M. Buyckx - Maxime Buyckx, MD is a Nutrition Officer, Nutrition Planning Assessment and Evaluation Service, FAO.
La communauté internationale s'engage à lutter contre les carences en micronutriments
El compromiso de la comunidad internacional en la lucha contra la carencia de micronutrientes
Over the last decade awareness of the magnitude and seriousness of micronutrient deficiencies has been rising, as has the commitment to alleviate these problems, The International Conference on Nutrition (ICN) held in Rome in December 1992 clearly defined the priorities and the strategies that should be followed to reduce micronutrient malnutrition in a sustainable manner. According to the ICN's World Declaration on Nutrition and Plan of Action for Nutrition, sighed by ministers of 159 countries, first priority should be given to food-based strategies, as experience has shown that the most effective and least costly approaches to reducing micronutrient deficiency problems are to increase the availability and consumption of micronutrient-rich foods.
Prior to the ICN, the World Summit for Children, held in New York in September 1990, called for urgent action to combat micronutrient deficiency diseases and set ambitious goals for the virtual elimination of the problems resulting from vitamin A and iodine deficiencies and for the reduction of iron deficiency prevalence by one-third before the year 2000. Subsequently, the Montreal conference Ending Hidden Hunger1 stressed the importance of building awareness and reiterated the commitment of countries to control micronutrient malnutrition.
1 Ending Hidden Hunger was a policy conference on micronutrient malnutrition sponsored by FAO, the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the World Bank, the Canadian International Development Agency, the United States Agency for International Development (USAID) and the United Nations Development Programme (UNDP). It was held from 10 to 12 October 1991 in Montreal, Canada.
Since 1985, FAO has participated actively in defining and implementing programmes to reduce micronutrient malnutrition and to address other micronutrient problems as well, FAO has strongly supported the promotion of the production and consumption of micronutrient-rich foods as the only truly sustainable solution to micronutrient deficiency problems. This activity also falls clearly within FAO's mandate and overall strategy which emphasizes the relationship between nutrition and agriculture in order to ensure food security and to improve the health and nutritional status of the populations of different countries
Le monde prend de plus en plus conscience de l'ampleur et de la gravité des carences en micronutriments et son désir d'y remédier ne fait que croître. Sur le plan international, il faut en premier lieu améliorer la disponibilité et la consommation d'aliments riches en micronutriments, car c'est le moyen le plus efficace de réduire de façon durable les problèmes liés aux carences en micronutriments, Les principaux problèmes sont dus aux carences en vitamine A, en iode et en fer, et la façon la plus naturelle, la plus efficace et la moins coûteuse de lutter contre celles-ci ou de les prévenir est d'accroître l'absorption des substances en question. Il faut toutefois modifier les possibilités d'accès aux vivres, ainsi que la production, la distribution et la consommation des aliments qui contiennent ces vitamines et éléments, minéraux.
A ce jour, la plupart des activités destinées à réduire la prévalence et la gravité des problèmes posés par les carences en micronutriments n'ont pas donné de résultats tangibles ou durables, pour des raisons d'ordre opérationnel, économique, logistique et technique. On s'est surtout attaché à fournir des suppléments sous la forme de capsules, tablettes et injections qui ne contenaient que des micronutriments spécifiques et n'avaient aucun effet bénéfique sur l'ensemble du régime alimentaire, Ces programmes d'apport en micronutriments, concentrés dans le secteur sanitaire, ont échoué dans les pays en développement lorsqu'ils étaient réalisés à grande échelle et sur de longues périodes.
Le Sommet mondial pour l'enfance a appelé à adopter de nouvelles stratégies intégrées pour résoudre les problèmes de carences en micronutriments, et la Conférence internationale sur la nutrition (CIN) a jeté les bases d'une stratégie cohérente qui tente de résoudre les problèmes au moyen d'activités alimentaires et agricoles durables. Pour mener à bien les interventions alimentaires proposées, il faut qu'il y ait une coordination entre les secteurs de l'agriculture, du commerce, de la santé, de l'éducation et de la communication, Dans de nombreux pays, il faudra insister sur la production alimentaire à faible échelle, L'enrichissement des produits courants (par exemple sucre, sel, huile et produits à base de céréales) est également recommandé, notamment lorsque d'autres aliments hautement nutritifs ne sont pas disponibles. La législation, le contrôle des aliments, la commercialisation et la transformation des produits alimentaires jouent un rôle crucial dans la réussite des activités d'enrichissement des aliments. Il faut informer le grand public, notamment les populations à risque, des problèmes liés aux carences en micronutriments, par le truchement des systèmes de santé, d'éducation, de vulgarisation agricole et de communication. La consommation d'aliments riches en micronutriments devrait être un des principaux indicateurs retenus pour évaluer les résultats de tout programme visant à réduire les carences en vitamine A, en fer ou en iode.
