United Nations System
Standing Committee on Nutrition

Report of the Sub-Committee on Nutrition at its Twenty-Eighth Session

Hosted by the World Food Programme,
at the Stanley Hotel, Nairobi, Kenya, April 2 – 6, 2001

• A. Introduction
• B. Fifth Report on the World Nutrition Situation
• C. Kenya Coalition for Action in Nutrition (KCAN)
• D. Symposium on Nutrition and HIV/AIDS
• E. Working Group Reports
• E.1 Nutrition of School Age Children
• E.2 Capacity Development in Food and Nutrition
• E.3 Micronutrients
• E.4 Nutrition, Ethics and Human Rights
• E.5 Breastfeeding and Complementary Feeding
• E.6 Nutrition in Emergencies
• E.7 Household Food Security
• E.8 Prevention of Foetal and Infant Malnutrition
• F. Parallel working meeting of the UN Agencies
• G. Parallel working meeting of Bilateral Partners
• H. Parallel working meeting of NGOs/Civil Society
• I. Informal report from the "non-Steering Committee" UN Agencies
• J. Summary of decisions taken during the Final Plenary
• K. Closure of the 28th Session
• Annex 1: List of Participants
• Annex 2: Statement

A. Introduction

2.  Dr. Ngongi then called upon the SCN plenary body to observe a moment of silence for Dr. Abraham Horwitz who died on July 10, 2000. Dr. Horwitz served as chair of the SCN from 1986 to 1995.

B. 5^th Report on the World Nutrition Situation

4.  The 4^th Report was based on the theme nutrition throughout the lifecycle and covered available indicators of nutritional status from foetal life to the elderly. This report, produced in collaboration with IFPRI and launched during the 27^th Session in Washington, included trends in breastfeeding and complementary feeding, as well as a full chapter on nutrition and human development. The report was well received; printed copies have been distributed worldwide. The full report is available on the SCN’s website and statistics available to the Secretariat indicate that the frequency of downloads ranged up to 800 full copies per month during 2000.

5.  The Secretariat requested reactions and guidance from the SCN plenary on questions concerning both the content and style of presentation of the 5^th Report. What audience do we really need to reach? How should the content differ from previous publications in this series? Should we use less technical language that might make the 5^th Report more accessible to a readership outside the nutrition community? There was a general feeling that the report should provide an update of key nutrition indicators, as in the past. However, the report must go beyond this to highlight the key connections between nutrition and emerging issues in other sectors. The tracking of resource flows to nutrition, equity issues, HIV/AIDS, building capacity for nutrition and the role of physical activity in emergent nutrition-related non-communicable diseases were all mentioned. Several speakers highlighted the importance of adding value to the large body of work on-going this year in relation to the major conferences, and avoiding "an omnibus".

C. Kenya Coalition for Action in Nutrition (KCAN)

7.  The Kenya Coalition for Action in Nutrition (to read "Kenya CAN") is a non-political, multidisciplinary coalition of individuals, organizations and agencies dedicated to promoting good nutrition for all Kenyans through advocacy, networking and resource mobilization. KCAN uses Profiles, an interactive computer model for policy analysis and advocacy, to sensitize key decision makers on the importance of nutrition in national development. KCAN’s work is set against a backdrop of widespread poverty (60% of Kenyans live below the poverty line), an escalating HIV/AIDS pandemic and a stagnant economy.

D. Symposium on Nutrition and HIV/AIDS

9.  The keynote address was given by Dr. Peter Piot, Executive Director of UNAIDS. Dr. Piot reminded the audience that in Africa in particular, AIDS emerged against a backdrop of many other problems – poverty, conflict, inadequate infrastructure. Its effects have been to make those problems and their consequences far worse, by eating away at social capital. In some countries in Africa, one in three adults is living with HIV/AIDS. The HIV epidemic is increasingly driven by many of those factors that also drive malnutrition – in particular poverty and inequity. Nutrition and HIV operate in tandem, at the level of both the individual and the society. For individuals, nutrition deficits probably make people with HIV more susceptible to disease and infections of all sorts. Malnutrition is one of the major clinical manifestations resulting from HIV infection, both in children and in adults. Dr. Piot urged the nutrition community to assist in applying proven strategies on a scale commensurate with the epidemic, and to reinforce within the HIV world key messages on nutrition as a core part of any essential care package.

10.  Other speakers at the symposium were Mrs. Sophia Mukasa Monico, Director of the The AIDS Support Organization in Uganda, Professor Oliver Saasa, former Director of the Institute of Economic and Social Research at the University of Zambia, and Dr. Stuart Gillespie of IFPRI. The afternoon session was opened by Dr. Phetsile Dlamini, Minister of Health and Social Welfare, Swaziland. Dr. Dlamini said that a recent sentinel survey of women attending antenatal clinics in Swaziland showed that the rate of infection had climbed from 31% in 1998 to 34.6% in year 2000. Life expectancy is falling. Dr. Dlamini argued that pharmaceuticals, in the absence of good nutrition, cannot achieve major advances against HIV/AIDS. She also reviewed a range of programme interventions in place in Swaziland. These include development of a nutrition book for people living with AIDS, a nutrition help line, a quarterly nutrition newsletter circulated to parliamentarians and the public, community support to production of micronutrient-rich foods, and measures to protect optimal breastfeeding.

11.  This was followed by a panel discussion on the implications of the HIV/AIDS epidemic for nutrition programmes. Panel members were Dr. Elizabeth Marum of the Centers for Disease Control and Prevention, Kenya; Dr. Ruth Nduati of the Department of Paediatrics, Kenyatta National Hospital, Kenya, and Dr. Phillip Mwalari of the National AIDS Control Council, Kenya.

