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Part V. Nutrition policies and programmes

Part V. Nutrition policies and programmes

Chapter 33. Assessment, analysis and surveillance of nutrition

Nutritional problems are complex in their aetiology, and there are many different nutritional deficiency diseases Knowing how they occur is one vital part of solving and, better still, preventing nutritional problems The ability to predict their occurrence makes prevention a more realistic prospect

A great variety of data can throw light on the risks of malnutrition in a community or a nation Between 1946 and 1975 large national nutrition surveys were conducted in many countries They often included the collection of a broad range of dietary, clinical, biochemical, anthropometric and socio-economic data The surveys were often designed to detect evidence of a range of vitamin and mineral deficiencies as well as protein-energy malnutrition (PEM) The surveys were expensive to conduct; they required well-equipped laboratories and numerous personnel Many of the earlier surveys in over 20 countries were supported and largely conducted by the United States Interdepartmental Committee for Nutrition for National Defense Subsequently, international agencies such as FAO helped countries conduct large national nutrition surveys. In the United States, major nutrition surveys were conducted in ten states between 1968 and 1971.

All of these surveys provide a wealth of data on nutritional status, usually for a representative sample of the population. Unfortunately, in most cases the data collection did not seem to result in a broad set of actions to deal with the nutritional problems found in the surveys.

By about 1975 it was generally agreed that such detailed surveys were not necessary and that, because PEM in young children was thought to be the most important problem, simplified surveys, using mainly anthropometry and selected dietary and socio-economic indicators, would be more appropriate. Nutritional assessments were increasingly based on measurements of weight and height. There also was a move away from national surveys to more local surveys and in some countries, such as Kenya, to regular data collection to assess trends. Anthropometric surveys were to some extent replaced in the 1980s by rapid appraisal methods which involved the collection of a broader range of data but used new methodologies. At about the same time there was a move to collect qualitative as well as quantitative data and to conduct surveys related to a single micronutrient deficiency, such as iodine deficiency disorders (IDD).

In working to assess the nutritional status of a community, it is important to decide on the objectives of the assessment, how the analyses will be done and what actions are feasible. It is important to draw from experience and to design the most appropriate data collection exercise. For example, in an assessment in a large, newly established refugee camp, it might be advisable to collect more than just anthropometric data; in the past, when nutritional status in refugee camps was judged only on anthropometry, deficiency diseases such as scurvy and pellagra were missed. Social scientists might be consulted to help decide what qualitative data would be most useful and how these might be gathered and analysed.

Large and expensive surveys, in which a wide variety of nutrition-related data are collected, are seldom justified and should never be done unless there is reasonable assurance that the data will be used for an action programme and that adequate resources and funds are available. In many countries expensive surveys have been carried out and little action has followed. It has been suggested that ten times the amount spent on a survey should be available for programmes aimed at overcoming the deficiencies identified by it. It is therefore important that the information collected be kept to the minimum required to assess or monitor the situation, and that surveys be simplified as much as possible. Some information used for the assessment of the nutritional status of a community can also be used for evaluation of programmes and for nutritional surveillance.

Types of data for assessing and analysing nutritional status

Today the main interest in a survey might be to determine nutritional status at the household and local level, rather than at the national level. The following ten types of information can be useful in assessing the nutritional status of a community:

Only the first five are discussed here since a nutrition survey comprehensive enough to collect all these types of information would very seldom be undertaken.

Clinical examination

Clinical examinations are often given low priority as a means of assessing the nutritional status of a community. Moreover, most countries in Africa, Asia and Latin America suffer a lack of vital statistics, accurate figures for agricultural production and laboratories where biochemical tests can be performed. Records of local food habits and practices are difficult to obtain. Under these conditions clinical and anthropometric examinations are the most simple, most practical and without doubt the most sound means of ascertaining the nutritional status of any particular group of individuals.

The nutritional status of a community is the sum of the nutritional status of the individuals who form that community. However, in any survey only a representative group of persons needs to be examined. To give a true picture, these people should normally be chosen completely at random, not taken from any particular age group, sex, religion, social class or area within the community. Stratified sampling is valid under certain circumstances. For example, if a survey is being carried out to determine the importance and prevalence of PEM among the young in a given area, it would be sound to restrict examinations to children up to five years of age. If the exact date of birth of the child is unknown, the age should be estimated using local historical, agricultural or social events as time indexes.

The clinical nutrition examination should be carried out by a person with medical training. Although it may be possible to train non-medical personnel to recognize such conditions as angular stomatitis, mottled teeth and even oedema, collection of clinical data by people with inadequate medical knowledge could lead to incomplete survey results. For example, a person looking for the dermatoses of kwashiorkor or the skin changes of pellagra should also be able to recognize scabies and eczema. However, non-medical persons can be entrusted to collect anthropometric data (physical measurements).

In order to avoid overlooking important details, the clinical examination should be systematic. The examiner should look for specific signs, and their presence or absence should be recorded on a standardized form. A modified sample of a form that has been found useful in East Africa is presented on the following page.

Using this form, examinations should start at the head (i.e. hair, eyes, mouth), move down the body and end at the feet. Central nervous system (CNS) signs may in some instances be omitted; they are relatively rare and the tests may be difficult and time consuming to perform.

Anthropometric data

Anthropometric data can be collected by medical or non-medical personnel. In the former case, they can be included as part of the clinical nutritional examination. However, it is often simpler and faster if a reliable person other than the medical examiner records the height and weight during a survey.

Weight. The weight of a person is the most important single anthropometric measurement that can be taken. In children its interpretation is dependent on knowing the age of the child with some degree of accuracy. Weight should be measured with the subject nude or wearing the minimum of clothing (shorts only for males, light dress for females). Footwear should be removed.

Spring scales are less reliable than balance scales. In many countries, balance scales have been supplied to clinics and health centres by the United Nations Children's Fund (UNICEF). At boarding schools a good scale is often available in the kitchen, where it is used for weighing sacks of food. Similarly, in a village the local market master or the owner of a small shop will usually have a produce scale that can be borrowed. Special baby-weighing scales are necessary for accurate weight measurement of children under two years of age.

Height. Height is also a very important measurement in the assessment of nutritional status. As with weight, its interpretation in children is dependent on knowing the age of the child. Height should be measured with the subject barefoot. Though many different types of equipment are available, height can be fairly accurately measured with a tape-measure or a ruler. The following method may be used.

Locate a vertical wall rising from a truly horizontal floor. Make a horizontal pencil line about 2 cm in length at a height of 1 m from the floor (60 cm for children). Then, using sticking plaster, sticky tape or a drawing-pin, secure the bottom of a 1-m length of tape-measure to correspond with the line. Similarly fasten the top, which will now be 2 m from the floor. The person being measured stands against the wall facing outward (Figure 17). The height of the individual is ascertained using a block of wood having a true right angle. A rectangular block with the dimensions 30 x 10 x 20 cm is adequate, although a triangular block of the same dimensions, as shown in Figure 17, is easier to handle.

Clinical nutrition examination (for use of medical personnel)

Name................................

Sex................................

Pregnant? ................................

Height................................

Haemoglobin................................

Haematocrit................................

Date................................

Age..................................

Lactating?................................

Weight................................

Upper-arm circumference ................................

Triceps skin thickness................................

Hair

    1. Lack of lustre? ................................

    2. Depigmentation (colour change)? ................................

    3. Texture change (thinness or sparseness)? ................................

    4. Easily pickable? ................................

Face

    1. Moonface? ................................

    2. Pallor? ................................

Eyes

    1. Xerosis conjunctivae or xerophthalmia? ................................

    2. Keratomalacia? ................................

    3. Conjunctival thickening or wrinkling? ................................

    4. Bitot's spots? ................................

    5. Conjunctival injection or vascularization? ................................

    6. Corneal scars? ................................

Mouth

    1. Angular stomatitis? ................................

    2. Cheilosis of lips? ................................

    3. Angular scars? ................................

    4. Spongy or bleeding gums? ................................

    5. Mottled teeth? ................................

    6. No. teeth decayed (D) ................................

    7. No. teeth missing (M) ................................

    8. No. teeth filled (F) ................................

    9. Total DMF teeth................................

Glands

Thyroid................................

Goitre ................................

Grade (0,1, 2, 3) ................................

Parotid enlarged? ................................

Skin

    1. Xerosis (dry scaly)? ................................

    2. Follicular hyperkeratosis? ................................

    3. Mosaic (crazy pavement)? ................................

    4. Pellagrous dermatosis? ................................

    5. Skin haemorrhages (petechiae or ecchymoses)? ................................

    6. Flaky-paintdermatosis? ................................

    7. Scrotal or vulval dermatosis? ................................

    8. Oedema? ................................

    9. Ulcers? ................................

Muscles

    1. Wasting? ................................

Skeleton

    1. Epiphyseal enlargement? ................................

    2. Beading of ribs (rickety rosary)? ................................

    3. Skeletal deformities? ................................

    4. Subperiosteal haematomas? ................................

Central nervous system (CNS)

    1. Psychomotor change (apathy, misery, etc.)? ................................

    2. Sensory loss? ................................

    3. Calf tenderness? ................................

    4. Loss of ankle or knee jerks? ................................

    5. Motor weakness? ................................

Internal system

    1. Hepatomegaly? ................................

    2. Splenomegaly? ................................

Remarks (include other abnormalities)

................................

...............................

The measurement of the length of young children presents more difficulty. A suitable apparatus consists of a flat board of dimensions 120 x 40 x 2 cm with a headboard 30 cm high fixed at a right angle to one end. The triangle used for height measurements can be used as a sliding foot-piece. A metal tape-measure is nailed to the board for readings in centimetres.

A less satisfactory alternative is to push a flat wooden bench, available in most dispensaries and schools, up against a wall in the corner of the room and measure it off in centimetres, starting about 50 cm from the wall and going up to 150 cm. The triangle is again used as a foot-piece.

When the length of an infant or toddler is being measured, the child must lie flat and straightened out to full length (see Figure 17). For research purposes or where adequate funds are available, commercially made length boards can be used.

FIGURE 17. Measuring height

Series readings. A series of readings of weight and/or height of an individual taken at, for example, monthly intervals gives valuable information. In an adult, weight loss indicates that energy intake is below energy output. Gain in weight indicates a more than sufficient energy supply. In adults a series of weight readings might be used, for example, during a famine to ascertain whether relief measures are adequate, or in a normal year to see if weight drop occurs during the hungry season. In children a series of monthly height and weight readings gives an extremely valuable record of the child's progress and nutritional status. It is worthwhile to keep a record of measurements taken of the heights and weights of children in schools, dispensaries and even community centres. The measurements can be carried out by either medical or non-medical personnel. When weight is measured in a series of readings, the figures are useful even without those for height.

If single readings of weight or height are available, they can be compared with a standard weight or height. The individual child's actual weight or height can then be expressed as a percentage of that expected for his or her age or in terms of standard deviations or Z scores. Standard tables for weight, height and certain other anthropometric measurements are given in Annex 2, based mainly on United States National Center for Health Statistics (NCHS) reference values as recommended by the World Health Organization (WHO).

Weight for height. When weight and height have both been measured, it is possible to determine how near the child is to the standard weight for height. Even if the age of the child is not known, it is possible to assess nutritional status to some degree by expressing the weight as a percentage of that expected for the child's height or length or in terms of standard deviations or Z scores. This figure gives a relative measure of how thin the child is. Another commonly used method is to calculate the body mass index (BMI) (see Chapter 23 for details).

Mid-upper-arm circumference (MUAC). The measurement of the circumference of the left upper arm midway between the acromion process (the bony tip) of the shoulder and the olecranon process (the point) of the elbow is being increasingly used as an index of nutritional status. Fibreglass tape-measures that do not stretch should be used. This method does not provide nutritional status information as reliably as does measurement of weight and height, but it has the advantages of being inexpensive and usable where no scale is available for weighing. Furthermore, between about eight months and five years of age the standard arm circumference increases very little. An arm circumference above 13.5 cm can be considered normal for children from one to five years of age. MUAC between 12 and 13.5 cm indicates moderate malnutrition, and below 12 cm indicates more serious malnutrition. The MUAC measurement may be especially suitable for use by persons with a minimum of training or for gross assessment of nutritional status in famine areas.

Head and chest circumference. The head circumference can be measured using the same tape-measure used for MUAC. The tape is placed horizontally around the head at a level just above the eyebrows, the ears and the most prominent bulge at the back of the head. Head circumference is related to brain size, but brain size is not necessarily related to intelligence.

The chest circumference is measured horizontally at the nipple line. Up to six months of age the head circumference is usually larger than the chest circumference. Children over 12 months of age having a head circumference larger than the chest circumference are abnormal; this is evidence of poor growth of the chest.

Skinfold thickness. The skinfold thickness can only be measured if a pair of skinfold callipers is available. This instrument is designed to measure the thickness of the skin and subcutaneous fat using constant pressure applied over a known area. The two most common sites for measurement are over the triceps and in the subscapular region. The measurement is of considerable value in assessing the amount of fat and therefore the reserve of energy in the body. Unfortunately this instrument is rarely available in small hospitals, let alone health centres and dispensaries. This situation could easily be rectified, since the instrument is not expensive. The two most common skin callipers used are the Harpenden, made in the United Kingdom, and the Lange calliper, made in the United States.

Laboratory tests

Many laboratory tests have great value in determining nutritional status, but few of them can at present be performed outside large hospitals. Only those tests that are widely available are discussed here.

Haemoglobin. An accurate assessment of haemoglobin level is by far the most important laboratory information that can be obtained in any nutrition survey. Accurate haemoglobinometers are rarely available in district hospitals, health centres and dispensaries. However, some cheap and simple-to-use haemoglobinometers which are reasonably accurate are now available.

In hospitals and for field research the cyanmethaemoglobin method is recommended. Blood is collected from a finger, ear lobe or heel prick. Two measured samples of 0.02 ml of blood are added to Drabkin's solution (a cyanide-ferricyanide solution). The specimen should be stored cool and protected from sunlight. The haemoglobin is determined later the same day using a spectrophotometer or other apparatus.

Haematocrit or packed cell volume (PCV). This determination is also important in the diagnosis of anaemia. A capillary tube is filled with blood from either a vein or finger prick. The sample is spun in a standard electric or hand centrifuge, which separates the red cells from the plasma. The haematocrit or PCV is the percentage of the blood volume composed of red cells.

Red cell counts and blood films. Red cell counts are not easy to do and add little information to the above tests. However, it is easy to prepare a thin blood film on a glass slide. Such slides are useful, since they enable the size and uniformity of the red blood cells to be seen. Use of such slides may facilitate the diagnosis of malaria and the haemoglobinopathies that may also cause anaemia.

Serum protein. Determination of total serum protein and especially of the serum albumin and globulin levels can only be undertaken in a well equipped laboratory. These data are useful in cases of kwashiorkor, but they have not been found helpful in the diagnosis of mild or moderate PEM.

Examination of stools, urine and blood for parasites. After haemoglobin estimation, the next most important laboratory tests in a nutrition survey are strictly non-nutritional. There is little doubt that parasitic infestation and malnutrition are closely linked. The medical nutritionist must examine the individual and the community on all aspects related to public health. Laboratory examination should therefore be made of stools for the ova of hookworm, roundworm, Trichuris species, Schistosoma mansoni and other parasites; of urine for albumin, casts and Schistosoma haematobium; and of blood for malaria parasites. These tests are all easily performed in most dispensaries. They require only a microscope, a hand centrifuge, some laboratory glassware and a few simple reagents. Precautions should be taken in collection and disposal of specimens. Quantitative tests to assess the parasite load should be performed if possible.

During a nutrition survey it may be preferable to do these examinations on a separate day or during the afternoon following clinical examinations in the morning. In a large community it is advantageous to restrict these examinations to one particular group, such as all the children at the local school. The results will give a reasonable picture of the prevalence of diseases such as malaria and hookworm in the community. It is easier and more hygienic (especially with regard to stool examinations) to deal with a selected group than to collect specimens from people scattered over wide areas who have assembled in large numbers at a centre for clinical examination.

Biochemical tests. Certain biochemical tests (see Chapters 13 to 20) are useful for assessing deficiencies of almost all the minerals and vitamins. Even though in many developing countries vitamin A deficiency and IDD are important public health problems, very few local hospitals have laboratories that can conduct tests to assess these deficiencies. Similarly, in countries where pellagra, ariboflavinosis and rickets occur there are very few laboratories that can assess these deficiencies.

Table 37 lists the important nutrient deficiencies and indicates laboratory tests used for their assessment.

Dietary surveys

Accurate assessment of the dietary intake of a community takes much longer than getting a picture of the community's nutritional status by clinical or anthropometric examination. There are two main types of dietary survey. One relies on direct observation of a sample of the population, with their food measured and weighed over a given period of time. The other relies on inquiry, with a larger group of people questioned about their diet. Each type has a disadvantage: the former is very time consuming, and the latter depends on the memory, integrity and intelligence of the subjects questioned. Neither method takes account of past consumption or of uncertainties of food composition. Such involved methods are rarely justified or practical. It is often better to use cruder, simpler methods that provide data that reveal the causes of malnutrition and suggest corrective measures. The various methods of dietary survey are discussed below.

Observation. The only way to assess the diet accurately is to weigh and measure all the food that individuals eat over a representative period of time. A survey team goes to households and weighs and measures all food that is prepared, cooked and eaten, as well as that which is wasted or discarded.

If possible, the proportion of the total quantity of food prepared that is eaten by each individual should be weighed. (This is difficult in countries where household members often feed from one large communal dish or pot.) When the food eaten by each person on an average day has been ascertained, it is necessary to calculate the amount of each nutrient eaten by each subject or each family, using quantitative tables of dietary constituents.

A dietary survey of this kind requires a survey team of at least two persons that can cover two to four families at one time and perhaps 20 families in a month. It is essential to obtain truly representative households as samples and to cover a small, statistically acceptable sample of the population properly, rather than to try to cover more families in a less thorough manner.

Inquiry or recall. Direct inquiry cannot give very accurate information on amounts of energy or nutrients consumed. However, it can give an indication of the frequency of meals and the methods of food preparation and cooking, as well as providing details of the foods commonly consumed.

In developing countries it is most usual for a survey worker to go to a household and ask questions of the wife of the head of household. The answers are recorded on a form. This kind of inquiry depends heavily on the memory of those giving information and also on their attitude towards the person inquiring. False answers are often given unconsciously, or the subject may have some concealed reason for misleading the inquirer. For example, if the subjects believe that the inquiries are being made to ascertain whether famine relief food should be issued or increased, then quite naturally they will indicate that they are eating a small quantity and variety of food. If, however, they believe that the questioner is attempting to assess their standard of living or their degree of development, local pride may influence them to overstate the quantity and variety of food that they eat.

The most common method is to ask the subject to recall what was consumed during the previous 24-hour period. This is termed the 24-hour recall method. It is useful to have available local measures (bowls, cups, spoons) so that the respondent can indicate the approximate amount eaten.

Another survey method is to have literate people fill in a questionnaire. For example, schoolchildren may be given a questionnaire on which they are asked to record each morning for a week what they ate during the previous 24 hours. The process should be repeated at different seasons of the year. Such an inquiry gives no indication of quantities consumed, but it may provide useful information about meal patterns, the staple foods of each household, the frequency of consumption of certain foods such as meat, fish, eggs, fruit or vegetables, seasonal variations in diets, etc. Food frequency surveys of this kind can be performed on other groups of people. They provide qualitative, not quantitative, information.

Combined observation and inquiry. In a combination method, the observer goes to previously selected households and asks the wife of the head of household to show what food she intends to cook for the family that day. This food is then accurately weighed. The worker also records the number, sex and age of the people in the household. He or she then moves on to the next household. Clearly much more ground can be covered per day using this method than with a full-scale dietary survey as described above.

However, the respondent may have no idea of how much food she is going to use that day, or she may exaggerate the amount. This type of survey takes no account of food loss or wastage and gives no indication of what individual members of the family consume. The medical nutritionist is often very keen to know what the toddler or the pregnant woman actually eats, not what is prepared for the whole family.

One survey using this method, carried out in East Africa under the direction of statisticians, reported that the people surveyed consumed over 5 000 kcal per head per day. Malnutrition and undernutrition were known to exist in this area, and the likely intake of those questioned was 2 200 kcal. Clearly the average householders in this survey area had tried to impress the observer with how well they were living.

TABLE 37

Manifestations of important nutrient deficiency diseases

Disease

Nutrient

Prevalence

Clinical manifestations

Laboratory tests

Protein-energy malnutrition; kwashiorkor, nutritional marasmus

Protein and energy

Very high

Growth retardation and wasting; in kwashiorkor; oedema, flaky-paint dermatosis, hepatomegaly, hair changes, mental signs; in marasmus; loss of subcutaneous fat, extreme wasting

In kwashiorkor; low total serum protein and very low serum albumin levels; low levels of digestive enzymes; in marasmus; low urinary hydroxyproline

Xerophthalmia

Vitamin A

High

Night blindness; conjunctival xerosis; Bitot's spots; corneal xerosis and ulceration; keratomalacia, corneal scarring

Low serum vitamin A levels; altered relative dose response; changed cytology of conjunctival cells

Beriberi, Wernicke's encephalopathy

Thiamine (vitamin B1)

Moderate/low

Weakness; peripheral neuropathy; loss of reflexes; ataxia; weight loss; oedema; dyspnea; heart failure; in infants; tachycardia, aphonia, heart failure; in Wernicke's syndrome; ataxia, ocular signs, psychosis

Low whole blood or erythrocyte transketolase activity; low urinary thiamine In 24-hour urine collections or per gram of creatinine; low thiamine In whole blood

Ariboflavinosis

Riboflavin

High

Cheilosis of the lips; angular stomatitis; glossitis; seborrhoeic dermatitis, often of genitalia

Raised levels of erythrocyte glutathione reductase; low urinary Riboflavin levels in 24-hour urine collections or per gram of creatinine

Pellagra

Niacin

Moderate/low

Photosensitive dermatitis on light-exposed areas; diarrhoea; stomatitis; mental contusion, depression and psychosis

Low levels of urinary N-methyl-nicotinamide In 24-hour urine collections or per gram of creatinine; low niacin in whole blood

Scurvy

Ascorbic acid (vitamin C)

Low

Swollen fragile papillae between teeth; bleeding gums; petechial and other skin haemorrhages; depression; weakness; in infants; tender swellings of bones; frog-leg position

Low leucocyte vitamin C; low serum ascorbate levels

Megaloblastic anaemia

Folate, vitamin B12

Medium

Anorexia; tiredness; dyspnea; ankle oedema; cheilltis

Low haemoglobin; hypersegmentation of polymorphonuclear leucocytes; megaloblastic red blood cells; macrocytic red blood cells; low levels of serum folate

Rickets, osteomalacia

Vitamin D

Moderate low

In rickets; craniotabes, bony deformities, rickety rosary because of enlargement of costochondral junctions, bow-legs, kyphosis, bossing of skull; in osteomalacia; bone tenderness and pain; kyphosis and bony deformities, waddling gait, tetany

Low plasma 25-hydroxycholecalciferol levels; Increased plasma alkaline phosphatase

Microcytic anaemia

Iron

Very high

Tiredness, weakness, dyspnea, pallor of tongue, nailbeds and conjunctiva; occasionally pica

Low haemoglobin; low serum ferritin; low transferrin saturation; raised free erythrocyte protoporphyrin; hypochromic macrocytic red blood cells

Iodine deficiency disorders, goitre, cretinism

Iodine

Very high

enlargement of thyroid gland; in children born of iodine-deficient mothers cretinism, mental retardation, deaf-mufism; strabismus

Low urinary iodine levels

Zinc deficiency

Zinc

Low

Acrodermatitis enteropathica with bullous dermatitis; dwarfing; hypogonadisim

Decreased plasma zinc levels

Dental caries

Fluoride (plus other causes)

Very high

Tooth cavities; tooth decay; loss of teeth.

Excess fluoride causes dental fluorosis

  

Reducing random and systematic errors. In almost all methods of obtaining dietary information there are common errors which make the data unreliable or even lead to wrong conclusions. These errors can be random or systematic. Various precautions including quality control can be taken to reduce some errors. No dietary assessment measurements are completely precise.

Random errors are related to the precision of the dietary method used. If the number of observations made is increased, the influence of the random errors on conclusions reached will be reduced. Many such errors cancel each other out, and they are therefore of less concern than systematic errors.

Systematic errors cannot be reduced by increasing the numbers of observations, and they do not usually cancel each other out. They are often cumulative and may be increased when more observations are taken. They therefore constitute a more worrying problem than random errors.

Systematic errors may result from several kinds of bias. Possible biases on the part of the interviewer include improper writing down of answers; neglecting to ask certain questions; and failure to ensure that the subject understands the questions. Those on the part of the subject include provision of information that is not true but is believed to be the "desired" answer (perhaps to try to create an appearance of being either better off or worse off); underreporting or overreporting of the consumption of certain foods; and lack of understanding of certain questions.

Other major sources of error in dietary surveys include difficulties in estimating the size of food helpings or the size of an item eaten; poor memory of what foods were eaten; and failure to remember or to mention foods eaten between meals. Errors may also arise in translating the results recorded on the survey form into amounts of food in grams and millilitres and into nutrients consumed There may also be coding errors.

Methods that should be used to try to minimize errors include quality control; training, retraining and checking of interviewers, coders and data analysts; use of standard questioning methods and good data collection forms; consistent use of good and appropriate food models of different sizes and commonly used household measures and utensils; and finally instilling into survey workers and study subjects the vital importance of accurate information. Interviewers should understand that it is much better to admit errors rather than to hide them or falsify data. Respondents should be convinced that it is preferable to admit not knowing or not remembering rather than to provide an untrue answer.

Vital statistics

Vital statistics are those related to births and deaths in the community. Complete and accurate vital statistics are not maintained in all countries, nor are they likely to be in the near future. However, vital statistics are so important as an index of nutritional status and for other public health reasons that they serve a useful purpose even if collected in small areas only. Infant mortality rate (death during the first year of life) gives a good indication of the state of nutrition and the health of the community. The neonatal mortality rate (death during the first month of life) and stillbirth rate are also useful.

In developing countries, figures for the toddler mortality rate (TMR) (deaths between the first and fifth birthdays) are far more useful to the nutritionist than the other rates TMR values often give a good indication of the prevalence of PEM, although they do not necessarily illustrate the nutritional status of the whole community.

TMR often provides a clear indication of the comparative state of development of a country. For example, in Scandinavia, the former Soviet Union, North America and the United Kingdom, TMR is below 1 per 1000, while in much of Asia and Africa it is at least 35 times as much. The infant mortality rate is around 7 per 1000 in Sweden and from 35 to 150 per 1000 in most African countries.

Although it is normally impossible for an individual worker or a survey team to collect accurate vital statistics, some information of value regarding birth rate and death rate is usually available. For example, during a survey, one can easily ask all married women of child-bearing age two simple questions:

From these figures a percentage of children that have died and also some indication of the fertility rate can be obtained. Careful questioning might also elicit the approximate ages of the living children and a rough estimate of the age at which the others died. Questioning as to the cause of death, if carefully done, may produce useful information.

It must be emphasized that information gathered in this way provides only rough estimates of the true figures, but these are nevertheless useful and will have to suffice until such time as proper vital statistics are maintained

Other useful data

As indicated above, many other types of information are helpful in assessing nutritional status. These include other health statistics and medical information. Diarrhoea rates, measles incidence and other disease data have implications for nutritional status. (See Chapter 3 for the relationship of nutrition to infection, health and disease.)

Since food security (see Chapters 2 and 35) is partly dependent on food production, agricultural data are useful in judging the likelihood of food security and its relationship to nutrition. Economic data provide information for judging the nutritional climate in a community or a country. Figures on incomes, purchasing power, food prices and food distribution are useful. Data normally obtained by food scientists are helpful in judging nutritional status, food quality and food safety.

Participatory and rapid appraisal techniques

In the field of nutrition, as in social, agricultural and other fields, it has been increasingly realized that participatory methods of collecting information have many advantages. Involving members of the community, the potential beneficiaries, at the stage of data collection can prove extremely valuable. The active participation of the community in assessment and analysis, rather than only in the action stage of a project or activity, is likely to be very helpful. It assists in educating the public, in mobilizing local resources, in empowering people and in sustaining the success of actions taken. The community members, whether villagers or urban dwellers, come to understand their health and nutrition situation and the underlying causes of various problems. They offer alternative options for change and play the central part in implementing actions. This kind of participatory development, which is now suggested for nutrition, was well described 30 years ago by Paulo Freire working in Brazil. He termed it "conscientization" of the community, or helping community members become more aware of the causes and consequences of nutritional problems and, more important, how they can work together to prevent and overcome such problems.

A new series of techniques have emerged in the last decade as tools for participatory appraisal exercises. Semi-structured interviews, with either selected individuals or focus groups, are combined with observation (e.g. transect walks) and visualization techniques (such as mapping, seasonal calendars, ranking exercises, time charts and Venn diagrams). These techniques are particularly useful to gain an understanding of people's food habits and related beliefs, food entitlements and existing constraints and the role of the different family members in relation to nutrition (household food security, health and care). The choice of the techniques and their combination will be determined by the information needs and time constraints of community members. It is essential to cross-check the information gathered through different techniques. The information must be analysed on a regular basis to identify inconsistencies and remaining gaps, to be addressed in the next stage of the appraisal.

Participatory appraisal can best be carried out jointly by the community and local development staff, as it is a continuous process and should be an integral part of development activities at community level (for identification and selection of activities to promote household food security and nutrition, monitoring and evaluation, and reformulation).

Another major change in data gathering for assessing the nutrition situation of communities is the acceptance of rapid appraisal methods. Rapid appraisal exercises can help develop a first understanding of the situation and identify issues on which further information is needed. They can then be complemented by formal surveys or routine data collection. The rapid methods borrow from anthropology and the other social sciences to obtain both quantitative and qualitative data. They offer promise because if properly used, they can provide useful information without the need for more complex survey methods or very large sample sizes. Even though rapid appraisal is usually carried out by international or national experts, it should involve local development staff who will be in a position to ensure follow-up of the process within their regular activities.

Nutritional surveillance

Nutritional surveillance is a set of activities to assemble information to assist in policy and programme decisions to influence the nutritional status of a population. It usually includes the regular and timely collection, analysis and reporting of nutrition-relevant data. Surveillance differs from surveys in that it involves the periodic or continuous collection of data.

For many years various kinds of nutritional information have been collected, often for decision-making, but nutritional surveillance did not become a central activity in national nutrition planning until after 1976, following the report of a Joint FAO/UNICEF/WHO Expert Committee entitled Methodology of nutritional surveillance (WHO, 1976).

Because nutritional status is influenced by many different factors, nutrition monitoring and nutrition indicators may come from many different disciplines and may be of many different kinds, ranging from meteorological data, to food production, to nutritional status of people and so on.

Because nutrition is an outcome of social, economic, health, agricultural and other conditions, the nutritional status of a population can be used as an indicator of the overall development of a society. Specific nutritional status indicators are often better indicators of equitable development than are traditional economic indicators such as gross national product.

Information for decision-making

Nutritional surveillance, like nutrition surveys, is not useful if the data collected are not used to improve the nutritional status of the population. The weakest part of many nutrition surveillance programmes has been that the data collected have not been used to solve nutrition problems. For various reasons decision-makers have not used the information to take action. Why? It may be that lack of information was not the problem, that the kind of information needed is not being provided, or that there is a lack of commitment and resources to solve the nutritional problems. In general, it is agreed that the information needs to be provided in an easily understood form and in a timely manner.

In the past, nutritionists, health workers and others collected data and passed them to decision-makers in the expectation that action would follow. Some rethinking is strongly recommended. It is suggested that the first step after identifying the important nutritional issues should be to discuss and review possible policies and programmes and to identify how decisions will be made to influence these policies and programmes. This exercise would influence decision-makers to identify for themselves the information that they need in order to make decisions. If this approach were taken, the data collected would be what the decision-makers needed and would be likely to be used by them. The data would be analysed and would be discussed with the decision-makers, and decisions could be made to take appropriate actions. Later the impact of the actions would be determined.

Before surveillance is initiated, there should be an assurance first that there will be good communication between the people and institutions collecting the data and second that the data will reach the people and institutions that have the power to make decisions.

Assessing and monitoring nutritional problems

There are a huge number of possible indicators of nutritional status. The following are some typical indicators of different kinds that have been used in nutrition monitoring (FAO/WHO, 1992b).

Local decisions need to be made on which indicators to use. It is best if only a few indicators are chosen and if these are suitable for relatively easy regular collection. In developing countries the most widely reported indicator of malnutrition is low weight for age. However, data used are often not representative of the population and have been gathered from hospitals or growth monitoring clinics. For nutritional surveillance the data should be representative of the targeted population (for example, children six to 36 months of age of a particular district) and should be collected periodically. The use of well-chosen sentinel sites where data are regularly collected is a means of obtaining such data. However, although weight-forage data provide a picture of the nutritional status and, if collected regularly, give important information on trends, they do not reveal the causes of the malnutrition identified. These underlying determinants can be grouped into those related to food security, health factors and child care (see Chapter 1). Data are often collected routinely on some of these causes.

In food crises early warning indicators may allow action before overt starvation. Indicators may be based on forecasts of food availability and food prices in the market. In countries where droughts are common, data on rainfall provide an early warning; these data are followed by food crop status and harvest yield estimates plus monitoring of food stocks, reserves, marketing and prices. Sentinel households can provide useful information, some quantitative (e.g. crop yields and food stores) and some more qualitative (e.g. subjective views about family food security and reporting when they have to sell their personal possessions to purchase food).

In relating health factors to nutrition the focus is usually on infections and on monitoring infectious diseases such as measles, whooping cough, diarrhoea, respiratory infections, intestinal worm infections and malaria. Important health interventions also deserve monitoring; these include immunizations, oral rehydration for diarrhoea, attendance at clinics and preventive measures such as health and nutrition education, sanitation and improvement of water supplies.

To monitor caring practices and their impact on nutrition, data could be collected on breastfeeding and weaning, time available to the mother for child care and competing activities, differential treatment of girls and boys, family responses to poor appetite or poor health in their children, etc.

Many of the indicators discussed above are rather directly related to PEM, but many are also associated with micronutrient deficiencies. Lack of food security, high rates of disease and deficient caring practices have a negative impact on vitamin A and iron nutritional status as well as on PEM. Specific micronutrient deficiencies may also be monitored, for example by monitoring night blindness rates for vitamin A deficiency or haemoglobin levels for iron deficiency. Objective data might be collected from sentinel households. Data on food consumption also provide useful information.

The use of rapid appraisal methods is potentially valuable in monitoring nutrition. Some of the data collected in this way might be qualitative, including some that provides information on the functioning of relevant programmes.

TABLE 38

The four types of nutritional surveillance

Objective

Type

To prevent short-term critical reductions in food consumption

Timely warning and intervention

To enhance the nutritional effects of development policies as expressed through programmes to assess policies and programmes

Policy and programme planning

To nationalize and maximize effectiveness of health and nutrition programmes

Management and evaluation

To assess and/or monitor indicators related to nutritional status as a basis for directing funds towards particular nutritional problems

Advocacy

Nutritional surveillance systems

There are four types of nutritional surveillance, distinguished by their different objectives (Table 38). A number of countries have only one type of surveillance system, while others have several or even all four. Where several types are used, they may be coordinated in an organized way and may use some common data.

