SCN Working Group Summaries

Nutrition, Ethics and Human. Rights

As a general conclusion it can be said that this Working Group's fifth meeting had achieved a remarkable consensus on the importance of a human rights approach to development in general and to nutrition improvements in particular. This consensus occurred in the context of an increasingly human rights-friendly overall environment. Nevertheless, effectively mainstreaming human rights in all UN activities, as called for by the UN Secretary-General, remains a challenge of enormous dimensions. For the contribution that the SCN is called upon to make in this specific field of nutrition with its main components of food, health and care, the unfinished agenda remains considerable.

To live up to the challenge of completing its unfinished agenda, the SCN needs to lift its human rights concerns from an isolated working group activity into the mainstream of its overall work program. This must also be reflected in SCN's resource mobilization and allocation within the work program. Specific recommendations included that the SCN should now institutionalize collaborative mechanisms with the HCHR to advance human rights approaches to nutrition problems. Through the HCHR, this collaborative mechanism should also extend to collaboration with the relevant Convention Committees of the human rights machinery. This activity should be a continuing part of the work plan of the SCN Secretariat. The Working Group should coordinate the work of developing appropriate indicators for monitoring the right to nutrition, in particular the right to food, by SCN member agencies and the HCHR.

Breastfeeding and Complementary Feeding

Eight issues were discussed by this Working Group and recommendations included the following. All implementing agencies should adopt a rights-based approach to all of their infant feeding programs; and an intersectoral rights-based approach to child survival growth and development should be adopted by all implementing bodies. Regarding maternity legislation it was requested that the SCN Secretariat use its good offices to approach the new Director General of ILO and express concern over the process towards the re-negotiation of the Maternity Protection Convention.

The Benefits of Breastfeeding Model (BOB) for assessing the economic value of breastfeeding should be used more widely to advocate for the introduction and strengthening of breastfeeding policies and programmes. The Breastfeeding Counselling training course and its complementary feeding component needs to be more widely implemented, particularly in countries affected by the HIV epidemic to counter the tendency to abandon breastfeeding protection, promotion and support. In the context of MTCT of HIV, global implementation of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly resolutions needs to be accelerated and strengthened. UNICEF should prepare a briefing note explaining the continued relevance of the Code in the context of prevention of mother-to-child transmission (MTCT) of HIV, explaining particularly the provisions concerning free and low cost supplies. It was recommended that additional research is needed on the relative safety of exclusive breastfeeding, on the effects of the alternative feeding options proposed in connection with MTCT of HIV on children's health and family wellbeing, and specifically on how mothers cope in practice using various feeding options. In all preventive MTCT initiatives, infant feeding practices and their effects on children's health need to be more closely monitored.

Nutrition in Emergencies

Dr. Mike Toole, Macfarlane Burnet Centre for Medical Research, Melbourne, Australia, gave an overview of the trends in nutrition assistance programs in emergencies between 1976 and 1999. Although the quality of nutritional assistance has improved considerably in the last two decades some of the same problems persist, for example outbreaks of micronutrient deficiency disorders continue. Additionally, the rapidly changing geopolitical context has raised new challenges in the provision of adequate food aid.

Recommendations included the need to systematically investigate programmes targeting adults and adolescents as part of any famine relief response. WHO offered to further standardize adult and adolescent criteria and protocols, determine survey methodologies and population prevalence cut-offs for malnutrition, and develop a common operational research agenda to prevent duplication of time and resources. WHO and UNICEF agreed to develop new strategies to manage and implement infant feeding in emergencies among populations with a high rate of formula feeding prior to displacement. The SCN Secretariat agreed that the RNIS should include more reports from the US and NGOs, and provide field reports through email or on the ACC/SCN website.

Household Food Security

Three topics from last year were taken forward: 1) interagency collaboration in food security programs, 2) operational methods for the targeting of food security interventions, and 3) how to integrate household food security into sector-wide approaches. Three new themes addressed in the current session were: 1) targeting, 2) agency sharing of information with a focus on key issues that remain unresolved with regard to household food security, and 3) prioritizing areas for this Working Group during 1999-2000.

Proposed areas of future work included an exploration of the linkages between macro-changes and food security at household and community levels. It was suggested that the linkages between macro-changes, including trade and economic and sectoral reforms, and efforts to address household food security at local level should be highlighted perhaps by holding a symposium with international financial institutions including the World Bank, the IMF and WTO. The Working Group should explore this option in consultation with the Working Group on Nutrition, Human Rights and Ethics. Another area was the operationalization of a rights-based approach to programming of household food security programs. Case studies of innovative programs which demonstrate the practical application of a rights-based approach to nutrition and food security, should be prepared by agencies for discussion at future meetings. Urban food security is a growing concern, yet receives less attention than rural food security. The Working Group should review evidence on trends in urban food insecurity, coping strategies and policies.

