PROGRAMME NEWS

AGENCIES REPORT ON THEIR ACTIVITIES IN NUTRITION

FAO

Risk Analysis for Food Safety, Consumer Protection and International Trade

FAO is collaborating with WHO and the International Life Sciences Institute (ILSI) in the development of a manual on ‘Risk Analysis For Food Safety, Consumer Protection and International Trade’. The manual will build on three joint FAO/WHO expert consultations:

à Application of Risk Communication to Food Standards and Safety Matters, Rome, 1998;
à Risk Management and Food Safety, Rome, 1997;
à Application of Risk Analysis to Food Standards Issues in Geneva

This information is of great importance in the context of understanding the obligations under the World Trade Organization Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement).

The objective of the manual is to bring together the findings of the three consultations with a view to creating a better understanding of the risk analysis process, its components and its application particularly for developing countries. The manual will include a description of the approach to risk assessment by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) and the Joint FAO/WHO Meeting on Pesticide Residues (JMPR), together with the application of risk analysis principles in Codex.

The manual will be available in 1999 from the Food and Nutrition Division, FAO, Viale delle Terme di Caracalla 00100, Rome, Italy; FAX 39 6 57054593, Email: [email protected]

Food Composition Activities

FAO activities in food composition are aimed at generating and updating food composition tables and related information for a wide range of practical applications.

In 1998, a number of major meetings were organised in cooperation with the UNU:

à Fifth OCEANIAFOODS Meeting: (For Australia, New Zealand and the Pacific Islands countries): Noumea, New Caledonia, 25 - 27 May, 1998.

à MEXCARIBEFOODS: (For Mexico, and the French and Spanish-speaking Caribbean countries): Santo Domingo, the Dominican Republic, 23 May - 6 June, 1998.

à Workshop on Food Composition Activities in the Near East. Manama, Bahrain, 14 - 16 June, 1998.

à III FAO/ACTAC Workshop on Food Quality Control and Safety. I FAO/ACTAC/MEXCARIBEFOODS Sub-regional Symposium on Food Composition. Varadero, Cuba 13-16 October, 1998.

à Fourth Asia and the Pacific Food Analysis Conference. Chiang Mai, Thailand, 16-19 November, 1998.

à Second SAARCFOODS Meeting (for Southern Asian countries). Kathmandu, Nepal, 21 - 23 November, 1998.

The final reports of these workshops will be made available by the Food and Nutrition Division, FAO, Viale delle Terme di Caracalla 00100, Rome, Italy; FAX 39 6 57054593, Email: [email protected]

In training activities, FAO organised the First MEXCARIBEFOODS Course on the Production and Use of Food Composition Data in Nutrition held in Santo Domingo, the Dominican Republic, 23 May - 6 June, 1998 for Mexico and the Spanish and French speaking Caribbean countries. FAO participated in the training course of the Agricultural University of Wageningen in October 1998, and in the training course on data management for Central and Eastern European countries held at the Food Research Institute, Bratislava, Slovakia, in November, 1998.

A Regional Meeting on Andean Crops was held in Arequipa, Peru, 20 - 24 July, 1998. The meeting report is being prepared by the FAO Regional Office for Latin America (FAO Regional Office for Latin America and the Caribbean (RLC), Casilla 10095, Santiago, Chile. Email: [email protected]).

The objectives of this meeting were to:

à analyse the research progress made in plant breeding, agronomy and technology transfer for the Andean Crops quinoa (Chenopodium quinoa), amaranth (Amaranthus caudatus), and lupine, tarwi (Lupinus mutabilis);

à examine their use and recommend strategies and actions to promote their consumption, considering both food and nutrition aspects;

à evaluate the present status of database on these crops; and

à formulate national projects on sustainable production and increased use of these crops.

A Latin American Congress on Food Carotenoids was held in Campinas, Brazil, 14 - 17 September, 1998. Proceedings will be published in the official journal of the Latin American Nutrition Society, the Sociedad Latinoamericana De Nutricion (SLAN: Dr HernL. Delgado, Calzada Roosevelt, Zona 11, Apartado Postal 1188, Ciudad de Guatemala, Guatemala, C.A. Tel: 502/2/723762/7 Fax: 502/2/736529 Email: [email protected] (affiliated body).

Nutrition Education and Communication

The need for rational, scientifically-sound dietary guidance for the public has never been greater. The ability of poor households to make the best use of scarce resources to achieve the maximum nutritional benefit possible is crucial to their well-being. In more affluent households, the need for consumers to make wise dietary choices from a wide variety of foodstuffs and within an environment of wide-ranging claims and confusing, misleading information is also important.

Promoting Food-based Dietary Guidelines (FBDG)

To help governments and others concerned with promoting informed consumer choices, FAO, in cooperation with ILSI, recently convened four inter-country meetings. These aimed to promote the development and use of food-based dietary guidelines and nutrition education activities, as recommended by the two Expert Consultations on this topic held in 1995. These meetings were held in Quito, Ecuador (24 November 1998, with nine countries participating from the Latin American region), Amman, Jordan (13-15 November 1998, with seven countries participating from the Near East region), and New Delhi, India (8-10 December 1998, with five countries participating from the Asian region). Specifically, the meetings aimed to:

à review the current scientific basis for establishing dietary guidelines;
à introduce a methodology for formulating FBDG;
à highlight successful approaches to providing nutrition education to the public.

These meetings bring together government authorities, personnel from academic and research institutions, nutrition educators, medical officers, representatives of NGOs, and the private sector and gain advice from internationally recognised experts. They form part of an ongoing collaboration between FAO and ILSI to strengthen national capacity to address diet and nutrition concerns, and follow the successful conclusion of two previous meetings held in Slovakia, and Lithuania, in 1997. Additional meetings will be held in 1999, beginning with one in Barbados for the English-speaking Caribbean countries.