Timely warning and intervention. Nutritional surveillance was first established to warn governments of poor nations of imminent nutritional crises. It was in part modelled on health surveillance for important infectious diseases. Certain infectious diseases such as plague and cholera are notifiable to WHO; countries require that each district or province notify the national ministry of health on a weekly basis of the number of cases of notifiable diseases. In famines or severe crises, data on famine deaths or serious famine-related malnutrition can be collected and reported. Unlike outbreaks of serious infectious diseases, famine brings with it many cases of serious malnutrition. Nutritional surveillance reports on indicators that would warn a government of an approaching nutrition disaster. As listed above, production patterns, market prices, food stocks and fall in body weights are possible indicators of food crises.

The types of data needed for an early warning system must be decided in the individual country or the affected region of the country. They cannot just be prescribed. It is important that the indicator system be sensitive and that it be able to predict food crises, even if warning is sometimes given of a crisis that does not then occur.

The first indicator may be rainfall below a certain level over a period of two or three agriculturally critical months. The next set of indicators might relate to the important crops in the field prior to harvest. These may be followed by estimates of food production and indications of food consumption. Finally, actual indicators of nutritional status such as the weight of adults and children in poor families may be monitored.

In some countries indirect indicators have proved useful, such as the pawning of household items, the movement from the consumption of a preferred food such as rice to a less desirable food such as cassava or the actual measure of food stores of sentinel households.

In Indonesia a timely warning intervention was introduced at the district level in drought-prone districts. Data collected at the district level could be provided quickly to the district official, who was given authority to take immediate action. A district-level food security system was established so that surveillance data indicating a shortfall in the food supply would result in delivery of a supply of rice to the local markets to prevent price rises and unavailability of rice. If the data had had to go to the capital city for review before decisions were taken, as is the case in many countries, long delays would have occurred. This example illustrates the need for data to be provided rapidly to officials authorized to take action speedily. Unfortunately the need is not often satisfied; data often end up as reports considered by people far from the scene, on which little action is taken.

Nutrition surveillance for policy and programme planning. Many kinds of indicators, including those listed above, can be used by governments or local authorities for surveillance to influence policy and programme planning. The data may be on nutritional status or on a variety of factors that influence nutrition. For example, anthropometric data may be collected on a regular basis to describe PEM trends over time. The data may be analysed to discern groups of the population most severely affected. They might be used to show which five provinces in a country have the worst malnutrition; which social groups are worst off; or what health factors are related to the most serious PEM. The next step might be to decide on direct interventions (perhaps supplementary feeding or nutrition education) for the most seriously affected groups and to suggest ways in which existing policies (for example, regarding credit for small farmers to improve agricultural productivity or subsidies for staple foods for the poor in urban areas) might be modified or strengthened to influence nutritional status.

Costa Rica has had a national nutritional surveillance and information system since 1978. The system is designed to target activities to the poorest parts of the population and the poorest areas of the country. The anthropometric data used include child height, collected when children enter primary school, and the weight of younger children, collected by home visiting. A goal of the surveillance has been to use existing programmes more effectively by targeting activities to the poorest families who have the most PEM.

In these types of programmes interventions may be clearly nutritional (supplementary feeding; iron supplements) or non-nutritional but expected to have an impact on nutritional status (measles immunization; improved sanitation and water supplies; actions to reduce women's work load).

Nutritional surveillance for management and evaluation. Surveillance can be used to evaluate programmes aimed at improving nutrition and to assist in their management. For example, data from growth monitoring over a period of five years might be used to evaluate whether an agricultural credit scheme has improved the nutritional status of children; or night blindness data might be used over time to evaluate whether horticultural activities are influencing vitamin A nutritional status.

Data collected might be used as an internal management tool to judge the efficiency with which programmes in different parts of a country reach their objectives, or to compare the effectiveness of two alternative interventions aimed at solving the same nutritional problem.

Nutritional surveillance for advocacy. Scientists are often reluctant to be advocates, believing falsely that advocacy is unscientific. It is highly desirable, however, that most of those involved in nutrition be advocates for action. If serious problems of malnutrition are found in areas where food and health services are available the situation is unacceptable, and it is right to advocate interventions to reduce malnutrition.

Conducting surveillance for advocacy mainly involves collecting data on the prevalence of PEM or micronutrient deficiencies or on related indicators and using these data to get support for action. Support can be solicited in different ways including making the government aware of the problems found or embarrassing the government into taking action by publicizing a serious nutrition problem in the news media. The objective is to influence policy-makers to allocate resources and to provide the needed assistance to allow interventions or programmes to be implemented to improve the nutritional status of the communities affected. For example, in Chile it appeared that a reduction in supplementary foods provided to poor families was adversely influencing nutritional status. Advocates used anthropometric data from the health monitoring system which showed a recent rise in the rates of malnutrition in children. When the government was presented with these findings, it reinstituted the supplemental food benefits.

Nutritional surveillance cycle

Table 39 illustrates ten basic steps in nutritional surveillance or in nutrition monitoring. These steps form a cycle; when Step 10 is reached, the cycle needs to continue. The first five steps involve assessment, data collection and analysis, while Steps 6 to 10 move to decision-making and the enactment of interventions based on the decisions.

Nutritional surveillance is part of a data or information management system. It is designed very concretely to provide the data and the information that will help decision-makers ensure that actions and interventions are implemented based on good information. It is hoped that nutritional surveillance properly used will help ensure good decisions aimed at improving nutrition, and that the decisions will be made by senior officials who have the authority, the ability and the resources to ensure proper action.

TABLE 39

Basic steps in carrying out nutritional surveillance

Scope

Assessment

Implementation

Impact

1. Problem identification, including desired impact of action taken

10. Actual impact

Intervention

2. Proposed policies and intervention strategies

9. Intervention enacted based on decision

Decision

3. Potential decisions regarding policies and interventions

8. Decision(s) made based on information

Information

4. Information needed to aid in decision-making

7. Data analysis: the transformation into information

Data

5. Data needed to generate information

6. Data collection action

Chapter 34. Improving food quality and safety

Food production and food demand receive a great deal of attention in agriculture and nutrition. Clearly for people to have a healthy diet enough food has to be produced and families have to have access to sufficient food which then is consumed in adequate amounts by each family member. These issues are discussed elsewhere in this book. What receives less attention in writing, in training and in action is the fact that the food and water that people consume need not only to be adequate in amount, but also to be safe and of good quality.

Most industrialized countries have well-developed systems to ensure a reasonable level of safety and quality of foods consumed. Most developing countries have rudimentary systems that need strengthening. For a food system to work effectively, all those involved in it - from production, through processing, to marketing and eventual consumption - must be educated about food safety and quality and must implement actions to ensure them. Consumer education is a part of this effort.

Consumers, the food industry, government ministries and international agencies all have important, interrelated roles in ensuring food quality and safety. Food control measures can help reduce food losses and food spoilage, promote appropriate food processing and help ensure food safety and quality for the local consumer, for local markets and for export.

These lofty goals require appropriate legislation, regulations and food standards. These in turn demand a means to ensure compliance, which entails surveillance or monitoring, usually carried out through food inspection and in many cases laboratory analyses. Poor countries may not have the trained staff or the facilities to do a very good job in this respect, so they often decide to limit their activities in the area of food safety by trying to avoid serious outbreaks of food-borne illnesses and serious food contamination. Without much laboratory backup, public health inspectors and related staff may visually inspect meat at abattoirs or in meat markets; visit shops to find spoiled food; and inspect restaurants, hotels and stalls that sell food. They can insist that reasonable standards of hygiene are observed.

Appropriate national authorities should at the very least take steps to educate the public about food safety and quality so that consumers can insist on safer, better foods. These practices may begin with the education of the farmers who grow the foods and continue with education at various stages along the food path, up to the family kitchens in rural and urban areas. Education and assistance to food processors and manufacturers are also important. All should be made aware of standards, food laws and existing regulations and how to adhere to them.

In many rapidly urbanizing poor nations, more and more food is sold, processed, cooked and even served by small-scale entrepreneurs such as market or street-corner vendors. At street-side stalls or tables food safety and quality practices are not infrequently ignored. As many students are frequent street-stall users, food safety and food quality should be included in nutrition education activities and in the curriculum in schools to empower students to recognize food that is of doubtful quality or safety.

Ensuring food quality in poor nations

Poor countries often do not have the institutions or the personnel to ensure food safety and control, although most do have some legislation, standards and regulations on the books. Governments would be wise to seek help internationally to improve their capacity in this regard. Small, poor countries can sometimes, with international assistance, share food microbiology and toxicology laboratories. The larger, emerging developing countries, sometimes called middle-income countries, should devote much more effort than they do now to ensuring food safety, and many can afford to do so. These countries are becoming highly urbanized and commercialized. The centres of the cities often appear modern and Western, with high-rise buildings, paved streets and running water in every household. However, nearby are often slums and squatter settlements which do not have safe water or satisfactory sanitation. In these areas the food that is sold is very likely to be contaminated and unsafe.

The food industry has an important part to play in food quality and safety at every stage of the food path from agricultural production onwards. For example, in the fields where crops are grown chemical fertilizers and pesticides need to be properly used; appropriate methods of preservation and storage need to be adhered to; and good technologies must be adopted to ensure food products at low cost but of high quality and safety.

International organizations can provide expert technical assistance and advice on various aspects of food quality and food safety, including the use and control of food additives; cut-off points for acceptability of food contaminants; and monitoring of simple hygienic practices in particular industries.

FAO and other organizations have a very important role internationally in advising member countries about appropriate legislation and regulations, which may include specific standards and guidelines related to quality, safety and labelling of foods put up for sale. Many of the standards and guidelines have been developed by the Codex Alimentarius Commission, a joint body of FAO and the World Health Organization (WHO) that provides international standards designed mainly to protect the health and welfare of the public while ensuring fair trade practices. These food standards help in international trade of food products. FAO, almost since its inception 50 years ago, has helped member countries improve the quality and safety of foods available for consumption by their people, through its staff expertise, meetings and expert consultations, numerous publications, assistance in standards development and numerous other activities. But for the countries themselves, adhering to standards and codes that help ensure the safety of foods must surely be considered a part of national or local food security.

An epidemic of a serious food-borne disease can have a significant negative impact on food trade within a country or internationally. A good recent example is the cholera epidemic which was first reported in Peru in 1991 and then spread first to other Andean countries and then to a wide group of Latin American and Caribbean countries. Peru is a major exporter of seafood, and very soon its trade was greatly affected, areas were quarantined and internal trade was limited. The result was a major negative impact on many poor people involved in the trade of seafood and later of other foods as regulations became extended. The epidemic led Peru to pay much greater attention to urban water supplies, sanitation, food handling and sale of street foods.

Food or water introduces health risks if it is contaminated with pathogenic organisms, toxins, pesticides or poisons. Any of these can lead to illness, sometimes in a few hours and sometimes a long time after their consumption. Perhaps the most common symptom or sign of illness resulting from consumption of contaminated food is diarrhoea. Diarrhoea can be caused by viruses, bacteria, parasites, toxins or poisons. An example of disease occurring a long time after the consumption of contaminated food or water is the development of certain cancers because of carcinogenic toxins.

Contaminated foods eaten at home or in public eating places may appear to be safe or may have evidence of contamination. If food, beverages, dishes or utensils are obviously unclean, if the food looks or smells bad, if a food that is meant to be eaten hot is served cool or lukewarm, if the environment where the food is served has flies, cockroaches or evidence of rodents or if food servers have dirty hands and clothes, then it is likely that the food being served is contaminated.

Sometimes it is difficult for people to refuse to eat food that they suspect may be contaminated. However, there are some steps that consumers can take, for example, at a stall selling street foods.

Remember the old saying, "If you can't boil it, bake it or peel it, then forget it!" This saying makes a lot of sense.

Simple steps to improve food safety

In every household, but especially in those with less than ideal sanitation, some knowledge about food-borne disease is very important. It should be imparted in every school and should be an element of health education at every level. Many people in developing countries have very little understanding of the germ concept of disease, i.e. that serious illness can be caused by unseen organisms. An important challenge for health educators is to ensure that people understand that microorganisms cause disease.

Diarrhoea is commonly caused by a variety of microorganisms which are in human faeces and get into food and water. The following simple preventive steps can be taken.

Latrine and faeces disposal

The first sanitary essential in the household is a latrine and a well-organized system of safe disposal of human excreta. Measures are needed to prevent human faeces from contaminating the household and its environs. Very young children may not be able to use a pit latrine, but their faeces can spread disease and therefore need to be disposed of safely. Animal faeces are not nearly as dangerous as human faeces, but they can spread disease.

Personal hygiene

All members of the household should understand the basic rules and practices of good personal hygiene and practise them. Hands should be washed after use of the latrine and before each meal, and by people preparing food. All aspects of personal hygiene, however, including a clean body and clean clothes, also have a role. Personal hygiene is much easier if adequate water is available.

Household hygiene

A third form of protection is to ensure a good level of household hygiene, which is especially important in the kitchen and wherever food is stored, prepared and eaten. These places need to be kept clean and as free as possible of vermin such as flies, cockroaches and rodents. A clean house is a protection against food contamination and resulting disease.

Food preparation and storage

Various aspects of food preparation and storage have been described in Chapter 32. In the home, irrespective of its circumstances, the best possible efforts should be made to store, prepare and serve food in a way that minimizes the dangers of contamination and to make the meals as nutritious and as appealing as possible. This is relatively easy for an affluent household that has a refrigerator, a gas stove, running hot and cold water in the kitchen and a flush toilet. For a poorer household where there is no refrigerator, where food is cooked outside over a wood fire, where water is carried for two hours from a contaminated stream and where there is a pit latrine, food hygiene is a struggle.

Food preparation to ensure food safety

Bacteria that cause disease multiply rapidly in many foods, but more rapidly in foods of animal origin that are warm and wet. Small amounts of sugar enhance bacterial breeding, while larger amounts reduce it. If foods are not stored at low temperatures millions of bacteria will breed in them. Meat stew will deteriorate very quickly, stiff maize porridge moderately quickly and bread less quickly.

Uncooked dry rice granules will not deteriorate quickly. It should be understood that parasitic eggs (such as those of roundworm) or parasitic cysts do not multiply in food, but they do cause disease.

Four steps to improve food hygiene

Cleanliness along the food chain is the major preventive measure to avoid disease from contaminated food. People should be advised to observe the following household tips.

    · Buy fresh food that looks clean and uncontaminated and has a good appearance. It should not have a bad smell, mould or discoloration. If the food is canned, the can should not be bulging, dented or discoloured.

    · Store the food in a safe cool place. Many foods are best stored in a refrigerator. Dry foods such as cereal grains and flours or legume seeds should be left in a cool dry place in containers that prevent rodents and other pests from gaining access to them.

    · Prepare the food for eating in a clean environment, with clean hands and clean utensils, and cook foods such as meat thoroughly to kill all organisms. Uncooked foods are safe to eat if peeled; if they are not peeled, then washing thoroughly, perhaps in a chlorine solution, will increase their safety. Tomatoes can be dipped in boiling water for two minutes or soaked in a chlorine solution. Lettuce is very difficult to clean thoroughly and presents a danger. Bananas are peeled and are safe.

    · After the meal, leftover food should be stored safely, and some foods that cannot be stored may be fed to domestic animals. Food areas should be cleaned, utensils well washed and garbage buried or burned some distance from the house.

These tips apply almost equally to the small vendor or to those who prepare and sell street foods, although they are not easy to enforce.

Although many cooked foods in a poor household without a refrigerator should not be stored for very long, it is helpful to cover food, perhaps with gauze, to let in air but not flies. Alternatively, food can be kept in a simple "meat safe" which can be a simple wooden box on legs with metal or plastic screening on the sides or across the front. Each leg of the meat safe can be stood in a bowl or can of water to prevent ants and cockroaches from entering the safe.

Biological contamination of food

Organisms are much more common contaminants of food and causes of disease than toxins or chemical poisons. More than 25 organisms, including bacteria, viruses and parasites, infect humans and cause specific disease after being consumed in contaminated foods. Microorganisms are ubiquitous, but only some of them are pathogenic (disease-causing) in humans.

Many of the pathogenic microorganisms are passed out of the body in faeces; they infect another human being when they reach the mouth, taken there perhaps by unwashed hands, utensils or flies. This type of transmission is termed faecal-oral transfer.

Gastro-enteritis or diarrhoea resulting from toxins produced by microorganisms can be distinguished from diseases caused by microorganisms invading the lining cells of the gastro-intestinal tract. The spread of both types is similar. The most important types of microorganisms are listed below.

Viruses

It is now clear that many outbreaks of diarrhoea, particularly in children, are caused by virus infections, mainly rotavirus or Norwalk virus. These viruses do not multiply in food, but they do in the intestine. The measles virus can also cause diarrhoea.

Bacteria

Many different bacteria are food borne and cause gastro-enteritis and other diseases.

Many different types of salmonella have been identified and found to be pathogenic. In some countries salmonella is the main cause of food poisoning. It may be transmitted through consumption of raw or undercooked eggs or through contamination of foods with salmonella by food handlers. Usually symptoms begin less than 48 hours after the food has been consumed. The disease is self-limiting, usually ending within six days. Salmonella typhi leads to the serious disease called typhoid fever, which is also spread by faecal-oral transmission. It is characterized by intermittent fever, a rash, abdominal pain and great, sometimes lengthy, debilitation.

Some staphylococci, such as Staphylococcus aureus, a widespread organism, can lead to diarrhoea and vomiting. Clostridium (Clostridium perfringens or Clostridium welchii) is a common cause of food poisoning. These bacteria are anaerobic and produce spores which can be widespread. Clostridium botulinum causes a very virulent form of food poisoning. It is usually food borne, but it can also infect wounds. If consumed its toxin produces serious neurological and muscular signs and symptoms, and the disease is often fatal. In food-borne infections, the contaminated food, often a preserved meat, becomes the site for toxin production by the clostridia. The spores are resistant to heat, but the toxins are destroyed by thorough cooking.

The disease that used to be called bacillary dysentery is caused by four Shigella species that infect foods: S. sonnei, S. flexneri, S. dysenteriae and S. boydii. These bacteria lead to marked diarrhoea, sometimes accompanied by vomiting and blood in the stools.

A very serious bacterial infection is cholera, caused by the organism Vibrio cholerae. The infection involves much of the small intestine Cholera is an acute infection leading to profuse and frequent watery stools, vomiting and abdominal pain. The patient may soon become severely dehydrated and may die rapidly Oral rehydration can be life saving.

Other food-borne bacteria incriminated in diarrhoea or other diseases include certain serotypes of Escherichia coli (although many forms of E. coli are non-pathogenic); Campylobacter species; Bacillus aureus; and other vibrios such as Vibrio parahaemolyticus.

Parasites

Parasitic infections can be transmitted in food and water. The most prevalent intestinal worm infection is Ascaris lumbricoides (roundworm), which infects about 1 200 million people worldwide. Female worms in the intestine of an infected person produce millions of eggs which pass out in the faeces. If faeces are not properly disposed of, the eggs can get in the household environment or in dust being blown around, can get into food and can infect new subjects. Whipworm (Trichuris itrichiura) and the protozoan infection Giardia lamblia are spread in the same manner and can cause serious disease.

Other parasites are transmitted through consumption of raw or undercooked food. Pork or beef that is not thoroughly cooked may be infected with Taenia solium (pork tapeworm) or Taenia saginata (beef tapeworm) which if eaten will infect the consumer. Pork tapeworm is a particular danger, because it can cause cysticercosis with serious complications. Undercooked or raw freshwater fish may be infected with a tapeworm called Diphyllobathrium latum. The tapeworm in the human gut competes with the host for vitamin B12 so the infection may lead to macrocytic anaemia.

Non-infective food toxicity

Non-infective toxins or toxic substances in foods for human consumption can be "natural" in that they occur in nature. In certain fungi, lathyrus, cassava and fish, for example, these are the most common toxins. Less common but of great importance are toxins that are artificially added to food, such as various chemicals used to assist in food production, including fertilizers, weed killers, insecticides and fungicides. Other toxins that cause problems for humans include metals such as mercury or lead, which may get into the food supply or be consumed inadvertently.

Below is a summary of some of the more important non-infective substances that have resulted in ill health when consumed in food.

Aflatoxins

A toxin produced by a mould called Aspergillus flavus was found in 1960 to kill poultry fed groundnuts contaminated by this mould. A flurry of research followed, and it became clear that aspergillus grows on many foods, including cereal grains, when stored damp in tropical countries. In animals aflatoxin produces liver damage and carcinoma. It is not yet clear if aflatoxins are a determinant in primary carcinoma of the liver in humans; it now seems more likely that the high rates of primary liver cancer in Africa are a result of hepatitis earlier in life. Aflatoxin does cause disease, however. Some countries attempt to monitor the aflatoxin content of foods. Other hepatotoxins are found in food but they are not as important as aflatoxin.

Lathyrus

Lathyrus sativus is a vetch that grows wild, but it is also cultivated, particularly in India, where it may be planted in wheat fields. A neurotoxin in the plant, when consumed in large amounts, causes a neurological disease which can first result in weakness or spasticity in the legs and eventually lead to crippling and paralysis. The disease, lathyrism or neurolathyrism, has been widely discussed in Indian medical literature.

Fungal toxins

Some forms of fungi such as mushrooms are delicious foods and perfectly safe to eat. Other fungi, some of them resembling mushrooms, are highly toxic and lead to gastro-intestinal symptoms and perhaps kidney damage. Consumption of food contaminated with the fungus Claviceps purpura leads to the disease ergotism, with nausea and vomiting, and also to more serious neurological and vascular problems.

Antivitamins

Certain substances in food can act as antivitamins, inactivating vitamins or limiting their absorption in the human gut. The best described is thiaminase, present in certain fish. It has been shown that animals fed raw fish containing thiaminase can become thiamine deficient. It has not been clearly demonstrated that antivitamins are a major problem in humans. Haemorrhages have been observed in cattle that consumed feed containing dicoumarol, a substance that can have a negative impact on vitamin K and lead to bleeding.

Cassava toxicity

Cassava is not indigenous to Africa, but it is widely used as a food in both East and West Africa, as well as in Asia and Latin America. It is usually eaten without any toxic effects, either because of the varieties used or because of local preparation measures that remove the toxin. Some types of cassava contain a cyanogenic glucoside which can result in acute toxicity with serious symptoms and death. It may cause nerve damage leading to paralysis, or it may behave as a goitrogen, aggravating iodine deficiency disorders (IDD) and causing goitres. In many African societies people know how to remove the toxin, mainly by soaking and sometimes also by grating and drying the cassava. Peeling cassava also helps remove the toxin. Toxicity occurs less frequently in Asia and the Americas.

Goitrogens

Some foods other than cassava contain substances that have been termed goitrogens, which appear to make those consuming them more likely to get goitre or IDD. The main goitrogens are thiocyanide, which reduces the levels of iodine in the thyroid gland, and thiouracil, which reduces the secretion of thyroid hormone. These goitrogens are most common in vegetables of the genus Brassica such as cabbage, cauliflower, mustard and rape (see Chapter 14).

Allergens in food

Many people are allergic to one or more foods. Allergens vary in composition and in the foods in which they are found. Shellfish and other seafoods are especially common causes of allergic reactions.

Metals in food

Industrialization, urbanization and the improper disposal of waste from factories and other businesses have caused metals which may be toxic to enter the food supply. A classic example is mercury in fish. In the early 1970s in the United States, various kinds of fish, such as swordfish, could not be sold because they had more than the permissible level of mercury, 0.5 parts per million (ppm). Mercury poisoning has also been a problem in fish in Japan.

Of much greater prevalence worldwide, especially in poor urban areas, is the problem of lead poisoning. Some of the lead consumed comes from foods, particularly animal foods such as meat and milk from animals that have consumed lead. Lead is also inhaled, for example from lead-containing fuels, and it can be ingested from water which has flowed through lead pipes and from the lead-based paints used in old houses. Lead poisoning causes long-term neurological problems, reduced psychological development in children and bone changes.

Other metals that have occasionally caused problems are cadmium, arsenic and selenium. The topic of fluoride excess causing dental or skeletal fluorosis is described in Chapter 21.

Agricultural chemicals

The green revolution, which has led to higher yields of cereals and other agricultural advances, has enhanced farmers' ability to produce food in adequate amounts to feed the rapidly increasing population in the world. Some of the advances are dependent on the use of chemical pesticides, which are used to control weeds and a variety of pests, from marauding animals such as rodents, monkeys and elephants to disease-causing organisms such as parasites, moulds, fungi, bacteria and viruses. Farmers also use externally applied medications such as insecticides and oral or injectable medicines such as anthelmintics to rid their domestic animals of, for example, ticks on the skin and worms in the intestinal tract. These chemicals, their residues or metabolites may end up in the food that humans consume; some of them present health hazards. Textbooks of toxicology cover these in detail, and only a few are mentioned here.

The Joint FAO/WHO Expert Committee on Food Additives (JECFA) is responsible for reviewing the safety of residues of veterinary drugs in foods for human consumption and from time to time recommends safe limits. The Codex Alimentarius Commission can then adopt these limits as recommended international standards.

Under optimal agricultural and animal husbandry practices the residues of chemicals used would not present a risk either to agricultural workers or to consumers. Most countries have regulations regarding the permissible use of these chemicals. Some have monitoring systems. The efforts of the Joint FAO/WHO Meeting on Pesticide Residues (JMPR) have resulted in authoritative reviews of the safety of agricultural pesticides. JMPR has assessed the potential health problems from these chemicals based on the current literature and has recommended maximum residue limits both for adoption by the Codex Alimentarius Commission and for broad dissemination to member countries. In poor countries the regulations are often not adhered to and monitoring fails to detect many potential or actual problems.

In the use of farm pesticides, the first risk is to the agricultural workers who use them. They need to have dear instructions for the use of the chemicals. They need to know how to protect themselves, and they must have protective clothing and facilities to clean their bodies and clothes after working with pesticides.

Pesticides may also contaminate food. They are used in food storage to prevent spoilage or loss of food, and in this way too may present a danger to the consumer.

Most countries have regulations for pesticide residues in foods, and these need to be monitored and enforced. For example, the United States Environmental Protection Agency lists maximal residue levels of some 90 pesticides in foods sold for human consumption. DDT (dichloro-diphenyl-trichloro-ethane), which was used both for agriculture and also to kill mosquitoes in anti-malaria programmes, has been banned by many countries (and by all countries for use in agriculture), but others have felt that the risk from malaria was greater than the risk of toxicity from DDT. Now there is greater concern for other insecticides. Of particular concern now are polychlorinated biphenyls (PCBs); the organophosphorus pesticides such as malathion and parathion, widely used in agriculture; dieldrin; and the herbicide chlorophenoxy acid. In most countries the Acceptable Daily Intake (ADI), set by FAO and WHO (via JMPR), is the standard for monitoring.

Although there have been a few industrial accidents involving workers accidentally being sprayed with pesticides and an occasional poisoning of a child who drank a pesticide solution, both are rare. Extremely few cases of pesticide poisoning from eating food have come to the attention of JMPR.

Food additives

Chemical or other substances are added to foods for human consumption for many different reasons. The most important perhaps is to preserve the food, but additives may also be used to change the colour, the taste or some other quality of the food. Some countries have very strict regulations governing the approval of a new food additive for use by the food industry. For those additives that are approved, the regulations usually state the maximum level that is permitted. Again it is JECFA that has established the safe levels which then have been used by the Codex Alimentarius Commission. Concerns regarding food additives are that they might be carcinogenic (stimulate cancer) or have a negative impact, including genetic or teratogenic effects, on the foetus if consumed by pregnant women. In the United States food additives approved for use by industry are listed as "Generally recognized as safe" or GRAS. The GRAS list includes many additives in use before 1958 which evidence suggested were safe, and new items introduced since 1958 which are rigorously tested to show among other things that even rather large amounts are not carcinogenic in laboratory animals. JECFA has prepared specifications for food additives which guide Member Governments to establish the identity and quality of additives being used. These specifications are also used by industry.

Radioactive contamination of foods

Happily, the contamination of foods with radioactive fallout, either from explosions of atomic bombs or from accidents at nuclear power plants, is rare. The accident at Chernobyl in the former Soviet Union in 1986 was the worst well-described accident of this kind. When radioactive dust is liberated into the atmosphere, it is blown by the wind and falls to earth where it may contaminate food crops such as cereals, fruits and vegetables, but also grass which is then eaten by cattle and other livestock. As a result the milk and the meat of these domestic animals may contain unacceptable levels of radioactive materials. Following the Chernobyl accident, elevated levels of diseases such as thyroid cancer (presumably because of fallout of radioactive iodine, 131I), particularly in children, and other malignancies have been reported.

Very soon after the Chernobyl accident FAO convened an expert consultation which recommended action levels for radionuclide contamination of food in international trade. No guidelines existed previously, so this rapid action was important. In the event of a nuclear disaster, people living in the area of the fallout should avoid eating foods that were growing in the affected area. They should also avoid consuming milk and meat produced in the area and foods that might have been exposed to dust fallout. Foods stored in sealed containers, including tins, are safe. The authorities should bring food into the area from unaffected areas as soon as possible. People all over the world should be made aware that a nuclear accident has occurred and that it could make their usual food dangerous.

Consumer protection

Many of the actions discussed earlier in this chapter will help protect the consumer and ensure a safe diet of good quality. Some other specific activities might further help the consumer. In many countries greater attention is now being given to food labelling, which may be controlled by regulations. FAO has had a leading role.

Recommended nutrient reference values for labelling purposes were established at an FAO consultation in 1988. Food packaging that provides useful information for the consumer can be helpful. It should, if possible, express in simple terms the amount of nutrients in the food, perhaps as percentages of the requirements or allowances of each important nutrient per serving of the food. The energy, protein, carbohydrate and fat content of one serving should also be included. In countries where there is concern about arteriosclerotic heart disease, this information might be broken down further to indicate the amounts of different kinds of fat, cholesterol and fibre. Food labelling might also include the amount of additives in the food.

Food advertising should use only truthful information and should not make claims for the food that are not true. Foods that can be harmful should perhaps not be advertised.

In 1981 at the World Health Assembly in Geneva, 118 nations voted in favour of adoption of the International Code of Marketing of Breast-milk Substitutes, which calls for the cessation of all promotional advertising of breastmilk substitutes to the public. (Only one country, the United States, voted against the code.) Many countries have introduced legislation to limit the promotion of infant formula, because it is generally agreed that breastfeeding is very important for good health and good nutrition and that promotion of infant formula has greatly eroded and undermined breastfeeding (see Chapter 7). The multinational corporations that manufacture infant formula continue strenuously to promote infant formula in other ways than advertising to the public, for example by offering free samples and by providing literature to the medical profession.

Improving food quality and safety in developing countries

Most countries have legislation to help ensure the safety, and sometimes the quality, of foods from production to retail sale. Farmers, food processors and the public, however, are not always conversant with the regulations. Moreover, dishonest traders may seek to ignore the regulations. As a result, unsafe foods that are contaminated or spoiled or have dangerous levels of chemicals are reaching consumers, sometimes widely, putting the public at risk of illness.

Most countries have established institutions or branches of ministries (such as a bureau of standards or a branch of the ministry of agriculture) designated to ensure food quality and safety. These mechanisms often need strengthening, and there are often too few well-trained people or well-equipped laboratories to monitor the situation. In some countries an interdisciplinary, interministerial committee could be established to examine all areas related to food safety, to ensure that the most important aspects get covered and perhaps to suggest the most important and most feasible priority areas. Such a committee could have many functions, but the main ones might be to promulgate and implement food safety standards; to establish means of monitoring, including inspection, sampling and testing; to recommend a programme for educating both food industry personnel and the public on food safety; and to find ways to involve and obtain assistance from international agencies such as FAO and WHO (with the Codex Alimentarius Commission) and other foreign institutions.

The following actions might be given priority for immediate strengthening because they would cost little and seem feasible and important:

Steps to improve the quality and safety of food are important if people are to have good health and nutrition in developing countries. Such steps will also benefit food trade because contaminated or unsafe food should not be traded either in internal markets or for export. The FAO/WHO Codex Alimentarius Commission can assist non-industrialized countries in implementing standards and codes with the objective of protecting consumers and promoting food trade. FAO can assist governments in modernizing their food regulations, in designing compliance systems, in training food inspectors and related personnel, in improving food analysis laboratories and training their staff and in actions to ensure better quality control by food producers, manufacturers and processors. Food quality needs to be protected from the farm to the consumer. FAO, with WHO, can also help with the scientific evaluation of food additives, various contaminants and medicinal products. In the years ahead countries will need to give consideration to the agreements of the General Agreement on Tariffs and Trade (GATT) regarding sanitary, technical and other regulations which may be barriers to food trade.

In conclusion, consumers have a right to expect that their food is safe and of good quality, and both the food industry and governments have a responsibility to honour that right. To do so will require knowledge on food safety on the part of farmers, food processors and the public plus effective food safety control activities by the food industry and government. Control of food safety requires that there be in place laws, regulations and standards related to food quality and safety plus a system for food inspection and for monitoring to ensure compliance. Some inspection and monitoring can be achieved without extensive facilities, but there will be a need for laboratories to undertake the important analyses recommended. International agencies such as FAO may be called upon for technical and other assistance. FAO's very important efforts in helping to establish and strengthen food control systems internationally and particularly in member countries must be recognized. The Organization's work and actions over many years have contributed substantially to significant improvements in the overall quality and safety of the food consumed in many countries, especially in developing countries worldwide.

Chapter 35. Improving household food security

Food security is frequently defined as access by all people at all times to the food they need for an active and healthy life. Household food security, in turn, means adequate access by the household to amounts of food of the right quality to satisfy the dietary needs of all of its members throughout the year. A family can secure food in two main ways: food production and food purchase. Both require adequate resources or income. Other less important, less common ways of obtaining food are through food gifts or charitable or government food allocations, in free school meals or with food stamps.

In Chapter 2 lack of food production and lack of food security were discussed as underlying causes of malnutrition. The importance of agricultural food production to underpin national and local food security was outlined. Food security was shown to be important at all levels, but particularly at the household level.

This chapter outlines some ways of improving household food security to improve nutritional status or to prevent malnutrition. As discussed in Chapter 1, food security for the individual child (or for the family) is one of the three essential ingredients (along with adequate health and adequate care) in preventing malnutrition. Individual food security is essential for good nutrition, but it does not ensure good nutritional status, because other factors such as disease, infrequent feeding, lack of care and poor appetite may adversely influence nutrition.

The achievement of food security requires:

The main underlying determinant of household food insecurity is poverty. In Asia, Africa and Latin America a large proportion of the population in both urban and rural areas is affected. It has been stated that not all poor people are undernourished, but most undernourished people are poor.

Household food security in each country, even if the country is food secure, depends partly on the extent to which the country pushes for greater equity in incomes, in land distribution and in access to services. National policies may not only help farmers achieve increased food production, but may also help people satisfy their food demands. Although household food security is most influenced by actions at the household level, factors and actions at the local, national and international levels also have effects.

Forms of food insecurity

Household food insecurity takes different forms which require different responses or actions. The approaches may be different depending on whether food insecurity is chronic (with households almost always short of food) or transitory (resulting from temporary adverse circumstances). Food insecurity may be seasonal; a family may have insufficient food perhaps each year or most years, but only in certain seasons.

