Effective policies and programmes
National and household food security
Refugees and displaced people
Policies aimed at improving growth and development of infants
Policies and programmes directed at young children
Great strides have been made since the 1950s in dealing with problems of poverty, hunger and malnutrition. Globally, food production has increased, the rates of preschool malnutrition have fallen and infant and child mortality have decreased in most parts of the world. Despite these impressive gains, poverty, hunger and malnutrition continue to be problems of staggering proportions.
Chapter 1 in this Report elucidated the importance of stunting as a good biomarker for the overall quality of life in a given country. Data in this Report indicate that the number of stunted preschoolers worldwide has increased during the period 1980 to 1995; more alarming is that fact that the numbers in Sub-Saharan Africa have increased by 62% during this time period. This chapter analyzes the underlying causes of malnutrition and identifies effective strategies for improving nutrition as the world enters the twenty-first century.
There continues to be tension among policy-makers, on the one hand, in the use of broad-based economic policies as a means of eliminating malnutrition, and on the other, the use of more targeted interventions. Malnutrition is complex; the reality is that typically a combination of different types of policies and programmes are needed to effectively alleviate poverty and malnutrition. Sustaining strategies for reducing and preventing malnutrition almost always involves a combination of macro-economic policies and more targeted interventions. Even in many industrialized countries where average income is adequate, pockets of the population - mainly the poor - are at risk of food insecurity and poor nutritional status. Chapter 1 identified the proximal causes of malnutrition at the individual level as related to food, health and care. While hunger and malnutrition manifest themselves at the level of the individual, the causes generally involve a combination of individual, household, community, national and international factors. It is important to understand these linkages as a way to identify the most effective strategies for reducing malnutrition in a given socio-cultural environment.
Food intake and nutritional status are inextricably linked. The impressive gains in global and national food supplies over the past 30 years were achieved because of effective investments in agricultural research. However, although food security has improved globally, progress has been uneven. Significant proportions of the population are still food insecure in parts of Sub-Saharan Africa and South Asia. The larger numbers of stunted children in these two regions discussed in Chapter 1 reflect, in part, the related problem of hunger and food insecurity in a broad spectrum of the population. In 12 of the 25 African countries reviewed in Chapter 1, stunting has increased. One clear policy implication is that continued investments in agricultural research with, particular emphasis on South Asia and Sub-Saharan Africa is needed.
National food security clearly does not resolve the problem of household level food security, let alone of health, care or poverty more generally. It is access to food - or the household's ability to obtain food - that is critical to ensuring household food security. Policies that increase the access of vulnerable households to food - either through increased income or decreased food prices - will enhance household level food security. Strategies that increase the income of the poor are the most sustainable means of improving household food security. However, it may take quite large increases in income to bridge the food security gap for low-income households. In the short-to-medium term, interventions targeted at low-income households may be needed to buffer vulnerable households against hunger and malnutrition. Parallel action in health is vital, as well as more general actions to deal with poverty, ranging from strategies to support pro-poor growth to education and measures to encourage gender equity.
An increase in household food intake is often assumed to improve the food intake of each of the individual members. However, the effect of increases in household food supplies on an individual's food consumption can be modified by a variety of factors. These include control of income, education of household members, and characteristics of the individual such as gender, age and birth order. In most settings, though, the amount of additional food needed to prevent growth faltering in a preschooler is small in relation to the family's needs. The critical needs are primary health care services such as immunization and the quality of care, including breastfeeding.
Also important are actions to deal with problems of 'hidden hunger' - inadequacies in micronutrient intake. Policies must focus not simply on closing the energy gap but doing so in a way that increases variety and nutrient density of the diet. Diversification of food production must be encouraged both at the national and household level in tandem with increased yields. In many countries this may be a longer-term goal; in the interim, programmes focused on specific target nutrients may need to complement the production-oriented, diet diversification policies. The dramatic expansion of such targeted programmes in recent years provides many examples to build on.