Nutrition Education in Schools and for the Public

FAO is also collaborating with the WHO School Health Promotion Initiative and is contributing to the various regional networks established by WHO under this Initiative by elaborating nutrition education components for primary schoolchildren. Technical materials are being developed as guidance for curriculum development and teacher training. They are expected to become available in mid-1999.

The English version of ‘Social Communication in Nutrition’ has been reprinted, and the French version of the Discussion Papers for the Expert Consultation on ‘Nutrition Education for the Public’, held in 1995, has also been printed. The nutrition education training package, ‘Get the Best from Your Food’, is now available in 13 languages, including Chinese, Hindi and Thai versions, and the publication of six versions in Eastern European languages, in addition to the existing Polish and Slovak versions, is imminent.

Household Food Security

The ability of households to acquire - either through their own production or through purchase or barter - the food they need to meet all members’ nutritional needs is fundamental to securing everyone’s right to food and their nutritional well-being. Some eighty countries in the world - most of which are in Africa - are classified as low-income, food deficit countries. This means that there is simply not enough food or resources available in the country to assure that each household can consume enough to meet its needs. To reinvigorate efforts to accelerate agricultural development and ensure that such development leads to improvements in household food security, FAO organised an inter-country workshop for eleven countries in eastern and southern Africa, held in Kiambu, Kenya, from 6-9 October 1998. Inter-sectoral delegations met to review the causes of household food security and opportunities for making lasting improvements in the conditions that enable households to secure their right to food. Macro-level social and economic policies and conditions, sector specific actions, and integrated community-based initiatives were reviewed. Recommendations were made for making household food security a primary objective of development and strengthening the capacity of governments and civil society and communities to accelerate and sustain improvements in household food security and nutrition. The report of this meeting will be presented to the ACC/SCN Working Group on Household Food Security at its 26^th Session in April, 1999 and to the ACC Network for Rural Development and Food Security. The National Thematic Groups on Food Security and Nutrition of the Network were specifically highlighted as key elements for moving the workshop’s findings forward.

For further information about FAO’s food and nutrition activities, please contact John R. Lupien, Director, Food and Nutrition Division, FAO, Viale delle Terme di Caracalla, 00100 Rome, Italy. Fax: 396 5225 4593 Email: [email protected] or [email protected] Web: http://www.fao.org/waicent/faoinfo/economic/esn/nutri.ht A new “Right to Food” website is also available: http://www.fao.org/Legal/

IFAD

IFAD has recently developed ‘Household Food Security and Gender Memory Checks for Programme and Project Design’. The aim is to assist in mainstreaming household food security concerns into the design and implementation of IFAD projects, with women being considered the main entry-point for addressing food security and nutritional well-being at the household level.

The ‘Memory Checks’ are intended as a tool for operationalising IFAD’s strategy to address household food security, as defined in its Paper for the World Food Summit¹. They are neither guidelines nor checklists. They are intended rather as ‘food for thought’ - a support to design teams in diagnosing and focusing on critical issues relevant to household food security and gender as they relate to each other in the overall project design and to their specific sector.

¹ Household Food Security: Implications for Policy and Action for Rural Poverty and Nutrition, Nov 1996; also published as Staff Working Paper Series on Household Food Security and Gender, Paper No. 1, Feb 1998).

All team members are provided with a summary of 12 household food security and gender issues to be addressed in design. Identification of the issues is based on IFAD (and non-IFAD) project experience in all regions, documented in evaluation reports. Readers are warned, however, that the issues are generic and require adaptation to the specific design context.

To assist sector specialists who may not be familiar with household food security and gender issues as they relate to their particular field, concise information sections are provided for agriculture, livestock, rural enterprise and credit, social services and infrastructures, environment and natural resources. These sections highlight basic issues, indicating their implications in terms of project design and implementation and risks if not appropriately taken into consideration. To assist teams in responding to the issues, short lists of ‘key information to obtain’ are also provided. These can be used either to collect new data or to systematise that which already exists.

Sections relating to specific production sectors look at:

à where productive activities occur, for women and men, within the household economy (who has what, who controls what);

à how the activity is organised in the household (issues related to gender division of labour, labour constraints and decision making)

à the link between productive activities and nutrition (for example, crop diversification for nutritional balance).

The Memory Checks are being tested in the five regions where IFAD operates, before formal adoption throughout IFAD. Results, so far, are promising and indicate their potential not only for the purpose of mainstreaming. They also have been useful as a tool to facilitate dialogue - both within the team and with governments and national implementing institutions - on IFAD’s key concerns relating to household food security and gender and how projects should address them. They have also been used successfully in participatory project planning workshops and could form the basis for planning sensitisation and training on household food security and gender during the life of a project.

Always within the framework of household food security, IFAD has launched in 1998 a new series in its Staff Working Papers entitled Household Food Security and Gender Series. It has also published, in collaboration with FAO and with the assistance of Supplementary Funds from the Government of Japan, a small research on Agricultural Implements Used by Women Farmers in Africa, using case studies in Senegal, Burkina Faso, Zambia, Uganda and Zimbabwe.

For further information, please contact Mona Fikry, Technical Advisor, Gender Issues, Technical Advisory Division, IFAD, Via del Serafico No. 107, 00142 Rome, Italy. Tel: 396 5459 2452 Fax: 396 519 1702 Email: [email protected]

IFPRI

Good Care Practices Can Mitigate the Negative Effects of Poverty and Low Maternal Schooling on Childhood Stunting

A recent study conducted by the International Food Policy Research Institute (IFPRI) in collaboration with the Noguchi Memorial Institute for Medical Research in Ghana found that the provision of good care practices to children between the ages of 4-36 months can partially compensate for the negative effects of low maternal schooling and poverty on child nutritional status in Accra.