12.  The Dr. Abraham Horwitz Memorial Lecture was given by Ms. Lucy Thairu, a graduate student from Kenya studying international nutrition at Cornell University. Her topic was Infant feeding options for mothers with HIV: using women’s insights to guide policies. In introducing this year’s lecturer, the SCN Chair noted that Ms. Thairu was selected from amongst candidates who submitted proposals to an annual competition for consideration by the SCN Secretariat. This lectureship was inaugurated by Dr. Richard Jolly at the 24^th session in Kathmandu in 1997 to foster the mentoring of young talent in the field of international nutrition, in keeping with Dr. Abraham Horwitz’ life long efforts.

13.  In his wrap-up, Dr. Badara Samb (UNAIDS) noted that although the HIV epidemic is over 20 years old, this symposium provided a first occasion for the Executive Director of UNAIDS to address the nutrition community. The approach to both problems, HIV/AIDS and malnutrition, is multisectoral, and community action is essential to address both. The two communities can take action now by using existing networks, logistics capability and opportunities in programmes. For example, HIV/AIDS awareness in the workplace can be raised, and workplace care programmes for people living with AIDS can incorporate nutrition. Breaking the vicious cycle between food insecurity and HIV will require building on local responses, creativity and innovation. There are also areas that need more analysis and peer review. There are many guidelines and actions at country level, these need to be systematically reviewed. The UN system has not adopted any nutrition guidelines for people living with HIV/AIDS, except for breastfeeding and mother-to-child transmission. But here too we need less rhetoric and more concrete action. Dr. Samb concluded by reminding the audience that the ACC/SCN Working Group on Nutrition and HIV/AIDS needs to move ahead on these priorities, beginning with delivering a statement on nutrition at the OAU Summit in Abuja in mid April, as well as the UN General Assembly on HIV/AIDS in June.

14.  Dr. Robert Mwadime, Regional Center for Quality of Health Care, Uganda, presented a work plan for eastern, central and southern African countries to improve access to nutritional care for people living with AIDS. These decisions were taken during the 28^th Session at an informal meeting to share materials on nutritional care:

• Food composition tables for the region are very old and need to be updated. Also, nutrient composition of traditional foods should be incorporated. FAO agreed to do this in time for the IUNS Congress in August, 2001.
• Countries are asking for assistance on how to develop guidelines for the nutritional care of people living with AIDS. FAO, WHO and the Food and Nutrition Technical Assistance Project (FANTA) will work together to develop manuals to train country teams.
• Assistance is also needed on how to adapt existing guidelines from other countries. UNICEF and the Regional Center for Quality of Health Care will work together on this.

15.  Mr. Mats Karlsson, Vice President for External Relations, the World Bank, emphasized the extreme importance of nutrition and food security to eradicate poverty. He commended the SCN for its innovation and commitment towards fostering dialogue amongst UN agencies, bilaterals and civil society. He noted the very strong African presence at the 28^th Session. He stated that the World Bank is committed to the Millenium Declaration, which makes it possible for all partners to work within a common framework, in particular towards a set of poverty goals. The International Development Targets are central to the Bank’s work. Mr. Karlsson said that Bank involvement in HIV/AIDS programming for Africa had been "fast-tracked" following Mr. Wolfensohn’s visit with 22 heads of African states. He urged the SCN to take up the challenge set out by Dr. Piot to work with the HIV/AIDS community in moving the nutrition agenda forward for Africa.

E. Working Group Reports

E.1 Nutrition of school age children Chair: Don Bundy, World Bank. Rapporteurs: Joy del Rosso, Save the Children USA; Lesley Drake, Partnership for Child Development

16.  An extraordinary meeting of the Working Group on Nutrition of School-age Children was held during the 28^th Session for two reasons. Firstly, there is an enhanced focus on school feeding and food-for-education as a result of recent new initiatives. Secondly, there is increasing UN activity on school health and nutrition as a result of the launch of Focusing Resources on Effective School Health (FRESH) Partnership at the World Education Forum in Dakar, Senegal. Country programmes using the FRESH framework and supported by all four original partners are now being rolled out in at least 11 countries in Africa. The Working Group reported follow-up to recommendations of last year in four areas: preparation of a technical review of the health and nutritional status of school age children globally, compilation of good practices for school-based health and nutrition services, increased access to knowledge in the area of school nutrition and health via the internet, and harmonization of partner agencies’ approaches to nutrition in the education sector, with special regard to the place of food in the FRESH framework.

The Working Group recommended that:

• WFP should coordinate an expert technical group to address outstanding challenges in creating effective school nutrition and health programmes. The expert group should comprise representatives from the appropriate agencies, participating countries, NGOs and technical institutions. Challenges to be addressed should include the economic and social benefits of school feeding, methods to identify high risk groups for feeding, exit strategies for food aid assisted school feeding, community based approaches, and monitoring and evaluation.
• WFP and the World Bank should work together, and with other partners, at country level in Africa where there are opportunities to explore the joint roles of WFP and Bank projects for mothers and infants (IMCI and reproductive health), underfives (early childhood development projects) and school age children (FRESH and school feeding projects).
• There should be greater emphasis on nutrition strategies that improve education, health and nutritional outcomes. WFP, the Bank, WHO and CIDA should explore how FRESH school-based services, especially deworming, can be synergistically linked with school feeding. These workshops will include participation from the education and health sectors.