Lorsque les stratégies et politiques se rapportant aux micronutriments sont examinées et élaborées dans les instances internationales, la FAO cherche toujours à soulever des questions liées à l'alimentation, à l'agriculture et à la nutrition. La FAO coordonne ses activités et programmes avec d'autres institutions spécialisées des Nations Unies, des organismes internationaux et des organisations non gouvernementales. Pour renforcer l'efficacité de ces efforts, il faut de toute urgence coordonner et intégrer, a l'échelon national, les activités sanitaires et les interventions alimentaires, La FAO aide les Etats Membres à formuler et à réaliser des programmes sur les micronutriments, mais il faut que la communauté internationale et les organismes d'aide s'engagent plus fermement à mettre en oeuvre cette stratégie axée sur l'alimentation si l'on désire, dans un avenir proche, réduire durablement les carences en micronutriments à l'échelle mondiale.
La sensibilización ante la magnitud y gravedad de los problemas de la carencia de micronutrientes y el compromiso para darles solución son cada vez mayores. La comunidad internacional reconoce que debería atribuirse la máxima urgencia al fomento de la disponibilidad y el consumo de alimentos ricos en micronutrientes, por ser ésta la fórmula más eficaz y sostenible para reducir los problemas relacionados con la carencia de micronutrientes. De éstos, los más importantes son la falta de vitamina A, de yodo y de hierro en cantidades suficientes, La forma más natural, eficaz y barata de evitar estas carencias y luchar contra ellas es conseguir una mayor ingestión dietética de estos micronutrientes, Para ello, sin embargo, es preciso introducir cambios en la producción, la distribución, el acceso y el consumo de los alimentos que son fuente de estas vitaminas y minerales.
Hasta la fecha, la mayoría de las actuaciones dirigidas a reducir la prevalencia y gravedad de los problemas relacionados con la carencia de micronutrientes no han logrado obtener resultados representativos y sostenibles, debido a factores de tipo operativo, logístico, técnico o de costo. Se ha insistido en el suministro de suplementos, como cápsulas, comprimidos e inyecciones, cuando éstos sólo proporcionan micronutrientes específicos y no tienen efectos benéficos sobre la dieta en general. Estos programas de provisión de micronutrientes, centrados en el sector sanitario, han resultado ineficaces cuando se han aplicado a gran escala y durante largos períodos de tiempo en los países en desarrollo.
La Cumbre Mundial en favor de la Infancia preconizó la adopción de nuevas estrategias integradas para dar solución a los problemas de carencia de micronutrientes, mientras que la Conferencia Internacional sobre Nutrición (CIN) preparó el camino para una estrategia coherente que resuelva estos problemas mediante actividades sostenibles en los ámbitos de la alimentación y la agricultura. Para llevar a cabo las actividades propuestas basadas en la alimentación, es necesario garantizar la coordinación entre los sectores agrícola, comercial, sanitario, educativo y de los medios de comunicación, En muchos países, habrá que prestar especial atención a la producción de alimentos en pequeña escala, También se recomienda el enriquecimiento de los alimentos habituales (por ejemplo, el azúcar, la sal, el aceite y los productos a base de cereales), especialmente, cuando no es posible el acceso a otros alimentos nutritivos de alta calidad. Una legislación apropiada, el control alimentario y la comercialización y elaboración de los alimentos son fundamentales para el éxito de las medidas de enriquecimiento de los alimentos, El público, especialmente las poblaciones de alto riesgo, debe ser informado a través de los medios sanitarios, educativos, de extensión agraria y de comunicación. El nivel de consumo de alimentos ricos en micronutrientes debería ser uno de los principales indicadores a la hora de evaluar el éxito de cualquier programa que tenga por objetivo reducir la carencia de vitamina A, hierro y yodo.
