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Incorporating nutrition components and considerations into development plans and programmes
Ensuring household food security
Protecting consumers through improved food quality and safety
Promoting breast-feeding
Combating micronutrient deficiencies
Preventing diet-related noncommunicable diseases
Assessing, analysing and monitoring food and nutrition situations

35. To date, FAO and WHO have received over 70 national plans of action along with over 145 country progress reports assessing country activities and progress in achieving the ICN goals. The plans reviewed focus on a wide range of issues and represent a country-specific selection of goals and strategy options. Most plans are modelled along the themes and major policy guidelines of the global Plan of Action and provide an overall framework to improve nutrition from a multisectoral perspective. A minority of countries have gone beyond the level of outlining broad-based strategies and programmes and are preparing detailed programme and project outlines, including precise time frames, attainable goals and realistic budgets (e.g. Cuba, Guinea, Laos, the Philippines, Western Samoa, Namibia). However, at this stage, most of the draft or final plans which have been prepared do not elaborate the specific activities or identify the necessary resources to implement the strategies or programmes they have outlined.

36. Most countries are identifying concrete goals for improving national food and nutrition situations within a given time-frame, mostly before the year 2000. For the most part, specific activities to achieve those goals have been identified but have not yet been sufficiently outlined for implementation. Recurring objectives include: increases in daily energy supply above or up to a certain level; reductions in child malnutrition; reduction or elimination of prevalence of vitamin A, iodine and iron deficiencies; promotion of breast-feeding; reductions in food-borne diseases and in contamination and adulteration of food; increases in food trade; adoption of food laws, regulations and standards; promotion of healthy diets and lifestyles and increase of coverage rates for nutrition monitoring of vulnerable groups.

37. While national plans of action reflect a rich variety in country and sector-specific approaches toward nutrition, there is a remarkable recurrence of specific issues within and between plans. The majority of developing countries indicate that they urgently need support to increase local capacity to formulate, implement and monitor food and nutrition activities. Many countries, particularly in Africa, recognize the weakness of the food security component in their national plans of action and indicate that comprehensive food security programmes are required, incorporating measures to increase food supplies, improve food quality and safety, reduce micronutrient deficiencies and provide food and nutrition information and early warning services. From the plans and country reports, it can be concluded that countries now recognize the fundamental role of agriculture in improving nutrition, but have difficulty in translating this understanding into specific activities in the food and agricultural sectors and in integrating nutrition considerations into agricultural development programmes. Countries indicate that "intensified support from FAO will be needed to fully address these issues.

Incorporating nutrition components and considerations into development plans and programmes

38. Countries indicate that existing coordinating bodies for integrating nutrition in development plans and programs frequently lack adequate capacity and resources and the proliferation of ad-hoc bodies and committees to enhance intersectoral cooperation and coordination often leads to dispersion of already scarce resources and capacity. Many countries, therefore, express the need to strengthen existing coordination mechanisms to increase long-term impact of development programmes on nutrition. Countries such as Kenya, Namibia, Myanmar and Western Samoa foresee establishing an umbrella organization to support intersectoral collaboration and provide technical assistance in policy formulation, programme development, implementation and monitoring. These organizations are expected to function as vehicles for integration of nutrition into overall and sectoral plans and programmes and have a major role in dissemination of relevant food and nutrition information.

39. Examples of efforts to enhance nutrition impact of development programmes are the Philippines and Sudan, which are outlining training activities to improve the capacity of line ministries and other relevant organizations at national and local levels to integrate nutrition components and considerations in their programmes. Mauritania and other countries have planned to develop manuals and training modules. Many countries also indicate that planners and policy makers lack awareness and understanding of prevailing food and nutrition problems and mechanisms to address them. Countries such as the Philippines, Western Samoa and Sudan, therefore, propose nutrition advocacy as a tool to sensitize policy makers and planners to consider nutrition in sectoral plans and programmes. Nutritional impact assessment should provide useful evidence for policy advocacy of how nutritional improvements contribute to higher returns on other social investments (schooling) and to increased agricultural productivity. To enhance the re-formulation of relevant policy recommendations, countries need to strengthen their capacity to assess the impact of development policies and programmes on nutrition. Policy assessment should allow the identification of policy changes needed to strengthen positive effects on nutrition, and mitigate negative effects; this in turn should also contribute to a more coherent national policy framework and intersectoral policy coordination.