The study begins with the premise that care is an important determinant of good health and nutrition among preschoolers, along with food security, availability of health services, and a healthy environment. A representative cross-sectional survey of households with children three years or younger in Accra, Ghana, was conducted to gain a better understanding of the nature of urban poverty and malnutrition and to disentangle the relationships between poverty, food insecurity, and malnutrition. Findings reported here used data from this survey to examine the constraints to good care practices, and to document the benefits of good maternal care for children’s nutritional status. An age-specific care index was constructed based on mothers’ reported practices related to child feeding and use of preventive health care services.

The constraints to good care practices in Accra

Life in urban areas presents special challenges for child care-giving. Time constraints, the need for women to work outside the home, and the existence of smaller families, which often result in limited child care alternatives, make the provision of care particularly challenging. In Accra, however, only low maternal schooling was found to be a significant constraint to good child care practices. Surprisingly, maternal employment did not result in poorer child care, but this is because mothers adapt their work patterns to the age of their child, in an effort to protect them. For instance, mothers of younger infants were less likely to work full-time (18%) than mothers of toddlers (67%). Also, if they did work full-time, 100% of mothers of infants < 4 months of age took their child to work while only 46% of mothers of toddlers did likewise. Household socio-demographic and economic characteristics did not appear to be constraints to good child care practices in this environment. There were good and bad care givers among both poorer and richer households.

The beneficial effects of good can practices

Using the age-specific child care practices index, IFPRI’s research also showed that care practices were strongly associated with children’s height-for-age z-scores. Good care practices were associated with three times lower prevalence of stunting (7% stunting among children of good caregivers compared to 24% among poor caregivers) and 2.5 times lower prevalence of underweight children (9% vs. 22%). The importance of care was confirmed by multivariate analysis, when controlling for various child, maternal and household characteristics.

Further analyses showed that care practices interacted significantly with maternal schooling and income categories. Good care practices made a particularly large difference in height-for-age z-scores (HAZ) for children of mothers with less than secondary schooling and for children from the two lowest income groups, as seen in Figures 1 and 2. Among mothers with less than secondary schooling, better maternal care practices brought the HAZ of children to the same level as that of children from more educated mothers or from wealthier families. The magnitude of the care effects among less educated mothers and poorer households was 0.5 z-score, a biologically meaningful difference.

Figure 1. Interaction between maternal schooling and caring practices on children’s height-for-age z-scores (HAZ)

Policy implications

In this urban population, good care practices could partially compensate for the negative effects of poverty and low maternal schooling on childhood stunting. Thus, effective targeting of specific education messages to poor and less educated mothers to improve their caring practices could have a major impact on reducing childhood malnutrition in Accra. Our findings also suggest that, at least in this context, mothers of very young infants may be particularly vulnerable to food insecurity and poverty because being full-time care-takers may jeopardize their ability to generate income for their household. This could be a particularly acute problem for women heads of households and is worth consideration in future studies.

Figure 2. Interaction between household income and maternal caring practices on children’s height-for-age z-scores (HAZ)

Copies of the results of this research are forthcoming in World Development and findings from the overall study are forthcoming in an IFPRI Research Report. Both can be obtained from Marie T. Ruel at IFPRI. Email: [email protected] Tel: 202-862-5600 All comments are welcome.

SIDA

The Swedish International Development Cooperation Agency (Sida) continues to support nutrition activities through several channels.

Institution-building support to the Tanzania Food and Nutrition Centre has continued since the Centre was founded in 1973, and support to the Nutrition Unit of the Ministry of Health, Zimbabwe, has continued since Zimbabwe’s independence in 1980. This support, however, is currently being evaluated and will be phased out in the near future.

Since 1989, Sida has provided over US$20 million to support the Integrated Child Development Services (ICDS) in four districts of Tamil Nadu, India. A recent evaluation of the ICDS in these four districts, found that levels of both severe and moderate malnutrition had decreased steadily during the period of 1989-97. Indeed, severe malnutrition in the districts now appears to be virtually eliminated. Subject to overall decision-making about continued Swedish support to India, however, this funding may also be coming to an end.

Sida was a major financial contributor to the SCN’s First and Second Reports on the World Nutrition Situation during the period 1988-92, and is providing support for the preparation of the Fourth Report, due out in December 1999.

Sida has long supported efforts to protect and support breastfeeding. The mainstay has been support to the International Babyfood Action Network (IBFAN). The WHO watchdog group in Geneva (IBFAN, Geneva) has received support since 1980; support is currently at about US$62,000 per year. IBFAN Africa also receives support of about US$25,000 per year. The World Alliance for Breastfeeding Action (WABA) has received support from Sida for several years, and currently receives around US$47,000 per year. The main WABA activities receiving Sida support are its efforts on several fronts to support the breastfeeding rights of working women. UNICEF has also received substantial support from Sida for several years towards its programmes to provide legislative and policy support to breastfeeding. This funding is currently at US$200,000 per year. Finally, the Section for International Child Health, Uppsala University, Sweden, has for several years received support for working on breastfeeding issues at the international level. This is currently at a level of about US$40,000 per year, bringing the total current Sida support to breastfeeding to some US$375,000 per year. This figure does not include the support to breastfeeding programmes and research in Tanzania and Zimbabwe, which would bring the total to well over half a million US dollars.