E.2 Capacity development in food and nutrition (formerly capacity strengthening in food and nutrition) Co-Chairs: Cutberto Garza, UNU and Barbara Underwood, IUNS. Rapporteur: Fre Pepping, UNU

17.  Progress over the one year existence of this Working Group was reviewed. Based on recommendations made last year, focus was placed on capacity development efforts in Africa. Africa faces many challenges with 47.3 million preschool children stunted. More than 50% of preschool deaths are related to malnutrition. The nutrition situation in many parts of Africa is deteriorating due to economic downturn, HIV/AIDS, reduced public sector spending and limited capacity to plan and implement effective programmes. Workshops were held in each of southern, eastern and western-central Africa over the past year. UNU and IUNS were facilitators. The workshops addressed the development of learning cooperatives, mechanisms for effective intra- and inter-regional cooperation, and training needs. Action plans were prepared through intensive consultation, and were driven by African professionals. The goals of these action plans are to inspire African leadership in nutrition to meet the challenges of combating malnutrition in a sustainable manner, drive national level nutrition agendas, and mobilize support for the sub-regional action plans and cooperation of stakeholders.

18.  The Working Group recommended that:

• Implementation of the sub-regional action plans should continue. Other efforts which are consistent with the overall vision of the African Capacity Development Initiative, such as the Information Technology project, West African Health Organization Initiative, and the UNICEF/IFPRI proposed project, can be integrated into these action plans.
• SCN member organizations should use this Working Group as a means to combine efforts and maximize potential impact.
• The new Dr. Abraham Horwitz Fellowship Programme, initially proposed for Latin America, should be expanded to other regions after evaluation of the response generated and the funding available.

E.3 Micronutrients Co-Chairs: Ian Darnton—Hill, HKI; Bruno de Benoist, WHO and Werner Schultink, UNICEF. Rapporteurs: Arjan de Wagt, UNICEF, Shawn Baker, HKI

19.  This Working Group reviewed progress in four areas: iodine deficiency disorders, iron deficiency anemia, vitamin A deficiency, and multiple micronutrient deficiencies. There has been major progress in controlling IDD, predominantly through iodization of salt. The main challenges for the future include providing special support to countries affected by IDD but which have no control programme in place, and ensuring sustainability of salt iodization. These two issues can be addressed through mobilizing the international community, developing partnerships of various stake holders including the salt producers, reinforcing the capacity of labs at all levels, and undertaking independent assessments of progress made by countries.

20.  Regarding iron, the Working Group noted that there have been a number of important activities in the area of control of anemia and iron deficiency over the past year. However, iron is still the ‘orphan’ among the three main micronutrients. The need to ensure a strong goal for reduction of anemia in the outcome document of the UN General Assembly Special Session on Children (Sept 19-21, 2001) was discussed. A small group met after the Working Group meeting and formulated new wording to be conveyed to Dr. Kul Gautum, Deputy Executive Director, UNICEF (see para 45).

21.  Advances and evolution in thinking in the vitamin A area were reviewed by the Working Group. There is growing consensus to adopt a new terminology, vitamin A deficiency disorders or VADD, to replace both "clinical deficiency" and "sub-clinical deficiency". The rationale for this change will be published by the International Vitamin A Consultative Group later this year. Estimates of people with VADD are not yet available. The new terminology implies a new approach to deriving estimates, especially for women and adolescents. On the programme side, much progress has been made towards controlling vitamin A deficiency via national immunization days and child health weeks. However, the need to pursue a package of approaches including supplementation, food fortification and dietary diversification was emphasized.

22.  Food fortification was discussed and presentations made by the Micronutrient Initiative and FAO. It was noted that food fortification should be part of a broad development strategy, i.e., part of an overall health and nutrition strategy which includes dietary improvement, supplementation and public health measures. However, some participants expressed concern about an emerging global alliance for fortification. There may be value in taking a cautious approach because of issues related to market protection and liberalization of food trade. Some felt that too little attention is paid to food composition databases and that knowledge of indigenous foods is quite poor. Several noted that fortification efforts also need to emphasize technologies for small-scale fortification to target those who lack access to centrally processed foods.

23. The following areas were identified by the Working Group as requiring priority attention in the coming year:

• The Working Group should continue to support a series of, by now, well-publicized recommendations developed over recent years and aimed at sustainable IDD elimination. These include increased support to small scale salt producers and waiving excise duties on potassium iodate.
• Integrated programme packages should be developed to address all causes of anemia, including iron deficiency
• As national immunization days are phased out, there is a need to develop other strategies to maintain high coverage levels of vitamin A supplementation
• Efforts to document the extent of VADD in adolescent girls and women need to be accelerated, and programmes developed to address the needs of these two groups.
• Community-based approaches integrating multiple interventions and various target groups should be developed and supported.
• At its next meeting the Working Group should focus on integrated approaches, including food-based approaches, rather than interventions involving single micronutrients.

E.4 Nutrition, ethics and human rights Chair: Urban Jonsson, UNICEF. Rapporteurs: Wenche Barth Eide, WANAHR; Uwe Kracht, WANAHR

24.  This Working Group convened its seventh meeting during the 28^th Session. The chair recalled that human rights thinking was new to the nutrition community in the early 90s. Over the years, this Working Group has been effective in promoting a human rights approach to food and nutrition programming. Follow-up to recommendations made last year was discussed. This included background work on the preparation of a manual on the interpretation and use of General Comment number 12 on the right to adequate food, and a new focus on benchmarks and indicators for food and nutrition rights programming and monitoring. Three international meetings have been held over the past year where the content and use of General Comment number 12 was discussed, e-groups have been established for the exchange of views and knowledge, and several countries have announced interest in organizing national seminars on the General Comment. A task force meeting was held, prior to the 28^th session, to review a draft paper on benchmarks and indicators. The task force felt that the draft paper would serve as a good basis for future work in this area.