Iodine Deficiency Disorders

Very notable progress has been made: it is estimated that 18% of IDD affected countries have reached the goal of Universal Salt Iodization (USI) (defined as more than 90% of the households having access to iodized salt). Although it is not yet possible to estimate the impact of USI on the iodine status of the population at global or regional levels since salt iodization programmes are still too young in most countries, it is clear that where salt iodization has been introduced for more than five years, the reduction in goiter prevalence and the improvement in iodine status is dramatic. For example the seven African countries surveyed as part of the multi-centre study carried out by WHO, UNICEF and ICCIDD in 1996, showed substantial improvements. The recent assessment of the IDD situation in some Latin American countries also confirms this trend.

The goal of IDD elimination is within reach. The road, however, is still long and success will only be achieved with sustained and continued effort. The challenge for the forthcoming years is twofold: first to introduce salt iodization in the 35 affected countries where it has not yet been implemented; second, to sustain salt iodization programmes - especially since a deterioration in iodine status has been seen in some industrialized countries where it had been believed that IDD was under control. In order to make programmes sustainable, it is necessary that governments commit themselves to the elimination of IDD and mobilize human technical resources towards this goal by facilitating collaboration between the relevant sectors. For IDD control health, trade and legislation sectors need to work closely together. Systems to monitor the quality control of iodized salt as well as the iodine status of the population need to be put in place. This implies reinforcing existing laboratories or developing a network of regional or sub-regional laboratories able to cover countries without properly equipped laboratories. And lastly, governments should adopt and enforce legislation regarding iodized salt.

Lifecycle Consequences of Fetal and Infant Malnutrition

The Chair, Nevin Scrimshaw, opened the meeting by explaining that it has become increasingly apparent in the last decade that the adverse effects of intrauterine growth retardation (IUGR) can influence the performance and health of offspring throughout life. For infants born with low birth weight (LBW) at the end of a term pregnancy, IUGR has occurred. Most LBW can be prevented by better food intake resulting in greater weight gain during pregnancy. About 24% of newborns in developing countries have IUGR. The chair commented that despite some weaknesses and criticisms of the early Barker studies, these studies have since been greatly expanded and standardized, and the results supported by similar findings in a considerable number of other countries, both industrialized and developing.

He recommended that this new Working Group be continued in order to provide the ACC/SCN with an annual critical assessment of developing scientific evidence, to give ACC/SCN members a chance to contribute to the dialogue, and to stimulate research, policy formulation and programme guidelines on this important topic. There is a need to establish a core research protocol to investigate a longitudinal relationship between IUGR and disease in later life in different populations. Programmes which address IUGR should be based on the Care for Women component of the UNICEF Care Initiative; an inter-agency meeting (similar to the recent iron consensus workshop) could help to move programmes forward. There is a need to identify and document best practices for the prevention of LBW which could be integrated into new comprehensive programs, including monitoring and evaluation. The successful approaches of Chile, Cuba and Costa Rica to reduce LBW should be reviewed for lessons learned. The ACC/SCN should consider a proposal from SIDA and Uppsala University for an international meeting in the year 2000 which will focus on women and nutrition, especially adolescent girls.

Vitamin A and Iron

The 1990 World Summit for Children set the goal of elimination of vitamin A deficiency (VAD) by the year 2000. While some progress is being made, there is irrefutable evidence that VAD is still widespread among children in the developing world. This is why USAID, UNICEF, CIDA, and Ml created a Global Initiative to secure commitment to achieving the year 2000 goal and to set benchmarks for countries. This Initiative recognizes the importance of multiple strategies to control VAD, however, vitamin A supplementation is a low-cost, sustainable strategy that has been in place for decades in some developing countries. Policymakers should be advised that vitamin A supplementation is not necessarily a short-term measure.

At the previous ACC/SCN meeting in Oslo the Vitamin A Working Group discussed the conflicting estimates between the UNICEF/MI/Tulane University Report and the WHO/UNICEF/MDIS report #2. George Beaton was commissioned by WHO to critically review the estimates on VAD made in these reports. Dr Beaton concluded that there are no reliable quantitative estimates of the magnitude of subclinical VAD but independent attempts to estimate this from the fragmentary information available would suggest that numbers lie in the range of 140 to 250 million preschool children. These estimates do not take into account subclinical and clinical VAD occurring in older children and adults so the suggested magnitude is a serious underestimation of the total magnitude and importance of VAD.