La FAO siempre ha tratado de que en los foros internacionales se aborden los asuntos alimentarios, agrícolas y nutricionales cuando se estudian y definen las estrategias y políticas en materia de micronutrientes. Los programas y actividades de la FAO se llevan a cabo en coordinación con los de otros organismos de la ONU, organismos internacionales y ONG. Para hacer más eficaz esta labor, es necesario trabajar urgentemente en la coordinación e integración de las actividades en materia de salud y alimentación que se realizan a nivel nacional. La FAO presta asistencia a los Estados Miembros en la formulación y aplicación de sus programas sobre micronutrientes. Sin embargo, para obtener resultados sostenibles en la reducción de las carencias de micronutrientes a nivel mundial en un futuro próximo, es preciso un mayor compromiso de la comunidad internacional y de los organismos donantes en la aplicación de esta estrategia basada en los alimentos.
Magnitude of the problem
No significant progress has occurred to reduce the magnitude of micronutrient malnutrition over the past few decades in spite of the efforts and investment that have been put into tablet-, capsule- and injection-based approaches linked to health care and social welfare systems. The major problems involve deficiency of dietary vitamin A, generally in developing countries, and shortages of iodine and iron in many developed and developing countries.
It is estimated that at least 40 million preschool children consume insufficient amounts of vitamin A; 13 million have some eye damage and annually 250 000 to 500 000 preschool children become partially or totally blind as a result of vitamin A deficiency, Approximately 190 million young children live in areas where vitamin A deficiency occurs, Some 37 countries, predominantly in Southeast Asia and Africa, are affected.
Worldwide, over 1 000 million people live in areas where iodine deficiency is a risk; 200 million have goitre and 26 million are mentally retarded because of this deficiency.
More than 2 000 million people worldwide are anaemic or have insufficient iron intake, Iron deficiency among pregnant women is a problem of public health significance in industrialized countries as well as developing ones, although the prevalence is higher in the latter (ICN Secretariat, 1992).
Essentially, the primary cause of each of these deficiencies is low dietary intake of a specific micronutrient. Underutilization and reduced absorption of micronutrients because of factors such as measles, diarrhoea and parasitic infections can also have a significant role, Increased dietary intake of vitamin A, iron and iodine is the most natural, efficient and inexpensive solution for prevention and control of deficiencies, However, this will require changes in the production, distribution, accessibility and consumption of foods that are sources of these vitamins and minerals.
Food as source of micronutrients
Micronutrients are available from many food sources. The same food may provide several micronutrients in addition to other nutritious elements such as calories and protein. For instance, green leafy vegetables and animal foods are rich in both iron and vitamin A, Fish products are rich in vitamin A and iodine. Production of and access to fruits, vegetables, meat, fish and other foods that are rich in vitamins and minerals should be strengthened. The increased availability of such foods will reduce the incidence and the prevalence of deficiencies and provide a more balanced diet, This will also have a positive long-term impact on nutritional and health status and improve the growth and working and learning capacity of each individual, Also, the promotion of home and community gardens, together with nutrition education activities, will help ensure that food is available within households throughout the year. It is hoped that women will be major beneficiaries of these efforts, since they are not only consumers but also food producers and caretakers of families.
Sustainable production of a variety of foods can ensure global food availability and access to food at the household level. It can also provide an adequate supply of vitamin A and iron and partial supplies of iodine as well as other micro - and macronutrients. Fortified foods can be another important source of micronutrients for wide coverage of populations at risk of deficiencies.
Micronutrient-rich supplements such as capsules, tablets and injections can only provide specific nutrients and do not have any impact on the overall diet, Furthermore, health-oriented micronutrient programmes have been shown to be impractical and ineffectual when carried out in developing countries on a large scale for a long period (Herrera et al., 1992). The overemphasis on narrow, short-term health measures has led to a misdirection of limited resources which could have been used to promote food-based solutions which could contribute more to individual well-being and community development, According to a recent assessment of programmes in Bangladesh, supplement programmes are not less costly than food production strategies (Greiner, 1993).
Strategies to reduce micronutrient deficiencies
In recent years, many activities to reduce micronutrient deficiency disorders have been implemented in developing countries, Most of these activities have been carried out within the health sector, although specific activities have taken place within other fields such as agriculture, communication, food technology and education. However, comprehensive integrated national strategies to reduce micronutrient deficiencies have not been discussed or formulated in most countries. Governments, decision-makers and planners as well as technicians from the different sectors must be fully aware of all the different approaches to solving the problem.
