APPENDICES

Appendix A. Nutrition and Related Indicators in South Asia

Appendix A1. Indicators: Bangladesh

Table 22 depicts the nutritional status with respect to selected indicators. Consumption of food items other than cereals are much less than the minimum requirement. Intake of extremely low pulses and legumes as well as fats and oils have been reported (Hossain, 1998). The reasons are mainly due to: a) low availability resulting from low production, b) high post harvest losses, c) increased population growth, d) poor intra familial food distribution, e) inadequate nutrition knowledge, and f) low purchasing capacity, especially in urban slum and rural poor areas. Per capita energy and nutrient intakes are directly related to socio-economic status. Table 23 shows child nutrition, health and food consumption indicators in selected slums.

Vulnerable households currently spend more on food as share of total household expenditure than less vulnerable households (62 per cent versus 52 per cent), and for grains as a share of total food expenditure (53 per cent versus 46 per cent). Per capita rice and wheat intake amounted to 1,165 and 107 kcal, respectively per capita consumption of rice being higher among less vulnerable households (1,191 and 1,133 Calories). Household consumption of green leafy vegetables (GLV) and fish show inter-slum variation.

Vulnerable households are less likely to consume fish and dahl in 2 days out of the 3 day recall period than the less vulnerable households (fish 14.9 per cent vs 26.9 per cent; dal 19.3 per cent vs 43.2 per cent). GLV consumption was low for all households irrespective of vulnerability.

The devastating floods are likely to lead to long lasting consequences [HKI Nutritional Surveillance Project, 1998]. Research shows a distinct seasonal pattern of malnutrition and increased illness coinciding with the monsoon season. The overall prevalence of diarrhoea among children within 24 hours of the interview was nine per cent, and there was no variation by gender or household vulnerability status. Nearly one per cent reported diarrhea lasting more than 14 days.

Worm infestation due to unhygienic latrine is closely associated with malnutrition, and survey reports indicate that more around three fourths of the population suffers from worm infestation. Worms increase malabsorption of iron, and anaemia. About one fourth of areas and about one half of households have access to hygienic latrines.

Table 22. Selected Nutrition Indicators for Bangladesh, Latest Available Year

Source: WHO/SEARO,1998

Table 23. Child Nutrition, Health, and Consumption Indicators for Slum Children, Aged 6 to 59 Months, Bangladesh, 1988.

Source: HKI, Bangladesh, 1998
* represents only children 24–59 months old
** refers to cough with difficulty in breathing

Appendix A2. Indicators: India

Between 1951 to 1995, food grain production has increased fourfold, famines have been eliminated but 53 per cent of children under 4 years, remain undernourished. In 1961–91, literacy rates more than doubled, yet half the population is still illiterate. And for females aged 7 and above, the proportion is 61 per cent. More than 45 per cent children do not reach grade five. Over the period 1961–92, life expectancy almost doubled to 61 years and by 1995 infant mortality has been more than halved to 74 per 1000 live births. Even so, each year, there are 2.2 million infant deaths most of them avoidable. More than 90 per cent of the population has access to safe drinking water. But declining levels, quality problems and contamination threaten the advances. As a result of systematic deprivation, women have always fared worse than men.

Wide regional variation is reported for Low Birth Weight (LBW) infants, ranging from as low as 2.7 per cent (Madhya Pradesh) and 5.1 per cent (Assam) to a high of 24.7 per cent (Tamil Nadu) and 40 per cent (Orissa). The disparity also ranges from a prevalence of 10 per cent for the privileged high socio-economic class to 56 per cent for the poor urban slum community [Bhargava et al. 1990; 1997]. Most births occur at 39 to 40 weeks gestation, and it is less for the low socio-economic groups. Studies on the growth performance of LBW children are subjected to in-depth evaluation. They show that adopted girls who were stunted at infancy experience growth but remain significantly shorter in adulthood than their non-stunted peers. This growth hastens the onset of menarche and further reduces the period of rapid pre-menarcheal growth.

Most of the reasons of for childhood malnutrition are attributed to the poor status of women and their nutritional condition. Weight gains during pregnancy are low, and anemia is common, not only during pregnancy but beginning in childhood. Malnutrition also results from delays in starting complementary feeding. There are significant inter-state differences in the nutritional status of children age 5 years and under, e.g. from 13 per cent in Meghalaya to 77 per cent in Gujarat. [Nutrition Country Profile, India, 1998]. It is above 60 per cent in Gujarat, Orissa, Karnataka, Maharashtra and Andhra Pradesh. The prevalence of stunting ranges from 20 per cent in Goa to 83 per cent in Gujarat. Wasting prevalence ranges from 28 to 32 per cent. The prevalence of severe PEM is shown in Table 25. Average Body Mass Index (BMI) values are similar for women and men, whereby 50 per cent had BMI below 18.5 kilograms/square meter, but a small proportion of men (2.6 per cent) and women (4.1 per cent) are obese (NIN, 1993). Marked improvement for children is reflected in reduced prevalence of underweight from 63 per cent in the 1975–79 period to 53 per cent in 1988–90. (APO, 1996).

The population is projected to increase by 43 per cent by 2025 (Table 24), but the rural population increased at a lower rate. The dietary energy supplies (DES) increased from 2,002 Calories to 2,390 kcal from 1965 to 1995. The increase in DES until 1995 has been attributed to higher daily per consumption unit fat energy (from 257 Calories to 362 kcal), due to in the share of fat (13 to 15 per cent) and carbohydrates (3 per cent decrease) of total DES. Although there has been a reduction in the share of cereals in the DES between 1964–66 and 1993–95, cereals remain the main source of energy, providing 1,494 Calories or 63 per cent of the total energy. The share of pulses decreased from 10 per cent to 7 per cent of DES. The Indian diet, largely vegetarian, provides 93 per cent, 84 per cent and 74 per cent of total energy, protein and fat supplies. The availability of animal products has increased slowly but continually over the same period. Food consumption in India is influenced by regional, ethnic, cultural, economic and agricultural factors, with no significant variation during the last 3 decades. Cereal consumption seems to decrease with increasing income, along with increases of pulses, milk, fish, vegetables and oils (FAO, 1994). The protein and energy content of diets increase with rising incomes (NIN, 1992). Wide inter-state variations remain.

