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close this bookSCN News, Number 16 - Nutrition of the School-aged Child (ACC/SCN, 1998, 80 p.)
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Programmes News

AGENCIES REPORT ON THEIR ACTIVITIES IN NUTRITION

FAO

Preventing Micronutrient Deficiencies

The workshop on the 'Prevention and Control of Micronutrient Malnutrition through Food-based Approaches in SAARC Countries' was held in Dhaka, Bangladesh, from 17-20 November 1997. It was sponsored by FAO in collaboration with the Thrasher Research Fund (USA) and the Micronutrient Initiative and was organised by the Agricultural Research Council of Bangladesh. All SAARC countries - India, Pakistan, Bangladesh, Nepal, Sri Lanka, Bhutan and the Maldives - participated in the workshop. Renowned experts working in the SAARC and other Asian countries were invited to present papers and discuss various facets of food-based approaches for the control and prevention of micronutrient malnutrition.

The workshop reviewed the current status of the problems of micronutrient deficiencies in SAARC countries and discussed food-based approaches for their control including the role of fruit and vegetable gardening, small animal rearing and the aquaculture at household level, processing and preservation to improve food security and nutritional value, nutrition education for improving consumption and selection of micronutrient-rich foods, and food fortification for improving food quality and nutritional value.

The workshop participants agreed that food-based approaches are the preferred, most practical and sustainable strategy for the prevention of micronutrient malnutrition and for the control of mild micronutrient malnutrition in SAARC countries. They recommended that food-based actions should be an integral part of all action programmes, both short- and long-term. They advised that SAARC countries look at their farms and not at their pharmacies for the solution of these problems. A report containing the recommendations, conclusions and technical papers is available from the FAO Food and Nutrition Division (contact details below).

Expert Meeting on Risk Communication1

1The Codex Alimentarius Commission has defined risk communication as: 'the interactive exchange of information and opinions concerning risk among risk assessors, risk managers, consumers and other interested parties.'

A Joint FAO/WHO Expert Consultation on the Application of Risk Communication to Food Standards and Safety Matters was held in Rome on 2-6 February 1998. The meeting was attended by 18 experts who identified strategies for crisis situations such as food-borne disease or illness outbreaks and for use in on-going risk communication activities. The experts recommended ways to overcome the barriers to effective risk communication and elaborated guiding principles for effective risk communication within the risk analysis framework.

The Consultation focused on two primary goals - the creation of more openness and transparency in the entire risk analysis process through the use of risk communication and the increased involvement of all interested parties (i.e., the government, industry, consumer organisations, etc.) in risk communication during the risk management process. The report of the consultation will be available later this year.

Comparative Analysis of Nutrition Interventions Workshop in Thailand

FAO, in collaboration with the Institute of Nutrition at Mahidol University, organised a workshop on Comparative Analysis of Nutrition Interventions, held in Bangkok, Thailand, 2-4 June 1998. The preparatory work and proceedings of the workshop has provided a major contribution towards the development of a manual on this subject. The manual will be based on lessons learned and wisdom accrued from comparative analyses of interventions, to identify what works and what does not. It is intended as a source of advice and inspiration for current and planned nutrition interventions by providing information on strategies, approaches and procedures that are known to have resulted in successful outcomes in past and ongoing interventions. The manual is intended to create an understanding of the need for ongoing monitoring to improve the cost-effectivenes and outcomes of nutrition interventions.

Development of a National Nutrition Training Programme for South Africa. A Technical Cooperation Project with the Government of South Africa

The Reconstruction and Development Programme of the Government of South Africa has developed an integrated nutrition strategy aimed at reducing hunger and malnutrition. To this end, FAO is working with the Government of South Africa to strengthen staff training programmes.

Specifically, FAO has helped the Government of South Africa to sensitise top policy-makers, mid-level administrators and programme managers to nutrition problems, their causes and potential solutions, and to increase national capacity to undertake community programmes through the training of resource persons and trainers of community nutrition workers. It is currently undertaking a needs assessment for the development of future university training/teaching programmes in human nutrition. The project is expected to be completed in August 1998.

Nutrition Education for School Children

A major component of FAO's normative work on nutrition involves nutrition education for the public. FAO encourages the development of practical and effective programmes of nutrition education in primary schools in developing countries. In cooperation with the School Nutrition Education Section of The Netherlands Nutrition Centre, The Hague, FAO is developing a planning guide for nutrition education in primary schools. The materials to be developed are partially based on the expressed needs of government school staff who have responded to a questionnaire inquiring on the current state and shortcomings of nutrition education in schools in English-speaking countries.

Currently, a planning guide for school inspectors and school supervisors is being prepared to allow them to initiate, support and guide nutrition education for schoolchildren in all schools in developing countries. A draft version of this planning guide will be reviewed and field tested in the beginning of 1999. Complementary documents, such as a teacher's guide and examples of good practice in nutrition education in primary schools in developing countries, will also be prepared. These documents will be particularly useful in schools which have adopted the WHO approach of Health-Promoting Schools (see page 8) but do not require that a school is member of the WHO programme. With a view to further enhance the benefits of the two programmes for the assisted countries, special efforts are being made to actively collaborate in the world-wide School Health Initiative, promoted by the WHO and its respective regional networks for Health-Promoting Schools. This collaboration will strengthen ongoing nutrition education through emphasising the food-based approach. This is hoped to have lasting positive effects on the food and nutrition situation of schoolchildren, their dietary attitudes, practices and choices.

World Food Summit follow-up: Nutrition Information Systems

To assess progress made in reaching the 1996 World Food Summit goals for reducing undenutrition, FAO is developing the Food Insecurity and Vulnerability Information and Mapping System (FIVIMS). This is part of the international effort to assess the nature, extent, magnitude and severity of malnutrition and to monitor trends over time.

FAO is requesting each country to provide the results of their most recent food and nutritional status surveys so that the database can be updated frequently. Many data collection activities have been undertaken in developing countries that need to be documented and catalogued at the international level. Identifying sources of such data with the help of governments and NGOs would prevent the neglect or even loss of this information and greatly increase the amount of material to be incorporated into FIVIMS.

FIVIMS will rely on a set of indicators to provide a comprehensive picture of the food and nutrition situation in a country. This will include food trade and production, market conditions, livelihood systems, social institutions, cultural attitudes, natural resources, health and sanitary conditions and feeding practices. Thus, FIVIMS can enable users to describe the food and nutrition situation, discern trends in the prevalence of undenutrition and provide an analysis of the major causal factors.

Within this framework, the Food and Nutrition Division is creating NUTRIDAT, a system to assemble and disseminate information about people who are underfed, undernourished or at-risk of becoming so. The database is currently located and maintained at the central level with copies of relevant country data being made available at the regional and sub-regional levels for trend analysis and policy work. FAO is collaborating with WHO and other agencies in sharing data for NUTRIDAT with a view to linking data from different agencies. Direct access to NUTRIDAT Central will be possible through the Internet and available on CD-ROM in 1999.