As shown in Chapter 3 of this Report, refugees and displaced populations are the groups most vulnerable to acute food deficits and malnutrition. Civil war and political upheaval have replaced natural disasters as the most common causes of new populations of refugee and displaced person.
A recent report from the Committee on International Nutrition (IOM, 1995) recommended a minimum ration allocation of 2,100 kilocalories per day in order to provide sufficient food energy for reasonable physical activity. WFP and UNHCR have adopted this recommendation as the initial reference value for designing food aid rations in emergencies. However, it is recognized that this initial value should be adjusted as soon as further assessment is possible. This newly defined ration level is well above the caloric level generally available to refugees and displaced people, and it remains to be seen how donors will respond to resulting increased requests.
Much attention is now being focused on the quality of the ration provided to refugees populations, particularly with respect to micronutrient content. A recent step was taken to provide a micronutrient-fortified blended food to all populations totally dependant on food aid. At the same time, questions are being raised on the reliability of the diagnosis of micronutrient malnutrition. Work has begun on developing diagnostic tests which can be used in the field.
All recent projections of food aid needs into the twenty-first century assume that emergencies will continue. Thus far, history has borne out this assumption. There are indications that food aid resources are declining (Shapouri and Missiaen, 1995), and humanitarian agencies are developing targeting methods to more efficiently use the aid available.
Unfortunately, food aid issues and nutrition have been highly visible only in times of famine and natural disasters. Once the acute food shortages have subsided, concern about chronic malnutrition receives less attention. Indeed, it is in many of the long-standing refugee/displaced situations (e.g., Southern Sudan) where the highest rates of wasting are continually seen.
Food insecurity and malnutrition will continue to be chronic problems that affect large proportions of populations in developing countries. The UN agencies can collectively be an effective vehicle for keeping the food insecurity issue for refugees and displaced persons on the policy agenda.
Malnutrition is caused not only by inadequate food availability but also by inadequate access to health services and a poor environment. Nutrition policy must be an integral part of health policy, co-ordinated at both the national and grass-roots level.
Macro-economic policies that result in increased national income are presumed to lead to increased allocation of this income to investments in primary health care and other social services that will improve nutritional status. However, basic services such as access to safe water and investment in health infrastructure do not show a close relationship to national per capita income levels (von Braun, 1991). Thus, we cannot assume that growth in national income will automatically result in improvements in the health and sanitation environment, at least in the short to medium term. Deliberate policies aimed at reducing malnutrition and improving nutritional status need to be implemented, in tandem with policies for increasing national and household income.
There is now a long rich history of investment in nutrition interventions in developing countries. Much has been learned about approaches that are effective in addressing malnutrition. Major improvements will accrue from preventive approaches targeted to subsets of the population. For ease of presentation these will be discussed from a life cycle perspective.
Some of the biggest gains in improving nutritional status will come from gains in improving neonatal outcomes. Birth weight is the single biggest predictor of growth in the early years of life. Interventions that target females as young girls or during the early teenage years prior to first conception have a potentially high payoff for the nutritional status of the newborn. This is of particular importance since early nutrition determines the growth potential of the uterus and hence the capacity for normal uterine hypertrophy when pregnancy occurs. The capacity of uterine/placental vasulature to increase blood supply to the foetus during pregnancy is modulated by the female's early diet.
Interventions that target a woman once she is pregnant often come too late. Preventive strategies will be most effective in improving birth outcomes. While nutrition interventions directed to high-risk pregnant women have been successful in decreasing the rates of low birth weight and prematurity, the optimal time for addressing nutrition concerns is preconception. This is true in terms of glucose control of diabetic women, weight gain in malnourished women, control of chronic disease (including obesity) and of nutritional deficits. Micronutrient deficiencies cause nutritional insult before most women know they are pregnant. Poor folic acid nutrition and neural tube defects are cases in point. Adequate nutrition is critical to foetal organo-genesis in the early stages of pregnancy.
The adolescent female is a stakeholder that has not been a typical target of nutrition intervention. Thus we have fewer models of how to deliver preventive nutrition services to teenage girls. There is a critical need to identify and test interventions that effectively reach female adolescents, including the appropriate role of nutrient-dense dietary supplements.