The prevalence of Bitot's spots in the population declined between 1976 and 1990 from 1.8 per cent to 0.7 per cent (WHO, 1995) (Table 26). Iodine deficiency disorders (IDD) have not declined in spite of many national goitre control programmes (WHO, 1993). In 1991, 74.8 million suffered its symptoms in 1991(WHO, 1993; NIN, 1993), such as irreversible brain damage being caused in the developing fetus during pregnancy and intellectual impairment in infants and young children. Iron deficiency anemia (IDA) is a public health problem among pregnant women and its prevalence (Hemoglobin level less than 11 g/dl) ranges from 47 per cent in Andhra Pradesh to 98 per cent in Rajasthan. It is higher in low socio-economic groups. Prevalence ranges from 40–50 per cent in urban areas, through 50–70 per cent in rural areas where hook worm infestation is endemic (UNICEF, 1990). Low bio-availability of iron and parasitic infections contribute to reduced physical work capacity and productivity, impaired cognitive functions and brain metabolism and reduced immuno-competence.

Table 24. Total Population, Urbanisation Rate, Individual Energy Requirements and DES, India, 1965, 1995 and 2025

* DES were obtained from FAOSTAT and were calculated as the average of three years (1964–66 and 1993–95)

Table 25. Prevalence of Severe PEM in Selected States of India, 1975–1979 and 1998–1990

Source: NNMB, Repeat Survey 1991

Table 26. Chronic Energy Deficiency (CED), Iron Deficiency Anaemia (IDA), and Iodine Deficiency Disorders (IDD) India, Latest Available Year

Source: WHO/SEARO, 1998

Appendix A3. Indicators: Maldives

The Republic of Maldives has a population of 253,198 (1997 estimate census) with a sex ratio of 105 males/100 females in 200 inhabitant islands. Maternal mortality rate (MMR) and infant mortality rate (IMR) continue to be high, with MMR is 1.5/1000 live births due to maternal undernutrition, inadequate availability of antenatal and post natal services and closely spaced pregnancies. Progress has been made with regard to IMR, currently at 30 per 1000 live births. The still live birth rate remains at about 22 per 1000 for the last 10 years. About 20.5 per cent of babies are born with a birth weight below 2,500 grams. Life expectancy increased to 66.95 years in 1992 (Ministry of Health and Welfare and WHO, 1995). Nationwide, the prevalence of stunting is 30 per cent, wasting 16 per cent and underweight around 39 per cent. Breastfeeding is common, but often supplemented by commercial milk. Anaemia prevalence is 70 to 80 per cent of pregnant women with hemoglobin levels below 11g/dl. Total goiter rate (TGR) is 23.6 per cent, and 65 per cent of children had urinary iodine levels below 10mg/dl.

Appendix A4. Indicators: Nepal

An estimated 40 per cent of the people live in poverty, with wide variation in socio-economic status being linked to geographical distribution. Small land holdings are indicative of acute poverty in mountainous terai region as compared to hills. Over 90 per cent of rural subsistence farmers engage in indigenous production. Some 70 to 80 per cent of cereals are produced for household consumption, with post-harvest losses in the range of 14 to 17 per cent. In 1996, the Multiple Indicators Surveillance found malnutrition was increasing. Table 27 shows selected nutrition indicators. Stunting prevalence ranges from 57 to 74 per cent in the mid western area, to 61 per cent in terai, 66 per cent in the hills and 69 per cent in mountainous areas. Wasting is higher in the terai. Undernutrition in adults and adolescents is noted as BMIs of less than 16 among 15 per cent of poor women, and BMIs of 16 to 18 among 40 per cent of women.

The national average per capita calorie requirement is 2150 kcal (Table 28), but it is 2340 kcal for hills/mountains and 2140 for terai regions. According to present consumption patterns, grains (including pulses and legumes) and potato contribute to 1864 calories, i.e. 87 per cent of food expenditure. Other foods contribute 286 calories, or 12.7 per cent of requirements and 44 per cent of total food expenditure. In rural areas, food expenditures remain over 60 per cent of total expenditure, and households feel they are not meeting their food consumption needs. Food availability data show major disparities between consumption and requirements, and there is evidence of intra-household food disparities favouring men over women and boys over girls.

Table 27. Selected Nutrition Indicators for Nepal, Latest Available Year

Source: WHO/SEARO, 1998

Table 28. Total Population, Urbanisation, Energy Requirements and DES, Nepal, 1965, 1995 and 2025

DES were obtained from FAOSTAT and were calculated as the average of three years (1964–66 and 1993–95)

Appendix A5. Indicators: Pakistan

Pakistan is the ninth most populous country in the world, with 140 million people in 1996 (UN 1996). The majority live in rural areas, but urbanization is rapidly increasing (Table 29). It is self sufficient in basic food stuffs, with the exception of edible oils, mainly palm oil and wheat, but it is classified as food deficient because its current food production does not satisfy the total demands of this rapidly growing population. In 1990–1992, 17 per cent of the population was reported still undernourished, as compared to 24 per cent in 1969–1971. At the national level, 40 per cent of children are underweight, and over one-half of the children are affected by stunting and about 9 per cent by wasting. Significant provincial variations exist in malnutrition rates. The prevalence of stunting appears to be associated with the overall level of development of the provinces, being lowest in Punjab and highest in Baluchistan, the least developed province. These anthropometric deficits are also systematically higher in rural areas, due to the lower socio-economic status and poor access to basic health services.

Diets are mainly cereal, providing 62 per cent of the total energy. Compared to other Asian countries milk intake is significant, but consumption of fruits and vegetables, and meat are low. Fluctuations in the availability of fruit and vegetables due to poor marketing facilities and seasons, are responsible for a high prevalence of micronutrient deficiencies.

The mortality rate for children under age 5 years, an important index of health and nutritional status, is high (137 per 1000 births). Several infectious diseases such as respiratory and intestinal infections remain responsible for up to 50 per cent of deaths among children under age 5 years, with malnutrition being a precipitating factor especially in the most populated areas.

Breast feeding rate is 95 per cent, with exclusive breast feeding being continued up to 4 months, supplementary feeding practices are a matter of concern (UNICEF 1995). A little less than three-fourths of children between age 7 to 9 months receive no solid foods and even at 12 to 17 months about 50 per cent receive only liquids. Rice and white bread (roti) are the main foods given from ages 7 months to 2 years. Several false beliefs and practices with respect to colostrum feeding are common which are likely factors in ensuing childhood malnutrition.