NUTRIDAT contains anthropometric information, and where available, consumption data at household level and food supply at national and sub-national level, as well as statistics on health and demography. The FAO database emphasises information on adults and school-age children.

In addition to NUTRIDAT, FAO's Nutrition Country Profiles provide concise analytical summaries of the food and nutrition situation in individual countries. This information is presented in the context of information and background statistics on food-related factors such as agricultural production, and other selected economic and demographic indicators. The information is presented in a disaggregated fashion; trends and sub-national differences are highlighed when available. The profiles indude consistent and comparable statistical data that are presented in a combination of colourful graphical displays, tables and maps, each supported by a short explanatory text.

Nutrition mapping is an innovative component of the profiles that presents the data in a visible and eye-catching manner. The maps combine information such as anthropometric status, micronutrient deficiencies, and energy and nutrient consumption where available, with information about safe water supplies and education, to provide an immediate comprehensive picture of the geographical distribution of vulnerable groups at sub-national level. With this visual aid, the locations of populations with major nutritional problems are clear. The maps also highlight gaps in information alerting policy makers that additional data collection is necessary. Nutrition country profiles can be requested from Food and Nutrition Division.

Source: FAO Food and Nutrition Division, Via delle Terme de Cara-calla, 00100 Rome, Italy. Fax: 396 5225 4593 Email: Food-Quality@FAO.org or Nutrition@FAO.org Web: http://www.fao.org/wai-cent/faoinfo/economic/esn/nutri.htm

IAEA

Among the most important events of 1997 for nutrition activities at the International Atomic Energy Agency (IAEA) were two major reviews. The first review focused mainly on the resources needed to ensure the sustainability of the health programme and on the identification of appropriate topics for coordinated research. The second review was concerned with thematic planning for future technical cooperation projects. Both reviews had very positive outcomes; consequently there is a significant expansion in IAEA's nutrition activities expected in the near future.

There are nine current and planned coordinated research projects (CRPs: see SCN News No.15p50) involving applications of isotopes for which funding is available:

· 1995-9. Development and application of isotopic techniques in studies of vitamin A nutrition.

· 1995-9. Reference Asian Man (dietary intake and body composition for selected trace elements of relevance to radiological protection).

· 1996-2000. Isotopic evaluations of maternal and child nutrition to help prevent stunting.

· 1998-2001. Isotope-aided studies of nutrient interactions in developing country populations exposed to multiple nutritional deficiencies.

· 1998-2001. Isotopic evaluations in infant growth monitoring (in collaboration with WHO'S Multicentre Growth Reference Study).

· 1998-2001 Application of nuclear techniques in the prevention of denerative diseases (obesity and non-insulin dependent diabetes) in ageing.

· 1999-2002. Development and validation of isotopic and complementary tools for nutritional assessment of iron status in developing country populations.

· 1999-2002. Development and validation of isotopic and complementary tools for nutritional assessment of zinc status in developing country populations.

· 2000-2003. Development and validation of isotopic and complementary tools for nutritional assessment of household food security in developing country populations.

Ongoing and planned technical cooperation projects have a common theme in trying to make practical use of nuclear and isotopic techniques to assess the impact of national nutrition programmes. Typical examples include studies of micronutrients (iron, zinc, vitamin A), breastmilk volume, energy expenditure and body composition. Individual technical cooperation projects have recently been carried out in Cameroon, Chile, Ethiopia, Peru, Sierra Leone and Sri Lanka, and new ones are currently being started in Chile, Ethiopia, Senegal and Venezuela. Larger-scale regional projects are in the planning stage in Latin America and East Asia. A new project is also expected to start soon in Indonesia, in collaboration with UNICEF, which will use isotope techniques in support of UNCEF's multi-country field trials of the efficacy of iron and zinc supplementation to reduce anaemia and growth faltering in infants. Other possibilities for joint projects are currently being explored with WFP, UNHCR and FAO.

For further information on any of these projects, please contact Robert Parr, Head, Section of Nutritional and Health-Related Environmental Studies, IAEA, P.O. Box 100, A-1400 Vienna, Austria. Tel: 431 2060 21657 Fax: 431 20607 Email: R.Parr@iaea.org

IFPRI

Urban Malnutrition

Preliminary results from work by Lawrence Haddad, Marie Ruel and James Garrett at IFPRI indicate that urban undenutrition is growing both in absolute terms and in terms of the share of overall undenutrition. Rural areas still contain the majority of undernourished children (except for Brazil), but the gap is closing rapidly. The authors conclude that there is a need for more research on identifying the main constraints to urban food security and good nutrition and on understanding the basis of effective community, programme and policy responses (see page 29).

Links between Women's Status and Child Nutrition

Preliminary results from work by Lisa Smith and Lawrence Haddad at Emory University and IFPRI indicate that women's status has a large positive and significant impact on child nutrition in the developing world. Utilising data from a wide range of carefully documented sources, a cross-section time-series data set was constructed with some 180 data points covering approximately 64 developing countries from 1970-1996. Country fixed-effects methods were employed to estimate the impact of per capita dietary energy supplies, female secondary school enrolments, access to clean water and the ratio of male to female life expectancy (the proxy measure of women's status relative to men) on low weight-for-age prevalence for children under five. Of the four factors, women's relative status has the largest elasticity with respect to child underweight prevalence1. The variable has a particularly strong effect for South Asia, a result in line with work suggesting that women's status is key to reducing child malnutrition there.

1 Elasticity: the percentage change in one variable resulting from a one percent change in another variable.

New/Partnership with CARE International

IFPRI's multi-country programme on 'Urban Challenges to Food Security and Nutrition' led by Marie Ruel and James Garrett has established a new partnership with CARE International in an effort to be more effective in linking research to programming in urban areas. Over the last six months, IFPRI and CARE have collaborated in carrying out urban livelihood assessments in Bangladesh, Tanzania, Togo and Ghana as part of the initial diagnostic phase in CARE'S urban programme development. Honduras is next on the list. Additional collaborative work is planned to work jointly on follow-on phases such as project design, implementation, monitoring and evaluation.

For further information, please contact Bonnie McClafferty, Outreach, FCND, IFPRI, 1200 Seventeenth Street, NW, Washington D.C. 20036, USA. Fax: 202 467 4439 Email: b.mcclaffeny@cgnet.com or if-pri@cgnet.com

UNICEF

UNICEF Meeting in Tanzania Develops Proposal for Community-based Programmes to Support IMCI

UNICEF and WHO are collaborating in the development and implementation of the Integrated Management of Childhood Illness (IMCI) programme (see SCN News No. 15 p56). Collaboration to date has largely focused on the integration of management at the level of the health facility, for which WHO has taken the lead. In the last year, a community and household component of IMCI has been developed, including strategies for community-based nutrition activities. Many of the deaths associated with the five IMCI diseases (malnutrition, acute respiratory infections, diarrhoea, measles and malaria) need improved preventive measures at the community and household levels. UNICEF is leading the development of the IMCI components at these levels.