Sida is currently discussing new directions for its future involvement in nutrition. In particular, Sida is concerned about malnutrition among women in developing countries, a neglected area.

Submitted by Gunilla Essner, Senior Programme Officer, Health Division, Department for Social Development and Democracy, Sida, Stockholm S10525, Sweden. Tel: 46 8 698 52 44 Fax: 46 8 698 56 99 Email: [email protected]

UNICEF

Integration of Vitamin A Supplementation with Immunisation: Policy and Programme Implications

Rapidly expanding vitamin A supplementation of young children and post-partum women through integration with immunisation activities, was the subject of a WHO/UNICEF consultation held on 12-13 January 1998 at UNICEF HQ in New York. The potential of vitamin A as a powerful child survival tool was re-emphasised at the meeting, and it was recommended that vitamin A supplementation should be part of routine and supplemental immunisation activities in all countries where vitamin A deficiency (VAD) is, or is likely to be, a public health problem. Furthermore, in countries where VAD has not been rigorously assessed, the meeting concluded that high under-five year mortality rates should be taken as an indication of the need to integrate vitamin A supplementation with immunisation.

Extensive evidence now shows the impact of vitamin A on reducing child mortality - an impact that is comparable to, if not greater than, that of any single EPI antigen. Yet until recently, in countries where vitamin A deficiency is considered a public health problem, less than half of all infants and young children had received vitamin A supplements while immunisation coverage was reaching 80% of infants. Thus millions of children remain at risk of vitamin A deficiency, despite being in routine contact with a health facility or health workers for immunisation activities. There is therefore a unique opportunity to increase vitamin A supplementation coverage to these higher immunisation coverage levels by providing high-dose vitamin A supplements at regular immunisation contacts and supplementary immunisation activities such as National Immunisation Days (NIDs).

High-dose vitamin A supplements can be given simultaneously with measles, and polio vaccines without adversely affecting seroconversion rates. Furthermore, a review of country experiences in integrating vitamin A supplementation with immunisation activities provides additional evidence of the feasibility of this approach.

In a recently issued joint statement on policy and operational questions relating to vitamin A and EPI/NIDs, WHO’S Global Program on Vaccines (GPV), Nutrition for Health and Development (NHD), and UNICEF undertake to ensure the inclusion of age-appropriate vitamin A supplementation of children and post-partum women with immunisation in all countries where vitamin A deficiency is, or is likely to be, a public health problem.

Many countries are already providing vitamin A supplements to young children and post-partum women either through routine immunisation or NIDs. UNICEF estimates that in 1998, at least 34 countries were integrating vitamin A supplementation with NIDs. In countries where no decision has yet been taken, or where a decision has been taken not to include vitamin A supplements, WHO and UNICEF advocate for its inclusion through the Inter-Agency Co-ordinating Committee (ICC) for immunisation and other appropriate fora. Furthermore, donor agencies such as CIDA and USAID will also be advocating for integration of vitamin A with immunisation through their respective country missions.

Support, in the form of a cash grant to WHO/GPV and a donation-in-kind of vitamin A capsules to UNICEF, has been made by the Canadian Government through the Micronutrient Initiative (MI) in Ottawa. The Canadian grant to WHO/GPV includes support for applied research, development of training materials, and surveillance and evaluation activities. The distribution of vitamin A capsules to countries planning for NIDs, is being coordinated by UNICEF’s Nutrition Section and dispatched from its Supply Division in Copenhagen. Requests for capsules or cash needed to support operational costs should be directed through the respective UNICEF and WHO field offices to Nita Dalmiya, Nutrition Section, UNICEF at e-mail: [email protected] or by fax: 1 212 824 6465.

A report of the meeting’s recommendations and conclusions ‘Integration of vitamin A supplementation with immunisation: policy and programme implications’ (WHO/EPI/GEN/98.07) has been produced to provide guidance to countries to operationalise these recommendations. The report has been widely distributed to all countries and other implementing partners through UNICEF and WHO, and may also be downloaded from WHO’s web site at http://www.who.ch/gpv-documents/

For further information, please contact Nita Dalmiya, Project Officer, Micronutrients Nutrition Section, UNICEF Headquarters, 3 UN Plaza, New York NY 10017, USA. Tel: 1 212 824 6375 Fax: 1 212 824 6465 Email: [email protected] or Tracy Goodman, WHO/GPV, Geneva, Switzerland. Tel: 41 22 791 3641 Fax: 41 22 791 4193 Email: [email protected]

Code Implementation Stepped up in East Asia

The Governments of China and Vietnam are among those that have taken steps towards implementing the Code of Marketing of Breastmilk Substitutes and subsequent World Health Assembly Resolutions. This year, however, both Governments took action to improve Code compliance within their territories.

Vietnam

In 1994, the Prime Minister of Vietnam issued Decision 307 on the Issuance of Regulations on Trading and Use of Breastmilk Substitutes to Promote Breastfeeding. Experience revealed, however, that the Decision required strengthening in three main areas if it were to realise the aims of the Code:

1. the scope of the products covered required clarification;
2. advertising needed to be prohibited rather than limited;
3. responsibilities for implementation, monitoring and enforcement needed to be allotted.

UNICEF provided technical assistance in identifying these weaknesses in the Decision and in drafting more effective regulations through a series of workshops involving representatives from relevant Ministries in Hanoi. Revised regulations should be ready for adoption in the near future.

China

China took steps to implement the Code with the 1995 Rules Governing the Administration of Marketing of Breastmilk Substitutes. According to the Mother and Child Health Department (MCH) of the Ministry of Health, the adoption of these Rules has led to a reduction in the most blatant violations of the Code. However, increasingly sophisticated marketing techniques - particularly those fostering close relations with health workers and professional bodies, leading to apparent endorsement of products by the medical establishment - were felt to be undermining Code implementation.