40. Benin and several other countries point out that official adoption of national plans of action and recognition by relevant development agencies are critical in the acceptance of nutrition as an essential component and impact indicator of development programmes. Countries, therefore, urge development agencies to integrate nutrition considerations and components into development assistance programmes. In developed countries, incorporating nutrition components and considerations into national policies and programmes mainly entails building linkages between consumers, producers, policy makers and legislators. Some countries indicate that policy makers and legislators need to create the enabling environment to allow farmers and food industry to make foods available at affordable prices that are consistent with dietary guidelines, while at the same time maintaining or increasing commercial competitiveness in a manner consistent with an ecologically sustainable development.

Ensuring household food security

41. Most national plans provide general policy guidelines and recommendations for integrating nutrition and food security components and considerations into development plans and programmes, rather than outlining well-defined macro-level and sector-specific activities. Many developing countries have expressed their need for comprehensive food security plans and programmes, and support through programmes such as the Special Programme on Food Production in Support of Food Security in Low-Income Food-Deficit Countries. The strategies proposed in their national plans of action are as numerous and diverse as the underlying causes. Only a few countries such as Namibia and Viet Nam are using the opportunity provided by the ICN to develop comprehensive policies and action programmes for food security and nutrition. Ecuador, Venezuela and others anticipate to prepare such national policies and programmes as an activity under the national plan of action for nutrition.

42. In identifying strategies and priority areas of action for ensuring food security, Sudan, Tanzania and other countries refer to existing national food security policies and guidelines on poverty alleviation, food security and child survival. In general, these policies cover a wide scope of strategy options, ranging from application of macro-economic management tools as pricing mechanisms, production and consumption subsidies, incentives, minimum wages and budget deficit controls, to more sector-specific approaches as development and transfer of agricultural technology, agricultural research and extension, environmental protection and agro-industrial development.

43. Other activities include establishing or strengthening food security and nutrition units in specific line ministries and institutions, whose core objective is to provide assistance in policy and programme formulation, impact assessment and evaluation. These units are also expected to assume responsibility for monitoring of food security and nutrition situations. Sudan, Viet Nam and other countries envisage supporting policy and programme development through establishment or improvement of early warning and information systems for food and nutrition. More action-oriented programmes involve development of physical infrastructure, reduction of post-harvest losses, seed multiplication, aquaculture development, agro-forestry, home and school gardening. It is important to note that, through the development of national plans of action, nutrition components and considerations are being incorporated into these activities, thus enhancing their impact, while, at the same time, allowing assessment of their bearing on nutrition.

44. Among developed countries the issue of food security is not explicitly addressed, as their plans focus mainly on food safety, dietary habits and health-related aspects of nutrition. Australia and New Zealand indicate that food security entails adoption of environmentally sustainable agricultural practices in an increasingly competitive international trade environment. They identify the need to assess the extent and analyze the causes of food insecurity among minority and vulnerable groups and to develop criteria for assessing patterns and levels of household food insecurity. New Zealand notes the strategic importance of food security in the face of events that would prevent or inhibit food imports or greatly reduce the country's food supply.

45. It is important to note that several countries (e.g. Namibia, Madagascar and Lesotho) are building linkages in their national plans of action between strategies to ensure food security and approaches to combat micronutrient deficiencies or improve food quality and safety. This clearly reflects the understanding that activities such as agricultural diversification, promotion of small-scale agro-industries, food processing, preservation and marketing, school and home gardening and nutrition education have the potential to contribute to improved food security.