In late April, the UNICEF Eastern and Southern Africa Region Nutrition Network held a meeting in Morogoro, Tanzania that included planning for IMCI at the community level based in large part on existing experiences with community-based nutrition programmes. The meeting drew a total of 78 participants from 19 African countries. Participants included government representatives from health, nutrition and IMCI coordinating units; UNICEF staff in health, nutrition, water and sanitation, communication and evaluation; representatives of WHO. USAID, BASICS, AMREF¹, and a number of research institutions.

¹ The African Medical Research Foundation - an NGO based in Nairobi with activities all over East Africa.

Among the community-based programmes described in detail at the meeting were the Madagascar Project NAC, the Kisarawe District (Tanzania) Child Survival, Protection and Development (CSPD) programme, the Zambia community breastfeeding promotion. community child heath projects coordinated by AMREF, and various community malaria and hygiene interventions. The meeting also provided an overview of IMCI, including the concept. components and strategies for the household and community component There were sessions on communication and soda) mobilisation, monitoring and evaluation and a field visit to several sites of the Morogoro District CSPD programme.

All countries represented at the meeting formulated plans for further development of the household and community component of IMCI and other community-based programmes.

Some of the main conclusions and findings from the meeting are as follows:

1. Better attention to documenting lessons learned

The various case studies showed that there is already a wealth of information on what works, yet systematic documentation of these community-based experiences and utilisation of this information to inform better programme design is lacking. A need was expressed for countries to undertake a more systematic review of community-based programmes. A more critical examination is required of the community processes to ascertain that repeated Triple A cycles are indeed taking place and that projects/programmes are not 'locked' into actions based on only the first round of assessment and analysis.

2. Scale of community-based programmes

The UNICEF Nutrition Strategy promotes community-based nutrition-oriented programmes as the best way to accelerate reduction of child malnutrition. Despite a lot of training and effort over the last decade to promote community-based programmes, there are still too few examples of programmes operating at a scale commensurate with a potential for a significant nutrition impact. UNICEF staff and other partners involved in these efforts need new kinds of training for this purpose.

3. Household and community component of IMCI

The meeting discussed at length the concept of IMCI and the opportunities it brings to promote improvement in nutrition and better management of childhood diseases through promotive. preventive and curative interventions. Renewed attempts to promote community-based nutrition programmes are necessary. Both through IMCI and independent of it, the pursuit of community-based nutrition programmes should be accelerated across the region. An agreement was reached on the need for individual countries to review what was already on the ground and develop further what may need to be done in order to strengthen or operationalise household and community-based programmes. The draft country proposals were a reflection of this, with several countries having proposed core nutrition-type community-based interventions including growth promotion, breastfeeding, adequate complementary feeding and others proposing to build upon mother support groups, community malaria interventions, and water and sanitation groups.

4. Advocacy

There was optimism on strengthening community-based interventions but concern for how to get governments to give community-based interventions more importance. Renewed advocacy, making the case for the importance of nutrition to national development, is needed. The 1998 State of the World's Children Report on nutrition has put the case forward that nutrition is a lever that can accelerate and potentiate economic development. Good nutrition is also a right that governments have committed themselves to achieving by signing the Convention on the Rights of the Child.

5. Community level 'workers'

Action at community level relies on a cadre of community level 'mobilisers'". The necessary support to mobilisers from the next level in service delivery, especially from extension workers, was not always forthcoming. The question of appropriate ratios of mobilisers to facilitators requires further discussion. The issue of payment of community-based workers was an area of concern that needs to be analysed carefully in each country. In various countries, the decision to pay community workers had already been made and some had included such considerations in their local government and decentralisation initiatives. The issues around cost-effectiveness and sustainability need to be thought through for each country. Ways of sustaining the motivation of the community workers though non-monetary and in-kind support also need to be developed.

6. Gender issues in community-based programmes

Health and nutrition programmes have not yet adequately facilitated the process of drawing in men and fathers in programming for improved care at household level. It was proposed that careful attention be given to this in further development of household and community IMCI and community nutrition programmes.

7. Communication and social mobilisation

Many nutrition and health outcomes are determined by behaviours at houshold level. The focus of communication programmes seems to be on behaviour modification and not on informed choices. Implementation of communication strategies has to be well founded in the understanding of what motivates people to change and which behaviours are the most important for achieving improved health and nutrition outcomes. The UNICEF programme communication group at UNICEF headquarters is developing tools that will be made available to guide country offices in their communication strategies.

8. Technical support areas

Countries identified areas for which additional support is required to further action on community-based programmes. These include planning for communication and social mobilisation; proposal development; orientation and training for household and community IMCI; assessing care-seeking behaviours; and community monitoring and information systems.

9. Next steps

All participating countries developed draft plans for strengthening community-based programmes. These plans need to be further discussed at country level. The UNICEF offices in the phase one IMCI countries - Madagascar, Tanzania, Uganda, South Africa, and Malawi - will receive funds from USAID to help implement their plans.

A meeting report is available on request from Roger Shrimpton, UNICEF, Mail code TA-24A, 3 United Nations Plaza, New York, NY 10017, USA. Tel: 1 212 824 6368 Fax: 1 212 824 6465 Email: rshrimpton@unicef.org For further information, please contact Vincent Orinda at UNICEF Health Section (email: vorinda@unicef.org) or Jim Tulloch, CHD, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tal: 41 22 791 2632 Fax: 41 22 791 4853 Email: tul-lochj@who.ch

Evaluation of UNICEF Support for Universal Salt lodisation in South Asia

UNICEF is undertaking an evaluation of its support to the universal salt iodisation (USI) effort in South Asia. Over the last few years, there has been a tremendous acceleration in progress towards USI in South Asia, resulting from concerted government intervention and support from agencies and donors. Progress has been so great that the type of assistance that can be usefully provided by agencies and donors is changing. This evaluation aims to take stock of the UNICEF contribution country-by-country over the last five years and to guide the process of planning for UNICEF's future support.

The evaluation will include:

· assessment of the current situation with regard to availability of iodised salt at the household level;

· measurement of the inputs and outputs of the UNICEF support programme;

· comparison of UNICEF USI inputs with those of other development agencies and government resources;

· measurement of the extent to which UNICEF's efforts have tried to stimulate demand and the extent to which they have been aimed at stimulating supply;

· assessment of the degree to which the private sector has supported the iodisation of salt; and

· examination of the quality of supply and legislation enforcement.

The evaluation is being coordinated by a steering committee chaired by the UNICEF Regional Monitoring and Evaluation Officer for South Asia. A questionnaire was sent to all UNICEF country offices in South Asia in late 1997 to collect data specifically for the evaluation. Findings will be analysed by an independent evaluator, discussed with the wider Nutrition Initiative in South Asia group (NISA) and reviewed by an external panel. The main output of the evaluation will be a 30-40 page report - stage one of which is expected to be finalised by September 1998.