The consequences of household food insecurity are as different as the causes. Which members of the household are most affected will vary, sometimes as a result of intrahousehold food distribution. Thus two families each with a mother, a father and two young children, with similar moderate but not severe insecurity, may respond in different ways, with different outcomes. The first family may believe in "children first" and despite food shortages may make certain that the two children receive all the food necessary for good growth and health; the adults then may develop signs of undernutrition or more likely will reduce their energy expenditure by reducing their activities and productivity. In the second family, the father may always satisfy his desires for food first, leaving the remaining food for the mother and, last, the two children, who get less food than required. In this family the children would show evidence of malnutrition. Sometimes, however, ensuring the energy and nutritive intake of the food producer and wage earner may be necessary for the family to get the food it needs for survival.

Who is at risk?

Households most likely to be food insecure, or at high risk of food insecurity, are the poorest. In rural areas these may be landless households; those with such small plots of land (sometimes marginal land) in relation to family size as to make adequate agricultural production impossible; sharecroppers or tenant farmers who get relatively little of the crop produced; pastoralists, fishermen, forestry workers and others who earn too little money or produce too little food for the needs of their families; female-headed households where the mother has many responsibilities for child care as well as farming; and poor households with a high dependency ratio or that have no or few active adults because of age, disease, disabilities or other reasons.

In urban areas also the most food insecure are the very poor, including households where there is unemployment or underemployment; single female-headed households with dependent children; elderly people living alone; destitute and homeless individuals; and those with chronic debilitating disease or serious disabilities.

Increasingly the acquired immunodeficiency syndrome (AIDS) epidemic is contributing to food insecurity, sometimes because adults who were breadwinners have become seriously ill or because orphaned children as young as 12 years of age have become household heads caring for younger children. In addition, where human immunodeficiency virus (HIV) infection is prevalent, the disease is having a major negative impact on agricultural production, on economics and on health services.

Variables and issues in household food security

Many variables influence household food security, and all of them can be manipulated to some degree to improve it. However, there are few easy answers or prescriptions for alleviating food insecurity. Recommendations often depend on local circumstances. Solutions will almost always involve participation at the local and household level.

Among the issues that influence household food security are adequacy of local food supplies; potential for cash crops and home gardens; urban versus rural food supplies; producer and consumer prices; available means of improving food production; food storage and stabilization of food supplies; employment questions; and labour-intensive versus labour-saving work. Agricultural and planning ministries and other organizations need to address some of these issues at the national level.

Other issues of great importance to food security involve gender. What roles do males and females have in the society? To what extent are females discriminated against? Do women have an unfair labour burden? Who controls household finances?

People have different ways of dealing with food insecurity depending on their systems of earning a livelihood or procuring needed food. There are major differences between subsistence farmers and pastoralists; between sharecroppers and urban workers; and between welfare recipients and those working in the informal economy. Clearly urbanization and migration from rural areas have a role in food security.

Evidence about household food insecurity and its causes strongly suggests that in many instances attempts to improve food security should start not at the national level alone -the classical approach - but at the household level, or preferably at both. Emphasis must be on local-level planning of community interventions and on using a participatory approach.

The three important requisites of household food security - an adequate local supply of food, stability in the food available and accessibility of food - are discussed below. For nutritional security there must also be adequate health and adequate care, and the food must provide all the nutrients needed for good nutrition.

Food supply

If there is an insufficient quantity of food to meet the food needs of a population, then some persons or some households will be food insecure. Various steps along the food chain need to be considered in relation to supply.

To improve household food security, various methods of increasing sustainable agricultural production of food (or other methods of food acquisition) need to be promoted. It is also necessary to ensure good harvesting and storage of food with the smallest possible losses; an effective and efficient marketing system; and good food processing and preparation. All these topics are discussed in detail in many publications, of which some are listed in the Bibliography.

At the national level food supply also depends in part on government and private-sector decisions and actions concerning what amd how much food to import and export, when to do so and how to allocate resources. These decisions in turn depend on whether domestic food production is able to meet local needs. If imports are necessary, the amounts and types of food imported will depend on many factors including political considerations, availability of funds and foreign exchange, trade policies, world food prices and perhaps availability of food aid.

Policy measures related to food supply

Some policy measures related to food supply include:

    · national macroeconomic policies and overall development strategies that ensure adequate public- and private-sector investment in agriculture and food production, including the much-discussed structural adjustment policies and greater consideration of equity issues, which is necessary if household food security for the poor is an objective;

    · appropriate agricultural and trade policies to enable expansion and diversification of food and agricultural production and availability, a proper balance between food and cash crops, an adequate and stable food supply, sustainability in light of environmental issues, adequate employment for the rural poor and improved market efficiency and opportunities;

    · policies that improve access to land and to other resources important for increased production, including credit, fertilizers and other agricultural inputs.

Often government economists and planners, considering the supply side of food security, address only the need for adequate energy for the population in terms of cereal grains and perhaps legumes. For good nutritional status, however, the production, supply and availability of other foods, including fruits and vegetables, need consideration.

Stability of food supplies

A reasonable degree of stability in the supply of food during the year and in all years is a necessary ingredient of food security. This stability can be ensured in various ways, including:

Access to food

Household food security depends on access by all household members to food that satisfies their nutritional needs at all times. Each household needs to have the resources, the ability and the knowledge to produce or to procure the foods that it needs to provide for the energy needs and the nutrient requirements of every member. It is important that households be able to acquire adequate quantities of food all year and in all years. The food must be culturally acceptable.

The acquisition of adequate food depends on how much a person, family or household:

There are obvious differences in how urban dwellers and rural farmers usually obtain access to sufficient food for themselves and their families. Most urban households usually need to obtain sufficient money to purchase enough food to satisfy the nutritional requirements of all their household members. By contrast, the rural landowner or farmer must have enough land, resources and labour to produce sufficient food to feed all household members or to sell for cash with which to buy the ingredients of an adequate diet for all. The rural family that has neither land nor labour usually needs to obtain enough money to purchase food, much as urban households do. Many farming households are also dependent on off-farm income-earning opportunities.

Where household insecurity is prevalent among both urban and rural people, attention has to be given to ensuring that farmers are paid remunerative prices for their produce; that processing and distribution systems are expanded and efficient; that minimum wages are adequate; that prices of staple and perhaps other important foods are reasonable, or even subsidized; and that other essentials (such as housing, health care, education and transport) are affordable for those receiving the minimum wage. Programmes that provide social security, welfare and unemployment payments or that provide free or subsidized food (through food stamps or school feeding, for example) will help the poor and disadvantaged obtain access to food.

Rural farming households can take measures, and authorities can help them, to optimize production from their land and to get the most food and money from farm production. In some parts of the world implementing land reform policies to allocate adequate land to poor rural families and ending sharecropping might help families become food secure. In many areas livestock are integral components of farming systems and may provide insurance against bad agricultural years, as a form of asset that can be exchanged for money to purchase food. Rural families may also be assisted with credit, subsidized foods, food stamps or charitable help, especially in bad agricultural years.

It has been observed that where there is food shortage and famine, families with money and resources do not suffer from starvation. Very poor families have the fewest assets and thus are usually the most food insecure and the most vulnerable to serious food crisis.

Responsibilities for the right to food

Sustained improvements of household food security are likely to depend on actions at the local and household level and on the participation of the poor in bettering their own lives. However, this idea should not allow those who are better off to forget that adequate nutrition is a basic human right and that the occurrence

of malnutrition among so many people in the world is an indictment of all who permit it. The world is divided into nation States, each of which has a major influence on its own inhabitants. Each State has the responsibility to respect, protect and fulfil human rights, including the right to adequate food and nutrition. Respecting means that the State does not take actions or have policies that make it more difficult to procure food for the needs of its people, even in times of crisis or conflict. Two examples of protection would be preventing individuals from being deprived of their abilities to produce food or to earn money to purchase food; and establishing and enforcing regulations to ensure consumers a safe food supply. Fulfilment of the right to food and adequate nutrition includes the State's obligation to provide assistance to the vulnerable to meet their food needs even at times of shock or crisis.

Meeting desirable allowances for energy

It cannot be stressed enough that humans have a right to sufficient food and good nutritional status. "Sufficient" food, moreover, must provide not only for basic energy requirements, but also for the energy requirements of an active and healthy life.

Dietary needs have been discussed elsewhere in this book but deserve mention in regard to policies and programmes to improve food security. For good health and optimum nutritional status a person must consume food to satisfy all essential nutrient requirements or nutrient needs. In terms of energy, however, food has to be sufficient to satisfy not just the basic needs, but also the individual's wants for energy, provided that this does not lead to overconsumption and obesity. These energy wants, i.e. energy intakes sufficient both for basic requirements and also for the desired activities of each person, are now widely termed "desirable allowances".

The concept of desirable allowances has important implications for improving food security. If only energy requirements or needs are considered, a person in energy balance who is not clinically undernourished or does not have low body mass index (BMI) or low weight for height might be considered food secure. However, such a person may be foregoing desired activities to conserve energy. That person has unfulfilled energy wants, does not have enough energy to satisfy desirable allowances and is food insecure.

Energy balance is not an indicator of adequate energy intake. A person may be in energy balance, with energy intake equalling energy expenditure, but may in fact be greatly reducing his or her activity levels to remain in balance. Consciously or unconsciously he or she may choose to do less work on the farm, to reduce household chores, to play less with the children, to refrain from participating in sports and to curtail social and community activities, and instead may rest more and sleep more. This individual, though in energy balance, is nonetheless in a state of energy deprivation and is therefore not food secure; yet a physical examination may indicate no physical evidence of malnutrition or undernutrition.

There is a difference between affluent and poor people who are in energy balance over time. Generally, affluent people adjust energy and food intake to meet energy expenditures, while very poor people with food shortages adjust their activity to their energy intake (foregoing activities to conserve energy). Where food is plentiful, people may forego food or increase exercise to maintain balance (the jogger's syndrome); where food supply is deficient, they may forego activities to maintain balance.

Very little research has been conducted to determine what activities are foregone, and to what extent, in order to maintain energy balance when too little food is available. Policies and programmes are needed to ensure that energy wants as well as energy requirements are satisfied. Providing women with the opportunity and freedom to control their own fertility is also important. These issues are all highly relevant to any consideration of food security.

Indicators of household food security

As stated, adequate supply, stable availability and proper access to food are essential requirements of household food security. Indicators of household food security are then those related to food production and supply on the one hand, and food demand and access on the other. Manuals and books have been written on agricultural production, nutrition surveys, food balance sheets, household economics and other topics related to specific indicators of food security. Here a few key indicators are briefly mentioned.

Indicators related to food supply include:

Indicators related mainly to household access to food include:

In many countries with diverse topography, agricultural conditions and peoples, indicators may need to be rather specific for particular areas of a country or particular groups of the population.

Nutritional surveillance may be established as a system for regular monitoring of the food situation, the functioning of the food system and also some aspects of the nutritional status of the population (see Chapter 33). This system will then, depending on the data being collected, provide indicators of household food security. Sometimes nutritional surveillance is established as an early warning system to help predict serious food shortages and to trigger action. Some countries have established nutritional surveillance as a means of providing data to influence government policies.

Coping at the household level

Often poor households have amazing resilience and an impressive ability to cope with short-term crises and to survive on low incomes and what appear to be relatively low availabilities of food.

Transitory or short-term food insecurity is often the result of a shock that has struck a blow to the household. The coping mechanisms adopted depend partly on the nature of the shock and partly on the household's circumstances. Different members of the household may respond to a shock in different ways. It has been suggested that there are four main types of shocks (Maxwell and Frankenberger, 1992):

Where shocks cause transitory food insecurity, and also when families face chronic food insecurity, families take actions to ensure adequate food. Examples of such actions include:

Imaginative programmes to assist poor families to overcome the results of shocks will help reduce food insecurity.

Government actions to improve household food security

Food security may be influenced by anything that governments do to improve income and reduce poverty; to increase agricultural production, especially by poor rural families; to ensure prices that are fair to producers and consumers; and to make services available to people.

Some examples of more specific government actions include:

Besides these specific measures, governments need to have a sound overall development strategy which creates conditions for economic growth with equity. Poverty alleviation programmes need to be sustainable. This book is not the appropriate place to discuss how the poor countries of the South strike a balance between macroeconomic policy objectives and food security needs. Clearly the rate of exchange of currency in a country, the nation's export and import policies, the rate of inflation, the budget deficit and debt repayment obligations can all influence prices, unemployment rates and incomes of the poor. Much recent discussion has focused on structural adjustment programmes, sometimes mandated for poor countries to promote economic growth. These programmes have caused major problems for the poor, often through reductions in producer and sometimes consumer subsidies. Of great concern also has been the reduction in social services: previously, many countries in the South had free primary and secondary education and free health services, including both out-patient care and hospitalization, but by 1992, with implementation of structural adjustment and sometimes for other reasons, school fees and charges for health services had become common or even the norm. These changes have had a marked impact on the poor, in some cases worsening the problem of food insecurity.

In some countries, particularly in Asia and Latin America, economic development has progressed and the creation of wealth has resulted in a reduction of malnutrition and a lowering of infant mortality rates. However, in other countries, particularly in Africa, economic policies, in concert with very adverse socio-economic and ecological conditions, appear to have sometimes aggravated malnutrition. When this outcome can be predicted, governments need to consider taking early measures to compensate for likely adverse effects, to lessen the hardships for the poor.

Promoting rural development with a special focus on sustained reduction of poverty among the rural poor can improve food security. Appropriate technologies and sometimes producer incentives to increase both production and employment in rural areas can help to reduce food insecurity and poverty. These strategies need to be imaginative and innovative, but there have been successes which give grounds for optimism. For example, credit is often a serious problem for the rural poor, but the Grameen Bank in Bangladesh has made thousands of loans to poor people, many of them female-headed households. The bank has achieved a good record of repayment and has helped lift many people out of poverty. Agricultural extension aimed at poorer farmers has moved research results from universities and research institutions into the fields of poor farmers. Attitudes in many countries have changed, so that strengthening local leadership and empowering women are on the agenda of many countries. Participation and community involvement are increasing rapidly. Non-governmental organizations (NGOs) which work well with people at the local level are absorbing external funds that previously were poorly utilized by major government or international agencies. Some of these organizations are promoting participatory projects and attempting to empower women. Successes in any of these areas can improve household food security.

Agrarian reform remains a problem, particularly in certain Latin American and Asian countries. In several countries, lack of tenancy reform, continuing bias against females and social discrimination, including caste differentials, still contribute very significantly to food insecurity. Redistribution of land is still much needed. Lower-caste families need to have full access to all services. In certain countries, such as Indonesia, the strategy of resettlement on new lands, often on less-populated islands, can reduce food insecurity.

Government and the private sector can reduce poverty by increasing employment opportunities in both rural and urban areas. They should aim to improve both the incomes of the poor and also where possible their capacity to earn income. Some governments can invest in public works, particularly labour-intensive ones, and in programmes focused on parts of the country that have high rates of poverty.

At the local level community mobilization is probably the best approach to improving household food security and nutrition. Chapter 41 includes a detailed discussion on social mobilization to improve nutrition and gives a good example, that of a project in the United Republic of Tanzania aimed to improve nutrition by improving food security (particularly for children), care, health and health services.

Chapter 36. Care and nutrition

Very young children depend for their nutrition on good care. Of course, everyone benefits from care: health, nutrition, and general well-being blossom in a caring environment. Clearly very young children, certain older people, some sick people and some physically or mentally ill people are especially dependent on care. For young children the relationship between care and nutrition is especially strong. In this chapter special attention is given to the young child and how care may influence his or her nutrition.

Infants and young children up to age three years are almost totally dependent on others for food and therefore for good nutrition. Children three to five years of age have some ability to gather food, to select a diet and to feed themselves, but in most societies children up to the age of about six years, or school age, would also be considered in need of feeding care. Thereafter, care is highly desirable but not essential for survival. However, good care will always positively influence nutritional status and well-being.

Of the three underlying causes of malnutrition, namely food, health and care (see Chapter 1), the one with the least investigated and the least understood role is care. Food security (see Chapter 2) and health (see Chapter 3) have long been known to have an important relation to nutrition, and a huge literature and extensive range of interventions focus on them. Few programmes designed to improve nutrition include a set of actions to address problems related to care.

The English word "care" is both a verb and a noun. In The Oxford English dictionary definitions of the verb include to feel concern or interest, to provide food, attendance, etc. for (children, invalids, etc.), to look after and to provide for, and meanings for the noun include solicitude, anxiety, serious attention, heed, caution, charge and protection. Engle (1992) provided a working definition referring to the care of young children: "Care refers to caregiving behaviours such as breastfeeding, diagnosing illnesses, determining when a child is ready for supplementary feeding, stimulating language and other cognitive capacities and providing emotional support".

In most developing countries the mother is usually the main care-giver for the infant and the very young child, but in the common extended family grandmothers, siblings, the father, other family members and people outside the family often contribute to child care. As the child gets older care may be increasingly provided outside the home, for example, in day care facilities.

Adequate care is important not only for the child's survival but also for optimal physical and mental development and good health. Care also contributes to the child's general well-being and happiness, otherwise termed a good quality of life. Care influences the child and the child influences the care.

The inadequate food, health and care which lead to malnutrition can be factors at the international, national, local and family level. Child care may be influenced by international factors such as war, blockade or global determinants that keep nations in poverty; national factors such as equity issues and availability of good health services and education; local factors such as land distribution, climate, water supplies and primary health care; and family factors such as the presence of other family members, type of housing, availability of water, household hygiene and mother's knowledge.

Protection, support and promotion of good caring practices

Care-giving behaviours that contribute to the good nutrition, health and well-being of the child vary enormously from society to society and from culture to culture. A first assumption can be made that almost all societies value children and wish to see them grow to be healthy, intelligent and productive adults. A second assumption, which is more debatable, is that societies in general have traditional or culturally determined caring practices of which most are good and contribute well to child development, including good nutritional status.

Besides these two assumptions, it is submitted that in Africa as well as in most of Asia and Latin America, problems with good child care in the 1990s may be related more to an erosion of traditional caring practices than to the fact that important caring practices in the society were, or are, wrong or inappropriate, or important contributors to malnutrition. (There are exceptions; for example, a traditional caring practice that has been an important contributor to malnutrition is the favouring, in terms of diet, health and care, of male over female children in some areas of South Asia.) Traditional caring practices in their broadest terms have been altered, often for the worse, as a result of modernization, westernization and increasing urbanization (see Chapter 5). A good example, and the one most written about (see Chapter 7), is the decline of breastfeeding, which was a good traditional practice almost everywhere. Its decline has in large part been influenced by modernization, including promotion by infant formula manufacturers and the medical practices of Western-oriented health professionals.

Protection of good practices

Protecting is an essential part of any strategy for optimal care to ensure good nutritional status. Good practices need to be protected from erosion by many different factors. For example, in a society where most mothers breastfeed their babies for 18 months or longer, with no or few other foods introduced until the child is four to six months of age, protection should take priority over support and promotion of breastfeeding. Similarly, protection is warranted if a society traditionally provides a lot of stimulation for children; if the infant is seldom left alone but is carried on the mother's back; if fathers, grandmothers, older siblings and other relatives frequently help in child care; and if traditional weaning foods of groundnuts, green leafy vegetables and legumes with a local cereal gruel are the norm. These practices may be threatened by modern or Western influences. A new television set in the family may result in adults neglecting to stimulate their children; advertising and promotion of expensive manufactured weaning foods may lead families to poorer diets at higher cost; or work away from home may cause long separations of the mother and her infant.

Support

Support is particularly appropriate when mothers' or families' good traditional caring practices are threatened or being eroded because of changes in society, which may result from modernization, westernization or urbanization. Support includes activities, both formal and informal, that may help women in changing circumstances to follow those good caring practices that were once considered normal and are now threatened. Support may involve restoring confidence in mothers, strengthening their belief that traditional good caring practices may be better than new practices that may seem modern and up to date but are in fact inferior. For example, westernization and modernization may suggest that a modern woman does not breastfeed her baby in a public place; that canned baby foods are superior to home-prepared foods; that salt and sugar comprise a better treatment for mild diarrhoea than family soups and breastfeeding; that it is better for a child to stay at home and watch television than to go with the mother to the village market; and that eating with a fork is preferable to eating by hand after traditional hand-washing. In fact none of these "modern" practices is better for the child than the traditional alternatives.

In many developing countries paid employment for women away from home is an important factor in the erosion of traditional good caring practices. It has certainly made breastfeeding more difficult (see Chapter 7). Three months of maternity leave would help support mothers in providing initial infant care. Then, during the eight hours mothers are away from home, a crèche or day care centre at the place of work would be supportive. Support for good traditional care may include mothers' support groups or arrangements for adequate child care while the mother is away from home. Staggered working hours for different family members and a greater role for the father in child care could also help.

Promotion

Promotion is particularly important when some, many or most good traditional caring practices have been abandoned or lost. Promotion involves motivation or reeducation of mothers, other family members or whole communities. It is the most difficult and the most expensive of the three strategies.

It may be important to start by identifying the most important factors that led to the decline or disappearance of good caring practices. There must be evidence that the new caring practice is less desirable and less beneficial. A lack of such knowledge will almost certainly lead to failure of a promotional campaign. Properly applied social marketing methods and techniques may be useful. Political commitment and will may be necessary. The promotion of good caring practices will often involve public education and mass media efforts.

Some of the best examples of promotion of a good traditional caring practice that had been seriously eroded concern breastfeeding where it had markedly declined and been replaced with infant formula and bottle-feeding. Promotional campaigns in Brazil in the 1970s and in Honduras in the 1980s proved successful. Other practices for which promotion might be attempted include traditional breastfeeding and family feeding for children with diarrhoea; the carrying of children on the back of the mother where this has been replaced by leaving the child at home; and the use of good home-prepared weaning foods in place of expensive, less-nutritious manufactured foods.

Identifying good caring practices

Mothers, fathers, families and communities (as well as governments and international institutions) take actions all the time that influence nutrition. These actions are in the area of food, health or care. They are based on, or arise from, everyday decisions. They may have a positive or negative influence, or they may be neutral.

The first step in making decisions that will lead to actions to protect, support and promote good child care is to assess current caring practices that may influence nutrition. For many countries where there is fairly good knowledge about the food situation and about health status and health care, there may be very few published findings on child care, especially as it relates to nutrition. There will often be some information on breastfeeding and weaning practices, but there are usually very few data or even descriptions concerning caring practices that influence psycho-social and motor development, maternal factors such as mothers' self-esteem and mothers' beliefs and attitudes regarding child care, or household and community factors that greatly influence child care. There may be ways of obtaining such information rather quickly; this may be the first activity, and it is an important one.

A useful approach for identifying child-caring practices that seem to be desirable may be an investigation of "positive deviants" in a community. Positive deviants are young children who have good nutritional status even though they come from very poor households, have uneducated mothers, have limited access to food and health services and live in a community where most children have malnutrition. If it can be found that the mothers and families of positive deviants have a set of caring practices not usually used by other families, then it can be assumed that all or some of these caring practices are good and deserve protection, support and promotion. A comparison of negative deviants and positive deviants may also be useful.

Actions in favour of good care to ensure good nutrition

Actions in favour of good care can be divided into three groups: delivery of services, capacity-building and empowerment. All three can operate at different levels in society (from national to family), and each contributes to the others.

Delivery of services in support of child care may address the most immediate causes and may sometimes be curative rather than preventive; examples include oral rehydration for diarrhoea, deworming and child feeding targeted at malnourished children. In other cases delivery of services may address problems from the top down and may be preventive to some degree; examples include immunization and organized day care centres. It should be accepted that delivery of services may not be sustainable or if sustainable may have to remain in place for a long period unless other changes prevent or permanently cure the problem in society, not just in the individual child. Oral rehydration prevents death in a child and treats dehydration, but it does not reduce prevalence or incidence of diarrhoea in society. Acknowledging the limitations of an action is just as important for its effectiveness as recognizing its successes.

The next level of action, capacity-building, is aimed to deal not with the immediate causes but more with the underlying causes of malnutrition. Consequently actions at this level are often preventive rather than curative and are likely to be more sustainable. These actions are also likely to be most successful if they work mainly from the bottom up, not from the top down. Capacity-building is seen as of very great importance for improved care in relation to nutrition and may involve protection, support and promotion. Examples include infant feeding practices that permit a smooth transition from exclusive breastfeeding to mixed feeding to exclusive feeding of home foods; child care practices that are stimulating and influence good psycho-social development; health education to provide knowledge about protection against disease; and home hygiene and sanitation to prevent diarrhoea and intestinal parasitic infections.

The third level, empowerment, crosses the boundaries of service delivery and especially of capacity-building. In general, however, actions that are empowering for mothers often address the more basic causes of child malnutrition. Empowerment for women involves ensuring that they have rights that women in many societies lack. Every woman everywhere should have the right to earn income; not to be overburdened with work; to breastfeed freely and easily; and to have reasonable access to services and resources and to capacity-building activities. Possible actions at the level of empowerment include those that improve mothers' income or control of family income; providing good access to health care for women and their children; managing water supplies to lessen the burden on women; and also many activities that reduce poverty and increase equity (including some trade and price policies). Some actions that are empowering are top-down and others are bottom-up activities.

Investigations on current good caring practices, on how they might be threatened by new influences and on how they might be protected in changing, modernizing, urbanizing societies deserve a very high priority. Support for good caring practices is undoubtedly also an important action, but it is perhaps not such a high priority for research, although some investigations will be needed.

Relatively little is known about which good caring practices that are not now the norm for particular families should be promoted or how to promote them. Where caring practices are inadequate and are causes of malnutrition, studies are needed on appropriate alternatives, how they might be promoted and their potential impact on child nutrition.

Some research has been published on intrafamily food distribution, meal frequency, energy density of foods and some other practical topics; but very little is known about some other important subjects that are related to care and that may influence nutrition. The following are some of the unanswered questions.

The world's children, born and as yet unborn, depend on the finding of answers to these questions.

Chapter 37. Protection and promotion of good health

The conceptual framework discussed in Chapter 1 suggests that adequate food, adequate care and adequate health are all essential to good nutritional status. The important ways in which the protection and promotion of good health can contribute to optimum child growth and development and to good nutritional status of all humans are the focus of this chapter.

Chapters 3,12 to 24 and 34 have dealt with particular health and nutrition problems and how they may be prevented or treated as part of primary health care or in other ways. Other chapters examine food-based approaches for improving nutrition and health. Those discussions are not repeated here. Rather, this chapter highlights certain appropriate health strategies to promote good health with special reference to good nutrition. Topics include current thinking on primary health care, hospital treatment of malnutrition, nutrition rehabilitation centres, growth monitoring and promotion, immunization, oral rehydration, control of parasitic infections and acquired immunodeficiency syndrome (AIDS).

In developing countries the prevention of infections is a priority area for health workers and is very important also for nutrition. Actions to control infections include health education, hygiene, safe water, sanitation, immunizations and appropriate curative services. Disease transmission can often be reduced by behaviour change, so health education aimed at informing the public about the cause of disease and preventive measures is vital. Some of the messages may be directly related to nutrition, for example encouraging breastfeeding as a means of preventing diarrhoea, and others are directly related to food, including those regarding the many food-borne diseases which can be reduced by improved food hygiene. Food-safety programmes can help control faecal-oral disease transmission.

Although public health measures to prevent infections and other diseases deserve the highest priority, treatment needs to be easily accessible and adequate. Essential drugs, including some nutrient supplements such as ferrous sulphate and vitamin A, need to be available at health facilities.

Primary health care

Alma-Ata - a watershed

In 1978, at Almaty, Kazakstan (then Alma-Ata, Soviet Union) the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) held the International Conference on Primary Health Care. The conference helped define primary health care (PHC), placed it firmly on the world agenda and recommended it as a central strategy for the ministries of health of most developing countries. Nutrition is recognized as a vital part of PHC.

The overall goal of PHC is the attainment of the highest possible level of health by all people. Health is defined as a state of complete physical, mental and social wellbeing rather than just the absence of illness or disease. PHC, which deals with the primary causes of ill health, is the first interface between people and the health care system. Programme planners stress the need for preventive measures, local initiatives and intersectoral approaches to address the social and economic factors that contribute to ill health. Participants at the Alma-Ata conference concluded that PHC should include assurance of an adequate food supply and proper nutrition for all citizens; provision of safe water supplies and training in sanitary education; support of maternal and child health programmes, including family planning and immunizations; introduction of health education; appropriate care of disease and injury; and prevention and control of endemic disease, as well as the provision of essential drugs.

Past experiences

Primary health care was widely practised in many forms throughout the world prior to the Alma-Ata conference. However, no one had named the set of practices that make up PHC, nor did world health leaders collectively recognize the importance of PHC programmes to world health and well-being. Following the colonial period, some countries were left with more effective health care systems than others. Attempts were made to institute programmes that stressed preventive care and community health workers. These programmes were similar to PHC programmes today.

A small number of African nations, notably the United Republic of Tanzania, had some success in the 1960s in diminishing the urban bias by restructuring their health services. They also stressed preventive over curative services and the use of village-based health workers in place of doctors and hospital-based medicine. Programme planners concentrated on nutrition, maternal and child health and the control of infectious diseases, all of which are now considered part of PHC. This approach to health care was described in various publications.

The Alma-Ata conference was organized for a number of important reasons. First, during the 1960s and early 1970s, hope in the development strategies espoused by leading economists was dashed. These strategies stressed industrial development including the construction of expensive, capital-intensive infrastructure such as large factories, huge dams, electric power stations and superhighways linking the capitals to other major cities. Development based on the economists' blueprints failed more often than it succeeded, and those most in need of aid were overlooked. Huge amounts of resources were squandered on national stadiums, international airports and plush conference centres that did little to improve the quality of life of the majority of the people. Meanwhile, health, social services and agriculture-related activities languished. Health expenditures were concentrated on capital-intensive urban hospitals or "disease palaces" providing curative services, often serving mainly affluent and urban people. This model of development made the rich richer and the poor poorer. Now, however, the poor in many countries are increasingly better organized and are beginning to demand larger, more equitable shares of health and other resources. Interest in PHC has increased because it aids those most in need.

Second, many came to feel that modern technology alone was not the solution to major health problems in the developing world. At the same time, the Western medical model, the appropriateness of Western medical training for the conditions in developing countries and the ethics and intentions of some pharmaceutical companies were questioned. Gradually, people realized that social conditions were closely linked with the incidence of disease and that improvements in social and economic conditions bettered health. Improvements in agriculture and rural development began to receive more attention. China's successes in raising the health status of its population illustrated the role that socioeconomic change (in this case, increased access to land and employment opportunities for the poor) could have in improving health and in allowing local communities to generate the resources needed to provide health services. Increased agricultural production was seen to be at the heart of most rural development. Health professionals began to recognize that auxiliaries and traditional medical practitioners have a critical role in maintaining health, particularly in remote rural areas. (WHO began to use the term "traditional healer" rather than "witch doctor".) Scientists learned that both traditional and modern medical practices contribute less importantly than socio-economic improvement to the prevention or cure of disease and malnutrition. PHC, with its emphasis on prevention rather than treatment coupled with the extensive use of auxiliary or paraprofessional health workers, dearly can help to implement needed changes in the medical establishment.

A third factor that led to the organization of the conference and its endorsement of PHC was an increased recognition of the importance of self-reliance at the community and family levels. For example, in Tanzania the Ujamaa approach, in which the process of empowerment of people and communities is key, became a national effort to promote self-help. The concept involves people learning about, and gaining control over, the factors that create and maintain conditions responsible for malnutrition and ill health. The "barefoot" doctors in China appeared to be a good example of a successful system of local involvement. With only limited technical training, local inhabitants improved the health of rural populations and returned control over health care to the local level.

These changes in attitudes, beliefs and health practices sprang up in socialist and capitalist countries alike, both developing and industrialized. [The WHO publication Health by the people (WHO, 1975b) high lights several encouraging examples of health programmes based on community participation and self-reliance.] However, more assistance from international organizations was clearly needed to spread the message around the world, to provide assistance to initiate programmes and to coordinate programme efforts among countries.

Alma-Ata declaration on primary health care

On 12 September 1978 the Declaration of Alma-Ata, the credo of primary health care, was adopted by delegates representing more than 100 countries with the objective of improving health worldwide. The declaration, setting out an ideal vision of PHC, contained a broad but rather vague array of objectives for attaining "Health for All". These objectives can be divided into two main categories: those designed to aid in restructuring health systems to promote effectiveness and equity (medical impact); and those designed to build local self-reliance through the promotion of community participation and control over health care and resources.

Objectives in the first category were mainly concerned with improving the health status of populations in as short a time as possible. Based on definable criteria, such as infant mortality rates and disease prevalence, these objectives allowed for the quantitative assessment of PHC programmes and could be used to encourage communities, health workers and political decision-makers to address health. Increased coverage of services, appropriate health technologies and new approaches towards making health systems more efficient and equitable were stressed.

The objectives concerned with self-reliance emphasize local participation by encouraging the development of human resources (social empowerment), not just technical infrastructure. Decentralization of health planning and decision-making and the growth of local institutions to provide community input are also included in these objectives.

Seven essential features of primary health care

· Perhaps most important is universal availability; this implies the redistribution of health resources from more affluent urban centres, where they are now concentrated, to the rural and urban poor. Clearly, attention to concerns of equity is essential because a reduction in poverty and the provision of basic needs often improve nutritional status and general health. In addition, special efforts must be made to reach those who are usually overlooked, such as slum dwellers, inhabitants of remote rural areas and people without transport.

· Local people should participate in the planning and implementation of any programme that directly affects them. Involvement of the entire community is likely to ensure the continuation of programme activities.

· Prevention rather than cure should be stressed. Essential to any prevention programme are nutrition education and an adequate diet. Immunizations, maternal and child health services, provision of sanitation and ensuring safe water supplies are all examples of preventive programmes.

· Coordination with programmes in other sectors, such as agriculture, economics and social services, should be an important part of any PHC agenda. Nowhere is this more important than in the area of nutrition. Although nutritional problems are health related, to prevent malnutrition it is essential to give attention to agriculture, economics, education and social services and to confront political issues such as land tenure and access to economic resources.

· The use of simple low-cost but appropriate technologies needs to be stressed. For example, simple equipment can be locally repaired and is not as expensive to maintain; generic medicines are cheaper and often preferable to brand-name products; the breast is superior to a feeding bottle; the baby is often better off in a bed than in a bassinet; and oral rehydration at home is preferable to intravenous fluids in the hospital.

· Applied research and investigation, including evaluation, monitoring and surveillance, can contribute to primary health care. Health workers can participate in much-needed research activities such as the development of growth charts for children; maintenance of disease prevalence and incidence statistics (used to pinpoint important health problems); the upkeep of immunization records (to chart successes and failures); and surveillance of disease and nutrition. All of these activities contribute to modifications and changes in the PHC system based on new knowledge or demonstrated alterations in the health or nutritional status of the population.

· If reliance on cure-oriented medical professionals is to be reduced, an essential component of any primary health care programme will be training programmes for health auxiliaries. Personnel can thus be used more efficiently, and local people will have the opportunity to participate directly in community health care.