The World Summit for Children drew greater attention to micronutrient deficiencies and called for new integrated strategies to solve this problem, The ICN translated this awareness into a coherent strategy with a real commitment to solutions based on sustainable food and agriculture to ensure access to food and increased food consumption by the at-risk population groups, Appropriate resources must be allocated to undertake food-based activities, Improved coordination and integration of health measures and food and agriculture activities are essential to reduce significantly the prevalence of vitamin A, iron and iodine deficiencies as well as other micronutrient, health and nutrition problems.
Coordination among the agriculture, commerce, health, education and communication sectors is necessary to carry out proposed food-based activities, In many countries, emphasis must be given to small-scale activities for the production of fruits, vegetables and small animals to ensure that food is available to households, Additional sources of micronutrients can be obtained from fish in coastal zones or when and where aquaculture is feasible. In areas where production or access to other food items is difficult, the use of local underexploited and traditional plants, certain staple foods such as sweet potatoes or other plants rich in some micronutrients must be promoted. Stronger efforts should be made to improve processing and preservation of micronutrient-rich foods, Many crops are seasonal and postharvest surpluses are often lost if processing and preservation techniques are inadequate. Efficient methods for preserving the micronutrient value of foods should be promoted at the small-scale or semi-industrial level.
Fortification of sugar, salt, oil and cereal products is also recommended, especially for those areas or target groups that have no access to other high-quality nutritious foods or for use in emergency situations, Attention must be given to the price and marketing systems for fortified foods to enable the poorest and most affected segments of the population to obtain them. Industries that market and process foods have a key role in food fortification activities, since adequate levels of quality control in processing and marketing and assured shelf-life of fortified micronutrients can only be secured by their diligence, under the control of national laws and regulations established by the government.
Increasing awareness about micronutrient deficiency disorders and the ways to avoid and reduce their deleterious impact through the consumption of nutritious foods must be a major goal of any programme to reduce the prevalence of these problems, Hence, nutrition education, delivered through health, education, agricultural extension and mass-communication channels, must reach all the target populations and inform them about micronutrient deficiencies, Nutrition education should also be directed to adults and out-of-school youth, Awareness of fortified foods, the importance of food preservation and the appropriate kinds of food to consume to prevent micronutrient deficiencies should be a significant indicator for evaluating the success of any programme to reduce vitamin A, iron or iodine deficiency.
Monitoring and evaluation of activities to reduce the prevalence of micronutrient deficiency are essential to control programme development. Decisions on how to follow up or modify ongoing projects or activities can then be taken in order to ensure coordination, integration and cost-effectiveness of the programme.
FAO's mandate and its relationship to micronutrients
The Preamble to the FAO Constitution calls for actions for the purpose of "raising levels of nutrition, securing improvements in the efficiency of the production and distribution of all food... bettering the conditions of rural populations;...and ensuring humanity's freedom from hunger" (FAO, 1989). Within this framework, FAO is providing assistance and support to governments in their decisions regarding the implementation of strategies to reduce micronutrient deficiencies through food- and agriculture-based activities. FAO assists countries in developing food, agriculture and nutrition components as part of their plans to prevent micronutrient deficiencies as well as their broader development plans. Commerce, industry, education, information and other relevant sectors are informed on issues concerning micronutrient malnutrition.
In terms of specific interventions, FAO is assisting member countries in the formulation, implementation, monitoring and evaluation of micronutrient components of national nutrition programmes and of free-standing integrated micronutrient projects. Technical assistance for the establishment of food fortification programmes and to support household and small-scale food preservation and processing activities is also provided, Assistance in establishing food quality and control programmes and in determining the micronutrient content of vitamin A- and carotene-rich foods is given, FAO provides guidance on technical issues such as nutrient requirements and food composition tables and prepares technical and general publications on these topics for international distribution, Food and nutrition activities are integrated into FAO projects and programmes in such areas as rural and agricultural development, horticultural production, women's activities, reduction of food losses, communication and information, community forestry and fishery activities.