UNICEF was requested to organise a training workshop on Code implementation for Provincial MCH officers and key trainers from six regional training centres. The workshop, which demonstrated the use of the WHO Common Review Evaluation Framework (CREF) as a tool to assist in implementing and monitoring the Code, resulted in the adoption of recommendations for improved implementation, monitoring and enforcement of the Code within the health care system. The training will now be replicated throughout the regions.

For further information please contact David L. Clark, Legal Officer, Nutrition Section (TA - 24A), UNICEF, Three United Nations Plaza, New York, New York 10017 Tel: (212) 824 6372 Fax: (212) 824 6365, Email: [email protected]

WHO

Joint FAO/WHO Expert Consultation on Vitamin and Mineral Requirements

A joint FAO/WHO expert consultation on ‘Vitamin and Mineral Requirements in Human Nutrition’ was held in Bangkok, Thailand from 21 - 30 September 1998. Eighteen experts from all WHO/FAO regions attended the consultation to:

à review the most recent scientific information on specific nutrient requirements;
à prepare recommendations for the daily intake of vitamins and minerals.

The consultation reviewed and made recommendations for vitamins A, C, D, E, and K, the B vitamins, calcium, iron, magnesium, zinc, selenium, and iodine.

The consultation reviewed new evidence to suggest that some vitamins and minerals play an important role in preventing diet-related chronic noncommunicable diseases. Evidence to support the importance of micronutrients in immune function, physical work capacity, and cognitive function was also discussed.

The report of the consultation - expected to be published by mid-1999 - will serve as an authoritative source of information for improving the health and nutrition status of populations. It will provide information for procuring food supplies for population subgroups, interpreting food consumption surveys, establishing standards for food assistance programmes, and designing nutrition education programmes.

For further details, please contact R. Buzina at WHO/NHD Tel. 41 22 791-3316 Email: [email protected] or Joan Conway, Project Coordinator (FAO), Food and Nutrition Division, FAO, Viale dell Terme de Caracalla, 00100 Rome, Italy. Tel: 5705 3322 Fax: 5705 4593 Email: [email protected]

Vitamin A Supplementation During Pregnancy

WHO/NHD is conducting a trial registry to complete a systematic review of randomised controlled trials (RCTs) evaluating the effect of vitamin A supplementation during pregnancy on maternal and newborn outcomes. For this purpose, they kindly ask those researchers that have conducted, are conducting, or are planning to conduct RTCs of vitamin A supplementation during pregnancy to contact Mercedes de Onis, NHD, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Fax: 41 22 791 4156 Email: [email protected]

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

A WHO consultation on ‘Behavioural and Socio-Cultural Aspects of Preventing Obesity and its Associated Problems’, originally scheduled for October 1998 (see SCN News No. 16, p.59), was held from 14-16 December, 1998. Hosted by the National Institute of Health and Nutrition in Tokyo, Japan, this consultation forms part of WHO’S efforts to follow up on the recommendations made at the Expert Consultation on Obesity (Geneva, 3-5 June 1997).

The aims of the consultation included:

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

à review approaches for behaviour change;

à review and analysis of country experiences in promoting healthy diets and lifestyles, especially with respect to obesity.

The consultation prepared guidelines for developing multi-sectoral strategies to address behaviour change, reduce obesity-promoting aspects of the environment, and improve a population’s knowledge about the development of overweight and obesity and their prevention and management. Methodologies for designing effective behavioural strategies to promote the choice of appropriate diets and healthy lifestyles by individuals, families and societies were also identified.

For further information, please contact Chizuru Nishida, WHO/NHD. Tel: 41 22 791 3317 Fax: 41 22 791 4156 Email: [email protected] The final report of the June 1997 consultation will be published in the WHO Technical Report Series (TRS) before the end of the year (see SCN News No. 16, p71).

Update on the WHO Multi-Country Study on Improving Household Food and Nutrition Security for the Vulnerable

The WHO multi-country study on improving household food and nutrition security for the vulnerable was initiated in 1995 in order to examine the basic causes of household food and nutrition insecurity. These include widespread poverty, inadequate food and water supplies, social and gender discrimination, inadequate care and feeding practices, and poor levels of education, sanitation, and health and social services. This multi-country study is currently being implemented in China, Egypt, Ghana, Indonesia, Myanmar and South Africa. Due to the increasing global problem of urban poverty and malnutrition, urban or peri-urban communities have been selected as the focus of study in most of these countries.

Quantitative components of the study and their analyses have been completed in China, Ghana, Myanmar and South Africa. Currently, several countries are undertaking in-depth qualitative components and a multi-disciplinary expert advisory group is being formed to review and evaluate final outcomes.

For further details, please contact Chizuru Nishida, WHO Programme of Nutrition. Tel: 41 22 791 3317 Fax: 41 22 791 4156 Email: [email protected]

National Food and Nutrition Policies and Plans for achieving Food and Nutrition Security for all in the 21st Century: Development of Training Modules for Incorporating the Impact of Globalisation

To be effective, national policies and programmes need to take into account increasing globalisation and its impact on national and household food and nutrition security. To this end, WHO/NHD is developing training modules to assist countries - particularly those undergoing ‘nutrition transition’ - in developing and implementing effective and sustainable national food and nutrition policies and programmes. The modules are being developed in collaboration with the Nutrition Policy, Infant Feeding and Food Security Programme at WHO’S Regional Office for Europe, and Thames Valley University in the UK. The first field-test of the draft training modules was conducted in Moscow in 1997. It is envisaged that field-testing in several other countries will be undertaken before the training modules are finalised.