Implementation - rhetoric versus reality

Endorsement of the PHC concept has had major implications for participating governments, committing them to:

Experiences in implementing primary health care over the last 15 years showed that many governments, while adopting the rhetoric, made only slow progress in institutionalizing its concepts in practice. There is a large and growing gap between the intentions that governments express and the health care policies that they are actually willing or able to implement. Although the Declaration of Alma-Ata clearly defined PHC, its objectives, components and overall concept, in practice the principles have been applied in many different ways.

While many government officials have orally supported the concept, their implicit objectives are often in sharp conflict with those of primary health care. For those controlling many political systems, the maintenance of stability, the preservation of existing social and economic structures and relations and the monopolization of political powers are all high priorities. When primary health priorities are added they often create major contradictions, inhibiting the development of health care along the lines envisioned at Alma-Ata.

In the 18 years following the Alma-Ata conference, tremendous progress has been made in recognizing the importance of primary health care as an essential part of promoting food, nutrition and health care strategies that benefit those left out of previous development efforts. It has been very difficult, however, to institutionalize the concept of primary health care. When PHC is practised in line with the principles implicit in the Alma-Ata declaration, it is perceived as a threat by established interests such as the traditional medical profession and the urban élite.

Even countries with a substantial governmental commitment to health care, such as Thailand, find the implications of resource reallocation, community control and concern with the broad structural reasons for ill health too threatening to be accepted or tolerated. In Viet Nam, which radically restructured its health and economic systems, it has proved very difficult to overcome the urban bias, to change the attitudes of medical professionals and to sustain earlier health and nutritional improvements. Both cases demonstrate that strong political will is necessary to ensure the success of PHC, and both highlight some of the many obstacles in the way.

The numerous goals and objectives that are part of PHC often conflict, creating contradictions between programme rhetoric and programme reality, between self-reliance and equity and between the delivery of health care services and allowance for meaningful community participation. Overcoming these problems requires a balanced approach applied over a prolonged period and a recognition that different situations require different strategies and approaches.

In recent years there have been new international influences which have led to a move away from free health services in developing countries, including the structural adjustment programmes of the International Monetary Fund, UNICEF's Bamako Initiative and a move in many countries to capitalist, free-market economic systems. Hospital fees and payment for medicines are now common. However, by contrast, health is now regarded less as a welfare service and more as a development priority. The World Bank has now indicated a very significant attempt to increase assistance to countries for improvement of health services and public health. The next decade could see preventive medicine, with nutrition at its heart, move forward both as part of PHC but also in new programmes designed to deal with specific health and nutritional problems. Health for the poor will benefit if PHC programmes strongly directed from the centre (usually the ministry of health in the capital) are devolved to the local level. Then the local health establishment needs to involve communities in planning and implementing their own health actions.

Medical treatment of malnutrition

The ultimate objective of most comprehensive nutrition programmes should be to reach a stage where no children require treatment for malnutrition in hospitals, in other centres or as out-patients. No country has reached that goal, so treatment must remain a part of control. Treatment of malnutrition can be viewed as taking place at three levels: first, hospital treatment for severe and life-threatening malnutrition; second, nutritional rehabilitation or similar treatment for moderate malnutrition or after severe cases are discharged from hospital; and third, preventive care and treatment of mild malnutrition in maternal and child health and nutrition clinics or growth monitoring centres. At each level, prevention should be a component of the services offered. Not all countries have an organized system for providing all three levels of treatment.

Hospital treatment

It is generally agreed that admission to hospital is necessary for cases such as: a severely ill child whose life is in danger because of kwashiorkor or marasmus; a pyrexial toddler with a cornea near to perforation as a result of xerophthalmia; or an infant almost moribund from dehydration.

Some nutritionists have painted a bleak picture of hospitalization and its results. They suggest that hospitals may contribute more to mortality than to cure of malnutrition. In many countries high case fatality rates occur in children hospitalized for severe protein-energy malnutrition (PEM). The length of the hospital stay is often long, and discharged patients frequently die at home in the weeks following discharge or return with a relapse of their condition. Data do show that these problems are real. There has been no controlled study in which cases of severe malnutrition were randomly assigned to hospital or out-patient treatment. Nevertheless, poor results should not lead to a universal condemnation of hospital treatment for the very sick child. Rather, the criticisms should be used by paediatricians, doctors and nurses to determine what can be done to improve conditions and to reduce case fatality rates. There are too many paediatric wards where existing conditions offer little hope for the severely malnourished child. Rare is the hospital that provides the ideal treatment and environment for care and future prevention.

Case fatality rates for malnutrition vary greatly from hospital to hospital. The rates reflect not only the quality of the health care but also the severity of the cases admitted. Some parents only bring their children to hospital when they are almost moribund. Sometimes there is so much demand for hospital beds and such a heavy out-patient load that only extreme cases can be admitted to the wards. Hospitals with equally good staff and treatment regimes can have different fatality rates if one of them admits moderate cases of PEM and the other admits only very severe cases.

Many hospitals report case fatality rates from severe PEM of around 25 percent, although rates are sometimes as high as 40 percent and sometimes as low as 10 percent. In most hospitals, the majority of deaths from PEM occur within 48 or 72 hours of admission. Attention needs to be given to controlling hypothermia, recognizing hypoglycaemia and treating infections (see Chapter 12). Staff at all levels need to be well trained in the practical management of cases. Good nursing care is essential, but a large part of this, especially feeding, can be provided by well-trained auxiliaries.

During the recovery phase the treatment of the child needs to include an educational component. The mother, or a responsible guardian, should be admitted to hospital with the child and participate in the treatment, especially regarding the dietary measures. As recovery progresses the child is fed solid or semi-solid foods; these should be locally available, cheap and acceptable. Few paediatric wards have the design, staff or policy to provide nutrition and health education for patients or parents, yet it is an integral part of therapy which may prevent relapse in PEM, xerophthalmia, nutritional anaemias and many other forms of malnutrition. Where possible, learning by doing should be a part of the instruction.

Every attempt should be made to minimize the length of the child's stay in hospital. A shorter stay will reduce the cost of treatment that has to be borne by the State or the family and the time that the mother, entering hospital with the child, has to spend away from home, where other child health problems may exist or may be aggravated by her absence. Many hospitals keep malnourished children for months rather than weeks, increasing the risk of cross-infection. It is appreciated that recovery from marasmus is often very slow, usually much slower than recovery from kwashiorkor. Even so, it is seldom essential for children to stay in hospital longer than a few weeks.

Perhaps the main reason for the slow recovery of hospitalized children is a failure to provide an adequate total intake of energy. Children can benefit from very high intakes of energy and to a lesser extent protein until they reach near-normal weight for length. A reliable staff is essential to ensure that feeding is properly carried out at regular intervals.

Many relapses will be prevented and physicians will be more willing to consider early discharge if good follow-up services are available. Hospital staff should try to provide clinics at the hospital or in the community where food supplements are supplied free (or highly subsidized) for the child and sometimes for the whole family, and a system of home-visiting using auxiliary workers with suitable training.

Nutrition rehabillitation centres

In the 1960s and 1970s nutrition rehabilitation centres (NRCs) were widely promoted as a major answer to the problem of PEM in developing countries. This approach was unrealistic. Now such centres exist in many countries, but they play a rather small part in overall nutrition services worldwide. Each country needs to decide if such centres are of value or if some alternative measures can be used to rehabilitate moderately malnourished children before hospitalization is necessary and after serious cases are discharged from hospital.

NRCs when first established were described as centres organized either to have sleeping accommodation where children could be kept overnight or to resemble day nurseries or kindergartens where malnourished children could attend for a few hours each day, with the objective of educating the mothers through the nutritional rehabilitation of their children. The centres, established mainly in the 1970s in countries in Asia, Africa and Latin America and the Caribbean, differ quite markedly in their manner of functioning, but most of them have a common thread of objectives.

An NRC differs from a day care centre in several important respects:

The NRC provides the second level of treatment: the most severely malnourished are at first admitted to hospital, and the less malnourished attend health clinics. The NRC takes severely malnourished children after discharge from hospital during the important period of recuperation; moderately malnourished cases from the community; and less severely malnourished cases that are failing to make adequate progress following treatment as out-patients or at clinics. In this graded system of treatment, children discharged from an NRC continue to attend an outpatient facility or clinic. In certain cases such a service is provided at the NRC.

The NRC has always been envisaged as providing important nutrition education. It should also be economical to run and should provide services at a fraction of the cost of hospitalization. It is suggested that a centre should be an ordinary village or urban house, staffed with one or two village women who have received some practical training in nutrition and childfeeding. A typical centre can accommodate about 30 children, who receive three or more good meals a day and attend five or six days a week for eight to ten hours a day for three to five months. Mothers of children attending the centre may be required to provide one day a week of work to assist with the running of the centre. The participation of the mothers not only can reduce the number of staff needed but can also provide them with an active learning experience. The opportunity can be used to teach improved child feeding practices using local foods and other aspects of health and hygiene.

An NRC can play an important part in improving nutrition. However, the average centre taking 30 children for three months will provide services for only about 120 children per year. Very few countries can provide enough centres for all children with moderate malnutrition. If NRCs are to have a real impact on nutritional problems in a country, they must offer effective nutrition education and function also as demonstration and teaching centres.

Child health clinics

Child health clinics have been in existence in various countries for many years, and some have had an important role in reducing the incidence of certain deficiency diseases. In industrialized countries rickets was highly prevalent and was a major cause of child mortality a few decades ago. The establishment of clinics where cod-liver oil was dispensed and where attention to child health was provided was one of several factors responsible for its control.

Healthy children, whether from wealthy or poor families, benefit from regular visits to child health clinics. In many industrialized countries well-baby clinics provide this valuable service. For poor families and in developing countries generally, there may be no great advantage in separating attendance of well babies from that of sick babies.

Health clinics are meant to draw together the curative and preventive components of child health care. However, they also have the advantage of separating these important activities from the often overloaded out-patient services of many hospitals.

There is no universal rule to indicate what services a clinic should provide, but if at all possible, it should be linked with some more sophisticated health unit, often a hospital. The relationship might be close, as for example when a clinic is run as part of a general or children's hospital; or it may be remote, involving simply occasional supervision from a hospital in the region or district. If the link is remote, a well-organized referral system and a means of transporting patients to hospital should be features of the clinic. The professional staff in charge of child health clinics ranges from well-trained paediatricians to auxiliaries with some special training in child health and nutrition.

Much has been written about the means of communicating nutrition and health facts to those with little education. Important aspects of nutrition teaching by clinic staff would be to stress the value of breastfeeding, to emphasize the control of family size and spacing of children, and to pay attention to nutritional and health problems specific to the particular area. In areas where childhood diarrhoea is an important cause of morbidity, attention needs to be given both to preventive measures and to simple treatment with home fluids or oral rehydration therapy.

Child health clinics, often called "under-five clinics" in developing countries, should provide curative services at least for minor illnesses. Preventive medicine provided at the clinics should include at least two major components: immunizations and nutrition services.

Immunizations should be available, preferably free, and parents should be encouraged to use this service for their children. In most countries the young child would receive triple antigen against diphtheria, pertussis (whooping cough) and tetanus (DPT vaccine), BCG vaccine against tuberculosis, oral vaccine against poliomyelitis and live attenuated virus vaccine against measles. In certain areas vaccination against other diseases such as cholera may be warranted. (Vaccination against smallpox is not now necessary, because smallpox has been totally eradicated worldwide.) Some clinics may provide prophylaxis against malaria.

Nutrition services are basically of two kinds: making available nutritional supplements for malnourished children, and providing attention to growth and development of the child.

Supplements are designed to complement and add to the foods available at home for young malnourished children from poor families. The most widely used supplements have been protein-rich foods. It has been realized that growth deficits in children do not often result purely from protein deficiency and that mild or moderate malnutrition is almost always caused by poor total food intake and energy deficiency. Therefore, a supplement that provides a concentrated source of energy balanced with other nutrients including protein is most frequently needed.

In addition to food supplements, clinics may make available certain nutrient supplements. In areas of the world where xerophthalmia is endemic, children may be given a dose of vitamin A every four months. The vitamin A is usually provided in capsules each containing 200 000 IU (60 000 RE) of retinyl palmitate with 20 IU vitamin E added. If the child is unable to swallow the capsule, the end may be snipped off with scissors and the tasteless contents squeezed on to the tongue. In some areas specific vitamins or minerals may be given, such as iodine to prevent iodine deficiency disorders or iron to prevent iron deficiency anaemia.

The second and perhaps more important nutrition activity of health clinics is specific attention to good growth and healthy development. The promotion of good physical growth and optimum psychological development is of the greatest importance and should not be confined to clinics. It is mainly the responsibility of parents, families and communities.

Growth monitoring and promotion

Many different strategies, programmes and actions are undertaken by international agencies, national governments, individual families and others to promote good growth and development. However, there is one strategy above others that both in name and in stated objectives focuses specifically on the growth of children. This is growth monitoring and promotion (GMP).

In the 1980s, the use of the Morley growth chart (see below), used mainly at under-five clinics, began to be promoted in many developing countries as growth monitoring (GM). GM was the first of UNICEF's GOBI (growth monitoring, oral rehydration, breastfeeding and immunization) strategy to improve child health worldwide. Because growth monitoring itself does not improve growth, GM is now usually referred to as growth monitoring and promotion.

GMP should, where possible, be closely integrated into primary health care activities; it should not usually be a separate programme. It should focus on maintaining good growth in infants and children and not, as is often the case, be used mainly for rehabilitating children whose growth is poor. If growth monitoring of all children is to be the aim, it is essential that infants enter the programme soon after birth, because infants up to five months of age who are breastfed generally have satisfactory growth.

The GMP strategy has become controversial, with strong proponents and opponents. The many other actions taken to support or promote growth and development, although very widely practised, are not as visibly advocated as strategies for growth monitoring. Because of this, growth monitoring is deserving of attention, but not at the expense of limiting consideration of other actions that foster good child growth and development. It is also necessary to recognize that good growth is often related to other aspects of good child development and that those situations, environments and actions that promote good child development usually also help promote optimum physical growth. The two are intertwined. However, because physical growth is relatively easy to measure, much more reliance is placed on physical growth than on other aspects of child development as a gauge of childhood well-being.

Growth charts

In the 1960s under-five clinics became widely used around the world to promote good growth, nutrition and health in children. The growth chart became the centre-piece of these activities. In the 1980s this concept was further developed, and UNICEF and many countries promoted growth monitoring using growth charts. This was seen as a major action to reduce malnutrition and also to rehabilitate malnourished children.

On each visit to a GMP centre, every child should be weighed and measured. Accurate balance scales and good simple equipment for measuring length or height are essential. Recording the weight (and height) of children may serve three important purposes. It may help to detect children at high risk of developing PEM; it may be an important tool in assessing the effects of treatment; and most importantly, it can be used to follow the growth of the individual child.

Maintaining an adequate rate of growth has replaced prevention of malnutrition as the goal towards which clinics should direct their work. Experience has shown that the clinical syndromes of kwashiorkor and marasmus are usually preceded by months, and sometimes years, of failure to gain weight. The common exception is when a child develops kwashiorkor suddenly after an illness such as measles, whooping cough or diarrhoea. It is also now known that children with mild or moderate PEM have much higher mortality rates than do well-grown children.

Maintaining an adequate rate of growth has become a positive objective for both the clinic staff and the mothers who attend. A child who has failed to gain weight for several months is given special attention. In clinics the mother may be provided with a temporary supply of a food supplement and with instruction on improving the child's diet. The nurse or assistant uses the trend in the weight curve to assess the effectiveness of food supplements and of education in nutrition. When failure to gain weight is persistent, the child is referred to a physician or to the next level of health care.

Many countries use the growth chart developed by Morley in Nigeria (Figure 18). It has several unusual features in its design and use which help to make it more acceptable than previous charts. These include a calendar to record the child's age and a graphic and easily understood record of the child's recent and past medical history and state of nutrition and of the inoculations received. The fact that the mother, rather than the clinic, keeps the chart and that home visits are made to evaluate the work of the clinic stimulates interest. The appearance on the chart of certain factors that indicate whether the child is in a high-risk category and the indication of channels of growth that are based on weight standards are extremely useful.

The advantages of the calendar over many other methods of age charting are several. Formerly the most common charts in use around the world recorded the age of the child in months. After one year of age this becomes increasingly difficult; the necessity of a calculation at each visit led to errors and was a deterrent to graphing weight, especially in a busy clinic. On Morley's chart a simple calendar is constructed when the child is first seen. Against the growth curve, entries are made of important incidents such as cessation of breastfeeding, birth of a sibling or major diseases. With this chart, the worker can absorb the important facts of a child's medical history in a matter of seconds.

The chart should be colourful and durable and supplied to the mother in a tough open-ended plastic envelope. It is considered to be her property and not that of the clinic. Experience in several centres has shown that few charts get lost, probably fewer than the number of records mislaid in the average small hospital's card filing system.

The chart has an upper line representing a satisfactory weight for a healthy, well-fed child at each age. A lower line indicates the tenth centile or some other arbitrary standard which the child's growth should exceed. The standard is probably relatively unimportant. Of more significance than the position of the child's weight curve in relation to the standards is the relation of each weighing to the previous weighings of that particular child. The important point for the health worker to watch is whether the weight of the child is following a path that goes approximately parallel to the channel and steadily upward.

FIGURE 18. A simple growth chart

Date of visit

Weight

Arm circumference

Day

Month

Year

kg

G

Y

R

             
             
             

Indications for special care which can appear on the growth chart

The nine high-risk factors or indications for special care are:

    · maternal weight below 43.5 kg;

    · place in birth order greater than seventh;

    · death of either parent or broken marriage;

    · death of more than four siblings, especially between one and 12 months of age;

    · birth weight below 2.4 kg;

    · multiple birth;

    · failure to gain 0.5 kg per month during the first three months of life or 0.25 kg per month during the second three months;

    · breast infections in the mother and difficulties in breastfeeding, particularly those secondary to psychiatric illness in the mother;

    · measles, whooping cough or severe or repeated diarrhoea in the early months of life.

A positive approach

GMP is viewed as a strategy to empower mothers to maintain good nutritional status in their children and to prevent growth retardation. It is a preventive, not a curative, strategy; it is designed mainly to promote good growth and health, not to deal with malnutrition and ill health. Workers should obtain information on how mothers and families are managing to achieve good growth rather than mainly finding the reasons for growth failure. Praise and reinforcement should be an important feature of the programme.

Although the major emphasis is on maintenance of good growth, which can be viewed as a pre-emptive strategy, the programme should include a strategy for dealing with those few cases where the programme has failed and where children are not doing well and need special attention. This will usually involve some special advice from health workers regarding behavioural change aimed to achieve rehabilitation, and in some cases treatment or referral will be necessary. In some programmes the strategy may include dietary supplements.

In GMP programmes, much of the action should consist of positive reinforcement rather than corrective action. As a diagnostic exercise, GMP should serve as much to find out what mothers are doing right as what is going wrong. It is also used to detect early growth faltering, to find the likely reasons for it and to suggest to mothers corrective actions that are realistic and that they might try. GMP is likely to be relatively unsuccessful if used mainly to try to correct the growth of older children who are moderately or severely stunted, especially if these children are not wasted.

In all cases, meaningful involvement of mothers and families should be the heart of a GMP programme. It is a participatory exercise. It involves dialogue and discussion, not lecturing and scolding, and mothers should help in decision-making, for example, about the location, hours and organization of growth monitoring sessions. Mothers also need to be consulted about such matters as the need for privacy and confidentiality and whether it is appropriate in their culture to weigh children nude or clothed.

This is a view of the concepts of what good GMP should be, rather than what it usually is in practice in countries in Africa, Asia and Latin America. Growth monitoring continues to be practised in ways that ignore these principles. Too often growth monitoring is used mainly as a weighing and charting exercise and advice is given only to mothers whose children are doing badly. Often the mothers are scolded publicly, and advice is frequently impractical and does not recognize what would be useful to them. Inadequate time is devoted to dialogue, advice and education. In some parts of the world, GMP is regarded by health workers mainly as a tool for diagnosis of malnutrition. In other places, it is used to select children to receive free or subsidized weaning foods. Feeding can be a component of a GMP programme, but the full potential benefits will not be realized without the level of communication, dialogue and empowerment of mothers and communities described above.

At worst, growth monitoring consists of the routine exercise of weighing and charting with no advice given and with no use made of the chart, often because of lack of time or because of lack of training or knowledge regarding the proper use of other needed interventions. Where this is the case GMP is useless and wasteful of resources, including the mothers' time. In some societies, cultural prejudices against weighing of young children may be a reason for not introducing GMP or at least for sensitive efforts to overcome this difficulty.

Improving GMP

In a properly run GMP programme, most infants should be enrolled as soon after birth as possible. Children seen for the first time in their second or third year of life often will already have evidence of growth failure, and at this stage GMP can do relatively little to improve the situation, especially in stunted older children. When breastmilk is adequate and breastfeeding is the normal feeding practice, infants under four months of age usually show good growth. The first four months are therefore the most valuable period to establish dialogue and to provide positive reinforcement. This becomes most useful in the months ahead, during the nutritional danger period, which is usually between four and 18 months of age. The mother should be encouraged to tell the health worker about how long she expects to breastfeed, when she intends to introduce other foods, whether she wants to get the infant immunized and how she will deal with illnesses such as diarrhoea and respiratory infections. The worker at the GMP session should then cautiously advise the mother and discuss with her a strategy for maintaining good growth and health in her infant during the danger period, rather than concentrating on the rehabilitation or cure of malnutrition.

If dialogue is to be the heart of the programme, it is important that the health worker have a good understanding of existing child raising practices and the cultural, social and dietary environment of the community. Otherwise the messages may not be relevant, practical or feasible to implement and may not even be credible to the mothers. The health worker must also have a minimum of knowledge about the factors most likely to lead to growth faltering. For example, he or she should understand that after about six months of age breastfeeding alone often provides inadequate nutrition and needs to be supplemented; that too much supplementation may reduce suckling and lead to insufficient milk; that certain foods are bulky and have low energy density, but that there are ways to increase energy density; that as breastfeeding becomes less important, frequent feeding with other foods is important while breastfeeding should continue as long as possible; that infections in themselves may lead to growth faltering, but that starvation as a treatment for diarrhoea and other infections contribute to this; and that breastmilk and other foods should be provided during most illnesses.

To discuss these issues properly, the health worker needs to have enough time with each mother, adequate training and understanding of health and nutrition beyond charting. The right temperament and attitude are perhaps the most important qualities.

An operational rule might be that health workers must be given at least five to 15 minutes to talk to each mother and must be equipped with certain basic knowledge and reasonable communication skills. It is important that they know how to listen to the mother and how to elicit information from her, as well as how to provide positive feedback, encouragement and appropriate advice. Many of the skills can be imparted in training, but obviously some individuals are better listeners and communicators than others.

Another operational rule that follows is that GMP be integrated into PHC. Many of the messages and advice suggested are an integral part of PHC. In general, mothers should not have to attend separate sessions on different days for treatment of common infections, to have their children immunized, to receive vitamin A or anthelmintics, to get advice about oral rehydration, to have a prenatal examination or to obtain family planning advice. In fact, it should be the duty of the GMP staff to ensure that all children attending have been immunized against the six diseases covered in the WHO Expanded Programme on Immunization (see below), that mothers know how to prevent dehydration caused by diarrhoea, etc. GMP can be a part of PHC or it can encompass PHC activities. GMP can serve as an activity that brings the child into contact with the health services at frequent intervals. GMP can act as a catalyst in the strengthening of PHC activities. It is also much easier to carry out GMP as part of a well-functioning PHC system. Therefore, efforts to strengthen and improve PHC will also improve the feasibility of well-run GMP.

A good principle is that advice, nutrition and health education should be rather specific and aimed at the particular circumstances of each mother and child. The dialogue should give the mother the feeling that she herself is developing a realistic, achievable strategy to maintain the good growth and health of her child, and in this way she will see the benefits of the time that she has invested in the exercise. The content of the messages should be simple and must take account of the child in a family situation.

Finally, GMP should be conducted as near as possible to people's homes; at a time convenient to parents; in small enough groups to allow adequate individualized dialogue and short waiting periods; and in a way designed mainly to suit parents, not health workers. For example, in an urban setting where mothers work away from home, the sessions could be on a Sunday and the health workers could have Monday off. Unless some means are provided for combining GMP with simple therapy and other preventive services (for example, deworming, administration of vitamin A, provision of antimalarial drugs and possibly also simple treatment of common illnesses), attendance may be poor. In all cases, rural GMP activities based in a small village must be linked with and have backup from a health centre, dispensary or clinic.

Some physicians have stated that food supplements should not be provided at GMP sessions even for a child who is faltering, because supplements may have negative consequences for the programme. This view is not shared by all those involved in GMP. In the much-heralded Tamil Nadu Integrated Nutrition Project funded by the World Bank in India, free food supplements are provided to the most needy children, with the targeting based largely on the weight charts.

Under some circumstances GMP may be conducted not at a health centre, but by visits to people's homes. Home-based GMP is often popular with mothers, and it results in wider coverage, especially of the most neglected families; however, it is usually more expensive, because field workers can cover fewer children per day.

Although growth monitoring is simple in concept and is a relatively low-cost technology for helping to reduce the extent of malnutrition, it is very seldom done well. It requires good organization, adequate resources, an appropriate existing infrastructure and careful training and proper supervision of workers. In some locations cultural barriers may have to be overcome.

The success or failure of GMP depends on how the information and the chart are used. The weighing and plotting have to result in action, generally on the part of the child's mother (or parents or guardian) or the health worker, if there is to be a benefit. GMP is one among several means of attempting to achieve the desired goal of healthy growth. Are there other easier, cheaper and more feasible ways to promote good health and development in poor societies? This question should only be answered at the local level or by national ministries of health.

Immunization

Immunization is not a direct nutrition intervention; therefore it is not discussed in detail here, nor are recommendations given for how immunizations should be provided. However, because childhood infectious diseases contribute importantly to malnutrition, immunization needs to go hand in hand with more direct nutrition interventions. In fact it would be negligent for a nutritionist or for any organizer of a set of nutrition interventions to fail to make certain that children have been immunized.

Measles, tetanus and whooping cough (diseases for which vaccines have existed for many years) kill close to 3 million children worldwide each year and result in compromised nutritional status for many of those who survive. Despite these figures, it is encouraging that many countries, some of them very poor, have immunized as many as 80 percent of their children. Measles remains the biggest killer among the diseases that can be prevented by immunization, and it is also the most closely related to malnutrition. Measles is particularly lethal for children who have vitamin A deficiency and serious PEM. It is also clear that provision of medicinal vitamin A to malnourished children with measles will lower case fatality rates. In developing countries the main immunizations recommended and given are those to prevent diphtheria, pertussis (whooping cough) and tetanus (DPT), measles, poliomyelitis and tuberculosis (BCG). The immunization schedule recommended by the WHO Expanded Programme on Immunization (EPI) is provided in the accompanying box.

Immunization timetable of the WHO

Expanded Programme on Immunization

For immunizations in maternal and child health clinics the EPI schedule is as follows:

    · BCG: as soon after birth as possible, up to 12 years;

    · DPT and oral polio vaccine: at two, three and four months (with the possibility of starting at one month if one of the diseases, e.g. whooping cough, is highly endemic);

    · measles: at six to nine months of age;

    · tetanus toxoid: two doses one month apart in the last trimester of pregnancy, and one booster dose in subsequent pregnancies.

In mass campaigns, and to all children presenting after six months of age, immunizations should be given as follows:

    · first contact: measles, DPT, polio;

    · second contact, one month later: DPT, polio;

    · third contact, one month later: DPT, polio, BCG;

    · tetanus toxoid to pregnant women during the last trimester of pregnancy.

There are, of course, many other diseases for which there are immunizations. These are discussed in textbooks dealing with infectious diseases.

Oral fluids for diarrhoea

Diarrhoea, which can have many causes (viruses, bacteria, parasites, toxins and others), is a major public health problem in almost all developing countries (see Chapter 3). It usually contributes very substantially both to morbidity and mortality. The control of diarrhoea deserves high priority. The interaction between diarrhoea and malnutrition is well known.

Oral rehydration therapy (ORT) has for 20 years been strongly advocated and promoted by WHO and UNICEF and has also been a strategy at the national level. Diarrhoeal disease causes death, particularly in children, because of dehydration. Frequent liquid stools, sometimes combined with vomiting, lead to severe loss of water and electrolytes.

Until 20 years ago, the main life-saving medical measure in the treatment of severe dehydration was to provide intravenous (IV) fluids, often containing electrolytes, and glucose to provide energy. It was then found in studies, particularly in cholera patients with very profuse watery diarrhoea, that providing a glucose electrolyte solution by mouth will often rehydrate the patient just as well as IV fluids. In 1978 an editorial in the prestigious medical journal Lancet stated that "the discovery that sodium transport and glucose transport are coupled in the small intestine, so that glucose accelerates absorption of solutes and water, was potentially the most important medical advance in this century".

Oral rehydration packets are now widely available and extensively used. WHO recommends that these contain:

A packet should be added to one litre of boiled water.

There is no doubt that in hospitals the use of ORT in place of intravenous treatment for the dehydrated patient has been a major scientific and medical advance. Under medical supervision it can also work well in an out-patient setting for the dehydrated child or adult, provided good instructions are given and followed.

In recent years it has been shown that infants and young children with diarrhoea should continue to be breastfed as much and as frequently as possible. Thinking has also changed in terms of feeding during diarrhoea. Doctors often used to advocate "resting the intestine" during diarrhoea. Now experts agree that this is wrong and that both food and drinks should be provided. More recent research has shown that ordinary sugar (sucrose) and starch, which is the carbohydrate in cereal grains and root crops, also enhance fluid and solute absorption. For this reason cereal-based solutions and traditional rehydration mixtures are gaining acceptance.

It is now evident, however, that in many societies ordinary food and fluid are provided to children and others with diarrhoea. This should be encouraged, not discouraged. In such situations there is no need to promote the use of ORS packets for the home management of diarrhoea.

The aggressive promotion of ORS in packets as a treatment for diarrhoea needs re-evaluation. ORS was developed for treatment of dehydration in the hospital, and it works well there; but it is being promoted for the treatment of diarrhoea in the home, where it may be unnecessary and where alternatives are often available (see Figure 19). Breastfeeding, home fluids and local foods if given early in diarrhoea may prevent dehydration.

It should also be remembered that ORT does nothing to prevent diarrhoea. It is curative medicine to prevent diarrhoea deaths. To reduce diarrhoea requires improved sanitation; safe water supplies; good personal, environmental and food hygiene; health education; and improved standards of living for the poor.

Deworming and control of intestinal parasitic infections

At this moment over 2 000 million persons worldwide carry a burden of worms. High prevalence of infection occurs mainly in the non-industrialized countries, particularly in the tropics and subtropics. Ascaris lumbricoides, the large roundworm, is the most prevalent and is estimated to infect 1 200 million individuals - about one-fifth of the world's population. The two main forms of human hookworm, Necator americanus and Ancylostoma duodenale, infect approximately 800 million people. Ascariasis and hookworm disease have received much less attention than they deserve from doctors, public health officials and international agencies. These parasites and others such as the whipworm (Trichuris trichiura) and flukes of the genus Schistosoma have a negative impact on nutritional status and on child development. The control or alleviation of these and other common helminthic infections deserves a high priority because it would benefit millions of people and it is feasible and relatively cheap. Programmes to reduce the prevalence and especially the intensity of infections would be economical and would positively influence development.

There is now very strong evidence to show that ascariasis, especially when worm burdens are high, retards the normal growth of children and contributes to malnutrition. Several well-conducted studies have shown that children treated for Ascaris lumbricoides infections grow better after deworming than do untreated children. There is some evidence also that ascariasis is associated with poorer fat and lactose digestion and with reduced absorption of vitamin A and some other micronutrients. Heavy burdens of worms contribute to PEM and other deficiency diseases.

FIGURE 19. Home management of diarrhoea

Hookworm constitutes the most important of the human helminthic infections mainly because the parasite is an important cause of iron deficiency anaemia, a condition that has a high prevalence worldwide. It is extremely prevalent and often results in marked debilitation of the host. Iron deficiency anaemia is one of the world's leading nutritional deficiency diseases.

Both roundworm and hookworm may contribute to poor appetite, decreased food intake, intestinal abnormalities and poor absorption or increased loss of nutrients, which may result in PEM, anaemia or other deficiency states. Trichuriasis infections can cause diarrhoea and debilitation. These conditions may in turn lead to decreased energy, low physical fitness and decreased work output in adults and poor school performance in children. The decreased productivity may in turn lead to a reduced ability to grow or procure food. Infections aggravate poverty and malnutrition, and poverty and malnutrition worsen infections. This vicious cycle may adversely affect the development of whole communities (Figure 20). There is now more appreciation of the economic costs of these infections.

Control programmes that involve either reducing the prevalence of parasitic infection or deworming those infected will have an impact on the nutrition of whole communities where prevalence rates are high and large worm burdens are common.

In many parts of the world people often harbour several intestinal parasites at the same time. Polyparasitism is very common. In over 1 000 primary school children examined in seven schools in Kenya, 96 percent had hookworm, 95 percent had T. trichiura and 50 percent had Ascaris lumbricoides eggs in stool specimens examined. Half of these children had mild or moderate PEM, and about 40 percent had anaemia with a haemoglobin level below 120 g per litre.

In the long term, control of ascariasis, trichuriasis, schistosomiasis and hookworm disease will require measures to reduce simultaneously other infections spread by faecal contamination. Improvements in sanitation, water supplies, housing, personal and environmental hygiene and levels of living are needed, together with improvements in people's knowledge of disease transmission and prevention. Latrine construction has been on the agenda of health ministries in Africa, Asia and Latin America for over 50 years. However, in many countries the prevalence (and sometimes also the intensity) of helminthic infections remains as high as ever. With huge continuing population increases, the numbers of persons infected rise.

In the past 50 years there have also been major advances in the drug treatment of these conditions. Whereas in the 1950s it was necessary to use toxic medicines such as tetrachloroethylene for hookworm and antimony for schistosomiasis, there are now safe oral drugs such as albendazole and praziquantel. For intestinal helminthic infections, the new. drugs mean that regular treatment is now feasible, safe and often highly effective. Large-scale deworming is a strategy whose time has come. It is not only a treatment measure benefiting individuals, but also a public health measure. If large numbers of people, particularly children, are regularly dewormed in a community, then there will be reduced contamination of the environment. It is true that reinfections will occur, but it often takes time to build up the heavy parasite burdens that are most harmful. Over time infections will be reduced in terms of both prevalence and intensity.

FIGURE 20. Worm infection, malnutrition and lack of development

In the last 15 years whenever and wherever large numbers of children have been dewormed, the intervention has been very popular and the demand for deworming from neighbouring communities has been intense. Most mothers want their children to be rid of worms. Teachers report that treated children do better in school.

Deworming may be a useful entry point for primary health care. In 12 villages in Tamil Nadu, India, women were found to be much more willing to have their children weighed and to participate in growth monitoring after their children had received albendazole treatment.

Many anthelmintic drugs are now available. Piperazine salts, effective mainly against Ascaris lumbricoides, and bephenium against hookworm (though less effective against Necator infections than against Ancylostoma duodenale) are giving way to newer drugs. Levamisole, given in a single dose, is effective in ascariasis but much less so for hookworm. Pyrantel in a single dose is effective for ascariasis and relatively useful against Ancylostoma duodenale but less so against N. americanus. Mebendazole is highly effective against ascariasis and both forms of hookworm; it is usually given in doses of 100 mg twice a day for three days. Albendazole is equally effective and is given as a single dose of 400 mg.

