I. HOUSEHOLD FOOD AND NUTRITION SECURITY

1. Raising levels of nutrition is at the heart of the FAO mandate, and since its beginning the Organization has worked to help create a world free from hunger and malnutrition. At the World Food Summit in 1996, leaders of 185 countries recommitted their governments to achieving this goal and reconfirmed their efforts to implement the Global Plan of Action for Nutrition adopted by the 1992 International Conference on Nutrition (ICN). They also pledged to reduce the number of chronically undernourished people in the world by half no later than 2015.

2. The challenge of meeting these commitments in the Near East Region is unique. Nowhere in the world is the contrast of nutrition problems so striking. The nutrition situation in this Region spans the entire range of nutritional problems, from under-nutrition to over-nutrition, with extensive problems of micronutrient deficiencies as well. Many countries face the dual challenge of identifying food insecure households and assisting them in achieving nutritional well-being on the one hand, and of promoting appropriate diets, healthy lifestyles and food security for the overall population, on the other.

3. Improving household food security is recognised as the primary component of strategies to reduce widespread undernutrition. By definition, household food security is "the ability of the household to secure either from its own production or through purchases, adequate food for meeting the dietary needs of its members" (FAO/WHO, 1992). In practice this means that to be considered `food secure', households must be assured of having year-round access to the quantity and variety of safe foods needed to meet each household member's nutritional requirements.

4. Several countries of the Near East Region have been adopting policies and programmes to ensure household food security. Programmes such as subsidies of basic food commodities, especially flour (bread), sugar, oil and in some cases, rice, have been implemented in a number of countries. Such subsidy programmes tend to be costly, often involve imported food commodities, and are not necessarily most effective in reaching the populations in need. Governments are now implementing specially targeted nutrition programmes. For example, subsidising brown bread (which is nutritionally superior as it contains higher levels of vitamins, minerals, and dietary fiber) for middle and low income families and not subsidising white bread which is primarily consumed by upper income families is a more effective and less costly way of meeting the nutritional needs of food insecure families. Food rationing and food stamps are other examples of targeted programmes being implemented to improve the food and nutrition security of low-income families.

5. In some countries, nutrition intervention programmes such as school feeding for children in rural and urban areas are being provided. These programmes, in addition to meeting certain nutritional needs, have the added benefit of encouraging enrolment and attendance and reducing school dropout rates. Other programmes are being implemented to increase the production and consumption of foods necessary for a balanced and nutritional diet, through the promotion of home and school gardening.

6. Some population groups in the Region are suffering from micronutrient deficiencies such as iodine deficiency in some geographic locations; iron deficiency, particularly among mothers and children; and vitamin A deficiency among population groups with insufficient consumption of fruits and vegetables. To overcome these deficiencies, several governments are taking action for the fortification of salt with iodine and for iron supplementation for pregnant and lactating mothers. In addition, a number of governments are promoting the production and consumption of a diversified diet in order to meet the nutritional needs of all members of the family.

7. However, it is also evident from observations throughout the world that people's food security (i.e. their physical and economic access to nutritionally adequate food) does not automatically translate into their nutritional well-being. Nutritional disorders, including undernutrition, do not necessarily disappear once food security has been achieved. In addition to having access to foods that are nutritionally adequate and safe, people must have:

• Sufficient knowledge and skills to acquire, prepare and consume a nutritionally adequate diet, including those to meet the needs of young children;
  
  
• Access to health services and a healthy environment to ensure effective biological utilisation of the foods consumed; and
  
  
• Time and motivation to make the best use of their resources to provide adequate family/household care and feeding practices.

8. An individual's actual nutritional status is thus determined by a number of interrelated factors, of which food security is only one. The term "nutrition security" is, therefore, used to describe the condition of having access to all the food, health, social, economic and environmental factors necessary to achieve nutritional well-being, within the appropriate cultural context. This issue of household food and nutrition security has been emphasised in both the ICN and the World Food Summit, as well as in a number of national and regional meetings in the Near East. Therefore, this paper will focus more on nutrition education and consumer awareness, which is an important element of ensuring household food and nutrition security.