Both WHO and ICCIDD will be asked to act as external reviewers of a draft report version of the evaluation. If they agree, their views will be annexed in the final version of the report.

The steering committee is actively seeking offers of persons wishing formally to review the evaluation. For further information, please contact Roger Pearson, Regional Monitoring and Evaluation Officer, UNICEF South Asia, P.O. Box 5815, Lekhnath Marg, Kathmandu, Nepal. Tel: 977 1 417 082 Fax: 977 1 419 479 Email: rpearson® uncrosa.mos.com.np

The 1997 Afghanistan Multiple Indicator Baseline Survey

Afghanistan has been in a state of conflict for almost 20 years, leading to large-scale displacement and almost total collapse of the country's infrastructure. With an annual per capita income of approximately US $220 (in 1994), Afghanistan is consistently ranked among the poorest countries in the world. Access to populations within the country over the last two decades has been sporadic at best, and consequently the national situation in terms of health and sanitation has been unclear. In 1997, UNICEF undertook a multiple indicator survey in Afghanistan. Technical support was commissioned from ClET Intemational1. This is the first national-level survey carried out in the country for 25 years, and gives baseline indicators for development and relief programmes including health, nutrition, education, food security, water and sanitation.

1An NGO registered in the USA dedicated to building the community voice into planning and better governance.

The survey included over 60,000 people from 96 sentinel communities representing the five operational regions of the country. Mortality rates were very high: maternal mortality rates were around 400 per 100 000, and infant mortality rates were 140-150 per 1000. Female literacy was extremely low: less than 5% of rural women, and around 10% of urban women aged 15-49 years old knew how to read and write. School attendance figures reflected this dismal situation, with only 7% of girls attending schools in rural areas. Despite the ban on female education, a tiny fraction of female children in Herat and Kandahar regions did attend school at the time of the survey. These informal schools were maintained underground by mothers who defied the law against female education.

The survey showed that nationally, 25% of children aged 6-35 months were wasted and 52% were stunted. Stunting rates were higher among boys than among girls throughout the country. Highest stunting rates were seen in Kandahar region, where 63% of boys and 59% of girls were stunted. These data indicate considerably higher levels of malnutrition than have previously been documented, making Afghanistan one of the worst affected countries in the world.

Vitamin A deficiency (assessed by self-reporting of night blindness), was reported in about 3% of the children (aged 12-23 months) surveyed in Jalalabad and Kandahar. Nationally, 12% of children had received a vitamin A capsule, with higher coverage of vitamin A distribution in Jalalabad and Kandahar. National goitre rates (assessed by self-reporting of visible goi-ter) were 7.5 cases per 1000 people.

Assessment of breastfeeding practices showed striking differences in reporting from (and opinions of) women and men. Women reported that only 25% of infants were exclusively breastfed to 4 months, whereas men tended to overestimate this figure.

For food security, 42% of households reported that they had sufficient food in the week prior to the survey, implying that 58% did not.

For further information, please contact Roger Pearson, Regional Monitoring and Evaluation Officer, UNICEF South Asia, P.O. Box 5815, Lekhnath Marg, Kathmandu, Nepal. Tel: 977 1 417 082 Fax: 977 1 419479 Email: rpearson@uncrosa.mos.com.np

WHO

The Innocenti Declaration:
Continuing towards its Targets

The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, adopted in 1990, includes a number of operational targets. It calls upon international organisations to draw up action strategies for protecting, promoting and supporting breastfeeding, including global monitoring and evaluation of their strategies.

To assist countries in their efforts to monitor and assess progress towards achieving the operational targets of the Innocenti Declaration, and to identify areas where more effort is needed, the Programme of Nutrition recently gathered information in this connection in four WHO Regions. Information has thus far been received from 57% (108) of WHO'S 191 member states, many of which have made considerable progress towards achieving the operational targets of the Innocenti Declaration.

· Breastfeeding committees: Several countries have breast-feeding committees (58 % in the Africa Region (AFR), 22% in the Region of Americas (AMR), 65% in the Eastern Mediterranean Region (EMR), and 63% in the European Region (EUR)) and Baby-Friendly Hospital Initiative committees (74% in AFR, 80% in AMR, 53% in EMR, and 71% in EUR). These committees are composed of representatives from relevant government departments, NGOs, edu- cational institutions, health professional associations and infant-food manufacturers.

· National breastfeeding policy. Sixty-eight percent (AFR), 72% (AMR), 82% (EMR), and 60% (EUR) of countries have formulated national breastfeeding policies, and 57% of countries have plans of action for implementing the BFHI.

· Baby-Friendly Hospitals: The 4 WHO Regions have 13,526 hospitals with maternity services. There were 2,430 hospitals designated as being baby-friendly at the end of 1997, compared with 943 hospitals at the end of 1995. 4,578 hospitals are targeted to become baby-friendly (1,554 hospitals in AFR, 1,294 in AMR, 950 in EMR, and 780 in EUR).

· International Code of Marketing of Breast-milk Substitutes: Many governments have taken responsibility for adopting, implementing and monitoring the Code (61% in AFR, 80% in AMR, 53% in EMR, and 49% in EUR). Some countries are in the preliminary stages of drafting national measures for this purpose, while still others have hardly begun.

· Free and low-cost supplies of breastmilk substitutes: The distribution of free and low-cost breastmilk substitutes has ended in 5,949 hospitals (1,967 in AFR, 995 in EMR, 1,468 in EUR and 1,519 in the AMR).

· Maternity legislation: Governments of WHO member states are using different means to protect, promote and support breastfeeding by enacting imaginative maternity protection legislation (87% in AFR, 100% in AMR, 94% in EMR and 89% in EUR) and by providing information on breastfeeding through the mass media, i.e., television and radio programmes, newspaper articles and breastfeeding weeks.

The WHO Programme of Nutrition has consolidated the survey results in 'The Innocenti Declaration: Progress and Achievements', Parts I, II and III, published in the Weekly Epidemiologi-cal Record (73(5): 25-30,1998; 73(13): 91-94,1998 and 73(19); 139-144,1998).

This exercise will be repeated every 3 years, and the information collected will be included in the reports by the WHO Director-General to the World Health Assembly. To facilitate this process, the Programme of Nutrition has added a module on Innocenti targets to the WHO Global Breastfeeding Data Bank, and these will be seen as part of the Nutrition Surveillance system.

For further information, please contact Randa Saadeh, WHO Programme of Nutrition. Tel: 41 22 791 3315 Fax: 41 22 791 4156 Email: saadehr@who.ch

The Baby-Friendly Hospital Initiative (BFHI)

In assisting countries to maintain the credibility and sustainability of the BFHI, the Programme of Nutrition is continuing to develop re-assessment and monitoring tools based on the WHO/UNICEF BFHI Global Criteria. The monitoring tools are intended to aid data collection on key indicators related to BFHI and infant feeding practices. They have been field-tested in Poland and Bolivia, (Oman and Malaysia to follow) in close collaboration with Wellstart International (a WHO collaborating centre based in San Diego, California, USA), and UNICEF. The monitoring tools will be published at the end of 1998.