Protecting consumers through improved food quality and safety

46. In many developing and newly industrialized countries, improving food quality and safety has become a priority area of action to ensure adequate consumer protection and enhance domestic and international trade. National plans of action include strategies to overcome constraints in local capacity ranging from strengthening of national food control infrastructure (including institutions, legal framework, human resources and inspection services) to training of food producers, processors and handlers, consumer education and information.

47. Food-borne diseases, identified by the ICN as an important cause of ill-health and an underlying factor for malnutrition, remain a major public health problem worldwide. Surveys carried out in industrialized countries indicate that the estimated annual incidence of food-borne diseases affects up to 10% of the population. Reported cases of some food-borne diseases in these countries also indicate an increasing trend.

48. Data from developing countries are scarce and are not an accurate representation of the real situation. However, the high incidence and prevalence of diarrhoeal diseases in infants and children - up to 70% of the cases are due to contaminated food - point to an alarming food-safety situation calling for urgent action. From the very few countries which maintain a food-borne disease surveillance, e.g. Venezuela, it can be observed that the incidence of food-borne diseases are similarly increasing in developing countries. An analysis of the country reports and national plans of action prepared by Member States confirm this analysis. Most developing countries, particularly in Africa, have acknowledged their serious food safety problems, expressing concern about foods that are heavily contaminated with microbiological and chemical contaminants.

49. In the majority of developing countries, manpower development and training for food control personnel, industry and trade are raised as priority areas of action. In this context, reference is made to the need to strengthen regional training efforts and institutions. Many countries, particularly in Africa, also give great importance to the nutritional and economic value of traditional foods and their plans outline strategies to develop and improve processing and storage techniques for indigenous foods.

50. Many countries in Asia and some regions of Africa recognize the economic and nutritional impact of the informal food sector. Their national plans of action provide specific strategies to improve, control and monitor food quality and safety in this sector. In this respect, Egypt, Sudan and Western Samoa among others, raise the issue of providing access to potable water at household level and adequate infrastructure at street food vending sites as an important concern.

51. In view of increased trade liberalization world-wide, a majority of countries emphasize the need to strengthen food quality control activities for import and export purposes. This is expected to provide an adequate framework for expansion of food control and other consumer protection services to domestic markets. Countries such as Egypt, Lesotho, Western Samoa, Myanmar, Hungary and Cambodia and many others give much attention to development and promulgation of food laws, regulations and standards which are internationally recognized, while several developed and most developing countries foresee introducing or strengthening certification of food products, quality systems and laboratories.

52. In developed countries, much importance is given to food labelling and food composition activities. In the latter area, activities to strengthen regional food composition database networks are anticipated. Equally important is the promotion of food quality systems such as HACCP in the European Union and other industrialized countries through training and information programmes.

53. Many countries are developing special legal instruments to regulate food fortification. For instance, Madagascar, Côte d'Ivoire, Myanmar, the Dominican Republic, Nicaragua, Swaziland and Lesotho have outlined food control measures to support fortification of foods with micronutrients and in particular iodization of salt.

Promoting breast-feeding

54. The ICN reaffirmed the global goal for optimal maternal and child health and nutrition stated in the Innocent! Declaration: "all women should be able to practice exclusive breast-feeding and all infants should be fed exclusively on breast milk from birth to 4-6 months of age. Therefore children should continue to be breast-fed while receiving appropriate and adequate complementary foods, for up to two years of age or beyond.

55. The prevalence and duration of breast-feeding have increased in some parts of the world, such as Australia, Canada, the Netherlands and Sweden, often as a direct result of national and other support and promotion programmes. Unfortunately, however, breast-feeding trends continue to decline in other parts of the world, often in those areas where breast-feeding is crucial to infant survival, Brazil, Nigeria and Yemen, for example. Recent data collected from 44 countries (taken primarily from the Demographic and Health Surveys) on exclusive breast-feeding from 0-4 months show declining values and a shift away from optimal feeding modes. Exclusive breast-feeding rates at four months of age range from 41% in Botswana to 4% in Burkina Faso in the African Region. Early supplementary feeding and short breast-feeding duration with abrupt weaning are still the norm in many parts of the world. Breast-feeding rates in the 44 countries at 12-15 months range between 97% in Burkina Faso to 30% in Mexico. Breast-feeding into the second year of life varies from 85% in Rwanda to 7% in the Dominican Republic.