A parasitic infection that is even more important than these worm infections is malaria. It kills millions of people each year, causes severe illness in many others and is very difficult to control. Its relationship to nutrition is less clear than that of worm infections. However, malaria is known to cause a haemolytic (not an iron deficiency) anaemia, which may be particularly important in women of childbearing age and in children. The control of malaria requires a partnership of persons in the community and in health ministries, plus those involved in environmental issues, in education and in other fields. Work is progressing on a vaccine. Treatment is becoming more difficult because of drug resistance. Impregnated mosquito-nets over the bed to protect people from the insects at night are useful. Attacks on mosquitoes and mosquito breeding sites are important.

HIV and AIDS

The AIDS pandemic is a world problem. It is a health problem, a social problem and an economic problem for many developing countries. It has some nutritional implications. The human immunodeficiency virus (HIV) destroys the immune system and in adults results in overt signs of the disease AIDS often five to ten years after infection. As the disease progresses it causes anorexia; infections in the mouth make eating difficult; and wasting becomes a disease sign. In Uganda, AIDS is called "slim disease" because AIDS sufferers are usually very thin. It is said that male customers now favour plump prostitutes rather than thin ones, because they are thought to be safer.

One way in which HIV is transmitted is from mother to infant. It can be transmitted in utero or at the time of birth, but the HIV virus has also been found in breastmilk; it now seems that some babies are infected by breastfeeding, although this is an uncommon mode of transmission (see Chapter 7). It is worth repeating here that a consensus statement from WHO and UNICEF in summary advises that in areas where infectious diseases and malnutrition are the main cause of infant deaths and where infant mortality rates are high, pregnant women, including those who are HIV-infected, should be advised to breastfeed their babies after delivery, because the risk of HIV infection through breastmilk is likely to be lower than the risk of death from other causes. Recent research indicates that pregnant HIV-infected women who consume adequate amounts of vitamin A are less likely to infect their infants than those whose vitamin A status is poor.

Another relationship between HIV and nutrition arises because AIDS in some African countries and elsewhere is creating many orphans whose parents have both died of the infection. Poor orphans have a high risk of malnutrition.

In some countries where AIDS has resulted in sickness of many people and many deaths, there is a shortage of able-bodied people to produce crops and to undertake other activities necessary for food production or food acquisition. In some rural communities this shortage is having a markedly negative impact on agricultural production and is threatening the food security of many families.

The AIDS epidemic in heavily infected countries also has demographic implications because of markedly increased mortality rates in very young children and in younger adults. This increased mortality is raising the dependency ratio, that is the ratio of dependents (old people, children, sick individuals) to able-bodied productive adults. The higher dependency ratio also negatively influences food security.

Some general principles for prevention are almost universal, but in other ways the epidemic in each country may be different, and there may be somewhat specific behaviours influencing transmission in certain groups in a community or nation. Almost everywhere some level of surveillance combined with epidemiological studies will be helpful if appropriate preventive strategies are to be mounted. Investigations that provide information on behaviours likely to be linked to transmission are important but seldom accomplished. Unless the most risky behaviours in a population are known, sensible preventive measures are difficult to design. Each population may have specific social and cultural practices, mores and norms of behaviour and even particular communication channels that may influence prevention measures.

As the main strategy for prevention is likely to focus on preventing, reducing or modifying risky behaviours that may influence the spread of HIV, it is important to know which of these behaviours are most prevalent and who practises them in each society. For example, in the United States one risky behaviour that has been greatly reduced is blood transfusion using untested blood. A second behaviour, which has not been adequately addressed, is use of contaminated needles among drug addicts. These two behaviours probably have a relatively small role in the spread of AIDS in, for example, Brazil, India and Uganda.

There are only three known ways in which HIV is transmitted from person to person: through sexual intercourse; through blood; and from mother to infant. In each country educational efforts should consider these three modes of transmission and local behaviour patterns that influence activities at the national, local and individual level. Educational messages may need to inform people not only of how the virus is transmitted but also of how it is not transmitted. It has been reported that 25 percent of people in the United States believe that AIDS can be spread by mosquitoes or by eating food cooked by a person who has the HIV virus, and many think that donating blood puts a donor at risk. These are not methods of transmission, and it is worth educating the public on this subject. In some African societies AIDS, like some other diseases, is blamed on bewitchment or a curse from the gods because of some moral transgression. Education should be culturally sensitive and should conform with societal norms. The educators need to have credibility with the groups of persons most at risk of infection. This is often ignored.

Perhaps the most prominent obstacle to the prevention of AIDS in Africa is widespread fatalism. In East Africa when a baby dies, the roof of a house collapses or the harvest fails, it is said in Kiswahili to be "shauri ya Mungu", translated as "the will of God". This kind of fatalism has a useful function. Poor people have little control over many events that impinge importantly on their lives. It may be soothing then to accept adversity by saying, "this is the will of God". Many people shrug off risky behaviour either with this fatalism or by self-assurance that "other people get AIDS but not me". These commonly held views constitute a major obstacle to prevention of AIDS using educational methods.

Many infections are difficult to prevent. What can a person do to avoid contracting the common cold or pneumonia? AIDS, however, is generally spread by human behaviour, and if individuals avoid risky behaviours they reduce the likelihood of contracting the infection. Unless people can be made to understand this, AIDS will continue to spread. Thus the key to AIDS prevention is AIDS education using a wide variety of channels: community organizations and women's groups; the mass media and health services; appropriate religious organizations and social clubs; schools and colleges; and also entertainers, artists and politicians. Educational efforts should not await social science research of the kind discussed above, but would benefit from it.

The only certain way to avoid getting AIDS is, of course, to be sexually abstinent and to avoid contact with blood products. The next level of prevention is to have sexual intercourse only with a single partner known to be HIV-free and monogamous. Risk can be reduced by always properly using a condom during sexual intercourse, a practice often rejected by men from all continents. In many places, especially rural areas in Africa, condoms are not widely available and their cost is very high relative to income.

A more sustainable strategy to reduce the spread of AIDS in some societies lies in actions to endow females with much more control than is now common over sexual behaviour and in decisions related to their own health. Women must have rights to protect themselves from infection by promiscuous husbands or other partners. Education of females, more job opportunities and higher incomes would help.

Certain Asian countries such as India, the Philippines and Thailand are now experiencing rapid increases in AIDS cases. It is predicted that by the middle of the next decade Asia will have more HIV-positive people than Africa.

In the health sector much more widespread and vigorous treatment and prevention of other sexually transmitted diseases, including syphilis, chancroid and gonorrhoea, would help reduce the spread of AIDS. Early recognition of HIV infection and early diagnosis of AIDS, with appropriate counselling of both the infected person and his or her partner, is important. This requires more available testing in developing countries, and those who test positive must understand that they are likely to infect their partners and that they should either abstain from sex or practise "safe sex". However, this conduct is not usually realistic for prostitutes, unless programmes allow alternative sources of income for them. Widespread testing is relatively expensive for poor developing countries.

AIDS has a particular impact on women, not only because the disease will probably kill 2 million African women before the year 2000, but also because women bear the brunt of the consequences of the epidemic. It is usually women who look after sick individuals and orphans in the community; many already overburdened women are taking over the duties of husbands who have died of AIDS; and it is women who have to deal with the negative socio-economic and agricultural consequences of the AIDS epidemic. Women need to be in key positions in the design and implementation of AIDS programmes, and they also need to be a central focus of them. Women need to be provided with the facts and knowledge, the resources and the skills to deal better with the disease and its consequences in a less demanding, more effective and more humane way.

Support is needed for social science research so that action can be based on sound knowledge.

It is important to remember that although AIDS is a terrible scourge and will require large health and other resources, developing countries still have other health problems that may be more important or more prevalent than AIDS and that deserve more attention. Malaria remains a much greater killer, and worm infections and malnutrition are much more prevalent diseases than AIDS. New resources for AIDS control should not lessen health expenditures on other diseases, but should preferably come from reduced military expenditures or increased foreign assistance.

Chapter 38. Promoting appropriate diets and healthy lifestyles

The major nutritional problems in the world can be divided into two general categories:

These types of nutritional problems, their underlying causes, their clinical manifestations and some aspects of their prevention have been discussed elsewhere in this book.

The prevention of malnutrition in both categories is greatly assisted if the people affected have accurate information on what constitutes a healthy diet and how they may best meet their nutritional needs. Education at all levels is important in the promotion of healthy diets and lifestyles. For those who have poor diets or nutritional problems, nutrition education and health education are strategies to influence behaviour change. Behaviour change requires motivation and efforts to recognize personal preferences, lifestyles and perhaps time constraints. Nutrition education and communication are described in this chapter.

Protecting and promoting healthy lifestyles

Almost all governments in Asia, Africa and Latin America are advocating and working to enhance and improve development, and many international, bilateral and nongovernmental organizations (NGOs) are assisting with development in general or with specific development projects. Development involves change: cultural, social, economic and political change, and even changes in values. Any individual or group suggesting or implementing changes should consider carefully whether the outcome will be better for those affected by the change. Too often programmes and actions introduced from the outside foster change for the sake of change, or individuals or countries try to promote change to make others more like themselves, or agencies implement projects that involve change without considering the implications in terms of quality of life and with a naive assumption that all new structures are automatically better than the old ones.

Eight strategies for promoting appropriate diets and healthy lifestyles are given below. Some of these strategies do suggest changes. Where malnutrition is rampant and infectious diseases are prevalent, where these result from widespread food insecurity and a very unsanitary environment, and where the people (particularly women) lack knowledge regarding appropriate child feeding and do not understand the germ concept of disease, then clearly change is necessary if nutrition and health are to improve. There is a need for improved knowledge, improved resources and better standards of living.

In some groups of the population in the non-industrialized countries very rapid change has already taken place in the last 50 years: lifestyles have changed, age-old social practices are disappearing, and Western diets and modern ways are replacing traditional ones. Some of these changes have contributed to improvements in health, improved infant mortality rates and a reduction in certain forms of serious malnutrition such as xerophthalmia; but not infrequently these changes have also led to a new set of nutrition and health problems and to a less caring society. As described in Chapter 23, a steep rise in diet-related non-communicable diseases such as arteriosclerotic heart disease, obesity, certain cancers, stroke, dental caries, diabetes and others is occurring in many developing countries. Some of these problems have resulted from changing lifestyles including changed diets. Parallel with these changes there has also often been an increase in the prevalence of abandoned children, delinquent youths, child prostitution, elderly sick people not receiving proper care, and mental illness.

Not all change and not all westernization is for the good. Many poor societies possess social values that are superior to those found in many modern Western societies. Examples include emphasis on the extended family, better treatment of the elderly and infirm at home rather than in institutions, greater tolerance of the insane and more community spirit. Of course it is dangerous to glamorize life in the villages of developing countries. For many poor people life is extremely difficult; much of their day is spent doing hard manual labour, and they may lack sufficient food, housing or health care. There is no doubt that good health, a variety of social activities and, of course, enough food to eat are needed by all people everywhere. The argument here is not to oppose modernization or development, but rather to recognize, first, that all modernization and development efforts do not automatically provide benefits to the poor; and second, that some of those actions thought to be benevolent may actually downgrade the quality of life of poor people.

Adoption of so-called modern habits and lifestyles sometimes has mixed blessings. Transfer and application of modern food production technologies and food preservation and processing practices have resulted in better quality, more variety and greater safety of food available for consumption. At the same time, adoption of certain food habits and behaviours such as overconsumption of saturated fats, decline in breastfeeding and concomitant increase in bottle-feeding and cigarette smoking may be detrimental to good health and nutrition. It is therefore necessary that the potential ill effects of undesirable practices be offset by taking suitable preventive measures.

It is not suggested that change is necessarily bad. Change is inevitable and is necessary for the improvement of nutrition and health. Modern knowledge can be harnessed for the good of the poor, and each country should freely choose its actions. When change is encouraged, however, either by outsiders or by governments, it is important to consider the possible adverse effects of the changes. The question everyone should ask is: "Will the change improve the quality of life of most affected people?" Perhaps a nutrition and health impact statement should be required of all new projects before implementation, in the same way that environmental impact statements are now required in the United States.

As non-industrialized countries plan for the beginning of a new century, special attention is needed to prevent the adoption of lifestyles and dietary patterns that will lead their people into epidemics of heart disease, lung cancer, stroke, obesity, diabetes and other chronic diseases. Countries in their impatience for modernization should not neglect protecting those aspects of traditional lifestyles that are conducive to good health and nutrition A high priority should be given to protecting good traditional eating habits and good national diets; protecting good caring practices for children, the sick and the old; and protecting good moral, social and religious values The rush to modernity and to westernization could pose a major health and nutritional threat to the populations of developing countries.

Healthy lifestyles are implicit in the strategies described below, whether they refer to dietary guidelines or goals which should ensure a balanced, healthy diet or to areas such as training, education, extension or communications conducted by ministries of agriculture, education, health, women's affairs, community development, etc; workers in these strategies should be trained and employed to promote healthy lifestyles and better diets In all cases the aim should be to reduce undernutrition and infections and also to prevent the risks of non-communicable chronic diseases and health problems associated with inappropriate diets and lifestyles

It is not possible to prescribe a healthy lifestyle; in this book it is considered more appropriate to suggest strategies to promote appropriate diets with the aim of reducing diet-related health problems It is clear that

Lifestyles can be improved in many countries, especially for the poor, with:

Cutting across many of these areas, lifestyles of the poor would improve if there were more equity, and those of women and children would improve if there were no discrimination against females and if there were more empowerment of women

Eight strategies to influence behaviour for improved nutrition

Several strategies besides education are available and have been used to influence behaviour change to improve nutrition.

Eight of them are discussed here:

One important topic beyond these eight strategies needs special attention and is discussed in a separate section concluding the chapter: public nutrition education.

Dietary guidelines and food goals

Dietary guidelines are usually produced by governments but may also be provided by other groups. Chapter 23 discussed dietary guidelines mainly in relation to chronic diseases and described a set of suggested goals to help ensure food consumption for optimal health. These goals are somewhat unorthodox in that they were designed to be applicable both to poor countries where undernutrition is prevalent and to affluent countries where chronic diseases related to overconsumption or inappropriate modern diets are prevalent; in the past most national dietary guidelines were produced in industrialized countries and therefore addressed mainly problems of chronic disease, not undernutrition.

The dietary guidelines issued in the United States in 1990, which address mainly chronic health problems, have been augmented with an educational tool called the food guide pyramid (Figure 21). The pyramid, designed for nutrition educators and the public, replaces the concept of food groups. A pyramid is used because its base is wide, suggesting that most of the diet should come from carbohydrate-rich foods (the bread, cereal, rice and pasta group). The next broadest swath is the fruit and vegetable group. The pyramid may be appropriate for industrialized countries, but it is much less so for developing countries. The top of the pyramid suggests that fats, oils and sweets be used sparingly, but this may be appropriate only where the population tends to have excessive intakes of energy.

Revised dietary guidelines for the United States were published in 1995 which are simple and easily understandable by the general public.

Food and nutrition labelling

Literate people who are interested in selecting a nutritious diet can be greatly assisted by clear and accurate labelling on food products. Food labelling that gives information on nutrient content has been used more in industrialized than in developing countries. It can be useful in almost all countries and is particularly helpful if used with a set of dietary guidelines. Other useful information on the label may include an expiry date.

The FAO/WHO Codex Alimentarius Commission has produced guidelines on nutrition labelling which deserve serious consideration by governments, especially those that do not have nutrient labelling regulations or that are dissatisfied with their existing situation. These Codex guidelines deal with pre-packaged foods and foods for catering purposes.

Nutrition labelling is often criticized for being too detailed and therefore too difficult to use. It is true that labels often list the content of some vitamins and minerals that are not causes of serious deficiencies and are not of public health importance in the country where the product is consumed. In addition to data on the nutrient content of the food and perhaps the percentages of Recommended Dietary Allowances, food labels sometimes also provide other nutritional information, for example, dietary claims such as "cholesterol-free", "low-calorie", "high-fibre" or "sugar-free". Countries need to examine these claims, to determine their accuracy and perhaps to evaluate their effectiveness. It may be more important to draw up enforceable criteria for nutritional claims. Countries moving to develop guidelines or regulations for food labelling would be wise to consult the FAO/WHO Codex Alimentarius Commission and its publications.

FIGURE 21. Food guide pyramid

Source: United States Department of Agriculture/United States Department of Health and Human Services

Food advertising

Commercial advertising can serve to promote healthy eating, but it can also contribute to poor diets. Advertising, including food advertising, is difficult to control. Most countries expect advertising to be truthful, and truth in advertising is a basic expectation. Concerns regarding dietary claims on food labels also apply to claims made in advertisements for products and services. Advertising, particularly television advertising, of inappropriate foods to children has been the subject of much criticism and has been discussed in many reports. Most nations have agreed to the principle of regulating the advertising of breastmilk substitutes, and many have adopted appropriate legislation. However, advertising can also have a good impact on nutrition, and the food industry has an important part to play as indicated below.

Institutional meals

A well-balanced diet is not the only advantage of institutional feeding; the introduction of new, healthier foods and food habits can also be a result. School meals, for example, provide an ideal opportunity to introduce pupils to unfamiliar foods that are nutritious and to demonstrate to children what constitutes a well-balanced meal consistent with dietary goals and guidelines.

Food industry involvement

Every country has a food industry, large or small, and it always has a role in promoting and influencing the consumption of healthy diets. Clearly the main objectives of industrial companies are to market foods, to make a profit and to outsell competitors. However, this can only be achieved by responding positively to public demand for particular foods. For example, the dairy industry in many developed countries has responded to the desire of people to reduce their fat and energy intakes by marketing more low-fat milk and less whole-fat milk. In general, this modification has been helpful nutritionally and has come about as consumers have become more nutritionally informed. However, changes that are beneficial to nutrition or health in the industrialized countries of the North may not be helpful in poor nations of the South. For example, where undernutrition and protein-energy malnutrition (PEM) are common and where mean intakes of fat in children are below 10 percent of total energy, a campaign to promote low-fat milk would be inappropriate.

Ensuring a consistent message

Nutrition education makes much more sense to the public if there is some degree of consistency in the main messages. This is not to suggest that there is a need for control or censorship; but regarding nutrition and health, people are often confused because they hear different and sometimes conflicting messages. For example, many extension workers and others in ministries of agriculture may be promoting the consumption of diversified, energy- and nutrient-dense diets as the way to overcome micronutrient malnutrition, while others may be undermining these messages by advocating the widespread distribution of dietary supplements in the form of pills and capsules.

If nutrition educators can agree on the main nutritional problems and then on the appropriate advice to provide to the public, everyone's work becomes easier.

Consistency is important in all aspects of information, not just in content. Nutrition education must not distinguish four food groups according to one ministry and three according to another. Similarly, national agricultural and food policies need to address the nutrition problems of the country, and the ministry of health needs to promote sustainable solutions to the major deficiencies by advocating food-based approaches that address the fundamental problems of widespread poverty and food insecurity.

Protecting traditional diets

A neglected but important topic, protection of dietary tradition is especially relevant for those countries where diet-related chronic diseases (see Chapter 23) are not prevalent but where economic development permits at least some people to purchase a wide variety of foods, including animal food products.

In general, traditional diets in Asia, Africa and Latin America are based on cereals or root crops, with significant amounts of legumes, fruits and vegetables. Often poultry, meat and dairy products provide only a small proportion of total energy but are appreciated as side dishes or tasty additions to the staple foods.

Usually, these diets are protective against the chronic diet-related diseases described in Chapter 23. Relatively low in total fat, saturated fat and cholesterol, these diets are high in complex carbohydrates and fibre. If plenty of fresh vegetables and fruits are also consumed, these diets are often rich in carotene and vitamin C, which are antioxidants.

Protecting good traditional diets starts with protecting or enhancing the production and marketing of traditional foods. Working with the local food industry to help in safe food preservation and packaging is important, and making foods easier to prepare for the table would contribute much to their popularity. One obvious attraction of many Western dishes is their convenience; busy people are attracted to them and homemakers can save time using them.

Nutrition training

Most countries have far too few professionals who are expert in or knowledgeable about nutrition. Moreover, nutrition training is often a neglected topic for persons other than nutritionists and dietitians. A wide range of professionals could benefit from more and better training in nutrition: health professionals such as doctors, nurses, midwives, health assistants or auxiliaries; agricultural staff, including extension workers, research scientists and high-level ministry officials; teachers and others throughout the formal and non-formal education system; social and community development workers; workers in institutional feeding; staff in NGOs involved in development, health, agriculture, community development and other activities; professionals in the food and related industries; and many others.

A prerequisite for designing appropriate training at suitable levels is a review of the nutrition content of the curricula of training institutes of many kinds in various fields such as health, education, agriculture and community development. Most institutes will be found to have inadequate coverage of nutrition. If this proves to be the case, a group of experienced persons might be formed to make recommendations regarding strategies for improving nutrition training, changes in the curricula and the means to make the changes.

The first need might be to train the trainers. In poor countries this may require external assistance. In designing the training several questions need to be addressed. What are the most important topics in training, taking account of the most important nutrition problems? What do those being trained need to know in order to integrate nutrition in their jobs? Can some progress be made in the near future with the organization of short courses?

Nutrition education and communication

Nutrition education is a strategy that has been widely used for many years to promote healthy diets and thereby ensure proper growth of children and a reduction in all forms of malnutrition. The basis of any nutrition education programme should be to encourage the consumption of a nutritionally adequate diet, to promote healthy lifestyles and to stimulate effective demand for appropriate foods.

In the past, nutrition education was too often conducted in an unimaginative way. People were instructed to eat this or that food because it was "good for you". Attempts were sometimes directed at making radical rather than gradual changes in the diets of the people who were the targets of the nutrition education. As a result, very few of the nutrition education programmes were successful.` They were frequently carried out by persons of a different culture or social class from those being educated. The lessons of history show clearly that nutrition educators should start from the premise that most mothers are doing their best to feed their families properly. If they are not managing to do so, the reasons may well be beyond their control.

In most circumstances the nutrition education content must be formulated on the basis of a problem analysis. The education must be relevant to the reality.

Inadequate total intake of food by young children (energy deficiency) is the main cause of malnutrition in Africa, Asia and Latin America. Therefore, initial advice might be to feed a malnourished infant with the same food as before but more frequently, or to provide just a little more of the food. This advice should be more acceptable to parents than an attempt to make major, often unrealistic, changes in the diet. Other recommendations for change should be simple and feasible for the family, consistent with its cultural habits and of course nutritionally sound.

Nutrition education has frequently failed because the advice did not conform with the above criteria. Throughout the world there have been examples of nutrition education messages that urged poor mothers to provide their children with meat or fish every day, or one egg per day or three cups of milk per day. This advice may have been nutritionally reasonable, but in all other respects it lacked sense. Except in very few communities and countries, poor families cannot afford to provide these foods to their young children so often, and it is now known that it is unnecessary to do so. As described elsewhere in this book, there are cheap alternatives, the legumes being particularly good examples.

Nationally, nutrition education may be carried out by several ministries (health, agriculture, education, social or community development, etc.) and also by various NGOs. All these bodies should agree on common objectives for a nutrition education programme, and each ministry must decide how it plans to implement it. Factors that should be decided upon, which are rarely clearly defined, include the content of the message (discussed above), the target audience for the programme and the media to be used. This strategy may appear simple, but its application will require a change in both the philosophy and the operation of most nutrition education programmes.

The choice of media depends on the formal and informal information and communications infrastructure of the area in question. In general it is wise to use a combination of communications media in an integrated way. However, a concentrated radio campaign may often be the cheapest and most effective way of reaching the bulk of the population. In addition to stations controlled by the government, commercial radio and television should be used for nutrition education. Certain priority issues or areas of concern should receive concentrated effort.

As mentioned, the stress should be on small changes that will complement existing dietary practices and not on major changes. Failure has occurred in past campaigns that attempted to impart a mass of general information on nutrition, rather than hitting hard with a few well-designed messages in a limited number of priority areas.

The efforts of the various ministries and organizations involved in nutrition education should be closely coordinated so that the messages received from different sources will complement and reinforce each other.

Who should give nutrition education? When should it be offered? To whom should it be aimed? The answers to these questions are in general quite simple. Everyone who has the knowledge (for example, members of health teams, schoolteachers, agricultural extension workers) should provide nutrition education. They should do so at every possible opportunity (for example, the doctor when treating a patient, the midwife at the antenatal clinic, the health nurse when visiting a home, the extension officer at a farmers' meeting, the schoolteacher in a class or at a parents' meeting). Every person in the country should be the target of nutrition education. Even if the message concerns PEM in the preschool child, for example, the problem is so important that all people can benefit from being informed about it.

Perhaps the most persistent and frequent error that has been made in nutrition education has been the overriding attention given to animal protein. It is now generally agreed that protein deficiency is not the main dietary shortcoming to be overcome, and that even if it were, animal products do not offer a reasonable or feasible solution in most poor societies. PEM, which is the most important nutritional problem, is much more often the result of a low total intake of food by the child, who may then be deficient in both energy and protein. The solution is to increase the quantity of foods already eaten. If efforts are to be made to increase protein intake, then the stress should be on vegetable foods that are rich in protein, such as legumes, rather than on animal products. Nevertheless, in many nutrition education programmes of the past 40 years emphasis has been placed on increasing the consumption of meat, fish, milk, eggs and manufactured protein-rich foods. This education has totally failed because economic reasons have precluded the adoption of the advice and frequently the foods recommended have not been easily available.

Priority points for nutrition education

Priority points for nutrition education in many countries might include:

    · suggesting that young children be fed more frequently with existing foods;

    · suggesting that amounts of foods at each meal be increased for children during the weaning and post-weaning period;

    · recommending increased consumption by children of any legumes that are available and commonly consumed by the family;

    · promoting inclusion in the diet of foods such as groundnuts that are rich in protein and provide a concentrated source of energy;

    · promoting increased consumption of foods rich in carotene (dark green leafy vegetables and yellow fruits and vegetables) by young children in areas where vitamin A deficiency is a problem;

    · increasing availability of fruits and vegetables through promotion of home gardening;

    · demonstrating the proper preparation, cooking and processing of home-grown fruits and vegetables to preserve their nutritional value;

    · encouraging breastfeeding and discouraging bottle-feeding (i.e. protection, support and promotion of breastfeeding);

    · encouraging attendance by pregnant women at clinics where iron and other supplements are available and where the progress of pregnancy can be checked;

    · encouraging families' attendance with their children at under-five and similar clinics for immunizations and growth monitoring of children;

    · increasing knowledge about protecting the quality and safety of foods, and promoting sanitation, hygiene and safe water to reduce infectious diseases, which often contribute to malnutrition;

    · informing parents about the importance of continuing breastfeeding and other foods when children have diarrhoea, and about the use of home fluids and oral rehydration solution (ORS);

    · providing information on birth spacing and ways to limit family size.

These examples ate not all applicable to all communities or countries, but each is practical and appropriate for many areas.

Nutrition educators have much more to learn from commercial advertising, which has often been successful in changing food habits and attitudes (see the following section on social marketing). Commercial promotion uses the media skilfully. The talent available in commerce should be harnessed more often to assist with nutrition and health education.

Past nutrition education initiatives have had some successes but many failures in terms of improving dietary intake and reducing the extent of malnutrition in a community or a country. The failures have occurred not mainly because nutrition education is a wrong strategy, but rather because the methods used have not led to the desired behaviour change.

In the past 30 years new approaches have been used to elicit changes in behaviour with a nutrition objective, and there is evidence that some have been more successful than older, more traditional approaches. One approach, which has been termed "social marketing", uses some principles from commercial marketing. Other approaches using principles adopted from the behavioural sciences have also improved nutrition education efforts: nutrition educators seek to identify the nutrition problems and eating behaviours of people within the social context in which they live, taking cognizance of cultural factors; only then are the communication techniques chosen and appropriate messages formulated for specific or general audiences.

Social marketing

In recent years social marketing to promote improved health and better nutrition has been widely, and sometimes successfully, used. There have been some real success stories.

A major difference between traditional nutrition education and the newer social marketing approach is that the latter starts with what commercially would be called "consumer research". An attempt is made to discover, using various techniques such as surveys and focus group interviews, what the consumer or the public is doing and why. The older nutrition education approach started from the premise that malnutrition exists, that people's diets are bad and that people need to be told to eat a good diet providing foods in all four basic food groups. The new approach would be likely first to use consumer research to identify a few important problems such as decline in breastfeeding, infrequent meals or drinking of contaminated water, and would then address them. The results of the research regarding consumer views, perspectives and practices lead to decisions on appropriate messages, communication techniques and targeting.

In the commercial world test-marketing is nearly always done before launching a product. It may also be sensible in nutrition education using social marketing and modern communication techniques; the messages developed and the communication techniques chosen to tackle the problems assessed and analysed may be tried out in a limited way. They can then be reassessed, reanalysed and modified, changed or abandoned, before they are implemented for a larger audience.

These methods, if successful, could lead to a major national campaign or to more limited nutrition education activities in certain communities; they could lead to use of television time or to the use of communicators in the villages. The major difference between these and older methods is a recognition that people have reasons for their behaviour and that nutritionists need to respect and learn from people before they attempt to change their behaviour. It may be necessary to identify the resistance points that impede change. Any nutrition education approach that incorporates empowerment and respect for local culture is more likely to be successful than those that do not.

Those interested in using social marketing methods can obtain detailed information in publications included in the Bibliography.

Beyond social marketing, and sometimes including it, social mobilization has been successfully used in improving the nutrition and health of communities. This is a broader approach in which nutrition education plays a part. It is described in Chapter 40.

FAO and other United Nations organizations provide assistance for the development of appropriate nutrition education programmes. They maintain that nutrition education should be carried out broadly through schools, newspapers, television, radio and other mass media as well as through face-to-face contact. To be most effective, nutrition education needs to be integrated into broad nutrition improvement programmes like those described elsewhere in this book. Communication experts need to be involved in the design of programmes.

Chapter 39. Preventing specific micronutrient deficiencies

Over 30 micronutrients are essential for human health and for the proper growth and development of children. They are all vitamins and minerals available in foods. (See Chapters 10 and 11 for properties of micronutrients and Chapters 12 to 22 for deficiencies and disorders.) Micronutrient deficiencies are prevalent public health problems in many countries, especially developing countries. The micronutrient deficiencies that are most prevalent in the world are those of vitamin A, iodine and iron. Together with protein-energy malnutrition (PEM), these deficiencies constitute the "big four" nutritional problems. There is wide geographic variation in their prevalence.

In the early 1990s almost all countries pledged to devote major efforts to eliminating vitamin A and iodine deficiencies and substantially reducing iron deficiency by the year 2000. These tasks will be more difficult for some countries than for others, but all countries where these micronutrient deficiencies exist should have a policy and strategies to deal with them. However, the initiatives should not undermine, replace or reduce efforts to control PEM, which is often more prevalent and more important as a public health problem. In some countries some other micronutrient deficiencies may also constitute a public health problem and may perhaps be more important than the deficiencies of vitamin A, iodine or iron. In these countries appropriate attention needs to be devoted to the most important deficiencies based on their prevalence, the extent of the morbidity they cause, their contribution to mortality rates, their social and public health significance and, finally, the feasibility and cost of control. See Chapters 16,17 and 18 for discussions on thiamine, niacin and vitamin D deficiencies and their control.

Individual countries and communities can take many different strategies and actions to address these micronutrient deficiencies. It is important to make certain that the strategies and actions are coordinated and that consideration is given to strategic actions that address more than one nutrition problem simultaneously.

Comprehensive versus targeted approaches

Policies and programmes designed to control the three major micronutrient deficiencies are usually either comprehensive or targeted. A relatively comprehensive (or holistic) approach to deal with vitamin A deficiency might include public health measures, horticultural activities, treatment and control of infections, fortification of foods and judicious use of vitamin A supplements, allied with government activities to reduce poverty and improve food security. A narrowly targeted approach might be a distribution of high-dose vitamin A capsules to young children at high risk of vitamin A deficiency.

The comprehensive approach can be compared to firing a shotgun: many small pellets are fired, rather than a single bullet, and these may hit a wider area or different targets. The targeted approach, on the other hand, is analogous to using a rifle: there is one bullet, which is lethal, but only if it hits the target. Thus it has sometimes been termed the "magic bullet" approach.

For many public health problems and most types of malnutrition, the holistic approach is philosophically and politically preferable and is more likely to be sustainable than the narrow, targeted approach. In practice, the place for the magic bullet is in dealing with a single problem or individual.

Holistic approaches might appear to be more daunting, more difficult and perhaps slower for reaching the optimistic goals for micronutrient deficiency control. However, this need not be so, because the holistic approach can also embrace the magic bullet approach. A vitamin A deficiency control strategy, for example, can include targeting of high-dose vitamin A supplements along with initiatives for increasing production and consumption of carotene-rich foods, fortification, nutrition education and broad public health measures. Optimism that holistic approaches will be successful depends to some extent on a favourable political and social climate and some chance of social mobilization and community participation. Favourable economic development is a helpful but not necessary condition.

The goals of virtually eliminating vitamin A and iodine deficiencies and reducing iron deficiency substantially by the year 2000 are ambitious, but they are realizable in several countries. In all cases their realization will require a rather rapid and sustained increase in levels of appropriate activity. Achievement of the goals will depend not, as is often stated, primarily on political will, but more on government actions. Will is important, but actions are essential. Many international agencies, non-governmental organizations (NGOs) and others are poised to assist countries and their local experts in concentrating efforts to control micronutrient deficiencies. FAO, the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) are among the agencies concerned.

A micronutrient deficiency control plan

The first requirement, which some countries have already met, is to formulate a national plan with defined strategies and actions and clear lines of authority to take action. In most cases an overall micronutrient plan is desirable. However, specific deficiencies may call for different control strategies, involving different professionals and perhaps necessitating separate plans of action.

The prevalence of each deficiency in different parts of the country and the underlying determinants may or may not be well known. Action should not await new comprehensive nutritional surveys, but more detailed assessment of the micronutrient deficiencies and their underlying causes may be desirable. This can also provide baseline information to judge the effectiveness of actions taken. Baseline information on the prevalence of the deficiencies is often usefully supplemented with specific information on food intakes; relevant social, cultural and economic factors; and data on the health situation.

Four control strategies

Four main strategies can be implemented to reduce or control micronutrient deficiencies. They operate in concert with broader strategies to improve the quality of life in particular countries and communities. Actions at all levels - international, local and family - to improve household food security, individual health and care can have an impact on micronutrient deficiencies and should always be taken into account in micronutrient deficiency control strategies.

The four basic micronutrient strategies are:

These four strategies are listed in order of sustainability; clearly improved diets contribute to controlling a micronutrient deficiency in a much more sustainable way than medicinal supplements. Public health actions and fortification are of intermediate sustainability. Many public health measures, such as improved health knowledge, water supplies and hygiene, remain in place, whereas other measures, such as immunizations, require continuing action. Undoubtedly conferring the knowledge and ability to produce, procure and consume an appropriate diet is the most sustainable way to prevent micronutrient deficiencies.