For further details, please contact Aileen Robertson, WHO Regional Office for Europe, 8 Scherfigsvej, DK-2100 Copenhagen 0 Tel: 00 45 39 17 1717 Fax: 00 45 39 17 1818 Email: [email protected]

Revision of the Infant Feeding Content of Pre-service Medical, Nursing and Dietetic Curricula

WHO/NHD is initiating a global activity for protecting and promoting optimal breastfeeding practices by improving the pre-service education of health care professionals. The objective is to ensure that students in the health professions acquire basic knowledge and competence regarding lactation management prior to completing their pre-service education. This will help to increase health professionals’ credibility by providing them with accurate and complete education about breastfeeding from the start.

For further information, please contact Randa Saadeh, WHO/NHD, 1211 Geneva 27, Switzerland. Email: [email protected]

WHO’s Global Data Bank on Breastfeeding Prevalence and Duration of Breastfeeding in the European Region

Together with the UNICEF Office for Europe, WHO/NHD is about to publish a summary of available data on the prevalence and duration of breastfeeding in the European Region. This is the first stage in the process of publishing the full breastfeeding data set for all WHO Regions.

To implement the strategies and monitor the goals adopted at the World Summit for Children (1990), the International Conference on Nutrition (1992), emphasised the need to collect and disseminate information on infant and young child feeding, including data on breastfeeding prevalence and duration. In 1993, it was recommended that WHO be responsible for collecting data and reporting on breastfeeding trends. In 1994, the World Health Assembly requested the Director-General (resolution WHA47.5) to support Member States in monitoring infant and young child feeding practices and trends in health facilities and households, in keeping with the new standard breastfeeding indicators.

On the basis of a few reliable indicators, publication of these data will allow national authorities to analyse trends in breastfeeding over time, and evaluate the effectiveness of promotional programmes, such as the Baby-friendly Hospital Initiative, in achieving their goals.

Data will be published for the following indicators:

à Exclusive breastfeeding rate< 4 months: infants less than 4 months of age who were exclusively breastfed

à Ever breastfed rate: infants less than 12 months of age who ever breastfed.

à Predominant breastfeeding rate: infants less than 4 months of age who were predominantly breastfed in the last 24 hours.

à Mean duration of breastfeeding: average duration of breastfeeding in months.

à Median duration of breastfeeding: age in months when 50% of children are no longer breastfed.

à Continued breastfeeding rate (1 year): children 12-15 months of age who were breastfed in the last 24 hours.

à Continued breastfeeding rate (2 year): children 20-23 months of age who were breastfed in last 24 hours.

à Bottle-feeding rate (2 years): infants less than 12 months of age who are receiving any food or drink from a bottle.

This summary of information on the European Region from WHO’S Global Data Bank on Breastfeeding will be available in January 1999. For a copy, please contact the WHO/NHD, 1211 Geneva 27, Switzerland. Email: [email protected] or [email protected]

Promoting Healthy Growth and Development

A review of child development and nutrition interventions was undertaken by WHO’S Department of Child and Adolescent Health to provide guidance for selecting the types of interventions that can be effective in improving the growth and psychological development in children. It reviews the evidence that nutrition interventions and early childhood care and development programmes (ECCD) have positive impacts, even under poor socio-economic conditions. It summarises community - based studies and programme evaluations in the following four categories:

à Psychological interventions to improve psychological development;
à Nutrition interventions to improve psychological development;
à Nutrition interventions to improve growth;
à Combined interventions to improve both growth and development.

The review indicates that there is sufficient evidence from studies with adequate research designs to demonstrate that psychosocial interventions can improve psychological functioning and nutritional interventions can improve both psychological functioning and physical growth in children living in conditions of poverty. There is suggestive evidence that other types of community interventions can improve physical growth of children in conditions of poverty.

The evidence from community trials and programmes suggest that:

à Children respond to development interventions throughout childhood but interventions that are directed to supporting growth and development in the earliest periods of life - prenatally, during infancy and early childhood - are likely to have the largest impact.

à In general, the children in greatest need due to poverty or parent’s lack of knowledge and experience are the ones to show the greatest response to growth and development interventions.

à Growth and development interventions that utilise several types of interventions and more than one channel are more efficacious than those that are more restricted in scope.

à Programme efficacy and effectiveness appear to be greater when parents are more involved.

The review concludes with the following recommendations:

à The health sector should develop and implement new activities to promote appropriate feeding and responsive parenting in existing child health and welfare programmes.

à Other sectors need to expand and strengthen the health, nutrition, and breastfeeding components of existing early childhood development and childcare programmes both in centres and with parents and caregivers by providing counselling and training on responsive parenting and appropriate feeding.

à Research and development is necessary to determine the best strategies for delivery and implementation of the programmes.

It is suggested that the first effort be directed to the development of a culturally-adaptable counselling package that combines nutrition counselling on complementary feeding (with food supplementation as necessary) with counselling on psychological care (e.g. warmth, attentive listening, proactive stimulation, and support for exploration and autonomy).

An expanded research agenda could then be designed to compare and evaluate the effectiveness of different content, different types of programme venues (e.g. breastfeeding promotion, community-based primary health care) and different channels (e.g. community health workers, women’s groups, school teachers). Such research must be conducted in developing countries in collaboration with established in-country investigators. Training materials for community workers, monitoring and evaluation tools, and other tools for cultural adaptation, planning and community participation should be developed together with the counselling strategies.