Table 29. Total Population, Urbanization, Energy Requirements and DES, Pakistan, 1965, 1995 and 2025

Source: FAOSTAT

Appendix A6. Indicators: Sri Lanka

Table 30 shows the per capita annual supply of food from 1970 to 1991. Rice availability is reduced following liberalization. Consumption of roots and tubers, vegetables, fats and oils declined significantly in the 1990s. As price structure is a major determinant of food security, the impact of food purchases on nutritional status at the household level depends on the income and food quality, e.g. micronutrients. The low income group consumed on average, 1400 Calories, or equivalent to about 60 per cent of total daily energy requirements. As a result, the nutritional status of this group has not improved over the last 3 decades. Nationwide, stunting and wasting show an overall increase in prevalence among children under age 5 years. A large number of malnourished children belong to poor households. Female headed households account for about 17 per cent of all households, and these are among the poorest of the poor. Rural children have better exclusive breast feeding patterns than their urban counterparts.

Table 30. Dietary Energy Supply (DES), Sri Lanka, 1970–1991

Source: Sri Lanka country profile, FIVIMS workshop, 1998

Appendix B. Nutrition and Related Indicators in South-East Asia

Appendix B1. Indicators: Cambodia

Children under age 5 years in rural Cambodia are in serious need of interventions supplying not only more food, but also better water and sanitation, maternal care, and access to health services. Poor nutritional outcomes of underweight and low body mass indices are found in women in households deriving food from hunting and animal raising activities. The best nutritional outcomes are in women from households engaged in sugar palm work, borrowing, skilled labor, and chamkar growing. Poor nutritional outcomes in children are found often in households engaged in log cutting, sugar palm, crafts, or fishing. Children from households that participate in charcoal making, borrowing, skilled labor, or salaried work surprisingly, have the lowest rates of malnutrition. Severe stunting(less than -3.00haz) in children is associated with hunting, chamkar, and craft activities, while the highest prevalence of severe underweight is found in children where income comes from sugar palm, log cutting, and chamkar activities. The lowest rates of severe malnutrition are in children from families that participate in charcoal, salaried work, borrowing and animal raising (UNICEF-WFP Baseline Survey, 1998).

Appendix B2. Indicators: China

China's ability to feed over one-fifth of the world's population with only 7 per cent of the world's arable land is widely acclaimed. China, with more than 1.23 billion people in 1997, is the world's most populous nation. The technological development, institutional change, rural development and improved food security policies with limited natural resources are factors that deserve merit. China's per capita food availability and consumption have increased over the last several decades with average per capita food availability growing from less than 1700 Calories in 1960 to 2570 Calories in 1995. Increased domestic production is responsible for increased food availability. Protein intake and fat consumption per person per day increased over the same period, from 42 grams to 70 grams and 17 grams to 45 grams, respectively.

As per the 1992 World Bank estimates, the number of persons in absolute poverty has fallen from roughly 260 million in 1978 to 96 million in 1985, representing a decline from about one-third to 12 per cent of the total rural population. By 1996 the figure declined to 58 million, about 6.7 per cent of the total rural population (Huang et al., 1998). China's reform policies have chosen several approaches both agricultural and non-agricultural to address the problems of the economy that are intimately related with food security and nutritional improvement. There has been a rapid expansion of industry in rural areas to generate employment, and official policy targets stability of food supply and access for the poor, both vital components of national food and nutritional security. The government has developed a disaster relief programme and large scale food-for-works schemes. China has adequate capacity to weather natural disasters (WFP, 1994).

Although general nutrition has improved, malnutrition exists, particularly among the poor and inland provinces, children being especially vulnerable. An estimated one-fourth of the population are at risk of vitamin A and iron deficiency. However, in light of the present policies, China is capable of solving its food problems by 2025. Food self sufficiency will continue to be one of the central goals of agricultural policy. China may face formidable challenges from its growing population, but the future appears positive towards achieving national nutritional security.

Appendix B3. Indicators: Indonesia

Indicators used to monitor changes on food and nutritional status are compiled by the Nutritional Surveillance System (NSS) as part of Food and Nutrition Surveillance. Table 31 shows that national average food consumption in 1996 was 2019 kcal and 55 grams of protein. The total energy intake was higher in rural areas, but protein intake was higher in urban areas. Cereal consumption in rural areas was higher than urban areas, and the quality of diets in urban areas was better than in rural areas. Disparities exist for girls. The prevalence of stunting also varies by province with some above 40 per cent.

Data highlighting food and nutrition trends for Indonesia are shown in Table 32 for selected nutrition indicators. These show remarkable reductions in prevalence of PEM among preschool age children (Muhilal et al, 1998). Conducted in 1995, the National Socio-economic Survey found 35 per cent of children aged 0 to 50 months are below 80 per cent of the median weight for age. The National Socio-Economic Survey of 1989, 1992 and 1995 show a declining proportion of children in this group, from 54.7 per cent in 1986 to 35 per cent in 1995. This change coincides with increase in the proportion of children above 120 per cent of the median, and classified as overweight. In Jakarta, the prevalence of overweight is 9.1 per cent and obesity is 10.1 per cent. Among women aged 41–55 years, 13 per cent are overweight and 19 per cent are obese. Average height at school entrance, shown in Table 33, shows the proportion of stunted boys and girls is 31 per cent and 30 per cent, respectively. The prevalence of stunting among urban boys age 5 years is 4.5 per cent and 66 per cent among urban boys aged 11 years. Iron deficiency anaemia declined from 1992 to 1995 from 63 per cent to 51 per cent among both pregnant women, and from 56 per cent to 41 per cent among preschool age children, as shown in Table 34.

Iodine deficiency disorders decreased from 37 per cent in 1982 to 28 per cent in 1990. A sub-district level survey found its prevalence consistently decreased from 1980–1982 to 1990 and 1996. However, it increased in one province from 28 per cent to 33 per cent during 1990 to 1996.

National Vitamin A surveys show the prevalence of xerophthalmia declining from 1..3 per cent in 1978 to 0.3 per cent in 1992, but it remains above 0.5 per cent in a small number of provinces.