For further information, please contact Randa Saadeh, WHO Programme of Nutrition. Tel: 41 22 791 3315 Fax: 41 22 791 4156 Email: saadehr@who.ch

'Promoting Breastfeeding in Health Facilities: a Short Course for Administrators and Policy-makers' by WHO / Wellstart International

This short course (WHO/NUT/96.3) which provides practical guidance on policy and administrative changes needed to promote breastfeeding in health facilities, is available in Arabic, English, French, Russian and Spanish, and will soon be available in Italian and Portuguese. It has thus far been given in Egypt, Ghana, Kenya, Lithuania, Malaysia, Saudi Arabia, Spain, Swaziland, the UK, Ukraine and the USA. The course has had a major impact on BFHI status and progress. For example, in Ukraine alone, the course has been given twenty times and has prompted the establishment of a national breast-feeding committee and development of a breastfeeding policy. In Brazil, it is planned to integrate the course into the overall national training plan for breastfeeding, and it is seen as a tool to sensitise decision-makers and obtain their commitment to becoming baby-friendly.

The course is currently being used as the main advocacy tool to target private and university hospitals.

For further information, please contact Randa Saadeh, WHO Programme of Nutrition. Tel: 41 22791 3315 Fax: 41 22791 4156 Email: saadehr@who.ch

Joint WHO/Tufts Consultation on Nutrition Guidelines for Healthy Ageing

In view of the growing number and proportion of older members in populations of both developed and developing countries and the increase in diet- and lifestyles-related chronic noncommuni-cable debilitating diseases affecting the ageing population, WHO and the USDA Human Nutrition Research Center on Aging at Tufts University, Boston, USA, organised a joint Consultation on Nutrition Guidelines for Healthy Ageing from 26 to 29 May 1998. The specific objectives of the Consultation were:

· to review scientific and epidemiological evidence regarding the role of diet and other lifestyle factors, including physical activity, in health protection and promotion and noncommunicable diseases prevention in ageing populations; and

· to develop a report of a practical nature that will constitute an authoritative source of information for member country governments, nutritionists, medical practitioners, nurses, elderly care-providers, social workers and others.

The agenda of the Consultation included a wide spectrum of subjects related to nutrition and the functional and health status of ageing populations. These included assessment of nutritional status, nutrition and chronic diseases, water metabolism and dehydration, alterations in sensory systems, nutrition and immune function, nutrition behaviour and cognitive function, nutritional requirements and dietary guidelines. The Consultation also reviewed the demographic, epidemiological and social aspects of ageing with particular emphasis on a developing countries perspective and discussed the community support for improvement of nutrition, physical activity and behaviour (life-styles) of ageing populations.

The report of the consultation will be published by the end of 1998. For further information, please contact R. Buzina, WHO Programme of Nutrition. Tel: 41 22 791 3316 Fax: 41 22 791 4156 Email: buzinar@who.ch

Joint Consultations between WHO and FAO

The FAO/WHO consultation process seeks to periodically bring together world experts on specific questions where areas of responsibility overlap. The consultations are expected to draw conclusions and make recommendations that provide the best and most scientifically sound advice and information possible for Member States.

Joint FAO/WHO Expert Consultation on Carbohydrates in Human Nutrition: The purpose of this Consultation was to review the full scope of carbohydrates in foods, including their role in human diet, the effects of processing on their digestibility, their use in manufactured foods, and their role in disease conditions (see SCN News No. 14 p34). The report of the Joint FAO/WHO Consultation on Carbohydrates in Human Nutrition has just been published in the FAO Food and Nutrition Series (No. 66,1998) and is available from FAO (Sales and Marketing Group, Food and Agriculture Organization, Viale delle Terme de Caracalla, 00100 Rome, Italy. Tel: 39 6 5705 5727 Fax: 39 6 5705 3152 Email: Publications-sales@fao.org).

Joint FAO/WHO Consultation on Vitamin and Mineral Requirements in Human Nutrition: This Consultation will take place from 21-30 September 1998 in Bangkok, Thailand (see SCN News No.15p48)

WHO Global Database on Obesity and Body Mass Index (BMI) in Adults

This database was established in 1996 by the Programme of Nutrition, and is being steadily built up. The aim is to provide an up-to-date instrument - the only one of its kind - for establishing the magnitude and distribution of obesity and underweight in adult populations worldwide. Data show that many countries have problems of obesity and undenutrition, occurring side-by-side.

Currently, this database incorporates survey data from 91 countries. Population rates of BMI, or mean BMIs are classified according to the standard BMI cut-off points - i.e. 18.5, 17.0, and 16.0 for Grades 1, 2 and 3 undenutrition (thinness) in adults, and 25.0, 30.0, and 40.0 for overweight, obesity and severe obesity in adults. Some 61 countries (covering 70.4% of the adult population worldwide) have national mean BMI data, whilst 30 other countries have complete data sets including mean BMI and prevalences below and above the standard BMI cut-off points.

WHO welcomes new contributions to this database. For further information about how to contribute to the database, please contact Yun Ling at the WHO Programme of Nutrition. Tel: 41 22 791 3322 Fax: 41 22 791 4156 Email: lingy@who.ch

WHO Consultation on Behavioural Aspects of Preventing Obesity and its Associated Problems

A WHO Consultation to address behavioural aspects of obesity prevention and its associated problems is planned for 1-3 October 1998 in Tokyo, as part of WHO'S efforts to develop global, regional and national strategies for preventing and managing the increasing global public health problem of obesity (see also page 71).

The Consultation aims to:

· review and analyse emerging trends of nutrition transition and behavioural factors contributing to the development of overweight and obesity;

· review various country experiences in promoting healthy diets and lifestyles with respect to obesity;

· develop guidelines for effective behaviour-related strategies to prevent and manage obesity as a public health problem;

· identify methodologies for implementing and monitoring behavioural strategies for controlling and reducing obesity.


Multisectoral strategies aimed at reducing obesity and its environmental determinants, and to improve knowledge about obesity, its prevention and management, will be developed. Methodologies will be identified for designing effective community-based nutrition programmes to promote the choice of appropriate diets and healthy lifestyles by individuals and families.

For further information please contact Chizuru Nishida, WHO Programme of Nutrition. Tel: 41 22791 3317 Fax: 41 22791 4156 Email: nishidac@who.ch

IDD, Vitamin A Deficiency and Anaemia

In the last fifteen years, WHO, UNICEF and ICCIDD have worked with governments to combat IDD by ensuring adequate iodine intake through consumption of iodised salt. As a result, the elimination of IDD as a public health problem by year 2000 is no longer an Utopian view for a large number of countries. A report on the progress achieved by countries to control IDD will be submitted to the next World Health Assembly in 1999. However, programme sustainability is still a critical concern (see also SCN working group discussions, page 24). In addressing this issue, WHO is currently assessing the quality of IDD monitoring, and the WHO/UNICEF/ICCIDD document on 'Indicators for assessing Iodine Deficiency Disorders and their Control through Salt lodization' (WHO/NUT/94.6, WHO Geneva, 1994) is being revised.