II. THE ROLE OF NUTRITION EDUCATION

9. Nutrition education imparts basic life skills and is intended to instill and reinforce appropriate dietary patterns within a given social and economic context. Such education may aim to provide sufficient knowledge and skills to help people to grow, purchase, process, prepare, eat and feed their families the foods they need to meet their nutritional needs. Most basically, this requires knowledge of what constitutes a nutritious diet and how people can best meet their nutritional needs from available resources.

10. Being able to make good dietary choices is of primary importance in situations where food availability is limited and where income demands the very wise allocation of a household's scarce resources. However, as illustrated by many of the public health problems in many of the more affluent countries, the ability to make good dietary choices is still important even where availability and access to food is not a problem.

11. In both instances nutrition education can be instrumental in helping people to adopt healthier diets and improve their nutritional well-being. It can provide sufficient knowledge, can motivate and help instill confidence in people about their own capability to make good choices. Given that both diet and a lack of physical activity have been linked to a number of common non-communicable diseases throughout the world, nutrition education should also include guidance on healthy lifestyles, and on physical activity in particular.

III. OPPORTUNITIES AND CHALLENGES FOR NUTRITION EDUCATION

12. Nutrition education should be an important component of each country's efforts to improve the nutrition situation of its people. Some of the challenges confronting nutrition education include:

• Nutritional problems stemming from either deficient, unbalanced or excess food consumption have tangible costs, resulting not only in poor health and increased risk of early death to the individual, but also in reduced productivity and increased health care costs to the nation. Such suffering and loss of human potential, which arises from all forms of malnutrition, is unacceptable.
  
  
• By supporting nutrition education and investing in human development, governments of the Near East countries can assist their people in improving their welfare and increasing capacity and their productivity. Health care and medical costs could be reduced considerably through the adoption of more appropriate diets and lifestyles.
  
  
• The age distribution of the population in countries is changing. Until recently, the majority of people in the Near East were young and life expectancy was low. Today, life expectancy has increased substantially in many countriesand the number of elderly people is rising rapidly. Their unique nutritional needs need to be addressed and cannot be neglected.
  
  
• Given the high rates of urban growth found in most countries, soon more people will live in towns and cities than in the rural areas. As urban residents depend on food supplied by others, it is crucial that they have the skills and the ability to choose healthy diets and practise appropriate lifestyles.
  
  
• Some of the trends which are well-known in industrialised countries are also occurring in urban areas of the Near East Region. Economic development and urbanisation are altering dietary habits and lifestyle patterns, which can result in overconsumption when food adequacy is achieved among populations. Some segments of the population have more disposable income which allows them a greater food choice. As more children are eating away from home or taking care of themselves, they are making more of their own food choices. As more women work outside the home, consumers are purchasing more ready-to-eat food.
  
  
• At the same time that undernutrition is affecting large numbers of people, many countries are experiencing a shift in health status. While undernutrition is declining, overweight and obesity are becoming serious public health problems. Obesity in adults is well recognized as one of the risk factors for several non-communicable chronic diseases, such as cardiovascular disease (CVD), hypertension, stroke, non-insulin dependent diabetes mellitus (NIDDM) and some cancers (breast and ovarian in women, prostate in men) which lead to premature death.
  
  
• In addition to these demographic and lifestyle changes, new foods are becoming available as a result of new agricultural practices, new technology and trade. Generally, demand for traditional food is declining. The challenge is to ensure that new dietary behaviours are consistent with nutritional needs.

IV. A FRAMEWORK FOR PLANNING NUTRITION EDUCATION PROGRAMMES

13. The nature of the food supply and people's access to it are obviously fundamental to nutritional well being. Cultur and traditions, among other factors, influence the actual choices that people make. Nutrition education programmes, therefore, need to take into account the availability of food, people's access to food and the factors determining choice. A traditional role of nutrition education has been to increase the capacity of the household to use existing food resources to maximum advantage. This is particularly important in relation to breast-feeding, weaning, and supplementary feeding of children, dietary practises during infectious disease, nutrition during pregnancy and lactation and food hygiene. Education on the ways to produce food at the household level and on ways to store, process, and prepare these foods has also been incorporated into many programmes.

However, nutrition education also needs to accommodate social and technological change. The food supply of many countries of the Region is changing rapidly as a result of economic growth and with the increased availability of value-added, processed foods. Since traditional "nutritional wisdom" does not exist for the use of these products and people must learn about them as they can, well-conceived nutrition education programmes can be invaluable.