FAO's main thrust in international fora is to ensure that concerns of food, agriculture and nutrition are addressed when micronutrient strategies and policies are discussed and defined, FAO also provides a forum for the developing countries to discuss national and international strategies and to benefit from other countries' experiences as well as to express their needs for assistance. FAO coordinates its activities and programmes with other UN agencies, international bodies and non-governmental organizations (NGOs).
Conclusion
In many regions, insufficient intake of foods rich in vitamin A, iron and iodine as well as other micronutrients causes a variety of nutritional and health problems with their related social consequences, The elimination of micronutrient deficiency disorders has been given high priority in many countries and by international agencies devoted to improving the nutritional status of all. From a global perspective, most activities and programmes that have been implemented to control micronutrient deficiency problems have been unable to reduce significantly and sustainably the prevalence and severity of those problems, This lack of success has resulted from operational, cost, logistic and technical factors.
To improve these efforts, coordination and integration of health- and food-based activities at the national level are urgently needed. To date, a major obstacle has been the biased and unbalanced approach to dealing with micronutrient deficiency problems, which has emphasized health measures (distribution of capsules, tablets, injections). These supplementation programmes have experienced severe problems in their implementation, and their results have been limited, Nonetheless they continue to receive the most investment and attention, perhaps because they are perceived to be easier to administer than food-based activities.
The ICN Plan of Action for Nutrition in a specific section dedicated to micronutrient malnutrition has clearly stated that implementing food-based activities - that is, the production and consumption of micronutrient-rich foods including fortified foods, especially in the case of iron and iodine - should now be the focus of attention, A recent analysis, based on FAO food balance sheets, indicates that the availability of vitamin A and iron in food in certain regions of the world is still insufficient to cover the dietary needs of the population (UN ACC/SCN, 1992).
In addition to the food production needs mentioned above, major improvements are urgently needed in the preservation, processing, distribution and marketing of micronutrient-rich food. Nutrition education activities which are fundamental for ensuring the effectiveness of a food-based approach need to be promoted.
FAO will help member countries to implement these activities in the framework of the National Plans of Action for Nutrition which countries are currently preparing, However, an overall commitment to implementing the food-based strategy by the international community and the donor agencies is needed for sustainable reduction of micronutrient deficiency on a global level.
References
FAO. 1989, Basic texts of the Food and Agriculture Organization of the united Nations. Rome.
Greiner, T. 1993. Report to SIDA on two different nutritional blindness prevention programmes in Bangladesh. (Unpublished draft).
Herrera, M.G., Nestel, P., El Amin, A., Fawzi, W., Mohamed, K. & Weld, L. 1992, Vitamin A supplementation and child survival. Lancet, 340:267-271
ICN Secretariat. 1992, Preventing specific micronutrient deficiencies. Major issues for nutrition strategies. Theme paper No. 6. Rome.
UN ACC/SCN. 1992, Second report on the world nutrition situation. Geneva.
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EXCERPT FROM THE INTERNATIONAL CONFERENCE ON NUTRITION'S PLAN OF ACTION FOR NUTRITION 7. Preventing and controlling specific micronutrient deficiencies 38. Micronutrient deficiencies are a matter of major public health concern, They are widespread, although the prevalence of a particular deficiency can vary considerably within and between countries. Deficiencies of vitamin A (including beta-carotene), iodine and iron are especially important because of their serious health consequences, wide geographic distribution and the existing global commitment to their control. 39. Vitamin A deficiency and its consequences, including blindness, poor growth, increased severity of infections and death, are fully preventable, making its control one of the most effective child health and survival strategies that governments can undertake, The protection, promotion and support of breast-feeding is an effective way of preventing vitamin A deficiency in infants and young children. 40. Over one-fifth of the world's population lives in iodine-deficient areas. Iodine deficiency is the most common preventable cause of mental retardation. Additional consequences of iodine deficiency are reproductive failure, goitre, increased mortality and economic stagnation. Children, adolescent girls and women are particularly vulnerable. The means for its correction are readily available and provide an exciting opportunity for its elimination by the year 2000. 41. Iron deficiency and/or anaemia is the most common micronutrient deficiency, especially affecting young children and women of reproductive age. Uncorrected anaemia can lead to learning disabilities, an increased risk of infection and diminished work capacity and to death of women during pregnancy and at childbirth. Thus, iron deficiency has an impact on all segments of society. 