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close this bookEnding Malnutrition by 2020: An Agenda for Change in the Millennium - Final report to the ACC/SCN by the commission on the nutrition challenges of the 21st century (ACC/SCN, 2000, 104 p.)
View the document(introduction...)
View the documentExecutive Summary: Main Messages of the Commission Report
Open this folder and view contents1. Recent Progress
Open this folder and view contents2. Global Nutrition Challenges: A Life-Cycle Approach
Open this folder and view contents3. Societal Issues Underlying Malnutrition: Implications for Progress
Open this folder and view contents4. Food, Agriculture and Environment: Future Challenges
Open this folder and view contents5. Food, Nutrition and Human Rights
Open this folder and view contents6. Vision and Goals for the Future
Open this folder and view contents7. Establishing a New Agenda for Change
View the documentAnnex 1: The Establishment and Membership of the Commission
View the documentAnnex 2: Existing Nutrition Goals which Should be Maintained, Developed or Refined
View the documentAnnex 3: Ending Undernutrition in India by 2020
View the documentAnnex 4: Issues to be Considered by Regional and National Meetings
View the documentReferences

Annex 4: Issues to be Considered by Regional and National Meetings

In this annex we deal, in turn, with a number of issues which will need to be considered by regional meetings and members of the SCN:

Strengthening the base for action at the national level
Capacity building
Reinforcing the 20/20 Initiative
Priorities for action
Multi-sectoral approach
Targeted vs. population approaches
Emphasis on prevention: start early for optimum short- and long-term benefits
Pre-conceptual nutrition and ante-natal care
Breastfeeding and complementary foods
National political commitment to improve maternal and child survival
Social policies for improving nutrition
Safe water and sanitation
Moving to a regional approach for action

Strengthening the base for action at the national level

Strengthening the base for action within a country requires a sequence of events, all of which are needed if effective progress is to be made. These are:

Ensuring adequate national capacity for handling the complex issues associated with improving the education, health and welfare of the population.

Establishing an appropriate policy and institutional framework to develop strategies and drive forward integrated action.

Determining the priorities for action based on analyses of the specific needs of the country and its regions. This should include integrating the lessons of indigenous knowledge about food.

Integrating strategies to allow a coherent plan to be developed and implemented - using community involvement together with government, academia and the private sector.

Developing realistic targets for organisational, infrastructure, policy, dietary and other changes needed to achieve defined health goals.

Engaging governments through political processes which ensure continuing commitment to the selective support of the disadvantaged in society.

Ensuring monitoring systems which allow an assessment of the effectiveness of new measures.

Capacity building

One of the key areas for action in the future should be building sufficient nutrition expertise and operational capacity within countries to implement the necessary programmes. This kind of capacity building is fundamental to sustainable nutrition policies.

There is also a need for a coherent global approach to capacity building. Developing expertise and operational capacity within countries must be a key priority for the future. UN agencies, particularly the United Nations University (UNU), and the International Union of Nutritional Sciences (IUNS) should play a key role in promoting local capacity building, with the help of bilateral funding and other UN agencies.

IUNS has already held one workshop on promoting local capacity building in Manila in 1996. Together IUNS and UNU also held a follow-up regional workshop in June 1999 in Cape Town, South Africa; they anticipate further regional workshops for Latin America (collaborating with Pan American Health Organization), Asia and Eastern Europe. All these workshops are planned collaboratively with regional planning groups, the primary outcome being a 10-year action plan. The Commission strongly supports this initiative and urges that sufficient funds are made available.

The Commission therefore recommends that IUNS take the initiative in promoting, with national academic societies, the need for academic initiatives and the establishment of National Nutrition Councils. The IUNS is currently being reorganised, so the Commission proposes that IUNS be asked to undertake a special role as part of its promotion of international expertise in nutritional sciences. The standing of the nutritional science community will be enhanced if it is seen to apply its knowledge in a coherent way and for the benefit of society. This can be done by promoting and becoming involved in a National Nutrition Council, with the authority and accountability to parliament which denotes the newly recognised importance of nutrition to all societies. To do this IUNS will need to call on experience in established Councils and seek new ways of ensuring the practical application of new knowledge.