25.  The Working Group recommended that:

• Work on benchmarks and indicators for monitoring the realization of the rights to food, health and care to prevent hunger and promote good nutrition, should be intensified. The draft paper should be revised and discussed again next year. This revision can be accomplished via e-groups, an inter-sessional meeting at the time of the World Food Summit Five Years Later in November 2001, and specialist consultancies as needed.
• SCN member agencies should engage actively in work on benchmarks and indicators, notably FAO, UNICEF, WHO, WFP, UNHCR, the Bank and others. In addition, interested bilaterals and NGOs should join in this work and be open to financially supporting inter-sessional activities as needed. The SCN has a unique opportunity to combine the experience and expertise of member agencies in an integrated response to the continuing call from the human rights bodies of the UN, for indicators to improve national and international monitoring of economic, social and cultural rights in countries that are States Parties to the international human rights conventions.
• The Working Group should review the status of other rights-related work of relevance to nutrition within the agencies. This review will help to place the work of single agencies in the wider context of UN Reform as regards the revitalisation of human rights as a fundamental principle of all work of the UN system.

E.5 Breastfeeding and complementary feeding Co-Chairs: Miriam Labbok, USAID; Randa Saadeh, WHO. Rapporteurs: David Clark, UNICEF; Ted Greiner, Sida

26.  The agenda of this Working Group was designed to include reporting on agency and other activities in follow-up to issues identified last year, exchange of information on scientific, programme and policy advances, and provision of advice to the SCN on these matters, as well as identification of critical issues for further discussion as part of one to two year work plan. WHO provided a progress report on the Infant and Young Child Feeding Strategy, and FAO presented a paper on infant and young child feeding emphasizing child feeding and household food security. UNICEF provided an update on the Code and implications of the Convention of the Rights of the Child (CRC). It was noted that progress on the implementation of the CRC is fundamental to infant and young child health and nutrition. WHO presented the results of a systematic review of published literature related to the optimal duration of exclusive breastfeeding. This work concluded that there is a scientific rationale for policy recommending exclusive breastfeeding "for six months". Work undertaken by Wellstart underlined that infants may not be physically ready for foods other than breast milk prior to 6-7 months. A study on breastfeeding in four countries in Africa showed that there has been a reduction in support for breastfeeding as a result of fears and misinterpretation of the UNAIDS/WHO/UNICEF guidance related to HIV and breastfeeding.

27.  The Working Group recommended that

• The WHO should report back next year on progress towards the Global Strategy on Infant and Young Child Feeding, highlighting changes created through the planned open process and including input from bilaterals and interested UN and other agencies
• Implementation of the Code (especially new efforts in training and capacity in Code awareness), BFHI, ILO Maternity Protection Convention and aspects of the Innocenti Declaration should continue to be a focus of the reporting of the Working Group.
• The SCN Chair should write to the Director General of the WHO congratulating her on the process that led to improved recommendations on the duration of exclusive breastfeeding. The letter should also stress the importance of the Innocenti wording on the duration of breasfeeding "for at least two years".
• The SCN should call upon all UN agencies to actively promote exclusive breastfeeding in all populations, and to report on the balance of attention given to this as compared to attention given to prevention of HIV transmission through breastfeeding.
• Preliminary data on morbidity and mortality outcomes among exclusively breastfed, mixed fed and artificially fed infants and their mothers in the UN-sponsored pilot projects for the prevention of MTCT of HIV that provide infant formula should be presented as soon as possible. If outcomes among artificially fed infants are not better than among breastfed infants, this information should be disseminated and the feeding intervention should not be continued as part of the projects.

• Breastfeeding and breast milk should be taken into account in all work on household food security and in assessing women’s economic contribution.
• Complementary foods and feeding, related indicators, and training needs should be dealt with in depth by the Working Group next year, with a focus on both appropriate and adequate food and feeding behaviours.
• The SCN should request that all UN agencies report on support for, and progress in, community activities, programmes and advocacy for optimal breastfeeding behaviours. This would include appropriate nutritional, social and workplace support for all women of childbearing age, pregnant and lactating women.
• Early in the process of preparations for the 29^th Session, the Secretariat should remind Working Groups to interact with each other to ensure that issues of mutual concern are considered in all relevant meetings. The SCN Secretariat should also expedite the exchange of information amongst SCN members on meetings and strategy development on issues that might impact on breastfeeding.

E.6 Nutrition in Emergencies Chair: Anna Taylor, SCF UK; Vice Chair: Sultana Khanum, WHO. Rapporteurs: Frances Mason AAF, UK; Annalies Borrel, USA

28.  Adult malnutrition was first discussed by this Working Group in April 1999 and taken up last year in more depth. Subsequently, a supplement of the Refugee Nutrition Information System report was published summarizing knowledge on the assessment of adult and adolescent malnutrition in emergencies. This led to a one-day special meeting on adult malnutrition held during the SCN 28^th Session, the aim of which was to reach a common understanding of the recommendations on the assessment of malnutrition in adults and to identify practical steps to improve practice. Interim recommendations for operational agencies cover the following issues:

• when to consider assessment of adult malnutrition

• pre-requisites for surveying adults and the importance of a contextual analysis prior to carrying out an adult anthropometric survey

• adapting standard survey methods to the needs of the adult populations

• use of the Cormic-adjusted BMI and MUAC and data collection on functional outcomes

• the use of cut off points

• admission and discharge criteria for selective feeding programmes for adults

• research needs

29.  The Working Group also reported back to the SCN on priority issues identified last year. A document entitled Infant and young child feeding in emergencies has been prepared, filling a need for practical guidance that can be used by both policy-makers and relief staff. The publication has been supported so far by 12 NGOs and two UN agencies; additional support is sought. Training modules for infant feeding in emergencies have also been prepared. The purpose of these modules is to prepare emergency relief staff to support appropriate infant feeding and to describe the process of applying operational guidance. Again, this work is the result of collaboration amongst a number of NGOs and several UN agencies. The Working Group had expressed serious concerns last year about the WHO’s pricing policy regarding a manual entitled Management of severe malnutrition. The manual is now available for downloading from the WHO website. The need to prioritize gaps in knowledge, skills and practice in emergency nutrition across agencies has led to the design of a tool (a matrix) to be applied by each agency involved in relief work. This process will help to identify areas in which new work needs to be initiated.