14. Nutrition education and promotion interventions that aim at behaviour change need to be particularly well planned, targeted and implemented. Such programmes need to be placed in appropriate settings and employ appropriate communication channels and media. The following framework, which consists of four interactive components, can help guide the development of effective nutrition education programmes. The starting point is the identification of the nutrition issues for population sub-groups. This will lead to the selection of target groups (or population sub-groups) which, in turn, leads to the identification of those settings and sectors which provide the greatest access to the group. Finally the methods appropriate to the target group and the setting can be selected to achieve both individual and organisational change and to provide a supportive environment for change.

A. Nutrition issues

15. The starting point of any nutrition education intervention should be the identification of the nutritional problems affecting population sub-groups. Information on prevelance and trends of nutritional and diet-related health problems among the population is needed along with information about dietary intakes. Where dietary guidelines are not yet available, it is advisable to initiate their development in order to facilitate future nutrition education work.

In addressing the nutritional needs of population sub-groups, the identification of environmental, social, and intrinsic indicators that contribute to nutritional status is summarized below.

• Environmental indicators include structural factors such as poverty and income level, employment status and educational status. While nutrition education cannot contribute directly to changing such structural factors, knowledge about these factors and, in particular, how they relate to the nutritional status of the population sub-group, will influence the settings and methods of a programme.
  
  
• Social impacts of race, gender, age, and disability are significant factors that can create disadvantage in gaining access to adequate nourishment. Again, while nutrition education programmes can do little to mitigate these impacts, they must take them into account in the design, development, and implementation of programmes.
  
  
• Assessing the nutrition issues of population sub-groups using both nutritional status and social health indicators, should lead not only to risk reduction programmes aiming at malnutrition reduction, but also to programmes designed to promote and enhance the health of the population.
  
  
• Finally, the perception of a particular population sub-group of its own nutrition priorities will contribute significantly to the effective design of programmes. Programmes are much more likely to be effective if the issues of greatest significance to the group are addressed and, if they are involved in the planning, management, and ownership of the programme.

B. Target groups

16. Target groups of nutrition education interventions should be through a range of different groups, reaching well beyond the traditional "end user" of information, and the process could be implemented at three levels.

Primary target groups. This group can be distinguished by applying the life cycle approach: pre-birth and birth; maternal/infant stage; childhood; adolescence; adulthood; family; elderly. Differentiating by special needs, primary target groups can be, e.g. ethnic communities; newly arrived migrants/urban dwellers; unemployed and low socio-economic groups; people with disabilities; disadvantaged men or women.

Secondary target groups. People who will be used to reach the primary target groups. These can include health workers, teachers, agriculturists, media journalists, food producers and retailers, child care workers, village volunteers, etc.

Tertiary target groups. People who are able to facilitate or support nutrition education initiatives, including decision makers at all levels - politicians and administrators, and can also include such people as influential community or religious leaders.

C. Settings and sectors

17. This approach is intrinsically multi-sectoral because it relies on key settings which, apart from the primary health sector, are all external to health. The use of key settings, not traditionally seen as the domain of nutrition education programmes, enables population sub-groups to be reached where they work, live and play. The use of a wide range of settings and organizations provides for positive links to occur across disciplines and encourages a much wider community involvement in nutrition issues. It also enables precise targeting of the population to occur and the development of methods suitable to the measurable and perceived needs of these locations.

Furthermore, a settings approach can emphasise changes in organizations which support individual changes. Such an example is policy development that commits the organization to practices which support healthy eating, healthy food services or nutrition information services.

Settings for reaching the whole population can include primary health care services, general practitioners, community health services, families, villages and local communities, schools, day care services, work places, recreation settings - social organizations, arts, cultural and sporting groups, retail and commercial settings - street vendors, cafeterias, and food shops.

D. Methods

Two major groups of methods can be differentiated in the implementation of a nutrition education programme: a) education and communication methods (including communication channels), and b) education support strategies.

i) Education and communication methods and channels

18. Selection of educational methods should be based on what is appropriate for the target groups and the setting. An analysis of the determinants of the nutrition behaviour of the target group, including the factors likely to influence behaviour, is the usual starting point. In the widely used Precede model this takes the form of identifying the predisposing factors (knowledge, beliefs, values, attitudes, confidence) that provide the rationale or motivation for the behaviour; the enabling factors (skills, resources) and the reinforcing factors (family, peers, teachers, etc.) which reward or contribute to the persistence of behaviour. This is the kind of information that provides the basis for planning the education and communication methods to be used.