Improving diets, especially through dietary diversity

Clearly the ultimate goal in attainment of micronutrient food security is to ensure that people consume a diversity of foods that provide them with the required quantities of all essential micronutrients on a continuing basis. This surely should be the basic long-term strategy of all governments addressing the problems of vitamin A and iron deficiencies. (As stated in other parts of this book, iodine deficiency often cannot be controlled in this way, and salt iodization is recommended.) For infants, the protection, support and promotion of breastfeeding and emphasis on the health and good nourishment of the mother offer the best protection. To prevent iron and vitamin A deficiencies in adults, stimulating the production and consumption of micronutrient-rich foods is vital.

Nutrition education is an important part of this strategy. However, it will be effective only if the appropriate foods are available. Education to improve production and especially consumption of appropriate micronutrient-rich foods must go beyond old nutrition education methods which exhorted people to consume certain foods because they were "good"; education programmes must be designed to elicit behaviour change that will be permanent. A programme in Thailand, for example, successfully used social marketing methods to raise dietary vitamin A intakes in the northeastern part of the country, and Bangladesh has seen some successes in increasing home or village production and consumption of carotene-rich foods.

Improving dietary diversity is best considered as an integral part of community actions to improve household, and then child, food security. The actions planned will often be cooperative and may include agricultural activities, school-based projects and assistance to families, both urban and rural.

This sustainable approach to the control of micronutrient deficiencies is often criticized as being too difficult or at best a very long-term strategy. Recent examples from many parts of the world, however, suggest that good results can be seen in a relatively short time. Critics of this strategy are often those who are philosophically tied to "quick-fix", medically oriented solutions that can be planned from outside the country or outside the community. But the food-based strategy is sustainable and is the only one that controls vitamin A deficiency permanently.

Public health actions

Clearly any measures that reduce infections and promote good health will also help to reduce most micronutrient deficiencies, especially vitamin A and iron deficiencies. The relationship of nutrition and infection has been discussed in Chapters 3 and 37.

Specific health actions in the control of micronutrient deficiencies include early diagnosis and treatment of deficiencies. When a deficiency is recognized early and properly treated it cannot lead to serious consequences. Thus recognition by health workers that preschool-age children in a community have night blindness or Bitot's spots, that schoolchildren have small enlargements of the thyroid gland or that women have low haemoglobin levels can prompt timely medical action and cure. This evaluation can be part of primary health care.

At the next level are public health actions, particularly those that control infections. They include immunizations against infectious diseases; mass deworming and measures to reduce the transmission of parasitic infections; and improvements in sanitation, household hygiene and availability of safe potable water. All can help in the control of micronutrient deficiencies. Good maternal and child health services, availability of family planning, health and nutrition education and household and environmental hygiene measures contribute to reducing malnutrition.

Some of these health interventions are highly sustainable and many will have an impact on nutrition and health beyond the micronutrient deficiencies.

Fortification or nutrification of foods

Food fortification, usually salt iodization, is widely recognized as the most important strategy for the control of iodine deficiency disorders (IDD). Fortification can also contribute to the control of vitamin A and iron deficiencies among populations who purchase food and can afford fortified ingredients. Many different foods in industrialized countries are fortified with iron and vitamin A. Many North Americans get more than their total daily requirement of vitamin A and iron from one large bowl of a fortified breakfast cereal and from a slice of toast liberally spread with margarine fortified with both carotene and vitamin A. It is believed that food fortification was responsible for the control and often the virtual elimination of many serious micronutrient deficiencies that were prevalent in industrialized countries early in the twentieth century.

Food fortification has to be continued as long as there is a risk of people suffering from a particular micronutrient deficiency and dietary diversification or other steps are not removing the risk. The sustainability of a fortification programme depends on food industry cooperation, monitoring and legal enforcement.

Fortification, including salt iodization, has been successfully used for many years in industrialized countries, but in some developing countries there have been serious problems in introducing it. A national programme requires advocacy, political will and often multisectoral actions or involvement, with the participation of several ministries. It also requires cooperation from the food industry, whose opposition would make fortification difficult if not impossible. An early step to successful implementation is often the establishment of an interdisciplinary committee, including people from universities or research institutes who have conducted research on the problem; representatives of appropriate ministries including health, commerce and industry, finance and perhaps education and agriculture; and representatives of the food industry. Consideration can be given to fortifying more than one commonly eaten food. Chapter 34, which deals with ways to improve food quality and safety, includes an outline of the important factors to consider in a fortification programme.

Medicinal supplements

The provision of micronutrients taken orally or by injection is usually simply called "supplementation" rather than "medicinal supplementation", but in fact these supplements are generally provided as medicine or used in a medicinal sense.

Eight steps for successful food fortification

A food fortification programme to solve a micronutrient deficiency considered a national problem usually needs to follow a series of steps. These might include:

    · justification on the basis of data showing the prevalence, distribution and seriousness of the problem;

    · consideration of other methods to control the deficiency, such as food diversification;

    · advocacy to educate government decision-makers, the food industry and the public and to obtain their feedback;

    · selection of the food or foods to be fortified (based in part on criteria discussed in Chapter 34) and of the form of nutrient or nutrients to be added;

    · actions related to implementation, including establishment of an interdisciplinary committee to work with the food industry involved and the micronutrient supplier and determination of a time frame for implementation;

    · consideration of budget and organizational aspects, not necessarily after the preceding step;

    · development of legislation and other regulations;

    · establishment of a system for evaluation and continuous monitoring.

In practice, the key to success in carrying out these steps has often been the dedication of an individual or a small group that is knowledgeable about the problem, committed to its solution by fortification and tireless in seeking and involving allies from international organizations such as FAO, UNICEF, WHO, the International Anaemia Consultative Group (INACG) and the International Council for Control of Iodine Deficiency Disorders (ICCIDD).

(The term "food supplementation", in contrast, refers to the addition of more nutritious foods to a simple diet, for example, the addition of dried skimmed milk to maize meal as a supplement to basic rations in emergency situations. In this case, the added food is a food supplement, not a nutrient supplement; it is given as a food intervention, not as a medical intervention.)

The major role of supplementation with iodine, vitamin A or iron is as a short-term measure. It may be used in the longer term for individuals at special risk of the deficiency. Programmes of medicinal supplementation should usually be introduced for rapid improvement while long-term, sustainable interventions are planned and readied for implementation.

In some instances medicinal supplements may be the only feasible intervention to protect people. They are especially useful in the event of natural or civil disasters, when no alternative strategy may be immediately available.

Medicinal supplementation is the least sustainable strategy because it depends, first, on a delivery system that reaches almost all persons at risk of the deficiency and, second, on active participation, including behaviour change, by those at risk of the deficiency (or in the case of the children, by their families and guardians). These two essential components are very seldom fully realizable, and this is one reason for failure.

However, as indicated below, there is a good distance between a rejection of all supplementation and a decision to attempt a national programme to provide a medicinal micronutrient supplement (such as high-dose vitamin A capsules) to all children between six months and five years of age throughout the country. The middle ground is the usual choice and is most appropriate; this includes medicinal supplements for persons at special risk, as well as broader programmes, for example, provision of oral iodine to non-pregnant females of child-bearing age in IDD-endemic areas to protect their future foetuses from iodine deficiency while salt iodization is being introduced.

Micronutrient supplementation is more effective if it reaches people through existing delivery systems, for example, when iron is routinely given in antenatal clinics, vitamin A to malnourished children when they come for growth monitoring and oral iodine at school to female pupils 14 to 19 years of age. It has been suggested that high doses of vitamin A be given to infants at the time of immunization as part of WHO's Expanded Programme on Immunization (EPI), but this proposal should probably not be recommended. The infants would be "captive" subjects, but infants in their first six months of life are usually breastfed and at low risk of xerophthalmia, and there is evidence that high doses of vitamin A in young infants can cause undesirable reactions. Similarly, more and more projects have been aimed at providing schoolchildren perhaps once a year with an anthelmintic drug to rid them of intestinal worms, and vitamin A promoters have suggested that high doses of vitamin A be given at the time of deworming. However, school-age children usually do not have serious clinical manifestations of vitamin A deficiency. Targeted use of micronutrient supplements should aim at people at special risk of the deficiency, not at people who are easy to reach but who have little risk of the deficiency.

Preventing vitamin a deficiency

The reduction and eventual control of vitamin A deficiency in most poor countries where it is prevalent almost always requires a broad approach. Seldom will it be appropriate to use only one strategy.

The United Republic of Tanzania is one of several countries taking a broad approach. The country's interdisciplinary, interministerial national micronutrient committees have set actions in place to improve dietary intakes of vitamin A-rich foods. They include horticultural activities and nutrition education; public health actions of various kinds; an exploration of possible foods to fortify; and judicious use of high-dose vitamin A supplements, widely available through health services. At the same time, Tanzania is striving, by means of economic, agricultural and other policies, to improve the well-being of poor Tanzanians in a sustainable way, which if successful will also work to reduce vitamin A deficiency.

Each country needs to consider to what extent it will aim to use each of the four possible strategies described above. Communities and families also take their own actions, becoming participants to a greater or lesser extent in strategies planned nationally.

Improving the vitamin A intakes of at-risk people

In developing countries most people get most of their vitamin A from carotene in foods, not from preformed vitamin A, which is present only in foods of animal origin. Therefore endeavours to increase dietary diversity to improve intakes of vitamin A will focus mainly on raising the intakes of foods containing carotene. Certainly there is some place, if appropriate in view of incomes and availability, for modest attempts to increase intakes of foods of animal origin that contain vitamin A, but the main step is to promote the consumption of carotene-rich fruits and vegetables. Other sources of carotene in certain countries are red palm oil and yellow maize. It is also important that diets contain adequate fat, which assists with absorption of carotene, and enough protein for retinol transport.

Justifying medicinal supplementation

FAO (1993a) has suggested a set of questions that need to be answered to justify supplementation. These questions include:

    · Are there any population subgroups for which supplementation may be required as short-term assistance? Which? Why?

    · How well defined are these subgroups (women of reproductive age, infants, young children, the elderly, refugees or displaced persons)?

    · What are their specific needs? Have those needs been measured, or are they just presumed to exist?

    · Are we sure that the problem is so acute and urgent that supplementation would be appropriate?

    · Are we sure that we can match the acuteness and urgency requirements with appropriately massive and prompt interventions?

    · Where would we get the necessary supplies from? How would they be delivered? How would they be distributed? How would we ensure that the target population (and only the target population) gets them?

    · Is there sufficient support from the authorities (national, local) to ensure the success of the operation?

    · Are the proposed beneficiaries aware of the problems? What are their likely attitudes to the proposed assistance?

    · Are we confident that the assistance would continue for as long as needed? If this is not guaranteed, should we initiate the intervention, or not?

    · What parallel measures are we introducing to reduce the period over which supplementation would be needed? Will we be creating an ongoing expectation for the supplements? Has an end-point to supplementation been defined and accepted by authorities?

    · How can we ensure that supplementation does not prove counterproductive by giving the false impression that the basic causes of micronutrient deficiency are being tackled satisfactorily? How can we ensure that there is no consequent diversion of resources that might have otherwise been available for interventions which are either more sustainable or more long-lasting?

Answers to these questions will provide the basis on which to decide whether supplementation will be superior as a major strategy, feasible and likely to reach the objectives set.

To increase intakes of vitamin A- and carotene-containing foods, including breastmilk (see Chapter 7), it will often be necessary to stimulate changes, first in production and availability of these foods and second in consumption, especially by those who are at risk of vitamin A deficiency. Chapters 2 and 35, which discuss food production and household food security, and Chapter 38, which discusses strategies for promoting appropriate diets including the use of nutrition education and communications to influence behaviour change, describe methods appropriate for influencing change in vitamin A intakes.

Several projects have led to improvements in knowledge, attitudes and practice relating to consumption of vitamin A-containing foods and in some cases to improvements in vitamin A nutritional status. In Thailand and Indonesia social marketing and other methods were successfully used to increase consumption of vitamin A-rich foods. In Bangladesh the emphasis was on home production of carotene-containing foods and the consumption by children of more green leafy vegetables and carotene-rich fruits. This project was allied with an endeavour to raise families' awareness of night blindness as a sign of vitamin A deficiency. Reductions in night blindness then illustrated the success of the project. In the Philippines and Indonesia projects in selected communities have attempted to increase children's complementary consumption of foods rich in vitamin A with foods containing adequate fat. A dietary approach in the United Republic of Tanzania involves a broad set of activities, including information, education and communication components aimed at creating public awareness of the vitamin A problem and stimulating increased production and consumption of vitamin A-rich foods. There is wide use of radio and newspapers. Special efforts are being undertaken to improve horticultural practices and to link these with control of vitamin A deficiency. Work is under way to increase the production and improve the marketing of red palm oil.

Breastfeeding is protective against vitamin A deficiency. Colostrum is also rich in vitamin A. The baby who is exclusively breastfed for four to six months is protected against xerophthalmia, and for babies six to 24 months of age breastmilk provides very important amounts of vitamin A. For these reasons protecting, supporting and promoting breastfeeding is a very important strategy in the control of vitamin A deficiency. Breastmilk will provide more vitamin A if the mother has an adequate intake of the vitamin. Therefore foods rich in vitamin A should be promoted not only for young children, but also for women of child-bearing age and those who are breastfeeding their babies.

At the community level the health worker, schoolteacher, extension officer or social worker needs to emphasize the importance of vitamin A-rich foods for children and pregnant and lactating women. Families need to know which local foods of those that they can afford to buy and that their children will willingly eat are rich in carotene. Often children will prefer mango, papaya, yellow sweet potato and pumpkin over green leafy vegetables. When red palm oil and liver are available, children should have priority in getting these. Families might be assisted in growing vitamin A-rich foods in urban or rural gardens and in preserving them. Another action is to inform families how to prepare vitamin A-rich foods for consumption by children (see Chapter 40). The foods prepared and served to children differ from society to society, but cooked green leaves put through a sieve or shredded with a little oil or with groundnuts, or mashed cooked pumpkin, sweet potato or carrots, will often be appropriate.

The strategy of improving production and consumption of vitamin A-rich foods is the only sustainable long-term solution for controlling vitamin A deficiency. In most countries it should be a high-priority strategy.

Public health actions

The first health-related action is to ensure that health workers, especially those who see children in out-patient and in-patient facilities within the primary health care system, easily recognize xerophthalmia and appreciate those conditions and illnesses that raise the risk of vitamin A deficiency. Having made their diagnosis or assessed the risk, they must also be in a position to provide appropriate treatment, usually a high dose of vitamin A given orally. Of particular importance is routine oral administration of high-dose vitamin A to all measles cases: 200 000 IU for children over two years of age, and half this dose for those under two.

The second health-related action is to treat, and more importantly to control, infectious diseases. Many infectious diseases exacerbate vitamin A deficiency and not infrequently push a vitamin A-deficient child into overt xerophthalmia. Prevention of measles by immunization is a vitamin A intervention. Vitamin A given to a child with measles greatly reduces the risk of death. Infections influence vitamin A status by reducing appetite, thus lowering food intake and vitamin A intake. Viral, bacterial and parasitic intestinal infections may also reduce vitamin A absorption or conversion of carotene to retinol. Infections are made worse by PEM, which almost always is present in children with xerophthalmia.

The third health-related action is to take steps to control disease and promote health, because these might influence vitamin A status. Deworming of children, treatment and control of diarrhoea and respiratory infections, immunizations and improved sanitation and water supplies can all have a role.

The health sector's support of breastfeeding will also help in the control of vitamin A deficiency. Health and nutrition education also contribute. At the community level, it is important that families be motivated to have their children immunized, to seek early treatment, to control infections and to improve personal, food and household hygiene.

Fortitication with vitamin A

Fortification is an attractive strategy, especially when compared with medicinal supplementation, because the market system delivers the nutrient. When one or more commonly eaten foods are fortified with vitamin A, behaviour change is not required, and there is no need for a cadre of workers to take vitamin A capsules from house to house or for the major government expenditure that is required for supplementation. Fortification is usually a relatively low-cost intervention for governments. Once in place it needs to be maintained and perhaps mandated for the food industry by legislation. Thereafter it is a relatively sustainable intervention, unlike medicinal supplementation. Monitoring may be all that the authorities need to do.

The methodologies of vitamin A fortification are well tested. Hundreds of different foods have been fortified, mostly in industrialized countries without at-risk people especially in mind. Breakfast cereals of all types (based on maize, rice, wheat or oats), margarine, dairy products and other foods are fortified. Food technologists, who long ago developed methodologies for adding vitamin A to oils and fats, are now able to add the vitamin to many other foods. In developing countries the vehicles used for vitamin A fortification include monosodium glutamate (MSG), sugar, tea and margarine.

In the past, developing countries have tended to seek only one widely consumed food as the vehicle for vitamin A. Because the technology exists to fortify many foods, it now seems preferable to consider fortifying several foods simultaneously to achieve wider coverage. The risk of toxicity needs to be considered, especially where quality assurance is difficult to achieve. Industrialized countries such as the United States fortify many foods and do not report widespread cases of toxicity.

Fortification has not been an easy strategy to initiate and sustain in developing countries. In many countries the major problems of vitamin A deficiency are in children who may consume mainly local foods and very few foods that are centrally processed at a facility where vitamin A could be added. Another problem is the cost of the fortified foods and their affordability for the poorest, high-risk groups.

Nonetheless, national committees given responsibility for developing strategies to control micronutrient deficiencies to meet the goals of the World Summit for Children and the International Conference on Nutrition (ICN) need to give serious consideration to fortification for control of vitamin A deficiency. They may need the assistance of outside expertise, and United Nations agencies are often ready to provide it, but local food scientists and food technologists should be brought into the effort and should begin investigating the possibilities of fortification as a strategy. Thereafter it is necessary to consider the foods widely consumed by the poor that could be fortified. The conditions necessary for fortification described in Chapter 32 require consideration. Other decisions before a trial is undertaken include consideration of what form of vitamin A to use and at what levels, the cost and how and where the trial should be conducted. After the trial, it is necessary to consider whether legislation is needed, how monitoring will be conducted, how quality control will be`ensured and who will bear the costs.

Often, if all of a particular food is to be fortified, consumers can bear the cost: if all sugar or all MSG sold in a country is fortified with vitamin A, the price of the product can be raised very slightly per amount purchased. This is usually the best option. In a trial in the Philippines vitamin A and a flow-enhancing substance were added to MSG. The public usually purchased 2.4-g packets of MSG to add to soups, stews or other foods. It was decided to add 0.1 g of the fortificant and to reduce the amount of MSG per packet to 2.3 g to maintain the same packet weight. As the MSG costs more than the fortificant, the packet could thus be sold at the old price. It does no harm if families consume very slightly less salt, sugar or MSG per day.

Fortification of foods with vitamin A has been difficult in several countries mainly because of political constraints or industrial opposition and sometimes because of misinformation by advocates opposed to the use of the food vehicle or to the principle of fortification. Fluoridation of water supplies has received similar opposition.

When vitamin A fortification is implemented consideration might be given to simultaneous fortification of the chosen foods with iron and perhaps other micronutrients.

Medicinal vitamin A supplements

Vitamin A is a fat-soluble vitamin; once absorbed, it is excreted slowly and a good proportion of a high dose remains for some time in the body. Therefore large doses of vitamin A can be given at long intervals.

About 30 years ago it was found that 200 000 IU of vitamin A given to children aged one to five years protects them from vitamin A deficiency for some weeks. Most programmes provide vitamin A every six months, but by then serum vitamin A levels may have returned to deficient levels, so dosing every four months is probably preferable.

Governments using medicinal vitamin A supplementation sometimes attempt universal supplementation to reach all children of a defined age group in the country or perhaps in certain regions of the country. However, this approach has usually failed to reach the objectives set, has proved expensive, has required a complex delivery system, has had coverage rates that have dropped off rapidly after the first dosing and has missed the children most at risk of xerophthalmia. Populous countries with serious vitamin A problems such as India, Indonesia and Bangladesh have attempted nearly universal supplementation at least in some regions of the country. These programmes have no doubt benefited some children, but in general continuing attempts at universal supplementation are not justified. In Indonesia, the major reduction in xerophthalmia undoubtedly resulted more from general improvements in the standard of living of poor people, better household and national food security, improved health services, general improvements in the economy and national attention to nutritional problems than from high-dose medicinal supplements. Major reductions in infant and young child mortality and lowered rates of nutritional marasmus occurred simultaneously with the reduction of xerophthalmia.

Many countries are now targeting vitamin A supplements to particular groups or, more commonly, making them available to those at risk of vitamin A deficiency when they come in contact with the health care system. Free or subsidized supplements are made available to health centres, dispensaries, clinics and hospitals. This strategy has advantages over universal supplementation.

Groups to be targeted for supplementation might include all cases with signs of xerophthalmia, measles, moderate or severe PEM, gastro-enteritis or other selected diseases and conditions. In some countries vitamin A supplements have been tied to other health interventions, for example, child immunizations. This approach should probably be confined to children over six months of age. Supplementation could be combined with regular deworming of young children and with growth monitoring for children who have poor growth. It is also important to give supplements to children in refugee camps or in times of drought or famine. Providing women before pregnancy with vitamin A supplements is not recommended because of the increased risk of birth defects.

When selective supplementation is first introduced it is important to follow the Tanzanian example and train the primary health care workers in the appropriate use of vitamin A supplements. One- or two-day courses, led by a travelling team of trainers, can provide simple literature (e.g. a short hand-out), educate health workers on signs of xerophthalmia and present an agreed list of conditions that warrant vitamin A doses.

In all supplementation programmes there is a need to establish a record system to reduce the possibility that children will get high-dose supplements too frequently and therefore risk toxicity.

Vitamin A supplementation programmes should be used in combination with activities to improve dietary intake of foods rich in vitamin A and with public health measures aimed to reduce vitamin A deficiency. The use of fortification should also be taken into consideration.

The provision of vitamin A supplements to reduce the risk of mortality in groups of children who have no evidence of vitamin A deficiency is not recommended.

Preventing iodine deficiency disorders

Iodine is the easiest of the three important micronutrient deficiencies to control. The strategy most strongly recommended is not dietary improvement but salt fortification, usually termed salt iodization. Public health measures are not an important strategy for the control of IDD, but medicinal supplementation can have a place in highly endemic areas, especially as a short-term measure while salt iodization is being introduced.

Iodine is an absolutely vital nutrient, but humans require it in tiny amounts. Adults should consume 100 to 200 µg of iodine per day; this amounts to less than a spoonful of iodine per person every 50 years.

Improving diets

Nutrition education and other methods to influence people to change their diets do not work as measures to control IDD because the iodine content of foods depends more on geography than on the foods. The iodine content of plants is much affected by the iodine content of the soil in which they are grown. Thus most foods grown in soils depleted of iodine, found most frequently in highland areas, are deficient in iodine. The vegetables, cereal grains, legumes and other foods grown in iodine-depleted soils high in the Andes or Himalayas have much less iodine than those grown in the lowlands near the mouth of the Amazon River or in the Ganges Delta. Influencing higher consumption of particular local foods is therefore not effective. Seafood and seaweed are rich sources of iodine, because sea water has high levels of the mineral. However, these foods cannot be promoted in areas far from the sea.

Nutrition education and other methods to influence behaviour change can be used to reduce consumption of foods containing goitrogens, such as cabbage and other vegetables of the genus Brassica and also some kinds of cassava. In countries where salt is available in both iodized and non-iodized forms, nutrition education and other means should be used to encourage people at risk to use the iodized salt. Nutrition education can also serve to explain the cause of the problem and to stimulate demand for government and other action.

Public health actions

No specific public health measures are used to control IDD. However, good health care and medical services are useful in the diagnosis of goitre and hypothyroidism and in the recognition of cretinism and of metabolic and neurological problems in children whose mothers were iodine deficient during pregnancy. Large nodular goitres that do not respond to iodine or other medical therapy may require surgical excision.

Fortification

It is almost unanimously agreed that fortification is the most effective strategy for the control of IDD. Iodine has successfully been added to water, bread, milk, various sauces and mixed foods, salt and other foods. Recently research has again focused on adding iodine to drinking-water as a means of controlling IDD, but iodizing salt is the major recommended strategy to control IDD by the year 2000.

In temperate climates potassium iodide has been most widely used, but in tropical countries potassium iodate is recommended. It mixes readily with salt at levels from 40 to 100 mg of iodine per kilogram of salt. It is more stable and less likely to be adversely affected by heat and humidity than potassium iodide. The level of fortification varies from country to country and should be based on two considerations: mean levels of salt intake by at-risk populations and other sources of iodine in the diet.

The technology for iodine fortification of salt has been known for a long time, and it is a simple, relatively inexpensive process. It does not change either the appearance (including the colour) or the taste of the salt.

It is believed that once a government manages to get the iodization of salt well established and supported by legislation, it provides by far the best solution to the control of IDD for those who consume the salt, and the control should be sustainable. Many of the industrialized countries have maintained salt iodization for decades and have controlled IDD.

For a variety of reasons, not all of which have been fully elucidated or publicized, iodization of salt in many developing countries, even when legislated, has not been successful. It has not failed because the technology is wrong, but because of other failures in the system. To work, the strategy requires not only political will, but genuine political and government action; honest and incorruptible people at all levels, from top government officials to lower-level technologists; well-trained personnel with knowledge and expertise; social support for the exercise; and finally adequate funding. Control of IDD is an intervention for which poor countries can usually quite easily get support from organizations such as FAO, UNICEF, WHO, the World Bank and bilateral aid agencies. At US$0.05 per person per year, iodization of salt is a very cheap intervention.

FIGURE 22. Process model for a national IDD control programme

Source Dr B. Hetzel, ICCIDD

Six steps to a national programme of IDD control

Figure 22 illustrates the six steps needed for the development of a national programme of salt iodization.

    · It is necessary first to assess the prevalence of goitre and cretinism and the population at risk of IDD, as well as the status of the salt industry and salt importations in the country.

    · The findings from the assessment and from other sources must be disseminated to the public, to key government officials and to politicians. Communications should stress the effects of IDD on physical and psychological development of children and the possibility of adverse influence on school performance of children and on work productivity of all affected people and should emphasize that the deficiency burdens the State with handicapped citizens. This step perhaps needs to go beyond simple dissemination of information and might include strong advocacy.

    · The next step is the development of a plan. The plan is much more likely to be implemented if various actors are involved in the planning process: IDD experts, senior staff from the national nutrition institute and from research institutions and representatives from the salt industry and from consumer organizations. In many countries this effort should generate not only a plan but also an interdisciplinary committee, commission or implementation group with broad representation, a political mandate and proposals for funding (or ensured funding).

    · A political decision to move forward to implement the plan is the next essential step. It requires the commitment of funds and perhaps the use of some external financing and expertise.

    · Implementation of salt iodization follows, involving activities at the site where salt is prepared and distribution of the salt to the market, combined with education and training.

    · Monitoring and evaluation is the last step in what is a continuous cycle. There should be national monitoring of the distribution of the iodized salt, and if possible assessment of the iodine content of the salt at all stages of the food chain from the factory, to the retailer, to the household. There should be attempts to show the effectiveness of the programme in terms of reduction in goitre prevalence, perhaps using sentinel sites which may correspond to those used in the first step. In some countries measurement of urinary iodine and determination of thyroid hormone levels may be feasible as part of the evaluation. Reduction in rates of cretinism may be more difficult to demonstrate because goitres are highly prevalent, whereas cretinism usually is not.

It should be noted that the availability of a solution that produces a colour if added to salt that contains iodine has made it much more feasible to monitor salt locally to make certain that it is iodized. This is, of course, more a qualitative than a quantitative test.

In countries where iodization has been tried but has not seemed to work or where implementation has been fraught with difficulties, it is vital to assess the problems and the resistance points. Salt is a profitable, commercially marketed product, and efforts to develop successful partnerships among governments, the salt industry, retailers and consumers can make salt iodization successful.

Medicinal iodine supplements

Iodine can be provided medicinally to cure IDD, to reduce goitre size and to prevent IDD, including cretinism. Widespread dosing with either oral or injectable iodine has been used in high-risk areas and may be a suitable strategy to reduce IDD quickly while salt iodization is being introduced. Unfortunately, often much more time passes than planned before iodized salt is generally available and consumed.

The preparation most widely available is Lipiodol, which provides 480 mg iodine in 1 ml of oil. It can be either given by injection or taken orally. The doses of iodine in oil, which are much higher than daily physiological needs, are designed to work prophylactically. They provide iodine that lasts for many months. Injections of iodized oil are claimed to prevent IDD for three to four years, and oral iodine capsules for one to two years. Good evaluations have not been done.

In children injections of iodine in oil should be given in the thigh or buttocks. In adults and older children the thigh or buttocks can be used, but the upper arm is better. Oral iodine is often provided in capsules which are swallowed or as a liquid given using a dispenser or syringe which gives a measured dose into the mouth, if possible without touching the lips or tongue.

Oral iodine has many advantages over injectable iodine. It can be given by persons who are not trained to give injections, and therefore it is cheaper to provide. More doses can be given per hour. Above all, there is no risk of spreading acquired immunodeficiency syndrome (AIDS) or other infections which can be spread by syringes and needles that are not sterile.

An alternative to high oral doses of iodine is to provide physiological doses much more frequently. The product usually used is called Lugol's iodine solution. One drop of Lugol's iodine, undiluted, contains about 6 mg of iodine. Lugol's iodine can be diluted so that perhaps 1 mg of iodine is consumed per person per week. If one drop of Lugol's iodine is put in 30 ml of water, then one teaspoonful of dilute solution will provide about 1 mg of iodine.

Preventing iron deficiency

Iron deficiency anaemia is the most prevalent of the three major micronutrient problems. It is the only one common in both industrialized and developing countries, and it is the most difficult of the three to control. For this reason the goal for the year 2000 is to reduce its prevalence markedly and not to eliminate it. This goal is achievable.

Iron nutrition is more complex than that of some other nutrients (see Chapters 10 and 13). Dietary iron comes in two main forms, namely haem and non-haem iron, which are not equally well absorbed and utilized; various dietary components adversely influence the absorption of iron from the intestine; and other substances such as vitamin C enhance the absorption of iron.

Unlike iodine and vitamin A deficiency, iron losses are caused by a highly prevalent parasitic infestation: hookworm disease. Some 800 million persons worldwide, mainly in developing countries, harbour hookworms and are therefore at risk of iron deficiency because the hookworms cause blood and iron loss. Schistosomiasis is another parasitic disease that causes loss of blood and therefore loss of iron in the urine or in the faeces. As in vitamin A deficiency, infections also contribute to iron deficiency, but they are not as prevalent or important as hookworm. Thus the treatment and control of hookworm infections and schistosomiasis constitute an important part of the strategy to combat iron deficiency in many tropical and subtropical countries. This tactic is considered below in the section on public health actions.

Improving diets

To reduce the likelihood of iron deficiency, dietary diversity with a good balance of foods is particularly important. A small amount of food of animal origin such as meat, poultry or fish (especially the liver of these animals) is very helpful. While not essential, intake of animal products can greatly improve iron status. Cereals (such as rice, maize and wheat) and legumes provide most of the iron for most people worldwide; however, the iron is in the non-haem form, and absorption of the iron may be relatively poor. Diets promoted to control nutritional anaemias will include increased consumption of iron, but also foods rich in folate and especially vitamin C, which increases iron absorption.

Several of the foods being promoted to help control iron deficiency are the same as those recommended to improve vitamin A status; thus in many countries steps to increase dietary diversity might aim at the same time to improve both iron and vitamin A nutritional status. The promotion of green leafy vegetables and fruits will help both. Green leafy vegetables are relatively rich sources of iron and vitamin C and very rich sources of carotene, so an increase in their consumption will provide more iron, will enhance iron absorption because of the vitamin C and will increase the intake of vitamin A.

Another dietary measure is to reduce the intake at mealtimes of substances such as tannin in tea which decrease iron absorption or utilization.

The iron in breastmilk is very well absorbed, especially when compared with the iron in cows' milk or in products such as infant formula or milk powder made from cows' milk. Thus protection, support and promotion of breastfeeding is a strategy to prevent iron deficiency while the baby is exclusively breastfed, as well as to maintain iron status after the child is put on home foods while breastfeeding continues perhaps for 18 to 24 months. Breastfeeding also delays the return of menstruation, often by eight or more months. Menstruation is a cause of blood and iron loss for women. Thus breastfeeding may help to protect some mothers against iron deficiency when more iron is lost in menstruation than in breastmilk.

Public health actions

A broad range of public health measures and hospital practices contribute to reducing iron deficiency and other nutritional anaemias. The first area is obstetric practices. The traditional midwife often delivers the baby so that after birth it is below, not above, the mother. Also, in traditional practice the umbilical cord is not cut until it stops pulsating, or at least not immediately after delivery as is the practice of Western-trained doctors and obstetricians. When these two traditional practices are followed, considerably more blood enters the baby and red blood cell and haemoglobin levels are increased. They should be standard practices. Putting the baby to the breast in the first 30 minutes after delivery stimulates the uterus to contract, and this also reduces blood loss. Blood loss for the mother means iron loss, and many women go into delivery in an anaemic state. Iron supplementation during pregnancy is discussed below.

Another public health measure of great importance in many countries is the control of hookworm infestations. Other parasites may also contribute to anaemia, and their control will reduce its prevalence. These include schistosomiasis, which is a cause of blood loss in urine if the infection is Schistosoma haematobium and in the faeces if the infection is Schistosoma mansoni or Schistosoma japonicum. Malaria also causes anaemia, mainly a haemolytic anaemia because the parasite destroys red blood cells.

Control of hookworm disease as a means of reducing anaemia has been a relatively neglected strategy until recently. Hookworm can be cured with a single dose of an anthelmintic drug such as albendazole, whereas curing anaemia may require 100 or more doses of iron using ferrous sulphate or some other compound. The delivery system is much simpler and problems of compliance do not exist. Deworming not only prevents chronic blood loss in the stools, but also improves the growth and appetite of children; if appetite improves, food intake including iron and vitamin C intakes may increase. In endemic areas treatment should be given at least once a year, while other public health measures are introduced to control transmission. These include health education and improved sanitation and water supplies.

The prevalence of nutritional anaemias is also influenced by the availability of birth spacing services. Pregnancy and childbirth increase iron needs and therefore contribute to anaemia. Some family planning methods that help prevent pregnancy such as abstinence, condoms or contraceptive pills thus contribute to control of iron deficiency. In contrast, intra-uterine devices (IUDs) in most women increase menstrual and other uterine blood losses and may thus contribute to anaemia.

Iron and folate supplementation, discussed below as a separate strategy, is usually considered a public health action. Nutrition and health education is also important in controlling iron deficiency.

Fortitication of foods with iron

Fortification of a wide variety of foods with iron has been feasible and used for many decades. In industrialized countries many different purchased foods are enriched with iron, especially cereal-based products. Unfortunately, fortification is much less used in developing countries where iron deficiency is particularly prevalent.

Fortification offers a very important strategy for control of iron deficiency in almost all countries North and South. If iron deficiency is to be substantially reduced before the year 2000, much more attention needs to be given to fortification, usually combined with the other strategies discussed here. Studies and various dietary surveys may be needed to determine the extent to which iron intake, iron bio-availability and other factors are the major causes of anaemia and to determine which foods are widely consumed and lend themselves to fortification. Several foods may be fortified with iron (whereas it is recommended that iodine should be added only to salt), but careful monitoring and quality assurance are essential.