Capacity building strategies need to include training, human resource development, strengthening of the infrastructure for nutrition policies within states, and implementation of comprehensive national strategies. UN agencies should play a major role in facilitating this process.

It is important that:

Capacity building includes novel ways for linking centres of excellence as part of a network that includes the principal resources of expertise in North America and Europe. This is a need to which the IUNS should contribute.

The UNU is embarking on such a programme. Novel ways are needed to link expertise in many different scientific, medical, agricultural, social and economic areas.

New approaches should be developed to interlink funding initiatives involving governments e.g. the US and EU, with major foundations such as the Wellcome Trust, the Rockefeller and Ford Foundations.

More emphasis is put on capacity building at the organisational level. This is important in reducing the turnover rate of well-trained individuals from local nutrition organisations.

Reinforcing the 20/20 Initiative

The Commission commends the 20/20 Initiative. This Initiative should be fully implemented, and donor countries should also honour their commitment to providing development aid to the value of 0.7% of their GNP.

Specifically in relation to nutrition and health and maintenance of the investment in health education and social policies:

a) The IMF and the World Bank should be asked to build into their guidelines for adjustment programmes a specific and explicit provision for protecting the nutritional safety of children and for the other vulnerable groups in society, e.g. pregnant and breast-feeding mothers.

b) National governments should be asked not to cut their budgetary allocations for poverty alleviation and nutrition programmes.

c) Monitoring of adjustment should include public reporting on nutritional trends as well as the health and educational opportunities of the population. The emerging consensus on these needs should be reinforced by the G8 financial leaders.

Priorities for action

National and regional priorities for action need to be set in relation to the magnitude of the problems and taking account of their associated risk factors. Such an approach is set out in Table A1 (at the end of this Annex). This scheme has been applied to a range of major deficiency diseases, with four levels of population risk being selected. This approach is based on that developed recently by the US Institute of Medicine (1998). Different national plans of action are set out appropriate to each level of population risk. It is vital to integrate policies so that measures for dealing with iodine, vitamin A and iron deficiencies are linked, to maximise benefit and limit costs.

There is a need to assess other diseases and risk factors now prevalent or emerging as major issues, might be included in single co-ordinated approaches. Existing actions plans often involve very high level decision-makers and are geared primarily to one set of deficiency problems. The challenge is to extend and integrate these programmes so that all UN agencies can be involved and include the range of societal challenges now set out, for example, in Tables A1 and A2.

Table A1 sets out a possible set of criteria which national governments, perhaps in conjunction with UN-led regional meetings, should consider using when defining congruent strategies at a national level. Table A2 then illustrates potential linkages between the needs for combating prevalent micronutrient deficiencies and strategies for dealing with the other dietary diseases. By progressing through these analyses, a series of specific measures and targets may be formulated leading to a government or international plan for an integrated programme of action. The values and approaches are, for the present, simply inserted to help focus discussion and to illustrate the potential synergy which could come from these new national strategies.

Multi-sectoral approach

The agenda for action needs to incorporate the many components of societal change. It is increasingly recognised that achieving improvements in health requires action in a wide range of government policy areas. This approach is embedded in WHO's Health for All for the 21st Century global health policy and increasingly in national policies. Those seeking improvements in nutrition need also to recognise potential synergies with other policy goals - within or outside the health sector. Many of the agricultural and food security issues raised in Chapter 4, for example, also relate to protection of the environment.

Similarly, action is required at various different levels. International agencies and central government clearly have important roles. The input of local government and, most importantly, local communities is also vital.