Table 31. Average Food Consumption and Contribution to Total Energy, by Major Food Group, Indonesia, Latest Available Year

Source: Food Consumption Survey, MOH 1995;
* PPH - Pola Pangan Harapan (Desirable diet pattern)

Table 32. Selected Nutrition Indicators for Indonesia, Latest Available Year

Source: WHO/SEARO, 1998

Table 33. Prevalence of Stunting by Age, Sex and Area for Indonesia, 1994

Source: School Entrance Height Measurement, Directorate of Nutrition, MOH, 1995

Table 34. Prevalence of Iron Deficiency Anaemia by Target Group in Indonesia, 1995

Source: National Household Health Survey (SKRT) 1995 (Preliminary reports)

Appendix B4. Indicators: Myanmar

In Myanmar great diversity exists between the rural and urban regions due to rugged terrain in the hilly north and swampy marshlands and numerous rivers in the South. Table 35 shows selected indicators, which depict the nutrition situation in Myanmar. The National Plan of Action for food and Nutrition (NPAFN) as per the ICN declaration has developed an integrated action plan which addresses the above situation. The Central Board of Food and Nutrition oversees the implementation of the plan. Prevention and control of PEM, promotion of breast feeding, prevention and control of micronutrient deficiencies, research on nutrition related to ICN topics and promotion of household food security are being taken up under the plan of action.

Table 35. Selected Nutrition Indicators for Myanmar, Latest Available Year

Source: Country presentation at the FAO workshop on comparative analysis of nutrition interventions, June 1998

Appendix B5. Indicators: The Philippines

The Philippines has high population density and high population growth, which is increasingly concentrated in urban areas. A declining trend in the prevalence of underweight, stunting and wasting among children is underway. Micronutrient deficiencies, especially iron deficiency anaemia, iodine deficiency disorders and vitamin A deficiency, are prevalent among pregnant and lactating women, infants and elderly. This coincides with an increasing trend in the prevalence of overweight and obesity in children and adults. The Philippine Food and Nutrition Surveillance System (PFNSS) was formulated by the National Nutrition Council as early in 1976, and it is now in operation.

Appendix B6. Indicators: Thailand

Food self sufficiency attainment is one of the country's achievements. Even so, nutritional deficiencies persist. Daily availability of nutrients and dietary energy supply figures show that approximately 80 per cent of total calories come from carbohydrate. Fat availability is quite low (10–13 per cent of total calories), but it is gradually increasing. Dietary protein constitutes 10 per cent of total calories. Food expenditure and consumption patterns show the major share of food expenditure (77 per cent) are raw food items to be cooked at home. Bangkok is an exception. Average monthly food expenditure as a proportion of the total is lower among the better-off professional classes.

Dietary Patterns. Rice is typically the main source of calories and protein. Total food consumption decreased during 1960 and 1986 from 94 per cent to 92 per cent of the recommended dietary allowance (RDA). Protein consumption increased slightly from 11 per cent to 12 per cent, animal protein to total protein increased from 30 per cent to 45 per cent, fat consumption increased from 9 per cent to 21 per cent of total calories. Intakes of micronutrients were generally adequate. Calcium intake is 61 per cent of the RDA, and more than half the sample population reported an intake of less than the RDA.

Table 36 shows some nutrition indicators. The prevalence of Low Birth Weight (LBW) was 9 per cent in 1991. Protein energy malnutrition (PEM) has reduced. The combination of mild, moderate and severe malnutrition, measured as weight for age, declined from 51 per cent in 1982 to 19 per cent in 1990. Iron deficiency anemia among pregnant women is widespread with the highest rates of 36 per cent in the Eastern region, and and lowest rates of 20 per cent in the North (Thaineru, 1987). Among children under age 5 years, 29 per cent were anemic in 1988, and declined to 15 per cent in 1991. Southern Thailand has a higher prevalence of anemia due to high rates of parasitic infestation, especially hookworm. Iodine deficiency disorders also are endemic in the northern region and certain provinces. Iodine deficiency (IDD) manifest as goiter is prevalent in 15 provinces, with declines from 1989 to 1990 from 19 per cent to 16.8 per cent. In 1991, goiter prevalence among preschool children was high as 38 per cent in 10 upper Northeast provinces and 26 per cent in 11 Central region.

Diet related chronic diseases, such as overweight and obesity, are increasing in urban areas. Among Thai officials in 1985 (Tanpaichitr et al, 1990), 2.2 per cent of men and 3 per cent of women had a BMI greater than 30 (Leelahaghul et al, 1995).

Table 36. Selected Nutrition Indicators for Thailand, Latest Available Year

Source: WHO/SEARO, 1998

Appendix B7. Nutrition and Related Indicators: Viet Nam

During the last decade, Vietnam transformed itself from a food deficit economy into a rice net exporting country. With almost no land available for further expansion of the arable sector, the pressure on the existing land is very high. After a long devastating war and high rate of population increase, nutritional status is poor, especially for mothers and children. The average food intake is poor and ill-balanced. Rice is the staple food providing more than 80 per cent of protein and energy. In rural areas, the share of energy derived from protein, fat and carbohydrate is 12 per cent, 6 per cent and 82 per cent, respectively. According to the general nutrition survey, the average energy intake per capita of 22 per cent of households in rural areas is below 1800 kcal (Tu Giay et al, 1991). A declining trend is noted with reference to the prevalence of both protein energy malnutrition (PEM) and chronic energy deficiency (CED). The malnutrition rate of children under age 5 years declined from 51.5 per cent in 1981–1985 to 44.9 per cent in 1994, and to 39.8 per cent in 1998. Stunting is also declining, from 59.7 per cent in 1981–1985 to 46.9 per cent in 1994, and to 35.9 per cent in 1998 (National PEM survey 1998).

Appendix C. Some Country Strategies and Measures in South Asia

Appendix C1. Towards Nutritional Security: Bangladesh

The Bangladesh National Nutrition Council is the main body which develops policy guidelines needed to achieve goals of the National plans of action for nutrition and guides efforts to address nutritional security. Intersectoral Nutritional Programme Development is a major feature of strategies. The Bangladesh Integrated Nutrition Project is one major steps forward, being a comprehensive and well planned attempt to promote empowerment and community self reliance. Intersectoral development is among its unique components, whereby programmes are devised by different sectoral ministriesm divisions, and agencies and also by some NGOs to implement sub-projects in 40 thanas or sub-districts.