Iron is not an easy nutrient to add to foods in a form that is well utilized and does not alter the quality of the food. The difficulty is to find a form of iron that is adequately absorbed and yet does not adversely influence the taste, colour or other attributes of the food being fortified. Unfortunately, ferrous sulphate, which is cheap and well absorbed, will often react with food constituents and cause colour changes. Iron phosphate does not have these negative attributes, but it is poorly absorbed. Sodium iron EDTA (ethylene-diamine-tetra-acetate) has recently been used successfully in Guatemala and elsewhere. It seems to lack the negative features of other preparations, and the iron is well absorbed. In Guatemala the vehicle for sodium iron EDTA has been sugar.

Many different foods have been fortified with iron and therefore offer possibilities for any country. These include wheat, wheat flour and bakery products, rice, maize flour, salt, sugar, condiments (such as fish sauce in Thailand) and processed foods. Chocolate-flavoured milk with added iron has been successfully used to control iron deficiency in children in Mexico.

Thirty years ago two research projects in Tanzania, one to investigate the causes of anaemia and the second to evaluate school feeding, used a powdered meat product manufactured in Kenya. This method was more or less abandoned until very recently, when animal haemoglobin was again suggested as a food additive or fortificant. Its advantage is that small amounts of haem iron will greatly increase the absorption of the good quantities of non-haem iron provided by a cereal-based diet.

Nutritionists and public health workers interested in the reduction of iron deficiency should advocate the fortification of foods with iron and perhaps also with vitamin C, folate and vitamin A. Iron fortification in Latin America has been estimated to cost US$0.20 per person per year.

Medicinal iron supplements

In many countries the main strategy for reducing iron deficiency is medicinal iron supplementation. The most common supplementation programmes provide or prescribe iron only for pregnant women. The coverage is sometimes extended to lactating women, but usually only at one postnatal visit soon after delivery. These programmes miss pregnant women who do not attend antenatal clinics, pregnant women before their first visit to the antenatal clinic, most breastfeeding mothers, females at risk prior to their first pregnancy and between pregnancies and all other iron-deficient people (or those at risk of iron deficiency) including children and adult males. Research in Kenya showed that 50 percent of primary school children and 40 percent of adult male road workers had low haemoglobin levels. Clearly iron deficiency is not confined to pregnant women.

Most iron supplementation programmes worldwide use ferrous sulphate, which is very cheap and provides iron in a form that is well absorbed. It is usually given in tablets providing 60 mg of elemental iron, and women are advised to take three tablets per day throughout pregnancy. Sometimes the use of this regime in antenatal clinics is allied with health and nutrition education to influence clinic attendance, in part to reduce anaemia. Ferrous sulphate is often combined with folate; such a product is often supplied to countries by UNICEF.

Problems have been encountered with compliance. It is reported that many women do not take the tablets because of perceived adverse reactions such as constipation, abdominal pain and black stools. Antenatal centres, clinics and health centres often run out of tablets, or health workers fail to give them out even if they are included in essential drug supplies.

There is a need to expand the use of iron supplements beyond pregnant women to include lactating women, females before pregnancy and between pregnancies, premature infants or those with low birth weight and, depending on the circumstances, certain preschool- and school-age children and some male adults.

Two important recent developments may change the way in which iron supplements are recommended. The first, and the less important, of these is the development and availability of slow-release iron capsules or spansules. These are made so that the iron, often ferrous sulphate, is slowly released in the intestine. Their advantages are that one rather than three doses is taken daily and some of the adverse reactions are reduced.

The second change is based on limited studies reported in 1993 which suggest that iron taken once per week is as effective as iron taken three times per day. Therefore it may soon be recommended that pregnant women and all others who can benefit from medicinal iron supplements be advised to take their iron supplement once per week, not three times per day. If one ferrous sulphate tablet providing 60 mg of elemental iron taken each week or every five days proves to be sufficient, iron supplementation will be easier, more acceptable to the public and much cheaper.

The control of malaria will also reduce anaemia, but it is not discussed here because it is not strictly a nutrition intervention. For many tropical countries malaria is the most important health problem, and it is a major cause of child deaths. Malaria does cause anaemia, but unlike the anaemia resulting from hookworm infection, it is not strictly a nutritional anaemia. In heavy infections, with massive parasitaemia, malaria parasites rupture millions of red blood cells. This causes haemolysis, the haemoglobin being released into the blood serum. Treatment of cases of malaria and the control of malaria transmission deserve a very high priority. Textbooks of tropical medicine discuss malaria and its control in detail.

Simultaneous attention to several micronutrient deficiencies

There is great merit in combining actions to deal with several deficiencies at the same time. In particular, basic action to improve household access to and consumption of varied and adequate diets will help to control all micronutrient deficiencies. The fact that multiple benefits are achievable through food-based strategies is another reason why such interventions as home gardening, improved local food processing and nutrition education are the approaches of choice.

The following three topics also deserve further consideration.

Relationship of vitamin A to iron

For a long time it has been known that vitamin A deficiency is associated with anaemia and that it causes anaemia in animals. Now there is overwhelming evidence from many developing countries that vitamin A deficiencies are an important cause of anaemia in humans. In societies where vitamin A deficiency is prevalent, iron deficiency is almost always prevalent as well. Research suggests that where both are prevalent it is necessary to provide both iron and vitamin A supplements to achieve good rises in haemoglobin levels. Therefore in many developing countries provision of vitamin A supplements should be included in programmes to provide iron supplements for pregnant women and others.

Parasitic infections and iodine utilization

A recent study showed that subjects with intestinal parasitic infections given oral iodized oil absorbed the iodine less efficiently. It is suggested that in areas with a high prevalence of intestinal parasites, deworming should precede the provision of oral iodine supplements.

Supplementation with several micronutrients

In industrialized countries prevalent micronutrient deficiencies were generally controlled by a combination of improved food supplies and rising incomes and levels of education. However, some conditions, such as rickets, were also improved through the use of cod-liver oil and similar supplements. Many of these contained dietary vitamins D and A and other micronutrients. Parents either obtained them through the health services or purchased them in pharmacies or in grocery stores. Then at home children were regularly dosed with the supplement. It is possible, and trials are being initiated, to produce a nutrient mixture as a flavouring for milk or to be mixed with water. These mixtures, given daily or weekly, could provide approximately the recommended dietary allowances for iron, vitamin A, iodine and other nutrients known to be deficient in a community. If these flavourings, like cod-liver oil 60 years ago, can be made available through both the health services and the market, parents could be empowered to prevent micronutrient deficiencies in their children by regular dosing at home.

Chapter 40. Family feeding, group feeding and street foods

Most of the food that people consume in rural areas is eaten at home. This is also true in many urban areas, although street foods or foods eaten in stalls are providing an increasing percentage of food for urban dwellers. Inadequate family diets and family feeding are the fundamental causes of malnutrition in Africa, Asia, Latin America and elsewhere. For those who live away from home, particularly in institutions such as boarding schools, prisons or refugee camps, malnutrition or undernutrition may result from poor institutional diets.

This chapter deals briefly with food procurement, group feeding of different kinds and street foods. More information is available in books and meeting reports on each of the different methods of feeding described here (see Bibliography).

Food procurement refers to people's means of gaining access to the food they consume. Chapters 2 and 35, dealing with food production and food security, discuss the major methods by which humans in normal life obtain the food that they consume in their households. Also discussed are difficulties that make people food insecure and suggestions for improving food security at the national and household levels.

In households, the two most important ways of procuring food are own food production, most commonly on small farms in rural areas, and purchase of food using money earned from work at home or outside the home or from sale of farm-produced products (termed cash crops, although they may be food crops such as cereals, fruits and vegetables put up for sale). These two methods of food procurement are not discussed here because they have been covered in Chapters 2 and 25 and elsewhere in this book. Families or households may also procure food in other ways; these include take-home food donations, rations provided in exchange for work (food-for-work) and provision of supplementary foods to vulnerable groups. Foods may also be provided to households by friends or families as gifts or donations.

This chapter first deals with home feeding and then describes situations in which~people obtain food other than through home production, food purchases or gifts or consume food outside the household or home. Many of these situations are characterized as "group feeding". The general and most important categories covered here are:

Feeding the family

Earlier chapters have discussed the prevalent problem of household food insecurity, both temporary and chronic. Food-insecure households are those where there is often an insufficient amount of food to satisfy the energy requirements, and also the energy wants or desirable allowances, of family members. There are other households, perhaps the majority, where for most of the year there is adequate food to assuage hunger, to fill everyone's stomach and at most times to satisfy energy wants. However, this "sufficient" food may comprise predominantly bulky, carbohydrate-rich foods and be very low in micronutrient-rich foods. As described elsewhere, bulk and insufficient frequency of feeding may result in energy intakes too low for requirements of young children, even if the food is available. In addition, poor appetites may reduce intake. These problems are discussed in other chapters.

Different family members have different nutrient requirements which depend to some extent on age, gender, size, activity and other factors (see Annex 1). Meals should provide adequate food to ensure that each family member receives all that is necessary to meet his or her nutrient requirements.

Cereals such as maize, rice, millet or wheat, if lightly milled, will usually provide both sufficient energy and B vitamins, although in the case of maize not enough to prevent pellagra. Foods other than the staple must provide the extra protein, fat, calcium, iron and vitamins A and C required. Africans, Asians and Latin Americans usually obtain adequate vitamin D from the action of sunlight on the skin. Iron may be almost sufficient in quantity from staple foods but is not in an easily utilizable form (see Chapters 10 and 13).

The extra protein required may come from protein-rich vegetable foods such as beans, groundnuts, cowpeas, soybeans, lentils or other legumes. Some may come from animal products such as meat, fish, milk and eggs. If the main foodstuff in the diet is cooking bananas, cassava, sweet potatoes or some other starchy food, then an even greater quantity of additional protein is necessary than in a diet based on a cereal grain.

A mixture of vegetable foods eaten at one meal, such as a cereal and a legume (e.g. maize or millet and cowpeas) or a root, a cereal and a legume (e.g. cassava, sorghum and groundnuts), provides better-quality protein than larger quantities of a single vegetable food would; the mixture usually contains all the essential amino acids, whereas a single cereal, root or legume is usually deficient in one or more of the essential amino acids.

A diet containing good quantities of legumes and occasional animal protein foods in addition to a cereal, banana or root staple probably satisfies the family's requirements for energy, iron, protein and B vitamins. It also provides fat if the legumes include good quantities of groundnuts or soybeans or if the animal protein consists of fatty meat, fish, milk or eggs.

Such a diet is lacking only in vitamins A and C, which can best be supplied by fresh fruit and vegetables. Dark green leaves also provide much iron and some calcium.

Every family should be advised to put the above principles into practice so that all its members have a satisfactory diet. The variety so important for a balanced diet can be achieved if family members consume daily, or better still at every meal, a reasonable quantity of food from each column in Table 40, with the main bulk of the diet provided by the staple food. A certain amount of fat is also essential. This may be cooking oil or solid fat, or it may be obtained in the diet from milk, groundnuts, etc. If the main staple of the diet is a highly refined cereal, as opposed to a home-pounded or lightly milled one, then extra vitamin B-containing foods should be consumed. Figure 23, taken from FAO's Food and nutrition in the management of group feeding programmes (FAO, 1993b), illustrates how to make balanced meals.

TABLE 40

Categories of foods needed for a balanced diet

Staple foods

Energy-rich foods

Protein-rich foods

Foods containing vitamins and minerals

Cereals

Butter

Vegetable origin

Fresh fruits and vegetables

Maize

Ghee

Beans

  

Millet

Lard

Peas

Dark green leafy

Rice

Margarine

Groundnuts

vegetables

Wheat

Oil

Soybeans

Orange- and yellow coloured fruits and vegetables

Teff

Sugar

Lentils

Citrus fruits

   

Cowpeas

Guavas

Starchy foods

  

Animal origin

  

Bananas

  

Meat

  

Cassava

  

Fish

  

Potatoes

  

Eggs

  

Yams

  

Milk and milk products

  
   

Insects

  

Note: Appropriate spices, herbs, onion and salt can be added to increase the flavour and palatability of the diet.

FIGURE 23. How to make balanced meals

Source: FAO, 1993b

Table 41 gives seven examples of family diets based on the above information. In each instance the amount given is that which should be eaten by an average man. The amounts can be varied for women and children by using the tables in Annexes 1 and 3. Extras such as spices, tea and other beverages are not included, since, although they make the diet more palatable, they add little of nutritive value. The localities refer to places where this type of diet might be eaten; the diets are not average diets in these areas, but are suggestions as to what would constitute a satisfactory diet.

Where foods of animal origin are not often available, the quality of the protein in the diet can be improved by providing a mixture or variety of vegetable products at each meal. Thus if a household has maize and beans available it is far better nutritionally to eat some of both at each meal rather than to eat maize for two weeks and then beans for two weeks. Mixtures of vegetable products are frequently eaten by many people in Africa and Latin America. Examples, of which some are traditional dishes, include:

TABLE 41

Seven examples of reasonably balanced diets (quantities for an adult male)

Food

Amount

 

(g/person/day)

Philippines

  

Rice

500

Fish

100

Beans

150

Green leafy vegetables

100

Mango

100

Coconut

50

Oil

15

Salt

15

Uganda

  

Plantains (cooking bananas)

1 000

Sweet potatoes

200

Meat

50

Beans

150

Sweet potato leaves

150

Tomatoes

50

Oil

15

Salt

10

Mexico City, Mexico

  

Maize (as tortillas)

500

Meat

50

Beans

100

Tomatoes

100

Oranges

100

Onions

50

Oil

15

Salt

10

Masailand, East Africa

  

Milk

2 000

Animal blood

100

Maize

150

Wild leaves

100

Wild fruit

100

Bananas

200

Salt

15

Santiago, Chile

  

White wheat bread

400

Rice

100

Eggs

30

Meat

100

Carrots

100

Green leaves

50

Butter or margarine

25

Fresh bananas

100

Milk (in coffee)

60

Sugar

30

Salt

10

Rural Mozambique

  

Millet

400

Cassava

200

Sour milk

150

Tomatoes

100

Cassava leaves

100

Groundnuts

50

Bambara nuts

75

Baobab fruit

30

Salt

10

Coastal vilage, lndia

  

Rice

500

Fish

100

Lentils(dhal)

150

Papaya

150

Vegetables (mixed)

200

Groundnuts

75

Oil

20

Salt

10

The various foods do not have to be physically mixed together, but can just as well be eaten separately at the same meal.

Family feeding of infants and young children

The role of various nutrients in the diets of infants and young children has been described elsewhere in this book. The importance of introducing foods to supplement breastfeeding when an infant is six months of age has been stressed. Table 42 gives some examples of dishes suitable for infants and young children. There are of course innumerable other recipes. For each family the foods used will depend on local customs, food preferences, food availability and cost.

As can be seen from the recipes in Table 42, a wire sieve is useful in preparing infant foods. It serves to transform a solid or lumpy food into one of fine, soft consistency suitable for a child with few or no teeth. If a sieve is not available, one can easily be made by punching 20 to 30 holes in the bottom of an empty tin with a medium-sized nail (Figure 24). This makes a perfectly adequate sieve, but it should be carefully washed after each use.

Many adult dishes, after being put through a sieve, are suitable and good for young children. It must be remembered, however, that spices, especially those that have a burning hot taste, are unsuitable. Dishes containing curry powder, hot peppers, etc. should be avoided.

In this book no attempt is made to produce a weaning chart or daily menus for children of different ages. Tables of this kind tend to be too dogmatic and may prevent both teachers and mothers from deciding for themselves what is the desirable food in a particular instance. It is better that each family and each infant be treated individually as long as the diet is based on sound nutritional principles. Advice on diets should always be realistic and adapted to the foods most commonly used and most easily available.

As has been stated, breastfeeding should, under most circumstances, continue for as long as possible. An infant who has developed satisfactorily should begin supplementary feeding by the sixth month. A gruel of the local staple with added milk is an excellent food on which to start mixed feeding. If milk is not available, then any legume can be used instead. The supplementary food should at first be given in one feeding a day using a spoon and cup. After a week or two, when the child has become accustomed to semi-solid food, other dishes can be introduced. Next might come mashed fruit (e.g. mashed papaya) or vegetables, or possibly tomato or orange juice. A week or two later, some different foods, such as groundnut soup or bean mush (see Table 42), can be tried while the others are continued. At this stage, semisolid food might form part of two feedings a day.

By the end of the first year, all or any of the types of food in the recipes can have been tried, while breastfeeding continues. The infant should also by this time have been given the experience of trying many of the adult dishes of the family, with the exception only of obviously unsuitable foods such as peppery curries and alcoholic beverages.

During the period from 12 to 24 months, the infant can cope with many family dishes, but he or she should receive more frequent meals than adults and should have proportionately larger quantities of dietary fat, proteins and some other nutrients (see Annex 1). A number of the suggested recipes can continue to supplement the family food and breastmilk that the toddler receives.

TABLE 42

Dishes suitable for weaning and for toddlers and young children

Dish

Ingredients

Method

Gruel wit beans or groundnuts

Flour made from make, millet, cassava or rice

Prepare a gruel in the customary way.

 

Bean mush or groundnut soup (see recipes below)

While it is simmering in the pot, add bean mush or thick groundnut soup.

   

Stir vigorously. Cook for 2 to 5 minutes,

   

Remove the gruel from the fire or stove. Cool.

Gruel with sour (or fresh) milk or dried skimmed milk (DSM)

Flour from make, millet, cassava, rice, etc.

Prepare a gruel in the customary way.

 

1/2 cup sour (or fresh) milk or 1 tablespoon DSM powder

While it is simmering in the pot, add sour (or fresh) milk or DSM.

   

Stir and serve when sufficiently cool.

   

(Include salt and/or sugar if desired.)

Papaya mush or banana mush

1 papaya or 1 banana

Take a slice of ripe papaya, or a peeled banana.

 

4 tablespoons fresh or sour milk or 1 tablespoon DSM (optional)

Mash it in bowl or on plate.

   

Add milk or DSM powder, if available.

   

Mix and serve.

Amaranth or other green leafy vegetables with lentils

Handful of amaranth or other edible leaves

Wash amaranth leaves and remove stalks.

 

1 tablespoon family dhal (lentils)

Boil until leaves are tender (about 5 minutes).

 

1/2 teaspoon oil (optional)

Cut up leaves finely.

   

Mix heated dhal and leaf mush together, adding 1/2 teaspoon oil, If available.

   

Serve alone or mixed with gruel.

Vegetable mush

Handful edible leaves

Take some cooked green leaves and a cooked carrot, if available, from family pot.

 

1 carrot (optional)

Rub through sieve.

 

1 tomato (optional)

Take ripe tomato, if available, and rub through sieve.

   

Mix and serve alone or mixed with cooked mashed potato or cereal gruel.

Groundnut soup

1/2 cup groundnuts

Roast groundnuts until pale brown.

 

Pinch of salt

Remove skins.

   

Crush groundnuts with pestle and mortar(or on a stone).

   

Add salt. Mix with water to form paste.

   

Cook for 10 minutes in small quantity of water.

   

Serve alone or mixed with gruel.

Bean (or other legume) mush

50 g beans (or other legume)

Soak beans overnight. Boil in the usual way.

   

Mash with fork or spoon.

   

Force through sieve, removing skins.

   

Feed with maize or other gruel.

Groundnut

1 banana

Roast groundnuts and remove skins.

and banana mush

1 handful groundnuts

Boil or roast banana.

   

Put groundnuts and banana in mortar and pound until mush has a fine, smooth consistency.

Rice and lentil gruel

50 g lentils (or other legume)

Boil lentils or beans, or take a portion of beans cooked for adults.

 

120 g rice

Remove skins and crush through sieve.

   

Take cooked rice from adult meal.

   

Mash with wooden spoon until soft and creamy.

   

Add beans and mix.

Millet with beans or cowpeas

120 g millet (or other cereal) flour

Cook finely ground millet flour into gruel or thin porridge.

 

50 g beans or cowpeas

Soak beans overnight and simmer in water with salt.

 

Pinch of salt

Crush through sieve.

   

Mix with millet gruel and serve.

FIGURE 24. A simple sieve can be made from an empty tin

After the second year breastfeeding has usually ceased and extra energy- and nutrient-rich foods are important. The child is now able to cope with most of the family food but must get more than would appear to be the child's fair share. Extra dishes such as some of those suggested in Table 42 are highly desirable during this preschool period. The young child may need more frequent feeding (four or more meals a day) than the adult members of the family. Meals consisting mainly of starchy foods can be made more energy dense by the addition of a little oil or fat.

Institutional feeding

There are many types of institutions where people receive food. The most important of these are schools, because at any one time many hundreds of millions of children worldwide are attending school. Most attend for part of the day at primary and secondary schools, where meals may or may not be provided. At boarding schools, where children sleep overnight, meals should be provided to supply all the nutrients needed for health and growth. Nutrition of school-age children and ways in which children acquire food at school have been discussed in Chapter 6.

In the examples of institutional menus given below (Tables 43 to 48), the amounts of food are roughly designed to meet the likely minimum energy and micronutrient needs of the particular group in the institution. Thus, for example, larger amounts of food are suggested for older than for younger children. The quantities of the more expensive protein-rich foods of animal origin and of some other items such as sugar, fat and tea are not based mainly on nutrient requirements. These amounts may reflect the likely budget of the institution and the level in society of the usual participants. For example, the nutrient requirements of a 50-kg male adult in a prison and a man of the same weight in an army camp may be identical, but the sample diets suggest more meat for the army trainee than for the prisoner, as the former is likely to be given a more expensive, more "luxurious" diet.

Clearly, in institutional feeding the main dish should be based on what is normally eaten in the country. This may be boiled rice, maize tortillas, ugali (maize porridge similar to grits, eaten in Africa) or wheat pasta.

In all of the institutional diets for which examples are given below, small additions of beverages or foods that are locally liked or traditionally eaten can be added. In many parts of the world such additions might include tea, coffee or other beverages. Another addition might be a particular relish, spice or other product to make the food more tasty or palatable, such as salsa, chutney, jam, honey or tomato sauce. Many dishes made in particular countries need or benefit from certain additional foods such as tomato paste, garlic, green peppers or relish. These items, as far as availability and cost allow, should be included.

Nursery schools, day-care centres and kindergartens

Many countries have an increasing number of nursery schools, day-care centres and kindergartens which are established as pre-primary schools or where children from one to six years of age can be left while their mothers work. Children attending such institutions should receive a daily meal consisting of food rich in those nutrients likely to be deficient in the home diet. Toddlers could with advantage be supplied with any of the protein-rich dishes given in Table 42.

Older preschool children should be given a properly balanced midday meal similar to those suggested below for children in primary schools.

Every effort should be made to provide nutrition education for the mothers who bring their children to these institutions. Mothers could be asked to help with meal preparations and would thus get first-hand experience in preparing nutritious dishes for young children.

Day schools

The importance of a midday meal at day schools and of a good balanced diet at boarding schools has been discussed in Chapter 6. Some suggestions or examples for a suitable midday meal at a primary day school are given in Table 43.

For a secondary day school the same foodstuffs could be provided, but the amount of each item should be increased by about 25 percent because older, taller and heavier children have increased nutrient requirements (see Annex 1).

TABLE 43

Sample primary day school meals

Food

Amount

 

(g/person/meal)

Example 1

  

Make or rice

200

Mixed vegetables

50

Green leaves

25

Beans or groundnuts

100

Sugar

10

Milk (full-cream powder)

10

Oil (red palm)

10

Salt

5

Example 2

  

Bananas (plantains) or potatoes

400

Groundnuts

50

Mixed vegetables

50

Beans

50

Dried skimmed milk powder (DSM)

20

Oil (red palm)

10

Salt

5

Example 3

  

Cassava flour

150

Millet

100

Meat or fish

50

Beans

100

Green leaves

75

Fruit

100

Oil (red palm or other)

10

Salt

5

Example 4

  

Bread

150

Potatoes

150

Tomatoes

75

Onions

50

Beans

100

Fruit

75

Oil

10

Salt

5

It is not true that for a school lunch to be nutritious it must include a hot dish. Heat has nothing to do with nutritive quality. A cold lunch may be as nutritious as a hot lunch. It is the food served that determines the nutritive value of the meal.

School feeding or a midday school meal or snack can be linked with supporting activities. In some feeding programmes

parents can have a role, either a minor one in supporting school meals or a major one in organizing and managing school feeding. In Chapter 6 the link between school feeding and small-scale food production activities was mentioned. These activities are usually organized around school gardens which can produce nutritious foods for school meals or for sale. Other activities might include raising small animals (poultry, rabbits, pigeons, guineapigs, etc.) or keeping a school orchard or school fish pond.

School feeding and school food production can be linked very usefully with classroom activities relating to biology, health, home economics, geography, mathematics and agriculture. For example, practical lessons such as how to weigh and calculate amounts of foods in school meals and how to determine area and crop yields of school gardens can link mathematics to nutrition.

School feeding can be associated with school health services, which do not exist for many primary schools. It is useful to provide health examinations, some level of primary health care and first aid, to follow children's height and weight and to test their sight and hearing. A way should be found to make certain that children are immunized. There is also now beginning to be a movement to see that schoolchildren if necessary are regularly dewormed (where intestinal parasites are prevalent) and are provided with nutrient supplements such as iron, vitamin A and iodine.

There are many different reasons for and benefits of school feeding. These include preventing children from feeling hungry, which also helps them concentrate and benefit from classes; providing extra nutrients to improve children's nutritional status; improving attendance; and perhaps making it easier for mothers to work away from home, to be more productive in their fields or to increase their income.

Increasing data from research suggest that short-term hunger in schoolchildren who are not fed adequately before or at school adversely influences school performance, including learning and performance on psychological development tests.

Schoolchildren, even quite young ones, can assist school feeding in a number of ways. They can help bring water to the feeding site if there is no running water at the school; carry wood or other fuel to the school; help in food preparation, in maintaining good food hygiene and in keeping the feeding area and utensils clean; and participate in school garden or small animal production activities.

Boarding schools

Four examples of suitable boarding school diets are given in Table 44. The quantities of food given are suitable daily amounts for a secondary school pupil; these quantities should be divided up and served as three meals. Items such as meat, for which small daily amounts are indicated, may be given perhaps twice a week in larger amounts. For example, 20 g of meat per day make 140 g per week, which can be given in two equal portions of 70 g on Sunday and Wednesday.

In a primary boarding school, the same foods could be provided but with an overall reduction in quantity of about 25 percent because younger children have lower requirements than older children.

Hospitals

Hospital patients usually spend most of their time in bed. Their needs for energy are therefore lower than those of active persons of the same sex, age and weight. However, some may have increased nutritional requirements. These include patients who entered hospital undernourished; those who are pregnant or lactating or have recently had a baby; and those with diseases that require a special diet or extra nutrients. A generally suitable diet is shown in Table 45.

TABLE 44

Sample secondary boarding school diets

Food

Amount

 

(g/person/day)

Example 1

  

Make, rice or wheat (or mixture)

600

Beans

150

Groundnuts

100

Meat

20

Dried fish

20

Leafy vegetables

150

Fruit

100

Sugar

30

Dried skimmed milk (DSM) powder

20

Oil (red palm)

20

Salt

10

Example 2

  

Bananas (plantains)

600

Potatoes

400

Rice

150

Meat

20

Beans

150

Groundnuts

50

Mixed vegetables

150

Fruit

100

Sugar

50

DSM powder

50

Oil (red palm)

10

Salt

10

Example 3

  

Cassava flour

300

Millet

150

Green leaves

150

Fruit

100

Cowpeas

150

Groundnuts

100

Fish

50

DSM powder

50

Oil (red palm)

10

Salt

10

Example 4

  

Rice

300

Potatoes

150

Maize

100

Bread

150

Meat

50

Eggs

30

Vegetables (mixed)

150

Margarine

50

Sugar

50

Fruit

150

Lentils

75

Groundnuts

50

Jam

30

Oil (red palm)

20

Milk (fresh)

0.5litre

Salt

10

Agricultural estates and industrial enterprises

In some cases large numbers of agricultural and industrial workers spend six to ten hours working some distance from eating establishments. Where possible, a midday meal should be made available. The employer should decide, in consultation with the workers, whether the meal should be provided free, at subsidized prices or in a canteen where foods are sold more or less at cost. Free or subsidized meals will encourage as many workers as possible to partake. Canteen meals for workers may be expected to result in a higher output of work, a healthier, more contented labour force and reduced absenteeism. It is therefore often an economic advantage for an employer to provide such a meal.

Other institutions

A prison should provide a completely balanced diet suitable for persons doing heavy work. The diet should be cheap and simple. In some countries the scale of prison rations is laid down by law. In the United Republic of Tanzania each prisoner receives one 50-mg tablet of niacin per week in addition to the prescribed diet, to prevent the occurrence of pellagra. A suitable prison diet is shown in Table 46.

TABLE 45

Sample hospital diet

Food

Amount

 

(g/person/day)

Bread

100

Maize

200

Rice

150

Meat or fish

100

Vegetables

150

Fruit

150

Legumes

100

Milk (full-cream powder)a

75

Oil

20

Salt

10

a Or 0.5 litre fresh milk.

A diet that might be served in the army is shown in Table 47, and a diet for a training college of health, agriculture or police work is shown in Table 48.

Vulnerable group feeding

Throughout this book there are examples of groups within the population who are especially vulnerable to malnutrition and particular deficiencies. In general, the vulnerable are usually defined as children aged six months to six years who are undernourished and women who are pregnant and lactating. The term "vulnerable" is better used, however, if it is applied to those at special risk of malnutrition.

TABLE 46

Sample prison diet

Food

Amount

 

(g/person/day)

Maize rice, wheat or millet

750

Beans

150

Vegetables

150

Groundnuts

100

Meat

20

Sweet potatoes

50

Fruit

100

Salt

10

Oil

5

TABLE 47

Sample army diet

Food

Amount

 

(g/person/day)

Make, rice or wheat products

400

Bread

100

Potatoes

400

Beans

100

Vegetables (mixed)

150

Onions

25

Groundnuts

100

Fruit (fresh)

200

Fruit (dry)

50

Meat

250

Milk (fresh)

0.5 litre

Sugar

60

Oil

50

Salt

10

Thus vulnerable children may include those who do not have evidence of malnutrition but are at risk for any of numerous different reasons; for example, they may include children from very poor families, children from large families with narrow birth spacing and in some cultures female children from a low caste. Similarly, it might be better to say that women of child-bearing age, rather than just pregnant and lactating women, are at risk, and then again to find criteria such as poverty, female-headed households and other factors that place them at risk. Other vulnerable groups include older people if not cared for by an extended family, individuals with mental illness and orphans who are not cared for by relatives. Some chronic diseases such as tuberculosis and acquired immunodeficiency syndrome (AIDS) make subjects very vulnerable to malnutrition.

Supplementary feeding of young at-risk children may be done at feeding centres to which mothers take the children or by providing take-home food supplements or even rations for a complete diet. Research on supplementary feeding has shown that often some of the food taken home is consumed by others and not all by the target child. If the household is food insecure, however, this food may help all members. Consideration might be given to providing for more than just the nutritional needs of the child.

TABLE 48

Training college (health, agriculture, police) diet

Food

Amount

 

(g/person/day)

Rice

250

Bread (whole-meal)

200

Make

200

Potatoes

200

Beans

100

Groundnuts

50

Onions

25

Green leaves

50

Vegetables (mixed)

75

Fruit (mixed)

100

Sugar

60

Meat

100

Fish

25

Eggs

30

Butter

25

Milk (full-cream powder)

25

Oil (red palm)

25

Salt

10

Food substitutions

In the parts of this chapter dealing with home and institutional feeding, examples are given of specific diets or suggested menus. In each of the diets or menus, specific foods are mentioned as examples. They can be substituted, in many instances, by foods of equivalent nutritive value. Substitution may be desirable if the alternative food is preferred, is cheaper or is more easily available. Tables 49 to 51 give equivalents to suggest how much in weight of a particular food can be consumed to provide nutrients equivalent to those provided by a given amount of another food.

Table 49 suggests the amount in grams of some common foods to provide 1000 kcal of energy. Table 50 gives the amount to provide 10 g of protein, and Table 51 to provide 200 µg of vitamin A.

To find equivalents for other nutrients or the nutrient content of an institutional diet described here, readers can make the calculations themselves using the table of nutrient content of selected foods given in Annex 3.

TABLE 49

Amount in grams to provide approximately 1 000 kcal

Food

Amount

 

(g)

Rice

325

Maize meal

325

Millet meal

350

Wheat flour

350

Dried cassava

350

Bread

500

Plantains

800

Yams

1 000

Sweet potatoes

1 000

Potatoes

1 350

TABLE 50

Amount in grams d selected uncooked foods to provide approximately 10 g of protein

Food

Amount

 

(g)

Dried fish

16

Dried skimmed milk (DSM)

27

Soybeans

28

Winged beans

30

Dried groundnuts

32

Fish (sea or freshwater)

40

Meat (beef, mutton, goat or poultry)

40

Kidney beans

42

Cowpeas

45

Chickpeas or pigeon peas

50

Eggs

75

Cereals (rice, wheat or maize)

100

Potatoes

500

Plantains

1 000

Cassava

1 200

TABLE 51

Amount in grams d selected foods to provide approximately 200 µg of vitamin A

Food

Amount

 

(g)

Vegetables

  

Carrots

6

Leaves, dark green (spinach)

30

Pumpkin

124

Tomatoes

160

Leaves, light green (cabbage)

330

Fruits

  

Mango

25

Papaya

99

Lemon

6 600

Animal products

  

Beef liver

7

Human breastmilk

310

Cows' milk (whole)

646

Beef flesh

1 100

Supplementary feeding has been used in growth monitoring programmes where the food is provided only to children under five years of age who have evidence of malnutrition. This approach has been used in Tamil Nadu, India. When the children show a defined degree of growth improvement, they become ineligible for further feeding. The approach is claimed to be very successful in rehabilitating children. However, feeding only malnourished children, rather than children at risk, constitutes a curative approach, whereas a preventive one would in general be preferable.

Supplementary feeding of children is much more likely to have an impact on nutritional status of populations if combined with sustainable agricultural development and efforts to reduce poverty, allied with primary health care, immunizations, education about treatment for diarrhoea and deworming.

Supplementary feeding has possible disadvantages which need to be appreciated. Families who receive food for their children may become overly dependent on free food and may not make adequate efforts to improve home food security. If rations are used as an incentive to motivate attendance at growth monitoring centres, then if supplements are not available, attendance might decline.

The same general principles apply to supplementary feeding of women or any other group. Some programmes provide dietary supplements to all pregnant and lactating women. Foods likely to reduce anaemia are of particular importance. Medicinal supplements of iron, or iron and folate, are often also provided. If women are to be selected on the basis of risk, then the first criterion should be the level of poverty. Other risk factors include teenage pregnancy; death or malnutrition of a previous child; chronic disease such as tuberculosis or AIDS; low weight for height in small women; and poor social support, especially in female-headed households.

Supplementary feeding should not be done in isolation. Primary health care needs to be offered and must be easily accessible; nutrition and health education should be provided; and consideration needs to be given as to whether to refer mothers to family planning services.