Thus, for example, in India where adult underweight is prevalent a range of strategies will be needed. Relevant policies include agricultural development, land reform, rural development and social policies, empowering women, educational policies and the provision of ante-natal health care. Strategies for limiting the very high anaemia rates also require a major new effort on sanitation. Agricultural strategies will also need to include potentially major adjustments to enhance meat and milk production without increasing cereal use. Nutritional health policies also need to recognise the danger of any measures which promote and increase dietary fat production and consumption as a means of combating inadequate food intake. The agricultural priority should be to promote the production and use of nutrient-dense foods.

The need for regional and national approaches to these problems becomes evident when comparing the potential measures needed to combat deficiencies or disorders which may dominate in one society but not in another. Table A2 sets out the approaches needed for highly prevalent conditions. Thus, in countries where women have a low body weight there needs to be a strategic focus on the welfare of women during pregnancy. This priority does not obviate the need to deal with all women's undernutrition, but the impact of pregnancy in undernourished mothers has an inter-generational effect which is clearly a priority. Similarly, high rates of stomach cancer in Japan can best be reduced by a national move to limit the consumption of salted and fermented fish.

Until now, policy-makers and the public have considered the correction of deficiency diseases as fundamentally different from those measures needed for combating the epidemic diseases of adults such as obesity, adult-onset diabetes, heart disease, stroke and cancers. Deficiency diseases are societal concerns whereas the chronic diseases of adults are often seen to be an individual's responsibility to avoid dietary excesses. This disjunction in approach fails to recognise the scientific evidence on the nutritional basis of adult chronic diseases. The average blood cholesterol level of adults in a European or Scandinavian country, for example, was and often still is nearly double that found in Japan. Thus the vast majority of the population may need to change their diet; individualised approaches fail to recognise the societal issue. The individual approach neglects 15-year-old concepts which recognise the far-reaching impact of modest changes in individual health on the national burden of disease if a substantial proportion of the population is affected. The individual approach also assumes a preventive strategy based on personalised health education which US experience has shown to lead to a greater disparity in the health of different groups than in any other Western society where more coherent public health strategies are used.

The evidence on combating the deficiencies and disorders listed in Tables A1 and A2 is increasing rapidly. It is clear that substantial improvements can be made if national governments recognise the immense economic and societal benefits that can come from taking population-based approaches to these problems.

The agenda for action, therefore, should be based on the following principles:

a multi-sectoral approach to improving nutrition and public health

application of this integrated approach at all levels - international agencies, central governments, local government and within local communities

strategies adapted to regional, national and local needs

coherent public health strategies to combat NCDs; these should not focus solely on individual responsibility or rely on health education alone.

Targeted vs. population approaches

Targeted approaches can play an important role in improving national health in three ways. First, there is targeting of special groups where the societal mechanism allows cohesive action to be applied - for example, school meals for children or measures designed for use in ante-natal clinics. Secondly, there is targeting of vulnerable groups, e.g. in parts of a country where the availability of vegetables and fruits is limited by agricultural constraints. Thirdly, there is the selective targeting of individuals with particular nutritional/health problems. This third approach involves some form of health screening system which presupposes a health service with the capacity to do this. This could include, for example, identifying anaemic children and women or identifying families with a propensity for diabetes. However, diseases such as cancer or obesity are better targeted by the population approach. Until low-cost methods of identifying selective at-risk groups are made readily available, such groups cannot easily be targeted with special measures. The Commission concludes that in general, population approaches are those that deserve the highest priority since they tend to deal with major national issues where co-ordinated action by government is likely to bring the greatest benefit.

Emphasis on prevention: start early for optimum short - and long-term benefits

It is clear that the emphasis for nutrition in the 21st century should be on improving early nutrition and ensuring that the next generation have the best nutritional start they can hope for. Strategies are required to improve maternal nutrition for the prevention of low birthweight and to improve the nutrition and care of 0-24-month-old infants, for the prevention of stunting. Effective strategies will bring considerable benefits in the short term and in the long term - both in terms of better health in adult life and for future generations. Multi-pronged strategies are required.