Face-to-face education, either in groups or on a one-to-one basis, has been the traditional approach to nutrition education. In recent years this approach has been seriously questioned, mainly because of the cost in reaching large audiences. However, face-to-face methods are likely to be most effective for nutrition education because nutrition has a number of unique challenges and is different from many other issues in the health education area.

While the origin of all human behaviours is complex, nutrition education has the additional problem that good nutrition involves the capacity to discriminate among many different foods. It may be easier to identify a single substance (e.g. tobacco) as injurious to health, or to promote the benefits of a capsule or injection, than to provide the information required to make choices about a range of foods. However, it is the entire diet - meaning the amount and frequency of consumption of all foods - and not the ingestion of one particular food item which will affect health. In addition, nutrition is an area in which information alone is unlikely to be helpful. Advice on how to improve weaning food, for instance, requires not only information about what foods in what amounts and with what frequency but may also require the development of skills to grow and prepare these foods.

It is because of this complexity of factors determining dietary behaviour that face-to-face methods are likely to be the most effective for nutrition education. Evaluations confirm that programmes which have an impact on behaviour (not just on knowledge and attitude) depend on social context and interpersonal interaction to provide participants with the opportunity to practise the new behaviours and learn to solve their own nutrition problems over time.

19. Mass media strategies, on the other hand, are based on marketing and communication models which tend to deal with simple messages or a discrete food or behaviour. Nutrition education rarely deals with a single behaviour or single food. Nonetheless, mass media has been used effectively where this is the case, for example, encouraging the use of iodized salt. Using mass media has also been effective in raising community awareness of a nutrition problem, or most commonly as part of a multi-channel approach in which mass media supports other actions or face-to-face activities.

In general, it is agreed that face-to-face strategies are more likely to be effective in changing behaviour than mass media programmes. Using the strategies synergistically seems to be best option in most situations.

ii) Education support strategies

20. Beyond the actual communication of the nutrition messages, a number of strategies designed to support the education process will be necessary for securing success of the nutrition education intervention. For example:

Advocacy to influence decision makers to support nutrition promotion and to mobilize social support.

Policy (blueprints for action), can be developed at all levels of society. Apart from national policies impacting on the national food supply, local communities may make a commitment to allocating land for vegetable gardening; a day care centre can have a policy to only serve nutritious foods; a school can develop a policy to allocate specific time to nutrition education.

Community Action. Community-based programmes can increase community control over information (relating to food and nutrition); relationships (mobilizing social support, facilitating self help), resources (resource sharing, increasing purchasing power for food) and decision making. Community action can be critical for the sustainability of nutrition improvement.

Regulation. While regulation may be outside the direct sphere of nutrition education, nutrition educators and community members can advocate for certain kinds of regulation. Regulation of the food supply can be a major strategy to support nutrition promotion. Provided enforcement strategies are in place, regulation can ensure the safety of food from many contaminants and agricultural residues. Compositional standards can protect the nutritional integrity of basic food stuffs. Where there is a clearly demonstrated need (not just for marketing purposes), fortification with a vitamin or mineral can address a specific nutritional deficiency. Food labelling laws can provide valuable information to consumers and controls can be exerted over inappropriate or misleading advertising and marketing.

Food production and processing. Many successful nutrition education programmes have been supported by developing participants' skills in growing, processing, and preparing foods.

Raising awareness. Social marketing methods such as media, advertising, and sponsorships, raise awareness of nutrition issues in the community, influence public opinion, and give nutrition education a higher profile. The process of creating broad social support, will often be the first stage in effecting positive changes.

Organizational change. Collaborating with organizations and sectors, such as local government, social organizations, worksites, educational organizations, health centres, and cultural groups, can lead to changes within these organizations which support nutritional improvements. The "healthy hospital", "healthy worksite" and "healthy community" movements are such examples. Achieving organisational commitment to support improved nutrition can be a major factor in the sustainability of programmes.