WHO, UNICEF and other organisations launched a 4-year project starting initially in Africa in 1998, to provide vitamin A supplements to pre-school children during immunisation contacts and to women at delivery.

In order to assist public health staff to design and implement programmes for control of iron deficiency and its consequences - especially anaemia - WHO, with UNICEF and UNU is about to publish 'Iron deficiency: Assessment prevention and contror (WHO/NUT/98.6 WHO Geneva).

To assess the magnitude of micronutrient malnutrition, monitor the impact of programmes on populations, and assess the soundness of proposed strategies, WHO maintains the Micronutrient Deficiency Information System (MDIS) which includes three databases on iodine, vitamin A and iron. The iodine and vitamin A deficiency databases have already been published, and are currently being revised. The database on iron deficiency is still being developed.

WHO welcomes new contributions to all MDIS databases. For further information about how to contribute, please contact Bruno de Benoist, Programme of Nutrition, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 3412 Fax: 41 22 791 4156 Email: debenoistb@who.ch

Nutrition in Emergencies

The Programme of Nutrition is very frequently called upon by other UN organisations, humanitarian/relief NGOs, and member states to provide technical advice on management of nutritional emergencies, famine, or other disaster situations. The Programme of Nutrition provides technical inputs for strengthening capacities at national, subnational, and also international levels for the management of nutrition in emergencies. This is done through the production of guidelines, norms, criteria, methodologies and information on the monitoring/surveillance and management of nutrition in emergency settings, and through information dissemination and training.

Guiding principles for feeding infants and young children during emergencies. 1997 (see SCN News No. 15 p37).

A three-part practical manual pack: This pack, due be published by the end of this year, is for field staff working at the operational level in emergencies and for programme managers. It includes methods to calculate group nutrition requirements, assess and monitor nutrition status, and also includes information on food distribution and selective feeding.

Specific nutritional deficiency outbreaks still occur in refugee populations, and in other severely deprived or famine-affected population groups. The Programme of Nutrition is currently writing guidelines on how to manage and prevent these deficiencies. The following three technical reviews will be published shortly:

· Scurvy and its prevention and control in major emergencies.
· Thiamine deficiency and its prevention and control in major emergencies.
· Pellagra and its prevention and control in major emergencies.

Joint WHO/UNHCR Initiative to Develop Guiding Principles for Caring for the Nutritionally Vulnerable during Emergencies

In an effort to implement the World Declaration and Plan of Action for Nutrition of the ICN, the WHO Programme of Nutrition has been examining aspects of care-related nutritional vulnerability and household food and nutrition insecurity to develop strategies for caring for the nutritionally vulnerable during emergencies.

In order to develop consolidated strategies for caring for the nutritionally vulnerable during emergencies, a joint WHO/UNHCR Technical Consultation on Caring for the Nutritionally Vulnerable during Emergencies was held in Rome, 24-27 February 1998, hosted by the National Institute of Nutrition.

Two background documents were prepared for the Consultation:

· Caring for the Nutritionally Vulnerable during Emergencies: a Review and Implications for Policy.
· Caring for the Nutritionally Vulnerable during Emergencies (an annotated bibliography).

Specific aims of the Consultation were to:

· examine care-related and behavioural aspects of nutritional vulnerability and household food insecurity during emergencies, and to possibly develop approaches for assessing and monitoring these aspects of nutritional vulnerability;

· develop strategies and guiding principles for promoting household food and nutrition security and caring for the nutritionally vulnerable during emergencies, to be used as the basis for developing policies and programmes as well as training modules to assist health personnel and others working in emergencies;

· identify research needed in the area of care, household food and nutrition security and emergencies.


The Consultation provided a forum for exchanging information and experiences of experts, country representatives, NGOs, bilateral and international agencies. It compiled information on nutritional vulnerability, determining factors and possible approaches for assessing care-related nutritional vulnerability during emergencies. The Consultation also developed generic guiding principles for each vulnerable group, to be applied and incorporated into policies and programmes, and to serve as a basis for training modules to assist health personnel and others working in emergencies.

The generic guiding principles are being finalised by WHO in collaboration with UNHCR, UNICEF and various NGOs. The final document will also include simple tools for applying and implementing the guiding principles. A draft document will be ready to be circulated for expert peer review in late 1998.

For further information, and to request copies of the documents listed above, please contact Chizuru Nishida, WHO Programme of Nutrition. Tel: 41 22 791 3317 Fax: 41 22 791 4156 Email: nishidac@who.ch

For further information about any of activities of the Programme of Nutrition and requests for documents, please contact the WHO Programme on Nutrition, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 3326/3321 Fax: 41 22 791 4156 Email: clugstong@who.ch

Food Safety: GEMS/Food

The Global Environment Monitoring System/Food Contamination Monitoring and Assessment Programme (GEMS/Food), which now includes participating institutions from over 70 countries worldwide, collects and evaluates information on levels and trends of contaminants in food, their contribution to total human exposure and significance with regard to public health and trade. GEMS/Food continues to provide information from its database, held at the WHO Food Safety Unit, Geneva, to various users, including the Codex Alimentarius Commission and its subsidiary bodies. The Programme is described in a new brochure (WHO/FSF/FOS/97.9) available from the WHO Food Safety Unit (contact details on next page).

During 1997, GEMS/Food conducted two Analytical Quality Assurance (AQA) studies. The first - on pesticide mixtures - was coordinated by the WHO Collaborating Centre for Pesticide Analysis and Training located at the GTZ Pesticide Service Project in Eschbom, Germany. A report of this study is now available from the WHO Food Safety Unit (contact details on next page). The second - on heavy metal analysis - was conducted in cooperation with the WHO Collaborating Centre for Food Contamination Monitoring at the BgVV (Bundesmstitut fur gesundheitlichen Verbraucherschutz und Veterinarmedizin), Berlin, Germany and the report should be available from the Food Safety Unit shortly.

GEMS/Food has also recently issued a revised version of 'Guidelines for Predicting Dietary Intake of Pesticide Residues' (WHO/FSF/FOS/97.7), which offers simple, practical methods for assessing possible exposure to pesticides based on the best use of available information. In addition, GEMS/Food has pub lished its estimates of per capita consumption of raw agricultural commodities and certain semi-processed commodities for five regional diets (WHO/FSF/FOS/98.3). Finally, a full report is now available on the joint FAO/WHO Consultation on Food Consumption and Exposure Assessment of Chemicals in Food, including food additives, contaminants, residues of pesticides and veterinary drugs and certain nutrients which was held 10-14 February 1997 in Geneva (WHO/FSF/FOS/97.5 - see SCN News No.15 p55).