Eliminating childhood undernutrition should now be seen as a social and moral imperative. The costs and benefits of different approaches will vary. The Commission proposes, therefore, that during the next two years a series of analyses be undertaken to evaluate the likely costs and potential benefits of different possible approaches to tackling this problem, given the different national mechanisms for transforming policies on prevention.

Pre-conceptual nutrition and ante-natal care

The focus for the first stage in a policy to improve early nutrition should be the avoidance of low birthweight (LBW) and the promotion of an optimal birthweight distribution. Since low birthweight is such a major contributor to stunting, particularly in South Asia, the prevalence of low birthweight should be used as an intermediate target. A reduction in the prevalence of LBW requires a major programme focused on reproductive health starting from young girls through child-bearing age. Since fetal growth is affected by maternal height, pre-pregnancy weight, and weight gain during pregnancy, a new prevention strategy that considers the full life-cycle is needed.

A recent meta-analysis of published nutritional supplementation trials during pregnancy (de Onis et al., 1998b), conducted using the rigorous randomised clinical trial model, suggest that, in addition to smoking cessation and anti-malarial prophylaxis, the most effective dietary measures for combating LBW involve the provision of a balanced protein/energy supplementation. This supplement should also contain zinc, folate and magnesium. The n-3 fatty acids, obtained from fish oils, could well be helpful. Vitamin A provided in modest amounts as part of the supplement may also be needed, depending on the national prevalence of vitamin A deficiency. Although iron has no selective effect on LBW as such, women's iron status before and during pregnancy is important for their own health; it may also prevent the fetal programming of long-term susceptibility to such problems as high blood pressure, diabetes and heart disease. Maternal anaemia also limits an infant's iron stores at birth particularly with low birthweight. Thus poor iron status amplifies the risk of impaired brain development.

Ideally, nutritional care should begin before pregnancy is established. For example, the benefit of folate is maximal if given for at least two months before conception occurs. Healthier women can also make a greater contribution to the welfare and development of young children - a feature of great long-term significance not only to the family but to society as a whole.

Thus a new and coherent approach to combating maternal ill health, LBW, and long-term susceptibility to adult chronic diseases is emerging and should be developed into national programmes which are tested and evaluated.

Nations need now to:

define whether they have a high or low prevalence of LBW
specify the national target for halving the prevalence of LBW
devise appropriate general or targeted supplementation programmes, and
ensure appropriate evaluation of the different programmes.

These strategies need to be seen as the first phase of action: the longer-term impact of improving the growth and health of girls so that they mature healthily before starting pregnancy will be far-reaching.

Breastfeeding and complementary foods

As well as the prevention of low birthweight, the focus on early nutrition demands appropriate strategies for 0-24-month-old infants to prevent stunting. Breast-feeding and suitable complementary feeding form a key part of such strategies.

Exclusive breastfeeding for about the first six months of life and maintenance of breast-feeding into the second year of life should be the goal of major national programmes. Complementary feeding from around six months of age presents a major problem for many millions of women. Appropriate national strategies now need to be adopted.

Breastfeeding and complementary feeding strategies should include:

regular regional assessments of exclusive breast-feeding rates a more attention to the inappropriate use of water/sugar supplements while supposedly exclusively breast-feeding (a particular problem in South Asia)

providing women with selective support - with suitable foods for complementary feeding. Different approaches should be explored. For example, food vouchers might be proposed as a programme to be tried experimentally in two or three countries with donor support

immunisation; this must be maintained, with target dates set by countries not yet at 80% coverage

increased efforts to protect parents from commercial pressures to feed their infants artificially through global implementation and enforcement of the International Code of Marketing of Breastmilk Substitutes

encouraging the use of appropriate weaning foods, of low bulk and high nutrient density and based on locally available foodstuffs. Simple food technologies, such as germination and fermentation, to improve the quality of these foods should be further developed.