Iron deficiency is likely to be the main cause of anaemia in the industrialized world. In developing countries, however, anaemia is the result of various factors including intestinal hookworm infections, malaria, schistosomiasis, chronic infections in particular HIV, and nutritional deficiencies such as PEM, folate, vitamin A and B deficiencies to mention only some of the major contributing factors. This implies that any intervention to control anaemia should look at the causes of anaemia, which may vary from one region to another. Dr Vinodinni Reddy (IUNS) mentioned findings from India in which anaemic women assured of taking iron and folate daily still had 30% of the group anaemic after supplementation, possibility due to some other nutrient deficiency. In conclusion, anaemia is too often associated with iron deficiency; more focus should be put on the other causes of anaemia especially among poor segments of the populations.

Nevin Scrimshaw highlighted the important results of a technical workshop held in October 1998 in Washington, DC: Iron nutrition needs greater attention - it affects 3.5 billion people and has serious functional consequences that can include impaired cognition, decreased work capacity, reduced immunity and increased morbidity from infectious disease. Iron deficiency has massive economic costs that have been almost totally unrecognized. The cost benefit ratio of preventive programmes for iron deficiency is recognized as one of the highest in public health. New programme actions are required - little progress has been made towards the global elimination of iron deficiency, partly because it is a hidden deficiency without overt symptoms. Advocacy and national programmes have been constrained by erroneous perceptions that effective, practical interventions are not available.

An analysis by George Beaton and colleagues of the efficacy of intermittent iron supplementation in the control of iron deficiency anaemia in developing countries concluded that both daily and weekly iron supplementation are efficacious. Weekly iron supplementation is likely to be less effective than daily administration except in situations where supervision is feasible with weekly regimens and not with daily supplementation. Unless ways are found to greatly improve "compliance", neither daily nor weekly iron supplementation is likely to be an effective approach to preventing and controlling iron anaemia in developing countries. Future research priorities should be directed to development of other strategies either to effectively improve utilizable iron intakes or to greatly improve compliance in direct supplementation, daily or weekly.

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OBITUARY

Arnold Bender (1918-1999)

Arnold Bender has been described as "one of the giants who will leave an enormous gap in the field of Food Science and Nutrition". He made important contributions to these subjects not only in the basic science, but by building bridges between the disciplines of Food Science and Nutrition, academia and the food industry, bench science and its practical application, as well as between scientific research and public understanding.

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He was a man of encyclopaedic knowledge, renowned for his rapid recall of an infinite number of facts delivered with humorous anecdotes. Officially retired for 15 years, Arnold Bender did not lie back on his laurels but remained as active and physically unchanged as he was at the age of forty, until the last few months when cancer pulled him down. His final post before retirement in 1983 was as Professor of Nutrition and Dietetics and Head of the Department of Food Science and Nutrition at Queen Elizabeth College, which merged with King's College two years later. He was appointed as Senior Lecturer in 1965 and came to the post from a strong background of academic and food industry research. His first degrees were in Chemistry and Biochemistry from Liverpool. During World War II he was a research chemist with British Drug Houses Ltd, working on vitamin A, the stability of fats and the production of antibiotics. He then moved to Sheffield for doctoral work as a Nuffield Research Fellow on the biological effects of X radiation. As Assistant Lecturer of Biochemistry, he collaborated on amino acid metabolism with Nobel Laureate Professor Sir Hans Krebs. This work led him into the field of protein nutrition which was the main topic of Arnold's subsequent research.

Over the 15 years between 1949 and 1964 Arnold Bender worked on protein nutrition research in the food industry. This was the period when it was estimated that an important cause of malnutrition throughout the world was protein deficiency, partly due to a lack of protein supplies to fulfil world needs. With his colleague Derek Miller, this work culminated in the development of the Net Protein Utilization method of assaying the nutritive value of proteins - the Bender-Miller method.

His expertise in protein nutrition and food toxicology led to appointments on many influential national and European committees. He was also influential in the building of professional institutions through his membership on the council of organizations which included the British Nutrition Society, the Society of Chemical Industry, the Royal Society of Health, and the Institute of Food Science and Technology (of which he was a founding member in 1962). He later became President, and Vice President of the International Union of Food Science and Technology.

His awards included an Honorary DSc from the University in Madrid in 1983; in 1995 he was elected as one of the first Fellows of the International Academy of Food Science and Technology; and in 1998 he was recognized as an Honorary Fellow of the Institute of Food Science and Technology for his contributions to the profession.

Arnold Bender published many academic papers and books. Through his book, Nutrition for Medical Students, co-authored by his son David (a nutritional biochemist at University College London), he attempted to address the problem of the small place that nutrition occupies in medical curricula, in contrast to the fact that a majority of people consider the medical profession to be a reliable source of nutrition information.

Throughout his career he had been enthusiastically supported in his work by his wife Deborah; his other son, Brian, is also a scientist. Arnold Bender will continue to teach, as he did through most of his life, by donating his body to science.

Submitted by Dr Bender's good friend and colleague: Catherine Geissler BDS, MS, PhD, Professor of Nutrition, Head of Division of Health Sciences, King's College London.