56. In a remarkably short time, the Baby-Friendly Hospital Initiative has mobilized national authorities in at least 159 countries, where 14 000 hospital and maternity facilities have been targeted to become baby-friendly, to achieve the operational target of the Innocenti Declaration. In developing countries, 13 976 hospitals and maternity facilities have been targeted to become baby-friendly by 1995. In China alone, around 900 hospitals and maternity services had been designated baby-friendly by the end of 1994, thus approaching successfully the national mid-decade goal of 2000 baby-friendly hospitals by the end of 1995.

Combating micronutrient deficiencies

57. Iodine deficiency disorders (IDD) are the greatest worldwide cause of preventable brain damage in the foetus and infant and retarded psychomotor development in young children. WHO estimates that IDD are currently a significant public health problem in 118 countries where 1571 million people live in iodine-deficient environments and are therefore at risk, and 655 million people actually suffer from goitre. Approximately half the global goitre problem is found in Asia (WHO regions of South-East Asia and the Western pacific), but also 89 million in Africa, and 11.3% of Europe's population still has goitre.

58. Recent reports indicate that tangible progress in universal salt iodization, the most feasible national intervention for prevention and control of IDD, is being made in the 118 countries currently known to be affected by these disorders - for example in China, Latin America, in countries of South-East Asia, and in Africa. Of these countries, 37 have established universal iodization and 36 others have initiated some type of action. However, 39 countries have taken no action and information is lacking from the remaining six. Efforts are under way to stimulate action, where lacking, to complete universal salt iodization, and to monitor programmes to assure sustainability. Despite the magnitude of the problem, it seems realistic to anticipate that IDD will indeed be eliminated as a major public health problem by the year 2000.

59. More than a quarter of a million children are estimated to go blind every year due to a deficiency of vitamin A. The 1994 estimates from the WHO Micronutrient Deficiency Information System database indicate that at least 3 million children annually currently exhibit signs of clinical xerophthalmia. This estimate is substantially lower than the 1985 estimate of 14 million. The apparent progress in reducing the risk of blinding malnutrition undoubtedly reflects both successful short-term approaches through distribution of vitamin A supplements in countries with large populations of affected children, e.g. Indonesia and India, and a more equitable distribution of economic and social programmes to relieve poverty and conditions associated with deprivation. These latter conditions often precipitate clinical deficiency.

60. Although there is a downward trend in clinical vitamin A deficiency, WHO estimates that in 1994 at least 227 million children were at risk of a subclinical deficiency because of deficient vitamin A body stores. This translates into a significant compromise in health and the chances for survival of affected populations. Currently more than 65 countries have a problem of public health significance, and an additional 28 countries are likely to have such a problem.

61. Iron deficiency and anaemia have profound negative effects that include increasing maternal and newborn mortality, impaired health and development of infants and children, limited learning capacity, impaired immune mechanisms, and reduced working and productive capacity of those affected. Iron deficiency and anaemia are thus impediments to individual and national development. Iron deficiency alone affects an estimated 2000 million people in developed and developing countries combined, half of these with clinical iron deficiency anaemia and the remainder with deficient body-iron stores. Directly related to the truly massive problem of iron deficiency anaemia in women is iron deficiency anaemia in infants and young children. An estimated 58% of pregnant women in developing countries are anaemic, with the result that infants are more likely to be born with low birth weight and depleted iron stores. An earlier (1985) WHO global assessment indicated that 51% of children aged under five years in developing countries also are anaemic.

