprehensive information on food labels? Would something simpler be sufficient, instead?
Which are the important changes in people's diets and lifestyles that we consider useful to introduce?
What kind of infrastructure is available or will be needed for developing nutrition support material?
How could appropriate messages be developed? Which would be the most effective ways of communicating them? How efficient would they be?
How could we best use professionals such as teachers, doctors, nurses, agricultural extension and other community workers to inform, educate and motivate the public in general, or specific population groups?
How best could we also inform, educate and motivate food producers, processors or traders?