Homestead poultry production and Nutrition gardening programme aims to increase per capita consumption and nutritional status primarily among pregnant women, lactating mothers and young children. It also improves household food and nutrition security by increasing the production of homestead poultry meat and eggs. It also contributes to increased income among landless and marginal farm households, particularly women.

Publicity Campaign on Nutrition in the News Media and Nutrition Communication assists nutritional improvement of nutritional status by creating public awareness and bringing about behavioural change through innovative approaches. The Nutritional Surveillance Project (NSP) is a nationwide surveillance system initiated by Helen Keller International in collaboration with Institute of Public Health Nutrition, a number of NGOs and UNICEF to establish a sentinel surveillance system. Since 1989, the NSP has been working towards establishing a permanent system for monitoring health and nutrition status. The NSP has established base line health and nutrition indicators and identifies seasonal trends among children most vulnerable to the effects of chronic food shortage and disasters, and give a base against which interventions can be assessed. It also identifies high risk child populations under five before, during and after recurrent disasters, and identifies shifting patterns of risk, in order to facilitate the relief response by adjusting policies and prompt intervention by the government of Bangladesh, donors and NGOs. The NSP is thus an on-going database which can be used to evaluate the effectiveness and efficiency of regular programmes and disaster response programmes as well as for planning future programmatic activities. Relevant material is produced and disseminated for optimal development and disaster relief impact. The National Vitamin A Deficiency Survey during 1997 was conducted as a joint effort of the Institute of Public Health Nutrition (IPHN) and Hellen Keller International (HKI). Other programmes like the Evaluation of Universal Salt Iodisation (USI) and National Iodine Deficiency Disorders Survey help to monitor the process, particularly at the factory, and to assess the iodine status in terms of both clinical and biochemical parameters. This survey finds that 69 per cent of the population has urinary iodine less than 10microgram/dl, out of which 47 per cent already has clinical manifestations of goiter and 9 per cent has visible goiter. The entire population is at risk of IDD.

The Grameen Bank initiated as an informal credit programme in 1983, and has demonstrated remarkable success as a credit institution for poorest households. It provides loans to individuals (especially women) against group guarantees. It also grants collective loans for joint enterprises and provides long term credit for housing. Mobilization of savings is an integral part of lending, 94 per cent of beneficiaries are women. BRAC operates more than 34,000 schools for poor children to achieve basic literacy and numeracy requirements, BRAC programmes deal with main conditions of deprivation closely linked to the extreme poverty in rural areas, the main beneficiaries being women and children.

Appendix C2. Towards Nutritional Security: India

The Integrated Child Development Services, probably the largest of its kind in the world, aims to achieve four main objectives, which include: to improve the health and nutrition status of children under age 6 years by providing supplementary food to beneficiaries 300 days/year and by co-ordinating with state health departments to ensure delivery of required health inputs; to provide conditions necessary for overall child development through early stimulation and education; to enhance the mother's ability to provide proper child care through health and nutrition education; and to achieve effective co-ordination of policy and implementation among various departments to promote child development. Its integrated package delivers supplementary nutrition, immunization, health check ups, referrals and health and nutrition education to mothers and children. Tamil Nadu has introduced a new innovation, these services have been merged with the Noon Meals Programme. Community Based monitoring mechanism ensure monitoring and evaluation of the schemes relating to women and children at the grass root level by the community members themselves.

The National Nutrition Surveillance System collects information on determinant indicators, as follows: food grain availability, fertility rate, and primary health care coverage. This system produces data to support dissemination of a set of seven outcome indicators: namely, 1) nutritional outcome (e.g. per cent of underweight children under age 3 and between ages 3 and 6 years, per cent of pregnant women with moderate and severe anaemia); 2) economic outcome (e.g. per cent of households below the poverty line, average per capita income); 3) food balance sheets and food indicators (e.g. per cent of households who do not consume two square meals a day throughout the year, per cent of population consuming less than 80 per cent of RDA in calories, protein and micronutrients); 4) health indicators (e.g. infant and maternal mortality rates); 5) educational outcome (e.g. female literacy rate, per cent of children enrolled in Grade I, per cent of children completing primary school); 6) status of women (e.g. sex ratio, per cent of girls marrying below age 18 years); and 7) caring capacities (e.g. per cent of infants fed colostrum, per cent of infants being exclusively breast fed up to age 4 to 5 months, per cent with complementary feeding during age 6 to 9 months, per cent of population with access to safe drinking water and to sanitary facilities). Responsibility for nutritional surveillance is discharged through a three tier approach, namely, 1) community based monitoring through ICDS infrastructure, 2) database on nutrition through monitoring nutrition interventions, and 3) networking and collaboration with national institutions, academic institutions and NGOs to facilitate training of functionaries at various levels of infrastructure. (FIVIMS-India Paper, 1998).

The public distribution system is one of the major food subsidy and income transfer programmes in India, being sub-administered by the Ministry of Food and Agriculture. It provides essential food grains (and additional items like oil, sugar, semolina, fuel oil as kerosene) to poor households at subsidized rates. It involves a three tiered network with the Food Corporation of India as a national agency, wholesale at the State/District level, and Fair Price Shops at the retail level. The states have their own trading corporation, either working on its own account (e.g. Tamil Nadu), or acting as an agent of the FCI (e.g. Andhra Pradesh). Allocations of subsidized food are made by central governments, these allocations being boosted by the state's own efforts in procuring grain for the system. At all-India level, the Fair Price shops have increased from 48,000 in 1960 to 350,000 in 1990; with increasing decentralization, covering almost 85 per cent of the population.

The Integrated Rural Development Programme targets rural families below the poverty line. It provides capital subsidy and complementary credit at low interest rates to finance productive investments in income generating assets. Block level staff select potential beneficiaries in consultation with the village council, help them select viable investments (such as animal husbandry, agriculture, horticulture, weaving, handicrafts, etc.) and provide backup support when needed.

The National Rural Employment programme (NREP) replaced the Food for work Programme, and aims to generate additional gainful employment for the unemployed and underemployed in rural areas, to create productive community assets for direct and continuing benefits to bring about a general improvement in the overall quality of life in rural areas. It also aims to improve the nutritional standards of the poor through supply of food grains as part of wages. There has also been an unequal share of the NREP employment plan, with eastern states in India receiving a lesser share than what was due to them.