30.  The Working Group will take on this new work in the coming year:

• Following a proposal to implement therapeutic feeding through a community based programme, interested individuals should contact the Working Group to collaborate in this initiative.
• A task force has been created to spearhead a proposal to prepare a technical review of the scientific basis and origins of current field practice, entitled The meaning and measurement of acute malnutrition in emergencies. The proposal will be reviewed for breadth, scope and content by the Working Group. The Working Group requested that potential authors contact the chair.
• To consolidate and share training tools and ensure these are accessible by non-technical, management and technical staff alike, a comprehensive strategy for training initiatives in emergency nutrition will be formulated

E.7 Household food security Chair: Kraisid Tontisirin, FAO. Rapporteurs: Ken Simler, IFPRI; Shakuntala Thilsted, Denmark and Brian Thompson, FAO

31.  Dr. Tontisirin outlined the objectives of this meeting which were to take stock of what had been accomplished in the area of household food security since the last meeting, and to build consensus around a workplan to implement community approaches for achieving household food security and reducing malnutrition. The decline in the number of food insecure worldwide has been only 8 m/yr, while the target is 20 m/yr. The challenge is to find new strategies to accelerate the pace of improvement. FAO places emphasis on community-based approaches (a concept paper adapted from the CCPOQ endorsed document on household food security is available from FAO) that provide a viable and practical means to rapidly reduce malnutrition. These approaches involve mobilizing communities to take advantage of existing services. Factors contributing to malnutrition in Kenya were discussed. One problem is the decline in consumption of traditional foods. Support for women's groups in small scale food processing, to increase consumption as well as income, needs to be expanded

32.  The Working Group recommended that

• Partners interested in working within the broad framework of community-based strategies for household food security should be identified. Further, a Task Force should be created to guide work on this approach.

• A plan of action to incorporate community-based approaches into the UN Development Assistance Framework, the Common Country Assessment, and the ACC Task Force on Rural Development and Food Security should be drawn up.

• Countries, partnerships and alliances for assisting in the implementation of community approaches should be identified. A consensus meeting on community-based nutrition programmes should be considered for later this year, and possibly an ACC/SCN symposium on this topic in the future.

• Operational research on best practices at community level should be encouraged. A stronger case should be made for increasing investments in this approach to encourage the mobilization of resources.

• The use of food aid for improving household food security should be explored.

E.8 Prevention of foetal and infant malnutrition Chair: Jelka Zupan, WHO. Rapporteurs: Anna Ferro-Luzzi, Italy and Kathy Kurz, International Center for Research on Women

Dr. Zupan presented information on the new WHO global estimates of low birth weight, noting that data collection methods are improving. Sources are mostly surveys and hospital data. LBW is still prevalent in developing countries, the highest rates are seen in Asia. The new estimates show a slight improvement in the prevalence of LBW in some regions, although this could be because of better data. UNICEF supports LBW reduction programmes in eleven countries, offering an integrated package which includes provision of multi-micronutrient supplements. Core indicators are weight gain in pregnancy, birth weight, iron status and compliance. Informed consent is part of the protocol. Results will be available in about three years. A targeted programme aimed at reducing LBW amongst refugees in Tanzania was presented. Interventions addressed malaria and anemia and the quality of antenatal care; food rations were distributed. LBW was reduced from 33 to 14% in six months. The WHO antenatal care trial was presented. This trial (carried out in Argentina, Cuba, Thailand and Saudi Arabia) shows that a decrease in the number of antenatal visits does not adversely affect pregnancy outcomes. Working Group participants queried whether these results would pertain to regions with high rates of LBW. The merits of the life cycle approach to LBW were discussed in the context of work funded by the March of Dimes in the USA. The World Bank described a new initiative aimed at creating a global learning network. New evidence for the fetal origins of disease arising from a recent meeting in India was discussed.

F. Parallel working meeting of the UN Agencies

33.  This meeting was chaired by Namanga Ngongi and Milla McLachlan. Approximately 40 people attended from 14 UN agencies, including ECA and OCHA for the first time. The SCN Chair briefed the UN agencies on the status of ACC reform and how it might affect the work of the SCN. The ACC, this week in Nairobi, endorsed the report of the High Level Committee on Programmes which met in Vienna in February. The special tripartite nature of the SCN was recognized, as well the SCN's work in raising awareness of nutrition and harmonizing nutrition policy and approaches across the UN system and partners. While ACC has decided to move away from the concept of permanent subsidiary machinery, it also recognized the need for continued interagency coordination in many of the areas where it is presently undertaken. In order to allow sufficient time for a review of the subsidiary machinery, ACC decided that the current year would be treated as a transitional period. During this time the Committees would be invited to engage in a reflection on their role and function and provide their view on the matter to the High Level Committee on Programmes to enable the latter to complete the review process requested by ACC. If necessary, this period could be adjusted to accommodate meeting schedules. In the future, the SCN or its successor arrangement may still wish to bring matters to the attention of the ACC by exception, and to use various advocacy and communication channels as appropriate. Our Strategic Plan will continue to guide our work. A suggested new name for the SCN is the UN Forum on Nutrition.