Copies of the complete review can be obtained from the Department of Child and Adolescent Health, WHO. For more information contact Dr. Gretel Pelto, Dept. of Nutritional Sciences, Cornell University, Ithaca, NY 14850 USA. Tel: 607-255-6277 Email: [email protected] or Patrice Engle, Dept. of Psychology, Cal Poly State University, San Luis Obispo, Ca 93405 USA. Tel: 805-528-4052 Fax: 805-756-1134 Email: [email protected]

THE WORLD BANK

Just Taking Stock or Defining a New Paradigm? Nine Years of Determining Factors for Successful Community Nutrition Programmes

Over the last nine years, many events and efforts have taken place to identify the factors for successful community nutrition programmes (see Summary Table). These are still valid today and constitute the building blocks for successful community nutrition programmes. However, “the challenge is to find out how these successful programmes and projects can be made to go to scale. Most efforts to ‘scale up’ successful local programmes or projects have failed” (Urban Jonsson, report from ICN Meeting in New Delhi, November 1995). New success factors for large-scale community nutrition programmes were identified at a workshop held in Dakar, Senegal, on March 23-27 1998, in the context of the Regional Initiative to Reinforce Capacity for Community Nutrition.

Managers of eleven community nutrition programmes and projects throughout Africa were invited to the workshop. Six of these shared lessons learned, namely: Senegal’s Dioffior’s Community Nutrition Project, Senegal’s Community Nutrition Project executed by Agetip, Senegal’s ENDA-Third World’s Nutrition Program, the SIAC from Guinea, the SCAC from Niger, and the SECALINE from Madagascar.

The workshop defined a community nutrition programme as:

à answering a priority need felt by the community;
à involving the community in all stages;
à having an impact on nutritional status;
à being located near to beneficiaries.

The following factors were identified at the workshop to ensure effective community participation:

à ensuring that the community is in charge at all stages by creating community committees;

à reinforcing community skills for programme design and implementation;

à making as much use of local available resources as possible - for financing and manpower;

à ensuring that the quality of services is monitored by the community during supervisions, and that the data used are valid and reliable;

à developing a contractual relationship with the

à community, and ensuring that the community does the same with other actors;

à ensuring that there is good governance.

The following factors were highlighted as being necessary in order to ensure sustainability of a community nutrition programme:

à commitment by the community and by the State (the latter through a budget line and through political back up);

à integration of nutrition with other local development sectors (health, sanitation and agriculture), with civil society (NGOs and private sector), and most importantly, with local women’s groups;

à promotion of self-reliance by the community. This involves determining through discussions the financing and management capacity of the community;

à transfer of technical competencies to the community.

A New Paradigm for Scaling Up

The new paradigm that emerged from the Dakar workshop was the realisation of untapped possibilities in the communities that can be mobilised for large-scale nutrition work, namely through:

1. using manpower from the community;
2. the proximity of service delivery;
3. contracting out;
4. linking supervision to the management information system.

I. Using manpower from the community: traditionally, nutrition experts have spoken of ‘community involvement’. In Dakar, it was found that if the community selects its own agents from within the community to deliver the services, the chances of success are much higher than if someone from outside the community comes in. This aspect was mentioned in 1997 in Montreal when it was said that “existing community workers should be used”. We are now realising that there are people in the community who are not health workers - in fact many of them are unemployed educated or illiterate people - who would like to do something but do not know what to do. If a nutrition programme gets these people involved, supports them to get organised, trains them and supervises them, the programme will get some of the best delivery of services possible. These individuals are highly motivated.

II. Proximity of service delivery: although this concept is linked to the one just mentioned, in Dakar, it was agreed that service delivery should be made available within the community. This proximity ensures ownership as well as good coverage.

Summary table: Main factors for successful community nutrition projects, identified by chronological event

Success factors	Seoul 19891	Kennedy 19912	Mew Delhi 19953	Accra 19964	Montreal 19975	Dakar 1998
Human resource development: ongoing training, esp. in participatory approaches	Ö	Ö		Ö	Ö	Ö
Community mobilisation and participation/ownership: involving the community in all phases of programme planning and implementation	Ö	Ö		Ö		Ö
Political commitment at all levels	Ö		Ö	Ö	Ö	Ö
Careful monitoring, supervision, evaluation & management information systems at all levels	Ö			Ö	Ö	Ö
Replicability & sustainability	Ö	Ö				Ö
Commitment & leadership of staff	Ö					Ö
Targeting	Ö					Ö
Local women groups as key resources in management of activities	Ö					Ö
Multi-faceted activities integrated to local development programmes		Ö	Ö	Ö		Ö
Necessity for long term investment, especially important for scaling-up and to adapt to community needs		Ö		Ö	Ö	Ö
Institutional structure as a “winner”		Ö				Ö
Know, understand, accept, use conclusions of own community-based projects, especially important for Scaling-up			Ö	Ö		Ö
Necessity for long-term investment				Ö	Ö	Ö
Policy framework & institutional collaboration among different partners				Ö		Ö
Advocacy & raising awareness on nutrition issues at all levels				Ö		Ö
Community workers who come FROM the community (who are organised, trained, supervised and compensated for their work)					Ö	Ö
Proximity of service delivery						Ö
Use of contracting approach, which improves good governance and self-reliance						Ö
Link supervision to management information system and performance						Ö

¹ Seoul, Korea, August 15-18 1989: Crucial Elements of Successful Nutrition Programmes. The Fifth International Conference of the International Nutrition Planners Forum.

² June 1991: “Successful Nutrition programmes in Africa: What Makes them Work?” by Eileen Kennedy, The World Bank.

³ November 20-22 1995, New Delhi: Success Factors in Community-based Nutrition-oriented Programmes and Projects. Rapid Appraisal Prepared at the ICN Meeting, by Urban Jonsson.