Appendix C3. Towards Nutritional Security: Sri Lanka

Samurdhi Programme addresses the major problem of poverty and unemployment among youth through increasing their access to resources for self employment, enhancing their health and nutritional status and improving rural infrastructure. It aims to broaden opportunities for income enhancement and unemployment, it organizes youth, women and other disadvantaged segments into small groups and it encourages them to participate in decision making, activities and the developmental process at grass roots level. It also establishes and maintains productive assets to create additional wage employment opportunities at the rural level.

Samurdhi is based on participatory developmental principles. All aspects of decision making are centered around the village and cluster levels where the programme is planned and implemented by the organizations for this purpose. It aims to implement economic development projects identified on the basis of family needs, skills, assets and other abilities of participating families. They are encouraged to engage in developmental activities of their choice utilizing locally available resources. The Samurdhi Task force comprises youth in the villages of the ages between 18–35 years. It has an elected Executive Committee comprising of 7 persons. In addition to the two animators, seven other members have been elected to represent the governmental and NGO agencies engaged in youth and rural developmental activities in the village. Two full time persons are trained to conduct surveys in the village using a structured questionnaire. This training has enables them to conduct family profile surveys in respect of each village to gather information on socio-economic conditions of all household. The survey data has been analysed to ascertain the income level of each family to provide welfare, if the income is below the poverty line. The village will identify community work that could benefit the economic and social needs of the village and provide employment opportunities on a causal basis.

The food subsidy policy formed one of the major elements of Sri Lanka's welfare oriented strategy, the effects which were reflected in a fairly adequate calorie intake, a relatively low degree of malnutrition, a decline in death rate and progressive increase in the average life expectancy since the period of the country's independence.

A substantial modification of the food subsidy programme was introduced by the Food Stamp Scheme, almost two decades ago. The major fiscal advantage of the Food Stamp Scheme is that the size of the entitlement is set in nominal terms so that, unlike in the case of a commodity specific subsidy, where the quantum of the commodity is fixed, it is easier to maintain a stable budget. However, the Food Stamp Scheme is disadvantageous to the beneficiaries as the real value of this income supplement gets eroded with rising food prices. Studies on the Food Stamp Scheme and socio-economic indicators have revealed that the level of poverty has been much lower than the numbers that the Food Stamp Programme suggest

Appendix D. Some Country Strategies and Measures in South East Asia

Appendix D1. Towards Nutritional Security: Indonesia

Indonesia has always used the community based approach to nutrition interventions especially for the poor people, by its goal of ensuring stable and supplies for everyone, adequate protection from diseases, available health services for all and an environment that encourages good practices for those who need care. In all the interventions, every effort has been made to reduce malnutrition, irrespective of the rate of economic growth. These community based programmes increase participation at three levels- family, community and institution such as schools. The other aspect involves decentralization of the proposal plan and operation to the local level especially up to district and sub-district levels. At national level and provincial level the approach has been to guide and make technical directions only to the lower levels and conduct monitoring and evaluation (Muhilal et al, 1998).

The direction of general policy in Nutrition in the Replita VI and the long term development plans have been based on Guidelines of the State Policies (GBHN) as follows:

• Nutrition programmes should be implemented to improve self sufficiency of communities to adopt good nutrition behavior
• Nutrition factors should be based on factors of epidemiology, demography, geography, socio-economic background and culture.
• Nutrition programmes should be implemented with inter-sectoral coordination and increasing community participation
• Decentralization should be improved to increase district level responsibility in nutrition programmes
• Nutritional status improvement should be realized with improvement of optimal human productivity
• Nutrition programmes should be implemented and supported with a better nutrition information system
• Nutrition programme implementation should be based on the outcome of research an dscience development

The targets of nutrition objectives spelt out in the 6^th Five-Year Development plan are as follows:

• To achieve a per capita energy intake at 2,150 kcal and protein intake at 47 g/d
• To decrease the prevalence of total goiter prevalence from 28 per cent to 18 per cent, to prevent birth of cretins
• To reduce iron deficiency anemia among pregnant women from 64 per cent to 40 per cent, under fives from 55 per cent to 40 per cent, low income women workers from 30 per cent to 20 per cent.
• To eliminate vitamin A deficiency
• To reduce the prevalence of LBW from 15 per cent to 10 per cent
• To increase family awareness in nutrition by 50 per cent
• To increase the prevalence of exclusive breast feeding practices
• To detect other micronutrient deficiencies (zinc and selenium)
• To improve dietary diversification

This inherited cultural pattern of mutual help has been adopted as a guiding principle for national development of Indonesia. Without active community participation of village women's organizations, it is unlikely that a sustainable nutrition movement in the community could be achieved. The Nutrition Improvement Programme has introduced simple technologies in the community, the most important of which is the weighing of babies and use of growth charts, for monitoring and as a tool for education.

Appendix D2. Towards Nutritional Security: The Philippines

Since launching of the Philippines Nutrition Programme in 1974, there has been an extensive of nutrition interventions implemented in the country. The Philippines Plan of Action for Nutrition is envisioned as the framework for planning the various nutrition strategies of the country. With it presently drawing to a close, the Philippines is working strongly towards developing another plan with renewed emphasis on the role of local planning and co-ordination unit is due to recent developments in the government structure. In 1993, the entire framework of provision of basic services by the public sector underwent a radical reform with the implementation of 1991 Local Government Code. It operationalizes the constitutional provision on the autonomy of local governments and contains three main innovations (Brillantes, 1996). First, financial resources available to the local governments are much larger. Their share in national taxes through the Internal Revenue Allotment was raised to 40 per cent and their share in natural resource charges were also increased. Second, basic services are now the responsibility of local units. Health services, including field health and hospitals, are devolved, including social welfare services and agricultural extension. Third, the legal infrastructure for the participation of NGOs and GOs in the process of governance is established. This is done through their mandatory membership in special bodies at the local level, including the local development council, the Local Health and School Board. Supplementary feeding will now be implemented as a safety net rather than long term intervention, and only severe cases will be targeted. The size of the ration will be calculated on the basis of the needed amount to bridge the calorie deficit. A policy of graduating children from the feeding programme will be pursued and implemented. To sustain improvements from rehabilitation of severe cases of malnutrition, supplementary feeding should be complemented by other interventions like home food production, income generation and nutrition education that address the root causes. Weaning food production and distribution programmes will involve communities through organizations which can contribute to its successful implementation. Under targeted food price discount, food subsidy programmes in the format of targeted food discount (ration card system) will be revived. In order to contain programme costs, the discount would remain infra-marginal for rice and possibly, marginal for cooking oil. Targeted food discounts can take advantage of the existing price marketing system, which may address the moderate cases of malnutrition. For extreme cases, supplementary feeding may be more suitable.