62. National plans of action and country reports indicate that activities to combat micronutrient deficiencies are ongoing in many developing countries. Much work has been done by WHO, UNICEF and other agencies on the control and prevention of iodine deficiency disorders through the iodization of salt and the enactment and enforcement of relevant legislation. In the past, work on vitamin A and iron deficiencies has mainly focused on supplementation and to a lesser extent on fortification and agricultural based approaches. In selecting specific strategies to combat micronutrient deficiencies, most countries indicate that supplementation efforts should gradually be phased out and replaced by more sustainable food-based actions such as diversifying and increasing production, processing and marketing of foods rich in or fortified with specific micronutrients.

63. To support the application of food-based approaches, countries such as Kenya, Benin and the Philippines are planning training on various strategy options and aspects related to food technology and quality control. Other developing countries such as Cambodia and the Dominican Republic indicate that nutrition education and training of agricultural extension workers on food based approaches and health workers on assessment of nutritional deficiency disorders are critical to long-term elimination of micronutrient and other nutritional deficiencies. Countries such as Cuba, Laos, Viet Nam, Nicaragua and Bolivia have outlined programmes for agricultural and dietary diversification to increase availability and consumption of micronutrient rich foods and are also promoting food fortification. Australia and several other countries are developing dietary guidelines, recommending consumption of foods rich in specific micronutrients.

64. Several countries, such as Kenya, Morocco and Mauritania emphasize that apart from vitamin A, iron and iodine, other micronutrients such as vitamins D and C, zinc and calcium should receive greater attention. These and other countries argue that the extent and severity of specific micronutrient deficiencies is insufficiently known and priority should be given to situation assessment and analysis to allow development of appropriate strategies.

Preventing diet-related noncommunicable diseases

65. There has been increasing recognition in the past 40 years, especially in industrialized countries, that certain chronic noncommunicable diseases are closely related to diet and other aspects of lifestyle, notably emotional stress, reduced physical exercise, and tobacco smoking. Cardiovascular diseases are the leading cause of morbidity and premature death in the developed countries and are responsible for more than 12 million deaths each year, which is almost one-quarter of deaths worldwide. Trends indicate that cardiovascular diseases are decreasing in some industrial countries, where the highest mortality rates are found in low socioeconomic groups. However, a substantial increase has been observed in countries of central and eastern Europe as well as a general increase in developing countries. Cancer is the second cause of death in most developed countries. Recent trends show that, unless controlled, cancer will become the leading cause of death in several countries by the twenty-first century.

66. In addition, the increasing prevalence of diabetes has led to a large increase in related mortality and it is predicted that the number of people with diabetes may exceed 100 million by the end of the century. To prevent lifestyle and diet-related noncommunicable diseases, 12 countries in the African Region have already adopted education programmes, as have 11 countries in the Eastern Mediterranean Region, 20 in the European Region, and 5 countries each in the Region of the Americas and in the South-East Asia and Western pacific Regions. Consequently, the global picture is mixed, with some countries experiencing higher incidence trends than others.

Assessing, analysing and monitoring food and nutrition situations

67. It is evident from country reports and national plans that existing programmes and systems for the collection and analysis of food and nutrition information need to be enhanced in order to effectively monitor the impact of plans and activities for nutrition. Many countries express the need to develop appropriate sampling and analytical methodology and review indicators, coverage rates, time-lags between data collection and dissemination, access to data, data quality and relevancy. Recognizing the lack of coordination amid the enormous wealth of food and nutrition related data, industrialized countries such as Australia and Denmark plan to establish a national coordinated mechanism for food and nutrition monitoring.

68. Several countries in Latin America, Africa and Asia plan on strengthening existing national capacities for data collection, analysis and dissemination and advocate increased coordination and cooperation between various food and nutrition information systems to optimize resource utilization and improve information quality and relevancy. They plan to improve existing nutrition information systems, covering information on nutritional status of vulnerable groups, to also include food security and other relevant indicators. Training of relevant personnel, increasing community participation and enhancing sustainability of information systems are also recognized as important. In this respect, countries such as the Comoros, Côte d'Ivoire, Guinea, the Philippines and Sudan propose to establish local systems for nutrition surveillance and early warning, adapted to the local context and needs.

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