There are some interventions that fall under the classification of non-nutritional that can potentially be very effective. Education of girls has been shown to have a profound effect on age at marriage and age of first conception. Clearly, innovative ways to extend the education of girls into the teenage years need to be pursued. This would also provide the opportunity to integrate a nutrition communications component into a school-based system.
The caring skills of parents and mothers in particular are known to be an essential component of child development. Parenting and child-rearing skills, including the special needs of infants, need to be taught to females prior to the birth of the first child. Again, if female education is extended routinely into the teenage years, parenting skills can be taught as part of a school-based curriculum. This also provides the opportunity for psychosocial support and discussions of issues such as avoidance of substance abuse.
In areas of the world where formal female education is not the norm, other intervention alternatives need to be tested. The use of female community workers offers the potential to reach young women in a socially acceptable way.
Breastfeeding is the optimal form of infant feeding. Health procedures need to provide an environment that actively encourages breastfeeding. Baby-friendly policies such as rooming in and early, continued contact between mother and newborn need to be actively pursued. This active promotion of breastfeeding needs to continue once the mother returns home. Breastfeeding support systems are a critical element for the successful continuation of breastfeeding. Where this support is not provided by the extended family, women recruited and trained from within the community can fill this void. An increasing problem in many countries is the entry of women into the formal wage-earning sector as a result of urbanization. While there are clear benefits for women from income-generation, continued breastfeeding becomes more of a challenge. Specific policies at the work site can facilitate the ability of women to breastfeed - breastfeeding rooms, flexible work schedules. These are not policies that typically have been high priority for many employers. Governments and the public health community need to collectively advocate for changes in the work environment that encourage breastfeeding.
A second major issue for early child growth and development is the appropriate introduction of complementary foods. Here again, the hospital or health centre can serve as one point of contact with the mother to discuss infant feeding practices. Given the increasing prevalence of childhood obesity in developing countries, a discussion of overfeeding as well as underfeeding needs to be included.
There is a series of non-nutritional interventions which deserve to be highlighted. The health system needs to evaluate the overall obstetrical practices for their effects on neonatal adaptation and mother/infant bonding. Issues such as the use of birth rooms with family participation, active involvement of the father in the birthing process, and the avoidance or minimization of the use of depressants, anaesthetics and other medications which could interfere with successful neonatal adaptation all need to be directly addressed by health officials. There should be a consistent, articulated policy which optimizes mother/child interaction in the early days. Procedures also need to be specifically identified to screen for preventable causes of impaired mental development, as well as ways to identify infants at developmental risk based on perinatal or social risks. Having carried out the infant screening, interventions aimed at providing adequate social and medical support for families with children at risk for developmental problems need to be implemented. Often this level of support is needed in health systems that do not have the financial nor human resources to provide it, so creative community solutions may need to fill this void.
Particular emphasis must be placed on ensuring adequate growth and development for young children. This includes effective interventions to prevent stunting and improve mental development. The overall effect of collective efforts will be to promote healthy lifestyles, including diet. This is easier said than done.
Most of the nutrition interventions that have traditionally been used by developing countries have targeted children. However, those interventions have done less well in reaching preschoolers under three years of age. Some promising approaches have emerged. Community-sponsored child care programmes that simultaneously address a mother's time constraint while providing a mix of health/nutrition services offer one model for reaching the younger child. Nutrition screening and monitoring services can be part of the package included.
Data in this report indicate that tremendous progress has been made in eliminating micronutrient deficiencies. Despite this progress, deficiencies of vitamin A, iron and iodine are still highly prevalent in the world; estimates in this Report indicate that almost one-third of the population worldwide have a deficiency in one or more micronutrient. Because of a substantial commitment by donors, a number of effective interventions to deal with micronutrient malnutrition have been implemented. Some of the more common approaches include supplementation, food fortification, dietary diversification and control of parasitic and other infections. The challenge in the future will be a better identification of the most appropriate intervention or mix of approaches in a given country or local context Not each intervention will work equally well in a given socio-cultural environment. More attention needs to be given to operational research which will identify the key elements of a successful micronutrient intervention. Equally important is to determine how the results of the operational research will be used to guide future investment in micronutrient interventions.