Appendix D3. Towards Nutritional Security: Thailand

Thailand's health and nutrition development has spanned several decades with nutrition policies, plans and programmes being more recent innovations. A rethinking process of implementing health care in rural areas subsequently emerged and nutrition programmes were transformed into community driven programmes. Emphasis was given to maximizing community participation, with service delivery available everywhere. Solving nutrition problems and advocating nutrition improvement required integration of food and nutrition into national developmental policies. The Applied Nutrition Project was initiated and one of the important operational strategies involves developing intersectoral collaboration of various ministries in developing the national food and nutrition policy. It focused on improving household food security, controlling nutritional deficiency problems, nutrition education and the promotion of appropriate diets and healthy lifestyles and the promotion of protective foods.

The fourth National Food and Nutrition Plan (1992–1996) continued the developmental focus of achieving a better quality of life. This is being translated into practical action via the Basic Minimum Needs Approach, which constitutes key nutrition indicators such as birth weight, weight-for-age of under fives and school age children. This plan also includes emerging nutrition related issues ascribed socio-economic transformation such as food safety and sanitation as well as the prevention and control of chronic degenerative diseases. In terms of nutrition The success has been mainly been attributed to four critical elements. First, identification of protein energy malnutrition as the most important nutritional problem, and for the first time, the National Economic and Social policy and programming, one of the major achievements has been the implementation of the School Lunch Fund Act, which aims at providing primary school children at least one nutritionally balanced meal in a day. More recently, provision of free milk to school age children has been made and food based dietary guidelines, as well as recommendations for nutrition labelling have been developed. The use and interpretation of food labeling plays an important role in education for promoting healthy diets. A safety net for consumers to choose appropriate products has been developed.

The next plan (1997–2000) continues to rigorously carry on the country's food and nutrition movement especially in the midst of the adverse economic crisis facing the nation. This Plan puts greater emphasis on a ‘human-centered’ approach by upgrading capacities of the society and enabling to create a socio-economic environment that will foster human development. Current goals focus on improvement of quality of life by ensuring household food and nutrition security. Another strategy being rigorously implemented is dietary diversification and nutritional enrichment of the food supply. This has been suitably used in communities ‘at-risk’ of micronutrient malnutrition by suggesting appropriate food selection and combination to enhance the bioavailability of nutrients. Development of locally produced enriched vitamin rich foods include liver chips, pumpkin and mango candy and iron rich cookies using blood or liver. Iodization of salt and drinking water has been used to address iodine deficiency disorders. Development Plan included a separate national plan for food and nutrition. The plan set goals to eradicate severe PEM among preschool children and reduce moderate PEM by 50 per cent and mild PEM by 25 per cent. Second, comprehensive nutritional surveillance instituted through growth monitoring and ensuring regular weighing of preschool children at community weighing posts. Third, implementation of nutrition education and communication to promote and protect breast feeding, timely introduction of complementary foods, hygienic food handling and dissemination of correct information about food beliefs and overcoming food taboos. Fourth, strengthening of household food security by promotion of home gardening, growing fruit trees, fish ponds and prevention of epidemic diseases of poultry.

Appendix D4. Towards Nutritional Security: Viet Nam

During the past 10 years, there has been great economic reform called “renovation” in Vietnam with positive achievements. With respect to food and nutrition security, the following measures merit attention.

• Promotion of food production through intensive farming, extending the land food crops in particular in the delta of red River and Mekong River.
• Reduction of post harvest losses
• Developing food market, by which peasants are free to send their surplus rice in the market as other food products
• Income generation of the poor. For this the government entrusts the land to the peasant for use and promotes appropriate selection of plants, trees to increase income. There is also a movement to create a private farm specializing in the growing of nutritious plants and fruits adapted from other areas, e.g. longan, litchi mango, etc.
• Food security for nutrition improvement is undertaken within the frame of NPAN, for which there is closer collaboration between Agriculture and Health in improving nutrition.
• Strengthening the system of food security information.

Vietnam has two kinds of nutrition interventions, an emergency intervention of nutrition and a durable intervention of nutrition. For the emergency nutrition interventions, food aid is given to vulnerable groups such as pregnant women and children being underweight. From 1990, the World Food Programme continued to provide an expanded project of food aid in the support of package targeting pregnant and nursing women and malnourished and at risk children in selected districts. Under the durable nutrition interventions, the following project activities undertaken as a means of improving nutritional status of the vulnerable populations. Horticulture promotion involves establishing of family gardens especially in families with children under five years of age. Training and support agriculture and VACVINA extension workers and family garden promotion in fruit and vegetable production for household consumption. The nutrition education component produces nutrition education and training materials for community education in breast feeding, weaning food and infant care and family garden promotion. It also provides scales and simple growth charts for regular growth monitoring of children under five years of age. It also provides training support to community nutrition volunteers/educators and encourages the development of other PHC and community development activities (family planning, immunization, water and sanitation). Food analysis supports the development food analysis capacity of the National Institute of Nutrition, and nutrient analysis of vitamin A, fat, vitamin C iron and protein. Vietnam has recognized that training human resource for successful implementation of nutrition programmes is crucial for the efficiency of nutrition actions. Nutrition being a multi-disciplinary field, necessitates a broad based approach, through contact with field situations.