National political commitment to improve maternal and child survival

As the basis for accelerated action, a number of experimental approaches should be tried.

A new basic care proposal for maternal monitoring and intervention to prevent low birthweight could be developed on the basis of national trends in solving the problem. One such scheme might be as follows, based on Gambian experience.

1. All women who are pregnant should be registered by with a health centre by a particular stage of pregnancy, e.g. 20 weeks, with a monitoring of their weight (in relation to height) and of their haemoglobin.

2. All women from 20 weeks of pregnancy should be considered vulnerable and potentially eligible for a special balanced protein, energy and nutrient-rich supplement based on various criteria which need to be considered on a regional or national basis. Thus in some regions, if maternal weight (as BMI) is less than 20 kg/m2, or if maternal anaemia is present, if the country has seasonal food shortages, or is subject to a natural disaster, e.g. drought or crop failure, the selective interventions need to be specified.

3. Smoking cessation should be a goal and anti-malarial prophylaxis should be proposed for mothers in at-risk countries.

4. Pregnant women should be monitored by a health centre to see if they gain sufficient weight with no deterioration in their anaemia. Special measures could then be developed on a national basis for those who have failed to respond, e.g. because of parasitic infections.

5. Pregnant women should be encouraged to come for further health checks later in pregnancy.

6. Breast-feeding needs to be encouraged in all countries. The latest research shows a wide variety of benefits, especially if a mother breast-feeds her baby exclusively for six months, with further benefits if she continues breast-feeding for another six months or more, while providing complementary food and liquids. Mothers need to be enabled and supported to do this, through maternity leave and other supportive provisions and practices in the workplace as well as at home and in the family. Specific goals need to be established in relation to these needs.

Special schemes are needed based on the experience of Thailand in training a national group of health workers from every village and town precinct to involve all pregnant women. The nature and provision of the food supplements should be based on local food sources and should ensure adequate protein, energy and micronutrient intake. Special national schemes may well be needed to see these measures effectively implemented.

Social policies for improving nutrition

The previous sections outlined a range of nutrition, public health and food policies to improve the nutrition situation. In addition, a range of measures aimed at controlling the impact of global economic policies and actions have been recommended. Other areas of social policy, however, have been discussed in earlier sections and these can also have an impact on nutritional improvement (or deterioration). The relevant recommendations can be summarised as follows.

Efforts to improve community and nutritional health must involve the communities themselves, and mobilize them to ensure success. Governments and international agencies must set in place the conditions to help foster community participation, including strengthening of local democracy and finding ways of listening to community views.

New approaches are required to cater for the needs of expanded urban communities. Local and national governments need to make provisions for water security, food transport systems, urban gardening and access to sanitation facilities. At the same time, policies to stem the tide of urbanisation are required. This means measures to encourage people to stay in their rural environment - by providing amenities and income-generation projects, and by investing in roads and transport.

Access to safe water and provision of sanitation must be a cornerstone of any serious public health policies. Accelerated action is required to widen the provision of proper sanitation, ensure access to sufficient water for good hygiene and provide access to safe drinking water. Improving access and uptake of education is fundamental. Rights to education for all should be strengthened and enacted.

Women and girls should be the key focus: measures to eliminate discrimination and empower women are fundamental to social development. Legislative rights for women and support systems are part of the story. Long term societal change to end discrimination and promote equal sharing of burdens and responsibilities is also crucial.

The formation of informal credit and savings groups to reduce seasonal fluctuations in consumption should be supported. These informal groups should link up with the more formal financial systems to further insure against shocks that hit everyone in an area at the same time (Zeller and Sharma, 1998).

Safe water and sanitation

To make a real impact on childhood undernutrition it is essential to reduce the huge burden of gastrointestinal infection and parasitism which affects infants and young children as well as adults. The vicious cycle whereby infections exacerbate undernutrition which then increases susceptibility to infections has devastating implications for maternal and child health. Vomiting and diarrhoea can also cause a lack of appetite, substantial losses of micronutrients and may be a contributory factor to chronic adult energy deficiency.