34.  UN General Assembly Special Session on Children---Although nutrition did not figure strongly in earlier drafts of the outcome document (not a technical but a political document), the nutrition content had been significantly strengthened as a result of the Preparatory Committee meeting in February. FAO pointed out however that there was no reference to food and agriculture in the document, adding that a world fit for children is one where every child has access to safe and nutritious food. The current March 12 draft has gone to countries for review and will be discussed in mid June in New York. It was decided that the SCN should prepare a collective comment on the nutrition content, and convey this to Dr. Gautam along with improved wording for paragraph 30 on micronutrient deficiencies. There was a feeling though that too much emphasis is placed on nutrition actions in the post-natal period, rather than on reducing maternal and foetal malnutrition and low birthweight. This point could be included in the letter. Regarding the UN General Assembly on HIV/AIDS, June 25-27, the SCN will convey a message to this event, based on the outcomes of the Symposium on Nutrition and HIV/AIDS.

35.  Implementation of the Strategic Plan---The UN agencies undertook to report on their efforts to implement the SCN Strategic Plan, against the three main strategic actions: promotion of harmonized policies and programmes for greater impact, review of the UN system response to malnutrition and advocacy and mobilization. Several themes emerged. Most agencies need to take more time to internalise the Strategic Plan and generate interest, buy-in and support from their colleagues. The nutrition community needs to be more involved in the common country assessment processes. There are also opportunities to incorporate nutrition into the UNDAF process, Poverty Reduction Strategy processes and the work of the ACC Network on Rural Development. The UNDAF is not used efficiently for nutrition. Sector-wide approaches (SWAPS) tend to marginalize nutrition when health is discussed, hence there is uncertainty as to what SWAPS can deliver for nutrition.

36.  Budget and Financing---A comprehensive document covering the budget and financing of the Secretariat for 2000/01 and 2002/03 was presented by the Technical Secretary. The SCN had approved a core budget of $861,000 for 2000/01 at the 26^th Session in Geneva in 1999. Projected expenditures (as of March 14, 2001) to the end of this biennium total $780,000, against income of $714,400. The deficit is partly due to UNDP having suspended its contributions totally for this biennium. The SCN Chair will write to agencies to request increased contributions for this calendar year. For the next biennium, the proposed core budget is set at $860,000. Increases in the contributions from some agencies are proposed; these include UNHCR, UNFPA, IFAD, FAO, WFP and IFPRI. The programme budget, which covers costs of the Secretariat’s publications programme, is implemented subject to funds raised by the Secretariat. For 2002/03 these costs are estimated to total up to $920,000. The UN agencies approved unanimously the core and programme budget, as presented, for the period 2002/03.

37.  The 5th Report on the World Nutrition Situation---The UN agencies stressed the importance of knowing the audience. Good information is available from the Secretariat’s mailing lists as to current out-reach, but how are the reports used? Are we doing all that we can to maximize usage by communities outside the nutrition community? Ideally the report should speak to several audiences: the nutrition field, the policy makers and the public at large. It may be difficult to reach all three with the same document, so different presentations should be considered. The 5^th Report must go beyond providing an update of regional and global trends. Key messages must be "front and center" to move the nutrition agenda forward.

38.  On other matters, the Secretariat reported that Professor MS Swaminathan has agreed to serve as a Distinguished Nutrition Advocate. Additional names of possible Distinguished Nutrition Advocates for Africa are sought. The Secretariat reported that the German Federal Ministry for Economic Cooperation and Development has offered to host the 29^th Session in Germany, in March 2002. This was greeted with enthusiasm.

G. Parallel working meeting of Bilateral Partners

39.  This meeting was chaired by Arne Oshaug of Norway. The ACC/SCN bilateral parallel working session convened as scheduled during the week, including an additional evening meeting. The bilateral group is expanding: representatives from ministries in the Gambia, Kenya, Mali and South Africa took part. This reflects earlier discussions on the definition of what constitutes a "bilateral". In the spirit of the African Nutrition Capacity Development Initiative it was decided to shift from bilateral donors to bilateral partners. The bilateral partners emphasized that the Secretariat should invite both developed countries and developing governments to attend annual sessions through their normal communications channels, including the SCN News and the website. The following reflects the discussions and recommendations of the bilateral partners to the SCN:

• Within the multilateral system there are many important upcoming meetings of relevance to nutrition. This year there are two UN General Assembly Special Sessions, one on HIV/AIDS in June and another in September on children. In November FAO will host the World Food Summit Five Years Later conference. In order to ensure that nutrition is adequately reflected in the documents of these and similar meetings it is important to give input early in the process. To assist in this, rapid communication amongst SCN Working Groups, bilateral partners and NGO and UN leadership is essential.
• Nutrition issues are not often included in communications from the Secretary General and Directors General of the various UN agencies. This is a signal that nutrition is not a prioritized area, despite the goals and objectives stated in the documents of the World Summit for Children, the International Conference on Nutrition, the World Food Summit, the Millennium Summit as well as the International Development Targets to be reached by 2015. Opportunities to influence national policy considerations in many countries are consequently missed. The SCN Chair should work proactively to bring nutrition-relevant issues to the attention of top management in the UN system. To ensure consistency of message, and mutual support, the chairs of the bilateral partners and the NGOs/civil society cluster of the SCN should be involved in this work.