Appendix E. National Codex Contact Points
as of
16 June 1999

AUSTRALIA
Ruth Lovisolo
Manager
Codex Australia
National Offices of Food Safety
GPO Box 858
Canberra ACT 2601
Tel: +61 2 6272 5112
Fax: +61 2 6272 3103
Email: [email protected]

BANGLADESH
Director-General
Bangladesh Standards and Testing Institution (BSTI)
116/A, Tejgaon Industrial Area
Dhaka 8
Email: [email protected]

BHUTAN
Lyonpo Kinzang Dorji
Honorable Minister of Agriculture
Ministry of Agriculture
Thimpu
Bhutan
Tel: +975 2 22129
Fax: +975 2 23153

CAMBODIA
Mr. Lim Thearith
Assistant Quality Control Service
KAMCONTROL, 50E/144 Street
Phnom-penh
Tel: +855 2 3485
Fax: +855 2 3426166

CHINA
Mr. Zhou Kaizhong
Deputy, Director-Genera
l Department of Market and Economic Information
Ministry of Agriculture
Beijing, P.R. China 100026
Tel: 086-10-64193150, 086-10-64193156
Fax: 086-10-64192468
E-mail: [email protected]

FIJI
The Permanent Secretary
Ministry of Primary Industries
P.O. Box 358
Suva
Telex: FJ 2290 FIJI FISH FJ

INDIA
Mr. R. Gupta
Assistant Director General (PFA) cum Secretary, Central Committee for Food Standards and Liaison Officer,
National Codex Committee
Directorate General of Health Services
Nirman Bhavan
New Delhi 110 011
Tel: +91 11 3012290
Telex: 31 66119 DGHS IN

INDONESIA
Director-General
BSN - Badan Standardisasi Nasional
(National Standardization Agency)
Sasana Widya Sarwona Lt. 5
J1. Jend. Gatot Subroto 10
(PO Box 3123)
Jakarta 12710
Tel: +62 21 522 16 86
Fax: +62 21 520 65 74
Telex: 6 28 75 pdii ia

ISLAMIC REPUBLIC OF IRAN
Institute of Standards and Industrial Research of Iran
Ministry of Industries
P.O. Box 15875-4618
Tehran
Fax: +98 21 8802276/261 25015
Telex: 215442 STAN IN

JAPAN
Mr. Satoru Iitaka
Director, Resources Office, Policy Division, Science and Technology
Science and Technology Agency
2-2-1 Kasumigaseki, Chiyoda-ku
100 Tokyo
Tel: +81 3 3581 5271
Fax: +81 3 3581 3079

REPUBLIC OF KOREA
Mr. Younghyo HA, Director
Technical Cooperation Division
International Agriculture Bureau
Ministry of Agriculture, Forestry & Fisheries
#1, Joongang-Dong
Kwachon-si, Kyonggi-do 427-760
Fax: +82 2 507 2095

LAO, PEOPLE'S DEM. REP.
Dr. Vilayvang Phimmasone
Deputy Director
Food and Drug Department
Ministry of Health
Simeuang Road
Vientiane
Tel: +856-21 214014
Fax: +856-21 214015

MALAYSIA
Dr. Abd. Rahim Mohamad
Codex Contact Point Malaysia
Malaysian National Codex Committee
Food Quality and Control Division
Ministry of Health, Malaysia
4th Floor, Block E
Jalan Dungan, Bukit Damansara
50490 Kuala Lumpur
Tel: +60 3 2540088
Fax: +60 3 2537804
Email: [email protected]

MONGOLIA
The Director
National Centre for Hygiene,
Epidemiology and Microbiology
Ministry of Health
Central Post - PO Box 596
Ulaanbaatar
Fax: +976 132 1278 CBR MGL

MYANMAR
Director
Food and Drug Administration
Department of Health
35, Min Kyaung Road
Yangon 11191
Tel: 95 1 245331

NEPAL
Chief Food Research Officer
Central Food Research Laboratory
Babar Mahal
Kathmandu
Tel: +977 1 2 14824/2 12781

NEW ZEALAND
Codex Officer
MAF Policy - Ministry of Agriculture and Fisheries
P.O. Box 2526
Wellington
Tel: +64 4 474 4100
Fax: +64 4 474 4163
Email: [email protected]

PAKISTAN
The Director-General for Health
Ministry of Health, Social Welfare and Population Planning
Government of Pakistan
Secretariat Block C
Islamabad
Tel: +92 51 82 09 30
Cable: SEHAT ISLAMABAD

PAPUA NEW GUINEA
Dr. Ian I. Onaga
A/Chief Veterinary Officer
National Veterinary Laboratory
Dept. of Agriculture & Livestock
P.O. Box 6372
Boroko NCD
Tel: +675 217011/217005
Fax: +675 200181/214630

PHILIPPINES
Ms Ma. Concepcion C. Lizada
Bureau of Agriculture and Fisheries Products Standards
Department of Agriculture
Elliptical Road, Diliman
Quezon City, Metro Manila
Tel: +63 2 925 3795
Fax: +63 2 920 1849

SAMOA
Chief, Public Health Division
Health Department
P.O. Box 192
Apia

SOLOMON ISLANDS
Ezekiel Walaodo
Under Secretary (Agriculture)
Ministry of Agriculture and Fisheries
P.O. Box G13
Honiara
Tel: +677 21 327/21 581
Fax: +677 21 955

SRI LANKA
Director, (Environment and Occupational Health)
Ministry of Health - Room 149
385 Deans Road
Colombo 10
Tel: +94 1 432050/437884
Fax: +94 1 440399

THAILAND
Ms Metanee Sukontarug, Director
Office of the National Codex Alimentarius Committee
Thai Industrial Standards Institute
Ministry of Industry
Rama VI Street
Ratchathiwi
Bangkok 10400
Tel: +66 2 202 3435
Fax: +66 2 2478741
Telex: 84375 MINIDUS TH (TISI)
Email: [email protected]

TONGA
Mr. Haniteli Faanunu
Director
Ministry of Agriculture and Forestry
P.O. Box 14
Nuku'alofa
Tel: +676 23 402
Fax: +676 24 271

VANUATU
Mr. Benuel Tarilongi
Principal Plant Protection Officer
Vanuatu Quarantine Inspection Service,
Department of Agriculture and Horticulture
Private Mail Bag 040
Port-Vila
Tel: +678 23130
Fax: +678 24653
Email: [email protected]

VIET NAM
Mr.Nguyen Huu Thien
Director-General, Directorate for Standards and Quality
70 Tran Hung Dao Str.
Hanoi
Tel: +84 4 266220
Fax: +84 4 267418