Over 60% of the population in developing countries do not have access to proper sanitation. Similarly, at least a third do not have access to safe water. Strategies to widen access to safe water have brought their own problems. Water from many of the tubewells which have been dug has been contaminated with fluoride, arsenic or salt.

Access to safe water, improved sanitation and promotion of good hygiene should reduce the burden of intestinal disease. This in turn will improve the iron status of children, limit anaemia and prevent permanent brain damage.

Urgent action is needed to:

accelerate progress in provision of proper sanitation for all
promote good hygiene through community education
ensure that people have access to sufficient water for good hygienic practices
test the quality of water from recent tubewells and close dangerous wells
develop new targets and accelerated action for the provision of accessible safe drinking water.

Moving to a regional approach for action

There are major imbalances between what is needed and what is being done on a regional basis in different parts of the globe. In particular, there is continuing nutritional deterioration in many parts of Africa and the high prevalence of undernutrition in South Asia remains of great concern.

To solve these problems strategies are needed on a regional and then a national basis. These issues will need separate consideration at regional meetings in different parts of the world. It is suggested that these regional meetings should be held over the next two years with the involvement of all the relevant UN agencies. Particular UN agencies might well take the lead in a specific region, but it is important to engage the whole international community in establishing the appropriate framework.

To develop these potentially very different regional actions will need new approaches so that undernutrition and the prevention of other disorders can be achieved at an accelerated rate. There will be a need to mobilise the commitment and support of all the principal stakeholders in the regions -governments, NGOs, the private sector, academics -and include local and international agency involvement.

Countries will need to be encouraged to produce their own targets which can then be seen within a regional framework. This will allow the benefits displayed in one country to be readily considered by another. This in turn requires monitoring and reporting arrangements be developed so that countries can benefit from the experience of others.

These developments should build on the process established by the International Conference of Nutrition and the World Food Summit. The regional meetings have clearly been of value; now there is a need to bring in other agencies such as UNICEF, the World Bank and donor agencies. This complementary approach suggested by the Commission also has a long-term perspective and can build on and benefit from the ICN process.

TABLE A1

An approach to defining the level of population risk
based on sub-clinical signs of micronutrient deficiency and
on indices linked to long-term ill health

Level of population risk

Average Seasonal weight loss Kga

Women's low BMIb

Low birth weightc

Stunted childrend

Iodine deficiency

Vitamin A deficiency

Iron deficiency

Visceral obesitye

Coronary heart disease: average blood cholesterolf

High blood pressureg

Stomach cancerh

Large bowel cancerl


kg

Percentage of the population affected

IV (severe prevalence)

>3

³40

³25

³40

³99i

³20k

³80l

³20

>6.0

>20

>40

>30

III (moderate to severe prevalence)

³2 to <3

³30 to<40

³10 to <25

³20 to <40

³50 to <99

³10 to <20

³50 to <80

³10 to <20

5.0-6.0

>15-20

³20-<40

³20-<30

II (mild and widespread prevalence)

³1 to <2

³20 to <30

³5 to <10

³10 to <20

³20 to <50

³2 to <10

³30 to <50

³5 to <10

4.0-5.0

10-15

³10-<20

³10-<20

I (mild and clustered prevalence)

<0.5

³10 to<20

<5

<10

<20

<2

<12

<5

<4.0

<10

<10

<10

Note: This scheme is based on that proposed by the US Institute of Medicine (1998). The limits used are the Institute's for subclinical micronutrient deficiency. The others are provisionary and for discussion and analysis by UN agencies and Governments.

(a) Based on Ferro-Luzzi et al. analyses (1994). These values are inserted to illustrate but Ferro-Luzzi proposes a more intense index of absolute weight but taking account of the pre-existing BMI.