V. NUTRITION EDUCATION IN SCHOOLS

21. The framework described above, in principle, captures also nutrition education in schools. However, school-based nutrition education is of highest importance in any country and therefore merits a few more specific explanations.

Schoolchildren are recognized as a priority group for nutrition education, because:

• appropriate nutrition is crucial for the healthy physical and mental development of the growing child and adolescent;
  
  
• schoolchildren are current and future consumers and need relevant education and information in order to form lifelong healthful eating patterns;
  
  
• as future parents, schoolchildren will play an important role in the development of their own offsprings; and
  
  
• as members of the family unit, schoolchildren provide an important link between school and parents as well as the whole community.

Key features of effective nutrition education programmes in schools

22. Basic to effective school-based nutrition education programmes is the recognition that children learn best in a supportive environment that embodies and reinforces the principles taught. School-based nutrition education should therefore be more than just learning about food and nutrients. Rather, nutrition education programmes should also address the broader socio-cultural, economic and environmental issues relevant to food security and nutrition in the home and community; school-based nutrition education should include:

• advocacy and promotional activities that emphasize nutrition as one of the key-factors for physical and mental development, both for the current well-being of school children and for their future as adults;
  
  
• providing children with basic knowledge about food and nutrition, including food and nutrition topics in the school curriculum;
  
  
• providing a wide range of practical, community-based learning opportunities aimed at creating positive attitudes, skills, and behaviours. Such an approach could include, for example, school gardens, post-harvest food handling in rural schools, visits to food shops and markets in urban schools, learning about hygienic food preparation at home and school, and how to protect land and water resources;
  
  
• engaging nutrition and education officials, teachers, students, parents, and community leaders in the process of school nutrition education;
  
  
• implementing policies, practices and measures that encourage acquiring life skills and self-esteem for pupils; and
  
  
• striving to provide a healthy school environment with, for example, good school catering.

By simultaneously addressing pupils, teachers, school personnel, parents and the community, it is possible to accelerate improvement in both the learning and living environments of the students and to strengthen the school's position as a healthy setting for living, learning and working.

Nutrition education in schools should also be seen as a valuable entry point for building the capacity of both the school and community to respond to important food, nutrition and health needs.

VI. NUTRITION EDUCATION IN THE NEAR EAST REGION

23. Several countries have been actively promoting nutrition education through various government ministries. Ministries of Agriculture are disseminating food and nutrition information through agriculture extension services. In certain countries, Ministries of Information are disseminating nutrition messages through the various media. In a number of countries, Ministries of Education are including nutrition education in school curricula. Ministries of Health are providing nutrition information and awareness through health care services.

What is now needed is to set national priorities for addressing the major nutritional problems in each country and for monitoring the impact of programmes in nutrition information and education. This will require increased collaboration among the various ministries, NGOs and private sector.

FAO Regional Office (RNE) have organized a number of activities in the area of nutrition education. In 1997, an inter-country workshop on nutrition education and consumer awareness was held for Arabic-speaking countries. In 1998, a similar workshop was organized for non-Arabic speaking countries of the Region. In addition, RNE has produced several publications in Arabic, most notably, the booklets: "Get the Best From Your Food", "Nutrition Education for the Public", and the workshop proceedings on "Nutrition Education and Consumer Awareness". In addition, a review was carried out on the nutrition content of school curricula in 4 selected countries.

VII. CONCLUSIONS

24. The framework advocated here is located within a nutrition and health promotion model and broadens the scope of household food security and nutrition education to include health enhancement as well as risk factor reduction programmes. By recommending that the social health indicators of population sub-groups, as well as the epidemiological factors are considered, it moves household food security towards a focus on people, health and nutritional well being.

This change in emphasis requires programme planners to consider going beyond communication activities and including strategies designed to provide for environmental and organizational supports for behaviour change of the family. The key settings and sectors approach also shifts the emphasis towards creating supportive environments for behaviour change. Achieving changes in organizations to make them more supportive of nutritional improvements will also lead to increased ownership of nutrition issues and make the sustainability of positive changes more likely.

Many countries of the Near East Region are faced with rapid social and economic changes, some of which are having a negative nutritional impact on certain sectors of the population. Nutrition education can no longer afford to be only "picking up the pieces" after malnutrition has occurred, but must also find a way to promote and enhance preventive measures to ensure good nutrition for all populations.