• The SCN Chair should also raise the issue of nutrition expertise in the UN agencies. There is a need to develop and maintain sufficient and strong staffing in nutrition and food security, especially breastfeeding, young child feeding and maternal nutrition. Since this is suggested in order to properly reflect and address the implementation of policies and programmes, these positions should be supported from each agency’s core funding resources.
• Nutrition is not adequately reflected in WHO’s global health initiatives, such as Stop TB, Roll Back Malaria, Immunization and the Massive Effort Against Diseases that Cause or Perpetuate Poverty. Nor is nutrition mentioned by the Director General of WHO when this work is presented publicly. This sends a negative message about the importance of nutrition to these initiatives, a concern widely shared within the international nutrition community. The SCN Chair should bring this concern to the attention of the Director General of WHO in writing.
• The bilateral partners follow ACC reform with keen interest. The SCN is a unique forum, a stimulus for technical exchange and coordination within the UN family. The bilateral partners hope for and welcome a strengthened new SCN, as a result of ACC reform. The SCN Chair should communicate three main points to the UN leadership. Firstly, the bilateral partners highly appreciate the work of the SCN, in particular its role and accomplishments towards coordination of actions and information sharing. Secondly, bilateral donor countries were present initially in SCN annual sessions as observers – this relationship has matured and gradually developed into a tri-partite relationship of great value. Thirdly, the new SCN should continue formally under the auspices of the UN. UN agencies should continue to support its coordination role.

• This year’s Symposium on Nutrition and HIV/AIDS was timely; it showed the seriousness of the HIV/AIDS situation, and the essential role of food and nutrition in mitigating negative impacts. Presentations from professionals of Kenya, Uganda and Zambia illustrated a keen interest in building bridges between the nutrition and HIV/AIDS communities, while the Minister of Health and Social Welfare of Swaziland spoke of the need for political support at the highest levels in society. NGOs, such as The AIDS Support Organization (TASO) in Uganda, and young professionals like this year’s Dr. Abraham Horwitz Memorial Lecturer, show that there is a promising basis for local initiatives to tackle problems and possibly reverse the trend, when political and financial support are available.
• The bilateral partners welcome the African Nutrition Capacity Development Initiative. Capacity development is key to the development of African nations. The SCN is encouraged to continue providing a forum for the presentation and discussion of this and other similar initiatives.

• Reports on the World Nutrition Situation are valued highly. Read by a wide audience, they constitute important documents used for advocacy, in policy discussion and in higher nutrition training. These reports are free of charge to readers in developing countries. This is especially important where access to scientific and other important nutrition relevant information is problematic and costly. There is a need to revisit the frequency, content and format. Publication every four years may be adequate. Also, the reports could introduce a thematic angle along with the usual comprehensive technical coverage with statistics on trends and indicators in an annex rather than the main text. Country or regional updates could also be considered. Issues related to food availability and diet have more of less disappeared from these reports, and need to be better covered in the future.
• There are several encouraging features of the Secretariat’s budget and financing. There is a proposed increase in contributions from several UN agencies to the core budget proposed for 2002-2003. Specifically increases are sought from UNHCR, UNFPA, IFAD, FAO, WFP and IFPRI. UNDP will be approached to re-establish its funding to the SCN. If these materialize, the Secretariat will be on a stronger footing. The bilateral partners anticipate that the new SCN will have renewed financial strength and commitment from the UN member organizations.

• Over the past year, the bilateral partners have undertaken to prepare 12 nutrition advocacy papers of about four pages each, now in the final stages of peer review. The final publication will be ready one year from now, in a format readily useful for policy advocacy. This will be a contribution free of charge to the SCN.
• The bilateral partners welcome Germany’s offer to host the 29^th session in Germany, and agreed with the selection of symposium topic: Nutrition in the context of crisis and conflict. A second candidate topic was discussed, and received some support, i.e., food and dietary challenges as a consequence of globalization.

H. Parallel working meeting of NGOs/Civil society

41.  Regarding representation on the SCN’s Steering Committee, three co-chairs have rotated in the one position on the Steering Committee allocated for the NGOs/civil society. This is an attempt to represent the diversity of the agencies and organizations in this cluster. This has proved effective over the past couple of years and should be continued. Ian Darnton-Hill indicated he could no longer serve as co-chair. Barbara Underwood, by popular acclaim, will serve another year in her individual capacity for purposes of continuity, as will Ruth Oniang’o. A maximum term of three years for co-chairs was suggested. Dr. Flavio Valente, of the Global Forum on Sustainable Food and Nutritional Security, and based in Brazil, was subsequently confirmed as the third representative.

42.  Recommendations fell into three categories:

• Regarding roles within the SCN, the NGOs/civil society should have equal and full partnership within the SCN. On the organization of meetings, there should be a second parallel meeting during the week of the annual session. Working Groups should work throughout the year. The SCN should be more pro-active in seeking out civil society involvement, in particular the views of the NGOs/civil society should be taken into account when determining new topics for working groups, so that emerging field priorities are addressed. The SCN should continue to hold annual sessions in countries where adequate nutrition is a problem, but where visitors’ visas are not a problem.
• On representation, there should be two permanent seats on the Steering Committee for NGOs/civil society. National, non-donor governments should have separate representation. Local or national NGOs should be better represented, perhaps via existing consortia or umbrella groups. To ensure representation of all types of NGOs, as well as regional representation, a pyramid approach (sub-region to region to SCN Steering Committee) to information sharing could be tried. Regular feedback on monthly Steering Committee conference calls should be provided. The Secretariat should send a letter of commendation to the representatives’ home agency expressing the SCN’s gratitude for time spent and contributions made.

• Regarding communications, there should be an openness and awareness by the UN agencies and by civil society to each others’ strengths and potential. The NGOs/civil society should do more networking around the themes of the working groups. This could be done via NGOnut as a chat-room or clearing house, or PFEDA based at the University of Lille. NGO/civil society contacts and working group contacts should be published regularly in the SCN News. The SCN should be pro-active in publicizing SCN annual sessions and explaining that the symposia and working group meetings are open to the entire professional nutrition community.