(b) This is proposed based on FAO's analyses of BMI in women of >18 years (see Shetty and James, 1994 and James and Francois, 1994)

(c) Based on birth weights of <2500 g as listed in UNICEF's The State of the World's Children, 1998

(d) Stunted children aged 1 to <5 years defined as below -2 SD of height-for-age using the WHO reference

(e) Defined as % of population with ³1.0 ratio of waist:hip circumferences in men and £0.8 in women and not on basis of Caucasian waist measurements alone as given in the WHO Obesity Report, 1998

(f) Average total blood cholesterol levels in mmoles/l in adults aged 40-60 years

(g) Blood pressure limit taken as 140 systolic and 90 diastolic

(h) Cancer incidence rates, age standardised per 100,000

(i) Colon cancer incidence data usually includes rectal cancer so the combined value is used

(j) Subclinical iodine = prevalence of median urinary iodine values < 100 micro g/L

(k) Subclinical vitamin A = prevalence of serum retinol levels £0.7 micro mol/L

(l) Subclinical iron = prevalence of iron deficiency indicator below cut off (usually serum ferritin)

TABLE A2

A potential scheme for the preferred initial approaches to
prevention and control of dietary disorders in populations.

This Table illustrates the benefits of different interventions for level IV prevalence problems only

Prevalence level IV

Condition/deficiency

Seasonal weight loss

Women's low BMI

Low birth weight

Stunting

Iodine

Vitamin A

Iron

Coronary heart disease

High blood pressure

Stomach cancer

Large bowel cancer

Intervention

Supplementation

Targeted

+++

+++

++++

++++

++++

++

-

-

-

-

-


Universal

+

++

++

++

-

++++

++++

-

-

-

-

Fortification

Targeted

-

-

++

-

-

+++

+

++

++

-

-


Universal

-

-

-

-

+++

-

-

++d

++e

-

-

Food-based

Nutrition education

++

++

++

++

+

++

+

++++

++++

++++

++++

approaches

Food production

+++

++++

+++

+++

n.a.

+++

++

++++

++++

+

+


Food-to-food †

++

+

+++

++

-

++++

++++

++++

++++

++++

++++

Public health measures

Immunization

-

-

-

++++

-

++++

++++

-

-

-

-


Parasite control

-

++

++

+++

-

++

+++

-

-

-

-


Healthy water/sanitation

-

+++

+++

++++

-

-

+++

-


++++

-


Transport policies

+++

++

++

+

-

-

-

++

++

+

+++


Diarrhoreal

++

++

+

++++

-

+++

+++

-


+++

-


Disease/Acute













Respiratory Infections













Personal

++

+++

+++

++++

-

++++

++++

-


++

-


sanitation/hygiene













Activity facilities

++b

++a

++c

-

-

-

-

++

+++

-

+++

Note: This scheme for level IV, i.e high prevalence rates, is based on the US Institute of Medicine's (1998) analysis of the prevention of micronutrient deficiencies. The scheme has been extended to other dietary problems. Transport and physical activity facilities for leisure activity in the community and at work have also been added. ++++ very strong emphasis, +++ strong emphasis, ++ moderate emphasis, + light emphasis, - no emphasis.

(a) Low BMI may be exacerbated by the demand for work, e.g. carrying water, harvesting; improved facilities and tools may limit underweight by reducing the demand for energy expenditure

(b) Seasonal weight loss may depend on strategies to limit women's exercise demands

(c) Novel selective community action may be needed to protect women, particularly in late pregnancy, from excess work

(d) Folic acid fortification will reduce high levels of blood homocysteine levels and limit the risk of low birth weight as well as neural tube defects: in addition it potentially reduces the risk of cardiovascular disease.

(e) Potassium/sodium substitution should be a strategic approach to food processing in societies with prevalent high blood pressure

† Food-to-food fortification involves the mixing of staple foods e.g. mango with gruel at the household level to enrich nutrient content.