⁴ Accra, Ghana, February 1996: Symposium on “Effective Programmes in Africa for Improving Nutrition”, held at the SCN’s 23^rd Session (SCN News No. 14).

⁵ July 24-27 1997, Montreal, Canada: Success Factors in Community-based Nutrition Programmes. Satellite Meeting on Public Nutrition, IUNS Congress

III. The contracting approach: several large scale projects (in Madagascar, and Senegal in particular) contract service delivery, training, supervision and operational research to local groups, institutions and communities. These entities are often non-governmental, but sometimes a health district can be contracted for specific activities (eg., Guinea, Dioffior in Senegal), or a para-statal agency can do the job. This new approach shows that governments can use their funds to subsidise other actors to contribute to national objectives. Ministries of Health then take on a different role as they are not responsible any longer for service delivery.

IV. Linking supervision to the management information system with performance indicators was demonstrated at the workshop as being essential. Although it was said a long time ago that the information system should be used for decision making, it was never dear how to do it. Madagascar and Senegal’s large-scale community nutrition projects have developed a simple and effective monitoring system used by all levels for decision making.

The Summary Table illustrates how, in the past nine years, the nutrition community has been able to identify all the factors necessary for success on a large scale. The factors mentioned at the top of the table have been well integrated by the nutrition community, but as one goes down the table, one can see that some new factors have been added and others, not new, may have been forgotten for a while, but are making a come-back now.

Submitted by Tonia Marek, Senior Public Health Specialist, The World Bank. Email: [email protected], Serigne Mbaye Diene, nutritionist at BASICS/Senegal. Email: [email protected], and Maty Sy, consultant in human development. Email: [email protected]. The full paper can be obtained by request from any of those mentioned above.

CNIP

Cambodia Nutrition Investment Plan (1999-2008)

The Cambodian Nutrition Investment Plan (CNIP) proposes a US$ 90 million investment plan for nutrition over a ten-year period as part of the Public Investment Programme. It is proposed as a nation-wide plan covering both rural and urban areas, focusing on children and women. It is a response to addressing the very high rates of child and maternal malnutrition and high levels of infant and maternal deaths that affect all provinces in Cambodia. The root causes of these problems are a protracted civil conflict, widespread poverty and lack of availability and access to basic services.

The objectives of the nutrition investment plan are to:

à Incorporate nutrition considerations in national socio-economic development plans

à Reduce levels of protein energy malnutrition (PEM) in children under five years of age by half from the current level of 52%

à Eliminate deficiencies of iodine, vitamin A and folic acid and reduce by half the current levels of anaemia in children under five and pregnant women

à Reduce the levels of low birth weight (LBW) from the current 20% to below 10%

à Reduce levels of malnutrition of women of reproductive age from 20% to below 10% as measured by a body mass index (BMI) of below 18.5 kg/m²

The overall strategy of the proposed investment plan is a community-based approach emphasizing actions at the household level with supportive national level approaches. The basic strategy at the community level is to ensure sustainability by supporting actions that build up capacity and are empowering. Particular attention will be given to promoting behaviours and supporting services that improve availability, access and efficient utilization of resources. Emphasis will be given to issues related to care, health, sanitation and household food security.

For further information please contact Dr. Festo P. Kavishe, Project Officer, Head of CASD &Temporary Secretary NNPA/RETA Steering Committee, UNICEF, No. 11, Street 75, Sraschark Quartier, PO Box 176, Phnom Penh, Cambodia.

PHN

Micronutrient Support Activity

The Population, Health and Nutrition Center (PHN) of the Global Bureau, Office of Health and Nutrition is pleased to announce the award of the Micronutrient Support Activity (MSA) under the Nutrition Results Package.

The cooperative agreement has been awarded to the International Science and Technology Institute, Inc. (ISTI). Core sub-recipients are Johns Hopkins University, Helen Keller International, The Academy for Education Development and The International Food Policy Research Institute. Specialised resource institutions are CARE, Save the Children, Population Services International (PSI), Program for Appropriate Technology in Health (PATH) and International Executive Service Corps (IESC). The Executive Project Director will be Dr. Roy Miller.

This award will support activities related to micronutrient interventions and ensure coordination with other projects, organisations and donor agencies. The Micronutrient Support Activity has been developed in response to the needs of USAID missions and host country governments for technical assistance in managing interventions in vitamin A and other micronutrients.

An important element of the PHN Center’s Child Survival and Nutrition Results Package is the vitamin A enhanced effort (VITA). Where vitamin A deficiency exists, vitamin A will be integrated into USAID child survival programs globally. Strategic partners include USAID, host governments, cooperating agencies, NGOs, civic groups, the U.S. food industry, and multi- and bilateral donors. Key technical areas include integration of supplementation into CS programs, policy dialogue and advocacy, public/private sector cooperation in food fortification, expansion of private sector markets, community based behaviour/dietary change, donor coordination, and monitoring and evaluation of impact. A key element of MSA will be to assist missions in the implementation of VITA.

USAID’s new micronutrient efforts will consolidate and expand experience gained from past USAID programs in micronutrients. The MSA will actively launch significant global technical assistance activities such as prevalence assessments and test innovative technologies to increase vitamin A and iron consumption among high risk groups, particularly women and children.

Efforts and resources will focus on broad-scale transfer of technologies, skills and knowledge to assist developing countries to sustain micronutrient programs. This will include increased efforts in program and policy support, training and institutional capacity development, and information dissemination.

For more information please contact Frances Davidson, Office of Health and Nutrition, Child Survival Division, Washington, DC, USA. Tel: 2027120982.