42. Deficiencies of other micronutrients such as folate and other B-complex vitamins, vitamin C, selenium, zinc and calcium also significantly affect health and may merit increased attention by governments in countries where deficiencies exist, 43. Recognizing the international, regional and national resources, coordination and support required, governments, in collaboration with international agencies, NGOs, the private sector/industry, other expert groups and the community, should adopt ah appropriate combination of the following strategies: (a) Assess the extent and epidemiology of micronutrient deficiencies and develop a national policy for prevention based on their distribution and cause, the severity of deficiency and available resources. (b) Accelerate efforts to achieve the elimination of vitamin A and iodine deficiencies and a reduction in iron deficiency in accordance with the year 2000 goals of the World Summit for Children and the Montreal Conference on Micronutrient Malnutrition. (c) Formulate and implement programmes to correct micronutrient deficiencies and prevent their occurrence, promoting the dissemination of nutrition information and giving priority to breast-feeding and other sustainable food-based approaches that encourage dietary diversification through the production and consumption of micronutrient-rich foods, including appropriate traditional foods. Processing and preservation techniques allowing the conservation of micronutrients should be promoted at the community and other levels particularly when micronutrient-rich foods are available only on a seasonal basis. (d) Implement the most appropriate combination of the following measures: improved food availability, food preservation, food and nutrition education and training, dietary diversification, food fortification, supplementation and pertinent public-health measures such as primary health care, promotion of breast-feeding and safe drinking-water. International and regional cooperation in the sharing of resources to enable economies of scale should be encouraged. (e) Ensure that sustainable food-based strategies are given first priority particularly for populations deficient in vitamin A and iron, favouring locally available foods and taking into account local food habits. Supplementation of intakes with vitamin A, iodine and iron may be required on a short-term basis to reinforce dietary approaches in severely deficient populations, utilizing primary health care services when possible. Supplementation should be directed at the appropriate vulnerable groups, especially women of reproductive age (iodine and iron), infants and young children, the elderly, refugees and displaced persons. Supplementation should be progressively phased out as soon as micronutrient-rich food-based strategies enable adequate consumption of micronutrients. (f) Ensure and legislate for the fortification of foods or water with necessary micronutrients, where feasible, when existing food supplies fail to provide adequate levels in the diet. Fortification should be regularly evaluated for various reasons. Where iodine deficiency is a significant public health problem, the iodization of all salt for both human and livestock consumption is required, recognizing that this is the most effective long-range measure for correcting iodine deficiency. (g) Ensure that nutrition education and training programmes are Implemented at the community, school and national levels to provide information on proper food preparation, nutritional S value and bioavailability and other factors that affect micronutrient status, especially of the young, and to promote the consumption of foods that are rich in micronutrients. (h) Strengthen micronutrient surveillance capabilities and activities by devising indicators to monitor the above strategies for achieving national goals related to coverage, compliance and effectiveness in targeted populations. (i) Support research on the role of micronutrients in health and disease; on the development of inventories and food composition tables of existing and potentially significant food sources of micronutrients, including inter alia green and yellow vegetables and fruits, palm oil, fish and other locally available food sources of micronutrients; on weaning foods; on factors affecting the bioavailability of nutrients in food; on indigenous methods of food processing and preparation affecting micronutrient availability; on nutrition education; and on the improvement of existing techniques for the assessment and correction of micronutrient deficiencies. (j) Develop sustainable institutional capacities and human resources, including training of professionals, non-professionals and community leaders, in order to achieve the goals of micronutrient deficiency control and prevention. (k) Consider, as appropriate, coordinating micronutrient deficiency control activities under the direction of a national committee, with the appropriate political support, authority, legislation and infrastructure that reflects national commitment. (l) Encourage FAO, WHO and all other concerned international agencies and NGOs to provide assistance in combating all aspects of micronutrient deficiency problems, through monitoring and surveillance, research and production and consumption of micronutrient-rich foods. (m) Recognize that refugees and displaced persons, as well as being susceptible to iodine, vitamin A and iron deficiencies, are also susceptible to other deficiencies, particularly vitamin B deficiency (beriberi), niacin deficiency (pellagra) and vitamin C deficiency (scurvy). Donor countries and involved organizations must therefore ensure that the nutrient content of food used for emergency food aid meets nutritional requirements, if necessary through fortification or ultimately through supplementation. To the extent possible, such foods should be culturally appropriate. |