Disinfection of Fruits and Vegetables

WHO, jointly with FAO and in collaboration with the National Sanitation Foundation International, USA, has prepared a document on current practices with regard to disinfection of fruits and vegetables. The document provides a review of the hazards associated with fruits and vegetables, and the efficacy of different disinfection methods on the hazards. The report will be available from the WHO Food Safety Unit (contact details on next page) in September 1998.

Food Safety for Nutritionists

A WHO/Industry Council for Development (ICD) Course on Food Safety for Nutritionists is organised annually in Indonesia as part of the MSc Programme carried out by the South Asian Ministers of Education Organization (SEAMEO) in collaboration with the German Technical Cooperation Agency (GTZ). The objectives of the training course are to promote understanding of food safety and to enable participants to effectively reduce or prevent foodborne diseases. The training course is open to all candidates desiring to be trained in food safety. A training package entitled 'Food Safety for Nutritionists' is made available to the participants of the course, which consists of nine modules, lecture notes, set of overheads and student handouts. The course lasts for two to three weeks (see page 48 for more details).

Databank on Foodborne Disease Outbreaks

The Food Safety Unit, WHO is maintaining a global databank on food borne disease outbreaks published in the literature. The databank collects epidemiological data, including data on causative agents, number of people affected, signs and symptoms, food vehicle involved, place where the implicated vehicle was prepared and consumed, and factors contributing to the outbreak.

The databank has been developed to meet the increased demand for epidemiological information on foodborne disease. The objective is to compile epidemiological information necessary for a variety of purposes, for example, the application of Hazard Analysis and Critical Control Point (HACCP), risk assessment, health education in food safety, and understanding the role of food in the transmission of diseases.

For further information and to obtain copies of any of the documents mentioned above, please contact the Food Safety Unit, Programme of Food Safety and Food Aid, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 2555 Fax: 41 22 791 4807 Email: foodsafety@who.ch WHO Food Safety documents are also increasingly available on the web at http://www.who.ch/fsf/

Health for All in the 21st Century -the Nutrition Elements


Figure

Since 1978, when the policy on Health for All (HFA) was adopted at the Alma-Ata Conference, political, economic, environmental and social changes have occurred on an unprecedented scale. The need for a renewed vision and model of health to suit these new trends and their huge implications for health has resulted in an intensive worldwide consultation process led by WHO, aimed at formulating a new global health policy. A briefing document is available, together with the policy which has been endorsed by the World Health Assembly during its Session in May 1998.

In building on the strengths of the original policy, Health for All in the 21st Century sets out, for the first two decades of the 21st century, global priorities and targets which will create the conditions whereby people everywhere will have the opportunity to reach and maintain the highest attainable level of health throughout their lives. It gives added emphasis to 'health as a human right'; to gender sensitivity; and the paramount importance of addressing poverty and inequality as both root causes and results of ill health.

Ten new global targets have been set out to spur action and to define priorities for resource allocation (see Box). Achieving these targets will ensure that the overall goals of HFA are met.

How do nutrition concerns fit into the new HFA vision?

Nutrition is central to the first health target, where stunting rates will be used to assess equity within and between countries as a basis for promoting and monitoring equity in health. Stunting (defined as height-for-age more than two standard deviations below the reference value) has been recommended by WHO1 as an ideal indicator for determining priorities for allocation of resources to improve equity in health care. It measures the cumulative deficient growth associated with long term factors such as chronic insufficient daily food intake, frequent infection, poor feeding practices and possibly the low socioeconomic status of households. The initial quantitative target utilised for equity is that by the year 2020, the percentage of children under 5y who are stunted should be less than 20% in all countries and in all specific subgroups within countries.

1WHO Technical Report Series, No. 845, 1995

Box Global Health Targets to 2020

1 Increase equity in health and use the health equity index of childhood stunting.

2 Improve survival and quality of life, indicated primarily by reductions in maternal and child mortality rates and increased life expectancy.

3 Reverse global trends for tuberculosis, HIV/AIDS, malaria, tobacco-related diseases and violence/trauma.

4 Eradicate and eliminate certain diseases (measles, lymphatic filariasis, Chagas disease, leprosy, trachoma and vitamin A and iodine deficiencies).

5 Improve access in all countries to safe drinking water, sanitation, food and shelter.

6 Promote healthy life styles and discourage health damaging ones in all countries.

7 Develop, implement and monitor national policies consistent with HFA.

8 Improve access everywhere to comprehensive high quality essential health care.

9 Establish and strengthen operational global and national health information and surveillance systems.

10 Develop and enhance health research programmes at global, regional and country levels.

Nutrition is also specifically addressed elsewhere in the new HFA vision. In the second health target, a child mortality rate of less than 45 per 1000 live births has been set for the year 2020. In setting this target, the health community has undertaken to give priority to providing resources to the IMCI (integrated management of childhood illnesses), which aims to reduce the impact of the five major causes of death in children - one of which is malnutrition (see SCN News No.15, p56). More directly, the fourth health target specifies that by the year 2020, vitamin A and iodine deficiencies have been eliminated. By the same year, target 5 states that through intersectoral action, major progress will have been made in making safe food available to all.

Fulfilling the HFA vision

To achieve these targets, the document emphasises that committed action is needed. At the national level, governments will be responsible for creating an enabling environment for action in support of HFA. And it is the role of WHO, as the world's health advocate, to stimulate global action, provide global leadership for HFA and build strategic alliances with other UN agencies, the World Bank, NGOs, the private sector and other relevant partners in pursuit of HFA goals at all levels.

For general information about Health in the 21B1 Century, please contact Dr Roberta Ritson, WHO, Division of Policy Programme and Evaluation, Policy Action Coordination Team, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 2557 Email: Ritsonr@who.ch, or Mr Chris Powell, WHO, Division of Health Promotion, Education and Communication, Health Communications and Public Relations, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 2888 Email: powellc@who.ch. For specific information on nutritional aspects please contact the Programme of Nutrition, WHO (Tel: 41 22 791 3326 Fax: 41 22 791 4156 Email: clugstong@who.ch). Based on the WHO document A51/5 and briefing summary 'Health for all in the twenty-first century¹. Further information about Health for All in the 21st Century can be found on the WHO website at http://www.who.ch/hfa/index.htm

WHO/UNAIDS/UNICEF

Technical Consultation on HIV and Infant Feeding
Geneva, April 20-22 1998

Three million children worldwide have been infected with HIV. Most have been infected through transmission of the virus from their HIV-positive mother. About two thirds of mother-to-child transmission occurs during pregnancy and delivery, and about one-third through breastfeeding. The number of children infected with HIV is rising, reflecting the increase in numbers of women of childbearing age who are infected. In 1997 alone, more than half a million children were infected worldwide, and in a growing number of countries, HIV is now the single most important cause of child death.