Food-for-work and take-home food rations

Food-for-work, where food allocations are made in return for work rather than as free donations, is often used in food emergencies such as drought or famine. It was discussed in Chapter 24 in reference to starvation, famine and refugees. Food-forwork can also be used in development programmes and other situations.

Increasingly food-for-work has been used as full or partial payment of wages, often for work done on public works programmes planned by a government; as an incentive for voluntary labour; and sometimes as a budgetary support for a developing country. Food-for-work is a strategy often used by the World Food Programme (WFP).

The kinds of work undertaken have usually involved labour-intensive road building projects; environmental projects, including tree planting and forestry; and projects to open up new land. Usually these projects are carried out in areas with food shortages. They have both nutritional and non-nutritional objectives: to help prevent food insecurity, hunger and malnutrition, and to get good public work done. The internationally supported food-for-work programmes are usually also seen as economic assistance to developing countries.

Where food is given in exchange for work, it is highly desirable to provide some level of primary health care for workers and to give advice on nutrition, on how to prepare foods not normally eaten by those receiving the food and on what other foods besides the donated rations would help balance the diet.

Each programme establishes the amounts and kinds of foods to be given. These decisions should be based on sensible criteria and concern for local food habits. Often 2100 kcal are provided per person, but food needs to be provided to satisfy family needs, not just the workers' needs. Often five daily rations of 2100 kcal per day worked are provided as a family ration.

A typical ration would provide 400 to 500 g of cereal flour or rice, 25 to 50 g of legumes or pulses and 25 to 35 g of oil or fat. If available, about 20 g of meat or fish might be added. Fresh perishable foods are not usually included in the rations, and it is important that workers and their families supplement the ration with fruits and vegetables. There is some debate about the energy level; a higher level than 2100 kcal may sometimes be advocated.

Emergency feeding

Emergency feeding in conditions of famine and civil disturbances and in refugee camps is described in detail in Chapter 24.

Street foods

Although the term "street foods" has only recently become widely used, the sale and consumption of food on city streets goes back many centuries. Now street foods are recognized as having a very large role in urban food consumption, especially in developing countries and for the poor and middle classes. FAO studies have shown that in some countries street foods provide a very significant proportion of total food intake for many people. It is surprising that the nutritional, health, social and economic impact of street foods has not been studied or appreciated until relatively recently. FAO has had a leading role in drawing attention to the importance of street foods; the Organization has held conferences on the topic and provided advice to countries on appropriate measures to make these foods safer for the consumer. Because of its expertise in this area, FAO can provide very useful advice and assistance to member countries. A good deal of the following discussion has drawn on FAO publications and papers relating to street foods (see especially FAO, 1990a; Dawson and Canet, 1991).

FAO has defined street foods as follows: "Street foods are ready-to-eat foods and beverages prepared and/or sold by vendors especially in streets and other similar public places". This definition is now widely accepted. Street foods are mainly sold in urban areas, but they are also prepared and sold by vendors under similar circumstances in rural areas, and not strictly on the street. As mentioned in Chapter 6, it has become increasingly common for entrepreneurs to set up simple facilities or stalls adjacent to rural schools or to work under a nearby tree to prepare and sell ready-to-eat foods and drinks to schoolchildren and other passers-by. These foods have the same advantages and risks as urban street foods.

In developing countries the street food phenomenon has greatly mushroomed in recent years, in parallel with the huge increase of people living in urban areas, including the vast and ever-expanding megalopoli in Asia and Latin America and rapidly expanding cities everywhere. Street foods are also sold extensively in industrialized countries; it is not unusual for the New York banker or the London journalist to purchase a hot dog and a soft drink or a bag of fish and chips, respectively, on the street.

In cities in developing countries street foods provide a significant percentage of the total food intake of millions of people, have an important economic role and employ many persons, yet these activities are largely unregulated and create risks to health.

Even though authorities in many countries, North and South, regard food vendors on the street as generally undesirable and a cause of problems for the cities, the fact is that street vending has a vital role: urban workers and dwellers depend on it, it is a major employer, it contributes to the city economy and it is a major source of food for many people. Food vendors have also become an important part of urban social life and are not infrequently an attraction to the city.

City officials concerned about problems or potential problems caused by street food vendors should seek to resolve the problems, not drive the vendors off the streets. There are ways to improve the safety of street foods. Authorities should recognize that street foods are generally popular because they provide an accessible source of relatively cheap food of a kind desired by busy urban people such as factory and office workers, students, shoppers and travellers. Especially in the middle of the day, very few people can return home to eat. Street foods are also convenience foods: they save the homemaker or single person from cooking and perhaps from fuel gathering. Many poor people in crowded housing do not have proper cooking facilities, so the food vendor may provide breakfast, lunch and dinner. An FAO study revealed that in Bangkok street foods contributed 88 percent of the daily energy, protein, fat and iron intake of children aged four to six years.

In most countries the street food industry, even though very extensive and important economically, is considered part of the informal economy. It usually does not get much official or positive recognition. Consequently, governments and cities have not taken the necessary steps to improve the quality and safety of foods sold or generally to regulate the practice. The street food industry requires recognition, as it is often very large, involves large amounts of money, employs huge numbers of people and provides a real service to many citizens. Regulations should come at the same time as recognition. The industry is one of the few that can be entered with very little capital, relatively little education and only a small amount of expertise. Success requires hard work, ingenuity and street wisdom. These are characteristics of many unemployed people and of some who enter illegal parts of the informal economy. In many countries such as Nigeria and Indonesia, the majority of persons employed as street vendors are women, so the sector contributes to empowerment and economic gains for females.

Before the year 2000, there is surely a need for governments to recognize that street food vending is not a temporary phenomenon that will be replaced when development is successful. It may have undesirable features, but there are many positive aspects for cities and nations. What is now needed is recognition, legalization and improvement.

Regulation and control of street foods

The objectives of regulation and control are to improve the quality and safety of foods consumed and to let the industry have a positive role in city life. The difficulty is the risk that overregulation could drive the industry underground, force up prices and cause loss of jobs. Sensible steps must recognize the service provided by the industry. A prescription cannot be provided for the regulation and control of street foods in all countries. Appropriate regulatory activities must take cognizance of national differences, culture, local law and current street food practices.

In countries that do not have any regulations, the first step might be to recognize publicly the existence of street food vendors and to issue statements on the importance of the industry and its problems. The second step might be to map out and count the vendors and to classify them using some locally appropriate system. The third step might be to provide each vendor with an official licence. Usually a fee would have to be paid to obtain the licence. The fee should not be so high as to drive vendors away or underground, but it could go towards funds to assist in upgrading the hygiene and other practices of vendors.

It is necessary also to decide on certain minimum standards to help reduce health hazards. These standards will depend on local circumstances and probably should be established after consideration by a committee on which vendors and consumer associations have some representation. Regulations need to be appropriate and to fit in with national and city policies and legislation, and they must be aimed at improving the wholesomeness and safety of food sold without greatly raising the prices. They must have no negative impact of any significant degree either on employment or on the economy, and they must not greatly reduce the availability of street foods enjoyed by the public.

In some countries the first regulations introduced have been unnecessarily stringent health requirements for vendors which have contributed little to protection of the public. Regulations that should be considered might address the cleanliness of the facility, the quality and quantity of water used and the training of vendors regarding appropriate food handling practices in order to reduce the risk of contamination.

Regulations are only effective if there is some monitoring system and some surveillance. Inspections are useful and should be used not entirely for punitive purposes, but also for educational opportunities. Trained inspectors should be able to record violations and possibly to threaten or take action, but they should also be used to make constructive suggestions for improvement of vendor practices or for upgrading the stall or facility. Guidelines for the design of control measures for street-vended foods in Africa are being developed by the Codex Alimentarius Commission along these lines.

An advantage of recognition, licensing and regulations is that they move the street food industry out of the strictly informal sector and into the formal sector. This may make it possible for vendors to get credit or loans to improve their operations. A disadvantage, especially if licence fees are high and regulations strict, is that many vendors will attempt to evade licensing while continuing to practise their trade. There is also a strong possibility that inspectors will be bribed to close their eyes both to non-licensed vendors and to contraventions of the regulations.

Singapore, a highly regulated country with a strong economic base, chose to resettle its food vendors into particular market areas or centres and to issue licences dependent on health standards. Singapore street foods are undoubtedly cleaner than those elsewhere in Asia, but they are perhaps less convenient for the public, less amenable as social meeting places and more likely to be run by persons not in the lower strata of society.

Food hygiene and sanitation

It does not take knowledge of tropical medicine or epidemiology to appreciate that foods prepared and offered for sale on the streets of many cities in developing countries present a health hazard. Anyone who appreciates that germs cause disease can realize that food that has been touched by dirty hands and utensils, that is not served very hot and that has been covered with flies may be unsafe.

Foods may be contaminated not only with pathogenic organisms such as viruses, bacteria and parasites which cause human disease, but also by dangerous levels of food additives, toxins, residues of pesticides used in food production or preservation or other poisonous substances such as heavy metals, e.g. lead, which is toxic.

There have been reports of deaths or disease from consumption of street foods from many countries; instances have included 14 deaths in Malaysia from consuming rice noodles, 300 people becoming ill in Hong Kong from consuming food that apparently contained a toxic pesticide, and a cholera outbreak in India.

Contamination results from unhygienic practices in the preparation, cooking, serving and storage of food. Food vendors, unlike well-run restaurants, often lack refrigeration, good storage facilities and efficient stoves. Bacteria may be in the food when it is purchased, but they are likely to multiply if the food is not refrigerated or properly stored. Organisms in food may be destroyed by the heat of cooking, but if the food is not thoroughly heated and well cooked they may infect the person who eats the food. Some organisms produce toxins in food. The problems are usually related either to lack of coldness or refrigeration for food storage or lack of heat to cook the food. The other risk factors contributing to food contamination are lack of cleanliness of the premises, the utensils and the food handlers. After preparation and cooking, foods may be contaminated by unwashed hands; by flies, cockroaches, rodents and dust; and by holding at temperatures that encourage explosive bacterial reproduction.

A major problem for street vendors which then produces a health risk for the client is water. Ice can also be a source of infections; vendors may use ice made from contaminated water. In some countries it is rare for street food vendors to have running water, and it is common for vendors to have to fetch water from a considerable distance from their point of operation. Then there is a temptation to use the water sparingly, because getting water takes time and energy. The water carried to the stall or other facility may be clean and safe, or it may be contaminated. Some food sellers on the street may have water that is not potable, and they very frequently have an inadequate supply of water. Water is essential for cooking many foods, for washing foods, for making some beverages or for drinking, for cleaning cooking vessels and utensils and for vendors to wash their hands. Vendors may not have hot water for washing utensils. Not infrequently an operator will rinse off utensils for hours in one bucket of water which becomes increasingly dirty and contaminated. All of these practices greatly enhance the likelihood that organisms such as salmonella, shigella and Escherichia coli will be transmitted and that certain parasitic infections such as giardia and ascariasis will be spread.

The food hygiene problem is made worse by the fact that most vendors have very little knowledge or appreciation of the importance of safe, hygienic food handling. City authorities may not take steps to control the unhygienic practices of food vendors because the officers who have authority on the streets may not themselves be aware of the risks. Many of the consumers of street foods also have little knowledge of or interest in food hygiene. This compounds the problem, because they may not, for example, insist on foods being well heated or select food stalls that appear cleaner.

Another health risk to the public is that street food vendors are often unable to dispose properly of waste water and refuse. Often there is no good system for disposal of garbage, which may end up in the street or gutter. Similarly, used water may not go into a drain but may accumulate around the stall or in puddles on the street, where it may attract flies and mosquitoes which may breed and spread disease. Singapore has strict regulations requiring vendors to use plastic garbage bags and provides metal bins near to where hawkers sell food.

Precautions that an informed purchaser can take are to insist that the food be very hot, that it come from the heating area to the customer very quickly and that it be served on a clean plate. Food taken straight off the grill is likely to be safe. It is wise to select fruits that can be peeled just before eating, such as bananas, and to order a beverage from a bottle that can be opened just prior to drinking.

Nutritional quality of street foods

Relatively little research has been published on the nutritive value of street foods sold in different countries. If large numbers of people get 50 to 80 percent of their nutrients from street foods, then it is important that the foods be nutritious and provide a good proportion of the essential nutrients. The nutritional quality of street foods obviously varies enormously from country to country, but also from vendor to vendor in a large marketplace. On city streets around the world it is possible to choose a meal that is nutritious and well balanced, as well as very tasty.

People naturally select foods or dishes for purchase more on the basis of preference, price and affordability than on the nutrient content of the meal or on nutritional quality criteria. Clearly anything that can be done to improve the nutritional quality of foods sold on the street will be helpful.

Recommendations

The street food industry now has a very important role in the cities and towns of many developing countries. It feeds millions of people daily with foods that are relatively cheap and easily accessible. It offers a very significant amount of employment, often to persons with little education and training who might otherwise be difficult to employ. Taken as a whole, it is a big business with major economic and social implications. As described above, the industry can prevent risks to consumers. As cities expand worldwide, the numbers of street food vendors will also greatly expand. In the past authorities have tended to ignore street vendors or even to obstruct them or to attempt to rid cities of them. A better policy is to recognize them and to take action to improve their practices.

The recommendations made here are largely based on the FAO publications mentioned above, and some of them have been adopted in FAO member countries. It is recommended that the following should be considered by most countries.

Chapter 41. Incorporating nutrition objectives into development policies and programmes at the national and local levels

Prevalent malnutrition in a country is clear evidence of poor development, and poor development is also an underlying cause of malnutrition and hunger. Economic growth and development that do not lead to substantial reductions in malnutrition are growth and development that are wrongly conceived. Even undirected economic growth and development can lead slowly to reduced rates of malnutrition, but the improvement is often unacceptably slow, and as a result many poor people suffer unnecessarily. There is a need for well-conceived policies for sustainable economic growth and social development that benefit the poor and the undernourished. This approach to development has been termed "development with a human face". Its goal is to ensure stable and safe food supplies for everyone, adequate protection from disease, available health services for all and an environment that encourages and assists good caring practices for those who need care. Accomplishing these aims is not easy for poor countries struggling out of poverty. Nonetheless promoting growth with equity is possible, and this is the only moral strategy to adopt.

At the same time every effort should be made to reduce malnutrition, irrespective of the rate of economic growth. Several countries have shown that this is possible. Nutrition interventions directed at the major forms of malnutrition, such as protein-energy malnutrition (PEM), vitamin A deficiency, nutritional anaemias and iodine deficiency disorders (IDD), are usually needed, since they will help reduce malnutrition more quickly than economic growth alone is likely to do, even if it does have a human face. It is tempting to aim only or mainly at quick-fix solutions to micronutrient malnutrition while ignoring the more difficult actions needed to reduce PEM. This neglect is not desirable, because PEM is usually the leading form of malnutrition and steps to reduce PEM have other benefits.

The solutions to malnutrition can be assisted by governments, but in the end communities will often have the leading role in reducing malnutrition and promoting social development. People's participation is essential. It is necessary to recognize that the poor will be the principal actors in their own development and to foster policies and programmes that empower the underprivileged. Empowerment and participation of women are particularly important.

To succeed in reducing malnutrition it is important to strengthen technical and managerial capacities at all levels, from community to national; to address the problem of human resource development and training because most developing countries lack well-trained people in nutrition and related fields; and to pay particular attention to the status of women in society, not only because this is due, but also because women have the most important role in food security (and often in food production), in child care and in family health.

Undernutrition and malnutrition are an important part of the complex, widespread problem of poverty and deprivation that affects millions of people, perhaps the majority, in Africa, Asia and Latin America. The poor, the hungry and the malnourished are unable to live a normal life, are less likely to fulfil their potential as human beings and cannot contribute fully to the development of their own countries. In the last two decades the number of malnourished persons has declined moderately in Asia and Latin America. However, as indicated in Chapter 1, South Asian countries have a greater percentage of malnourished people than countries in Africa or the Americas. The numbers of persons who are poor or malnourished or both appear to be increasing in some African countries. One reason for the increase is that in many nations the population is increasing more rapidly than the services and goods necessary to relieve malnutrition and poverty. It is also clear that economic gains are slow and are not reflected in improvements in the quality of life of the majority of people. In many cases the gap between the rich and the poor is widening.

The challenge of malnutrition is so daunting and broad that it needs to be tackled by involving many different sectors, including governments, nongovernmental organizations (NGOs), the private sector, international funding agencies and United Nations organizations such as FAO, the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO). Of particular importance is good cooperation and coordination among government ministries and their staff; this applies particularly to ministries of agriculture and health, but also to other ministries such as those for education, community development and finance. Cooperation is also needed at the provincial, district and local levels.

The international conference on nutrition and its follow-up

Greatly reducing malnutrition and providing human beings with their right to good nutrition is not an impossible dream, and is within the reach of humankind. Political actions, more than political will, to implement well conceived policies and programmes at the national level, while simultaneously acting internationally, can serve to greatly reduce nutrition problems worldwide.

Over 100 nations endorsed the World Declaration on Nutrition and the Plan of Action for Nutrition at the International Conference on Nutrition (ICN) in Rome in 1992. Section V of the Plan of Action describes the responsibility for action. This section is quoted here, as it is believed that it can influence the work of many people at many levels in the next decade.

National food and nutrition policies

As stressed and reiterated at the ICN in 1992, food and nutrition policies should be an integrated and important part of national development plans. The general objectives of food and nutrition policies should be to improve the quantity, quality and safety of food eaten by the population, with the aim of ensuring an adequate diet for all people, and to try to ensure good health and adequate care for all. In nutrition there exists the paradox that overconsumption of food or of certain dietary items also carries a risk to health. For example, consumption of more food than is needed for energy expenditure leads to obesity, and the high intakes of cholesterol and saturated fats typical of Western diets that are high in animal products increase the risk of heart disease. A more equitable distribution of food between the poor and the affluent might thus improve the health of both groups.

As described elsewhere in this book, nutrition actions in most of the poorest developing countries are mainly addressed to reducing PEM and some important micronutrient deficiencies. Increasingly, however, the middle-level developing countries undergoing increasing urbanization and some industrialization are witnessing a very significant increase in noncommunicable chronic diseases related to nutrition such as obesity, arteriosclerotic heart disease, high blood pressure, non-insulin-dependent diabetes and some forms of cancer (see Chapter 23). This problem also needs to be addressed.

Excerpt from the Plan of Action for Nutrition

V. Responsibility for action

The recommendations of the Plan of Action need to be translated into priority actions in accordance with the realities found in each country and must be supported by action at the international level. Taking these into account, governments should prepare national plans of action, coordinated as appropriate with follow-up activities related to the World Summit for Children, establishing priorities, setting up time-frames and, where appropriate, identifying the resources needed and those already available. The strategies to reach the objectives may vary from country to country, and the responsibilities rest with a variety of agents from government institutions to the individual.

1. At national level

(a) Within the context of the national plans of action, governments should formulate, adopt and implement programmes and strategies to achieve the recommendations of the Plan of Action, taking into account their specific problems and priorities. In particular, in countries where it is appropriate to do so, ministries of agriculture, food, health, social welfare, education, and planning, as well as other concerned ministries, should formulate concrete proposals for their sectors to promote nutritional well-being. Governments at the local and provincial levels should be encouraged to participate in the process, as well as NGOs and the private sector.

(b) All governments should establish appropriate national mechanisms to prioritize, develop, implement and monitor policies and plans to improve nutrition within designated time-frames, based on national and local needs, and provide appropriate funds for their functioning.

(c) All sectors of society should be encouraged to play an active role and to assume their responsibility in implementing related components of the national plan of action. Households, communities, NGOs, private institutions - including industry, small-scale producers and women farmers, trade and services as well as social and cultural associations - and the mass media should be mobilized to help individuals and population groups to achieve nutritional well-being in close association with government and technical service sectors.

(d) Programmes aimed at improving the nutritional well-being of the people, in particular of the groups at the greatest risk, should be supported by allocation of adequate resources by the public and the private sector so as to ensure their sustainability.

(e) Governments, academic institutions and industry should support the development of fundamental and applied research directed towards the improvement of the scientific and technological knowledge base against which food, nutrition and health problems can be analysed and solved, giving priority to research concerning disadvantaged and vulnerable groups.

(f) In most countries, high priority should be given to the development of human resources and training of personnel needed in all sectors to support nutrition-related activities.

(g) National governments, in cooperation with local authorities, non-governmental organizations and the private sector, should prepare periodic reports on the implementation of national plans of actions with clear indications of how vulnerable groups are faring.

2. At international level

(a) International agencies - multilateral, bilateral and non-governmental - are urged to define in the course of 1993 steps through which they can contribute to the achievement of the goals and strategies set up in the Declaration and the Plan of Action, including promotion of new partnerships in economic and technical cooperation among the countries.

(b) The Governing Bodies of FAO, WHO, UNICEF, the World Bank, UNDP, Unesco, ILO, WFP, UNHCR, and other concerned international organizations should, in the course of 1993, decide ways and means to give appropriate priority to their nutrition-related programmes and activities aimed at ensuring, as soon as possible, vigorous and coordinated implementation of activities recommended in the ICN Declaration and Plan of Action. This would include, as appropriate, increased assistance to the member countries. FAO and WHO, in particular, should strengthen within available resources their programmes for nutritional improvement, taking into account the recommendations in this Plan of Action.

(c) Regional Offices of UN organizations and regional intergovernmental organizations, are requested to collaborate and facilitate the implementation and monitoring of the Plan of Action.

(d) Regional institutions for research and training, with appropriate support of the international community, should establish or reinforce collaborative networks in order to foster the human resource development needed, particularly at national level, to implement the Plan of Action; to promote inter-country collaboration; and to exchange information on the food and nutrition situation, technologies, research results, nutrition programmes' implementation and resource flows.

(e) As leading agencies of the United Nations system in the fields of food, nutrition and health, FAO and WHO are requested to prepare jointly, [every three years}, in close collaboration with member countries and the relevant specialized agencies and other UN organs, consolidated reports on the implementation of the ICN Declaration and Plan of Action by Member States and international organizations for review by their Governing Bodies.

(f) UN agencies have a special responsibility for follow-up. All concerned agencies and organs of the UN system are urged to strengthen their collaborative and cooperative mechanisms in order to fully participate at international, regional, national and local levels in the achievement of the objectives of the Plan of Action. The ACC/SCN should facilitate coordination of these efforts and, in close collaboration with its participating agencies, prepare periodic reports on their activities in implementing the Declaration and the Plan of Action for consideration by the ACC for submission, through ECOSOC, to the UN General Assembly.

Food production and demand

Adequate and stable availability of food at the national and household levels is one vital ingredient for good nutritional status. Most agricultural policies aim to increase overall production of food and non-food

products. To improve nutrition this increased production needs to lead to increased food consumption by poor non-food secure households. Ensuring the poor with jobs or livelihoods on a sustainable basis will also contribute to lowering rates of malnutrition. Without adequate food production or regular and adequate incomes, nutritional status will often be compromised. Agricultural policy with nutrition objectives needs to address not only how much food is produced, but what foods are grown, where and by whom.

Cash crops sometimes compete with food crops and result in low food availability for human nutrition. However, crops sold for cash (which may be food or non-food products) may provide income to farming families and enable them to purchase more food for family consumption than could be produced on the same area of land. Cultivation of cash crops may also provide more stable income for regular food purchase, but only if the money obtained is used to acquire enough food rather than for other expenditures. It has been shown that if income from sale of farm-produced items is controlled by women rather than men, more will usually be spent on food and less on unnecessary items and children will benefit more.

In many countries much of the agricultural activity is carried out by persons who do not own the land on which they work. Land reform may improve equity and nutrition. In rural areas employment in agriculture, forestry, animal husbandry, fisheries, etc. is important for providing income and contributing to food intakes. New labour-saving technologies may sometimes reduce employment opportunities and contribute to food insecurity. Labour-intensive activities, provided wages are reasonable, will contribute to good nutrition. Other agriculture-related factors that can also influence food security include control of post-harvest food losses, storage of food crops, transport and marketing.

Government organization for nutrition policy formulation and implementation

The need for coordination of nutrition policies and programmes has already been stressed. The main nutrition activities are almost always undertaken by government departments and ministries because nearly all countries are governed under a system that divides the functions of government in this way. Therefore, unless a separate ministry of food and nutrition is established, there needs to be some other mechanism to promote the proper development and coordination of national food and nutrition policies and programmes. It is necessary to ensure that policies within the various ministries are compatible, coordinated and, if possible, harmonized. The implementation of programmes, however, should remain the responsibility of the existing ministries, departments and agencies. As stressed below, many of the actions may depend on community mobilization.

In many cases there is no unit or organization that identifies, appraises and recommends in a systematic and comprehensive manner the measures and strategies that a government might use to meet the objectives of an adequate diet for the population. Similarly, there is seldom a structure or unit that analyses the nutritional implications of the national development plan and other programmes of government ministries. There is clearly a need to provide the function of overview and at least to have an identified focal point for nutrition.

In some countries various institutions or committees have been established to coordinate nutrition activities. In Zambia a national food and nutrition commission was set up soon after independence. In the United Republic of Tanzania the Tanzanian Food and Nutrition Centre has been established as a parastatal body with responsibility to the Ministry of Health. In Indonesia the National Development Planning Agency (Bappenas) quite successfully coordinates nutrition activities and ensures the inclusion of sound nutrition policy objectives in each five-year development plan (Repelita). Many other countries have interministerial committees to discuss nutrition matters that concern several ministries. During the preparations for the ICN, national focal points for nutrition were established in 159 countries.

In the 1990s nutrition planning is less in vogue than in the 1970s. Even so, some mechanism is needed to formulate national food and nutrition policies and to ensure intersectoral cooperation in their implementation. The ICN document Nutrition and development - a global assessment (FAO/WHO, 1992b) states:

The Plan of Action for Nutrition includes the recommendation (see the preceding box for full text of the section) that:

Food and nutrition policies are too important a part of national development to be ignored or only to be broken down into separate components of the activities of several ministries. All those concerned with nutrition can play a part, first by coordinating their activities with those of colleagues in other ministries and second by influencing the government to establish a suitable nutrition policy, planning and coordination mechanism. Sustained nutrition improvement is not usually achieved by implementation of vertical programmes. The benefits will come mainly from integrating nutrition considerations into various sectoral plans and policies of key government departments or ministries. Thus a mechanism to foster integration may be needed.

Beyond the need for national cooperation of ministries and departments, cooperation is vital at the district and village levels, with active participation of the stakeholders, if plans to improve nutrition are to be really effective. Community mobilization and community participation are of great importance.

Evaluation and monitoring of nutrition programmes

Public health and nutrition programmes are frequently conducted without any plans for their evaluation. Campaigns to increase household food resources, to construct more toilets, to triple the number of under-five clinics, to establish new school feeding programmes or to give increasing emphasis to nutrition education may be important activities in a country or community, but such activities are seldom adequately evaluated.

Monitoring and evaluation are important activities in programmes and projects to improve nutrition. In general, monitoring is mainly done by the project workers themselves, preferably with the participation of the communities whose members are the beneficiaries of the actions being taken. Monitoring usually consists of the periodic collection and analysis of appropriate data.

UNICEF (1991) in its Guide for monitoring and evaluation has defined evaluation as "a process which attempts to determine as systematically and objectively as possible the relevance, effectiveness, efficiency and impact of activities in the light of specified objectives. It is an action oriented management tool and organizational process for improving both current activities and future planning, programming and decision making". This comprehensive definition is appropriate and relevant to nutrition evaluation in developing countries.

Evaluation consists of efforts to appraise, measure or judge the progress made by a programme or activity towards its stated objectives. The government that supports a programme, the workers who implement it and the beneficiaries should all be interested to know how effective the programme is. An integral part of all applied nutrition activities should therefore be some form of evaluation.

Because evaluation includes a determination of progress towards certain objectives, it has two basic prerequisites. First is the need to have the objectives of the programme stated, preferably in writing. Second is the need for some baseline data, however simple. In other words, it is necessary to know the position before the programme begins and the changes that are expected to occur as a result of the programme. Evaluation sometimes consists of a measurement before initiation and after completion of the action. The difference between the two measurements indicates the change that occurred during the period of the action; it may or may not have been entirely produced by the action.

Evaluation is useful in several different ways. It helps the worker to know how he or she is getting on with the job and may suggest ways of improving the work or accelerating progress. It may suggest that certain actions produce good results and others do not. Evaluation is useful for the programme planners; by analysing the evaluation reports they can obtain a measure of overall progress and of the relative contribution of each component of the programme. This information facilitates logical planning and may lead to revision of the programme's operations or to new actions.

Evaluation should also provide the beneficiaries of the programme with an indication of what has been achieved. Because community support is essential to the success of programmes, it is incumbent on the workers to let those receiving help know how the programme is progressing, much as a company or business must from time to time let its shareholders know how the business is doing. Unless people are shown and made to understand the changes that are occurring and their own role in the change, much of the value of a programme may be lost. If the people understand the results achieved, they might well be encouraged to cooperate more fully and to assist in programme activities. Evaluation might also convince them and their leaders that an aspect of the programme about which they were sceptical is producing results. For example, in an area where there is little enthusiasm about school feeding, parents might be greatly influenced to support it financially and with self-help activities if they are provided with clearly understandable evidence showing that children who received meals grew better, learned more and were less prone to absenteeism.

Evaluation is therefore a constructive process that can gain more support for the programme from the government, outside agencies and the public. It can also encourage the workers and help them to be more effective and efficient.

It is often suggested that evaluation should be carried out by persons external to, and not associated with, the programme being evaluated. That view is not universally accepted. Although outside evaluators can be presumed to be unbiased and impartial while programme workers cannot, it is sometimes an advantage to have persons who work on a project serve on an evaluation team because of their deep knowledge and understanding of the project and of the community where it is being implemented. The responsibility for objectivity and for ensuring that data are unbiased in an evaluation report then rests with the outsiders.

There is increasing interest in the use of rapid appraisal procedures as tools for evaluation. This method often relies mainly on qualitative data. There is often a place for the use of both quantitative and qualitative methods.

Chapter 33, on nutritional assessment, analysis and surveillance, refers to data that might be used in monitoring, evaluation or both. The reader desiring more information is advised to seek out publications that provide details about monitoring and evaluation (see Bibliography).

Crucial elements of successful community nutrition programmes

The fifth International Conference of the International Nutrition Planners Forum (USAID, 1989) analysed major successful community nutrition programmes for Bolivia,, Brazil, India, Indonesia, Thailand and the United Republic of Tanzania and concluded that the nutritional status of poor population groups in developing countries can be significantly improved through nutrition-oriented community development programmes if certain critical elements are built into the programmes from their inception. It also pointed out that nutrition projects and programmes cannot substitute for a country's and government's political commitment to sustainable and equitable economic growth and social development. A comprehensive strategy that either incorporates nutrition elements into development programmes or uses a community development approach in nutrition programmes was recommended. The conference also suggested that institutional and individual commitment to community self-reliance in a broad development context is crucial to promoting nutritional improvement. The conference identified the following six critical elements for programme success.

Political commitment

Firm and consistent political commitment reflected in concrete nutrition financing and action is crucial. Political commitment can be generated from the community needing nutrition services, as well as through advocacy by the technical and scientific community and/or by international organizations.

Community mobilization and participation

Effective community mobilization for active participation is essential for nutrition programmes to succeed. It is best achieved by involving the community in all phases of programme planning and implementation, including needs assessment, decision-making and programme supervision, monitoring and evaluation. Decentralization of power to the community facilitates organization and enables the community to identify its own needs, to search for solutions and to participate actively in programme implementation. Women's groups are key resources for community mobilization and participation.

Human resources development

The quality of human resources is an important element. Commitment to community work and strong leadership qualities are basic criteria for staff selection. These traits are also expected in volunteer workers and in staff paid by the community. Relatively large investments are needed in basic training and frequent in service retraining. A combination of centre-based and field-based training may be the most effective. Skills-oriented, competence-based, comprehensive, multidisciplinary training is recommended, with special attention to the training of trainers.

Targeting

Appropriate targeting improves the efficiency and cost-effectiveness of nutrition intervention programmes by focusing resources on groups or individuals at highest risk and most likely to benefit from the intervention. When malnutrition is widespread, geographic targeting may be enough, but as the level of malnutrition decreases it is necessary to use a combination of geographic, household, family, economic and individual criteria. In targeting the poorest regions or communities, development of a minimum service delivery infrastructure is often required.

Monitoring, evaluation and management information systems

A functional management information system (MIS) for ongoing monitoring, evaluation and decision-making at the local and higher levels is an important element of programme success. A two-way (bottom-up and top-down) flow of information and decision-making should be established, with regular collection of reliable data, timely analysis and interpretation and immediate feedback. The MIS need not be highly sophisticated. It should not exceed the programme's data handling capacity or overload community workers as data collectors. A basic MIS includes a minimum set of data and indicators to be collected, analysed and used by the community, programme managers and policy-makers for decision-making.

Replicability and sustainability

Replicability and sustainability are interrelated elements of successful programmes.

Replicability is contingent upon the extent to which programme elements, methodologies and implementation processes are suitable to particular contextual features found in other settings. For nutrition programmes to make a difference in the long term, sustainability of positive outcomes is crucial. Sustainability is enhanced by consistent political commitment, active community participation, development of a trained resource base and programme cost-effectiveness vis-à-vis resources available in the country. Sustainability is built in from the planning stage when nutrition interventions are designed within the context and capacity of a country's local resources. Effective technology transfer or the creation of cost-effective locally developed technologies can increase a programme's sustainability.

Practical solutions to nutrition problems

The earlier part of this chapter has been rather general, dealing mainly with the processes necessary for actions and implementation. Presented below are some suggestions of actions that might be considered. This list is not a series of prescriptions, but rather a menu or catalogue of possible options. It is a summary of possible practical solutions to nutrition problems and is by no means complete. Some of the ideas may or may not be suitable for adaptation and adoption by a nation, a village or individuals in a community. Each area and each community has its own problems that must be tackled at the local level. The suggestions made here can therefore not be expected to do more than stimulate thought. Many of them may already be in practice.

Many of the solutions are educational, for again and again it has been stressed that one of the main causes of poor nutrition is a lack of knowledge about food, health and care. Many other suggestions are basically agricultural. This publication is not designed to give details on either teaching methods or agricultural practices. Information on increasing and improving food production must be sought in manuals of agriculture, horticulture, animal husbandry, fisheries and poultry keeping.

Improving nutritional knowledge

Lack of knowledge is an important cause of malnutrition. Nutrition knowledge can, for example, be improved by:

Improving and increasing food production

Increasing and improving food production is mainly an agricultural problem. Aims should be:

1 Improperly maintained fish ponds can lead to an increase in malaria and schistosomiasis (bilharzia). Public health advice should be sought and steps taken to prevent mosquitoes and snails from breeding.

Improving food distribution

Food should be equitably distributed but often is not, even where sufficient food is available. More equitable distribution can be achieved by:

Improving food and crop storage

In some developing countries an estimated 25 percent of all food produced is never consumed by humans. Instead it spoils or is eaten by insects, rats and other pests. Measures to correct this situation can be taken in fields, households, shops and warehouses. These may include:

Improving food processing and safety

Proper food processing can ensure that nutrient values of food are maintained at the highest possible levels, that food surpluses are utilized and that food is safe. Suitable measures are:

Improving health care

The following health measures could be considered to improve the nutritional status of local communities

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