The following issues are critical to specific nutrients:
· Universal iodization is a clear success story in reducing iodine deficiency disorders. Routine monitoring for compliance will be a key factor for sustaining this success.We have missed opportunities to address two or more micronutrient deficiencies simultaneously. Past interventions, by and large, have focused on a single micronutrient. Future efforts would benefit from identifying strategies that leverage intervention funds so that we can develop a collective approach for alleviating micronutrient malnutrition.
· Clinical signs of Vitamin A deficiency have decreased dramatically worldwide, in part due to successful mass dose supplementation interventions. Diet diversity strategies offer the potential for decreasing sub-clinical vitamin A deficiency in the general population. Food fortification is also important; more than one food vehicle is available for vitamin A in most settings.
· Recently implemented wide-scale iron fortification programs hold promise for reaching at risk populations.
· More research is needed on the extent of zinc deficiency and a fuller understanding of the links to pervasive stunting and maternal mortality.
Earlier discussions indicated that a mix of approaches to addressing malnutrition is typically needed, and the same is true for hidden hunger. A judicious mix of diet diversification, supplementation, fortification and public health measures is almost always needed. The key will be how to identify ways of co-ordinating the menu of interventions so as to maximize the impact in reducing micronutrient malnutrition.
The Third Report on the World Nutrition Situation highlights the progress that has been made in improving nutritional status. There is also an unambiguous message that food insecurity and malnutrition will continue to pose problems for large segments of the world's population as we enter the twenty-first century. There are clear policy implications that need to be addressed if governments and the international community are to be effective in improving nutrition worldwide.
No one solution, by itself, will be effective in eliminating hunger and malnutrition. A collective set of policies and related programme activities will be needed. There now needs to be a more serious and aggressive dialogue on how these pieces best fit in a given country environment.
The relatively positive long-term projections for global food supplies and the obvious link to nutrition are based on the essential role of increased agricultural productivity. These productivity increases will occur only if there is continued public and private sector investment in agricultural research. There is clearly a role for both national and international institutions to play. Sustaining the gains in agricultural productivity and extending agricultural technologies into untouched areas will depend on continued support for agricultural research. This need occurs at a time when investment in agricultural research is plateauing or declining.
Much more attention needs to be focused on the links between agricultural research globally and on ways of translating such research into public policy at the national and grass-roots level. This has been a major impediment to the adoption of potentially successful approaches for improving household food security.
A second essential element for improved household food security is income growth. Countries must continue to pursue policies that increase the incomes of the poor. However, even where national macro-economic policies have been successful in the short- to-medium-term, there is often the need for a social safety net to protect the nutritional status of vulnerable groups. Programmes that offer the greatest promise for preventing malnutrition involve early intervention. Unfortunately, the cadre of classical nutrition interventions have focused most often on cure and not prevention. This new paradigm of a preventive nutrition focus, with particular emphasis on young girls and teenage females, needs to be implemented in a number of settings. Operational research to identify elements of successful preventive interventions is essential.
Deliberate efforts aimed at reducing and preventing malnutrition are needed, in tandem with policies aimed at increasing national and household income.
The overall outlook for food security and nutrition for the twenty-first century appears relatively good. But this overall positive picture masks dramatic disparities in certain regions of the world in particular among refugee populations. For regions and countries most adversely affected, short-term assistance is likely to continue to be needed.
The dramatic gains in reducing hunger and malnutrition must be continued; one of the biggest mistakes at this juncture would be for policy-makers and donors to assume that the war to end hunger and malnutrition is over. National and international collaborative efforts need to continue if we are to enhance the gains that have been made. The ACC/SCN at its 24th Session in Katmandu convened a Commission in the Nutrition Challenges of the 21st Century. We look forward to discussing their proposals for innovative policies for the 21st century.
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