I. Informal report from the "non-Steering Committee" UN Agencies

J. Summary of decisions taken during the final plenary

44.  In the coming year the SCN will assess different organizational and reporting structures, taking into account decisions of the ACC and the High Level Committee on Programmes. The SCN will adopt a new structure at its 29^th Session, just prior to the spring session of the ACC.

45.  The 5^th Report on the World Nutrition Situation will identify elements in the development process that serve as both obstacles and opportunities to improved nutrition outcomes. The report may take the form of several strong analytical pieces, backed up by illustrative panels and boxes. The report will also include, as annexes, updates on trends in nutrition indicators. Over the coming year background papers (up to four) will be prepared, to serve as the basis for a workshop just prior to the 29^th Session. The Report will be launched at the 30^th Session and will provide the theme for the symposium that year. A task force will be constituted by the Steering Committee. Volunteers will be asked to identify in writing what they can bring to the process.

46.  A Statement on Nutrition and HIV/AIDS (annex 2) was approved for wide dissemination. The statement will be transmitted officially to Dr. Peter Piot (UNAIDS) in time for the HIV/AIDS Summit in Abuja, April 23 - 25, 2001. It will also be disseminated via the UN General Assembly Special Session on HIV/AIDS, put onto the SCN website and published in SCN News.

47.  The SCN decided to provide to Dr Kul Gautam (UNICEF) new wording for paragraph 30 of the draft outcome document for the UN General Assembly Special Session for Children. The wording, which was agreed upon during a teleconference call on April 11, is: "Through public/private collaboration, ensure progress toward substantial reduction in anemia, including iron deficiency, in women and children, and the elimination of vitamin A deficiency disorders, by 2010; and achieve sustained elimination of iodine deficiency disorders by 2005."

48.  The SCN accepted with warm appreciation an invitation from the German Federal Ministry for Economic Cooperation and Development to hold the 29^th Session in Berlin, Germany, March 11 - 15, 2002.

K. Closure of the 28^th Session

Annex 1  List of Participants

Chair: Namanga Ngongi

Technical Secretary: Sonya Rabeneck

Symposium Speakers:

• Phetsile K Dlamini, Minister for Health and Social Welfare, Swaziland
• Sam Ongeri, Minister for Public Health, Kenya
• Peter Piot, Executive Director, UNAIDS
• Stuart Gillespie, International Food Policy Research Institute, Washington DC
• Phillip Mwalari, National AIDS Control Council, Kenya
• Elizabeth Marum, Centers for Disease Control and Prevention, Kenya
• Sophia Mukasa Monico, Director, The AIDS Support Organisation, Uganda
• Ruth Nduati, Department of Paediatrics, Kenyatta National Hospital, Kenya
• Oliver Saasa, Former Director, Institute of Economic and Social Research, Zambia

Abraham Horwitz Lecturer: Lucy Thairu, Cornell University

Annex 2.  Statement

Statement by the ACC/SCN at its 28th Session 6 April 2001, Nairobi, Kenya NUTRITION AND HIV/AIDS

We, the ACC/SCN, recognize the devastating impact the HIV/AIDS epidemic is having on development, particularly in Africa. We further recognize that the epidemic is increasingly driven by factors that also create malnutrition - in particular, poverty, conflict and inequality.

HIV/AIDS and malnutrition often operate in tandem. Poor nutrition increases the risk and progression of disease. In turn, disease exacerbates malnutrition.

HIV/AIDS can be both a cause and a consequence of food insecurity. HIV/AIDS leads to reduced agricultural production, reduced income, increased medical expenses, thus causing reduced capacity to respond to the crisis. Food insecurity may lead to increased high-risk behaviors, for example, labour migration or engaging in transactional sex that increases the likelihood of infection.

Food and nutrition play an important role in prevention, care and mitigation activities in HIV/AIDS-impacted communities.

We, the ACC/SCN, recognize that:

1. the HIV/AIDS epidemic is not just a health issue but is reversing hard won development gains
2. a community-driven multi sectoral approach must be supported to address food and nutritional needs of all vulnerable populations
3. access to food is one of the main problems of HIV-impacted communities
4. nutrition and food security is a logical entry point for assisting affected communities
5. over time AIDS prolongs and deepens poverty, strips all assets and depletes human and social capital
6. HIV/AIDS attacks the most productive segments of the population, leaving behind children and the elderly
7. stigma undermines social capital and limits health-seeking behavior, including prevention of mother-to-child-transmission
8. women who are key actors in household food security and caregiving are particularly vulnerable to the effects of disease and its impacts
9. HIV/AIDS impacts agriculture through labor shortage, knowledge loss and a loss of formal and informal institutional support and capacity
10. breastfeeding remains of fundamental importance to child survival and development, whilst there is evidence of limited transmission of HIV through breastfeeding
11. nutrition is a core component of the essential HIV/AIDS care package promoted by UNAIDS

We, the ACC/SCN, commit ourselves to collaborate with the international community and Heads of State in particular in this effort by:

1. integrating food security and nutrition considerations into HIV/AIDS programming
2. concurrently addressing the HIV/AIDS crisis in our food and nutrition work, using existing nutrition networks and programs
3. identifying and implementing optimal approaches to food-assisted activities as part of larger care and mitigation programs, as well as food production and processing activities
4. taking steps to reduce stigma and protect humans rights of people affected by HIV/AIDS, including the right to food
5. elaborating and fully implementing nutrition care and counseling as part of the essential HIV/AIDS care package
6. operationalizing pragmatically the UNAIDS/UNICEF/WHO policy statement on HIV and Infant Feeding while protecting, promoting and supporting optimal infant feeding for child survival among all women.