Following the adoption of the Joint Policy Statement on HIV and Infant Feeding in 1997, WHO, UNAIDS Secretariat and UNICEF developed a set of three comprehensive guidelines to assist decision-makers and health care managers to implement the policy:

· HIV and Infant Feeding: Guidelines for Decision-makers.
WHO/FRH/NUT/CHD 98.1, UNAIDS/98.3, UNICEF/PD/
NUT (J) 98-1.

· HIV and Infant Feeding: A Guide for health care managers and supervisors,
WHO/FRH/NUT/CHD/98.2, UNAIDS/98.4,
UNICEF/PD/NUT (J) 98-2.

· HIV and Infant Feeding: A review of HIV transmission through breastfeeding,
WHO/FRH/NUT/CHD/98.3, UN- AIDS/98.5, UNICEF/PD/NUT (J) 98-3.

The documents recognise that HIV can be transmitted through breastfeeding. The documents also cover all alternative feeding options which are: commercial formula, home-prepared formula, heat treated mother's milk, milk from an established milk bank, wetnursing by a relative and earlier cessation of breastfeeding. The documents express the need to support the use of safe alternatives to breastfeeding when an HIV-positive mother makes a fully informed choice not to breastfeed and selects one of the above options. They also strongly emphasise that breast-milk remains the optimal source of nutrition for the majority of infants, including all infants of mothers not tested for HIV.

Implementation of the guidelines was discussed during a meeting convened by WHO in Geneva (April 20-22, 1998) that brought together representatives of governments from countries most affected by HIV/AIDS, scientists, and United Nations agen cies. The meeting was also attended by representatives of breastfeeding specialised NGOs and the infant formula industry.

Recommendations and outcome of the meeting

In addition to the key recommendation of increasing access to replacement feeding for HIV-positive women, the need to improve access to voluntary and confidential HIV counselling and testing, particularly for pregnant women, and counselling on infant feeding, was emphasised.

Participants also endorsed the need to implement measures to prevent breastfeeding from being undermined among HIV-negative women and among those who do not know their HIV status. There was consensus that methods for procuring, distributing and making available breastmilk substitutes should comply with the International Code of Marketing of Breast-milk Substitutes (see page 67) and subsequent resolutions of the World Health Assembly.

Strengthening health care services was also a priority, particularly reproductive health services in developing countries, to implement interventions that would reduce HIV infection in women and reduce mother-to-child transmission of HIV and ensure care and social support for HIV-positive mothers.

A full report of the meeting 'Technical Consultation on HIV and Infant Feeding: Implementation of Guidelines WHO/CHD/98.15, WHO/FRH/NUT/98.4, UNAIDS/)(.6, UNICEF/PD/NUT(J)98-4' is in preparation, and will be available on request from the Division of Child Health and Development or the Nutrition Programme at WHO, Geneva, or from the UNAIDS Documentation Centre, Geneva, or the Nutrition Section, UNICEF New York, TA -24A, 3 UN Plaza, New York, NY 10017. USA. The three documents listed above are available upon request from Randa Saadeh, WHO Programme of Nutrition. Tel: 41 22 791 3315 Fax: 41 22 791 4156 Email: saadehr@who.ch (CHF16, CHF11.20 in developing countries).

Sources: Felicity Savage (WHO/CHD), Ludmila Lhotska (UNICEF) and Randa Saadeh (WHO/NUT).

The World Bank

Nutrition Lending Update

The graph shows the latest figures for regional nutrition lending by the World Bank. South Asia and Latin America regions have the highest estimated lending for nutrition, although the Africa region has the highest number of projects that allocate funds to nutrition.


Yearly average of nutrition lending by region in millions of US$

The graph shows an overview of the average lending figures per year over the fiscal periods 1991-95 and 1996-2000. All numbers are based on projections; i.e. not actual disbursement.

Recently Approved Projects

Madagascar

The World Bank recently approved a US$27.6 million equivalent credit for a project to improve the nutrition for children and pregnant and breastfeeding women in Madagascar. The project will focus on reducing the number of underweight children, combatting vitamin A and iron deficiency, and reducing helminth infections. An educational component will increase awareness of malnutrition and its causes. This Community Nutrition II project, which will be national in scope, builds on the successful World Bank-supported community nutrition project Projet de Securitlimentaire et de Nutrition currently operating in two provinces.

The project will have several components. A Community Nutrition Programme will support community-based growth monitoring and growth promotion campaigns involving the weighing of children less than 3 years old. Food supplementation will be available for malnourished children as well as pregnant women, and vitamin A supplements will be given to young children and breastfeeding mothers. A School-Based Nutrition Programme will promote good nutrition and hygiene, provide iron and de-worming tablets, and treat children aged 3-14 years for worms both in and out of school. The project will also assist in financing nutrition-related activities in the health and agriculture sectors.

The Gambia

The World Bank recently approved a US$18 million equivalent credit for a project to improve family health in The Gambia. This is the first new World Bank supported project in The Gambia since 1994. The Participatory Health, Population and Nutrition Project will have far-reaching beneficial impacts on the health of The Gambia's most vulnerable populations - particularly infants, children, and women of reproductive age - by improving health services and promoting the active participation of individuals and communities in ensuring their own health.

Prepared through an extensive consultation process involving NGOs, community members, other donors, and the government, the project takes an integrated approach to improving family health. World Bank financing will support preventive health care activities, as well as support policy and programme development. A grassroots education programme will encourage community awareness, community involvement in health services, promote safe sex behavior, and strengthen basic health and nutrition. Training for health care workers, the expansion of family planning services and HIV/AIDS prevention programmes, and upgrading and maintenance of existing health infrastructure are also included.

The Philippines

The World Bank has approved a US$19 million loan to the Philippines for an Early Childhood Development (ECD) Project that will provide services to reduce childhood mortality and promote the physical and mental development of Filipino children, particularly those who are most vulnerable and disadvan-taged. The project also aims to establish an effective partnership between national and local governments in the provision of ECD services. It is designed to assist in compensating for past government under-spending in human resource development and poverty alleviation.

The project is part of a 10-year ECD Programme which seeks to expand and upgrade existing ECD programmes in the Philippines. One component of the project will involve supplying crucial inputs to maintain and upgrade five region-wide ECD programmes covering immunisation, improved management of sick children, prevention and control of micronutrient deficiencies (iron, iodine, vitamin A) through food fortification, education of parents on how to stimulate and promote young child development and improved curricula and health services for children in Grade 1.

For more information, please contact Claudia Rokx (crokx@woridbank.org), or Claire Hervey (Tel: 1 202 473 8294 Fax: 1 202 473 7917 Email: chervey@woridbank.org) at the World Bank, 1818H Street NW, Washington DC 20433. To obtain project documents please contact the World Bank's Public Information Center (PIC), 1776 G Street, NW, Room GC1-300, Washington DC 20433. Tel: 202 458 5454 Fax: 202 522 1500 Email: pic@worldbank.org Further information about the World Bank's recently approved projects can be found on the Web at http://www.worldbank.org/

Sources: C. Rokx, C. Hervey and World Bank 1998 press releases.