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THE MICRONUTRIENT FORUM


Summary
THE NEED FOR A “LIFE-STAGE” APPROACH TO MICRONUTRIENT INTERVENTIONS - A Comment on Micronutrient Intervention Strategies ACC/SCN Micronutrient Forum, Geneva, February 1993
PROGRAMME NEWS - MICRONUTRIENTS

A symposium to promote exchange of information on policies and programmes for micronutrient deficiency control -known as the “Micronutrient Forum” - was held during the ACC/SCN Annual Session, at WHO Headquarters, Geneva, on 15-16 February 1993. The proceedings of the symposium, chaired by Dr B Underwood (WHO), which included five papers with eight discussants, were summarized by Drs Bouis and Trowbridge; the text of their summary presentation is given here.

The Micronutrient Forum also provided an opportunity for participating organizations to describe their activities, as summarized in the “Programme News” section starting on page 36.

Summary

Howarth Bouis and Frederick Trowbridge

· A unifying theme of the discussion was to identify how to support national programs to reduce micronutrient malnutrition.

· There are an array of alternative interventions. No one type of intervention by itself will solve all micronutrient deficiencies. We need to identify the optimal combination of interventions to fit specific circumstances in a particular country or population. The primary strategies discussed were supplementation, fortification, dietary diversity (sometimes referred to as a food-based strategy), and nutrition education. It is important to identify factors which promote or constrain dietary diversity. Cultural values and nutrition education are important factors along with income and food prices. How income is increased (e.g. government investment and macro-economic policies) will affect greatly the dietary diversity of specific socio-economic populations.

· There are important complementarities in treating iodine, vitamin A, and iron deficiencies simultaneously. Populations at risk overlap, functions of organisations involved in implementation overlap, and populations that lack access to health care overlap. There are substantial complementarities in consuming adequate levels of a number of micronutrients concurrently (for example, vitamin C in the diet promotes the absorption of iron). The targeting of pregnant and lactating women and infants is particularly important in this regard. Nevertheless, some interventions are highly effective when implemented as free-standing efforts targeted towards a specific micronutrient problem. Examples include salt iodisation, vitamin A treatment in acute infection and iron supplementation in high risk groups.

· Any optimal strategy will be multi-sectoral involving several government ministries (e.g. health/nutrition, agriculture, trade) and private sector groups (farmers, food processing and marketing concerns, educators, and the medical and legal sectors).

· Short and long-term interventions. Interventions that are viewed as “short-term” approaches should be implemented with a clear view of criteria for phasing out or reinstituting measures as needed, based on ongoing monitoring. Some “short-term” strategies, such as supplementation of micronutrients in primary health care settings, may be effective on an ongoing basis when integrated permanently into primary health care services. Short and longer term approaches should be balanced such that short term strategies do not disproportionately draw on resources or inhibit later initiation of longer term strategies. Many countries have or are developing a National Plan of Action for nutrition that includes specific attention to micronutrients, as recommended by the participants in the ICN.

· There is an overriding need to find sustainable solutions. New interventions should be linked, as far as possible, with existing structures and programs promoting health and nutrition such as breastfeeding promotion, primary health care services, water and sanitation services, educational and agricultural programs. Communities need to be involved in the design of the intervention so as to gain support for and improve participation in the intervention and to provide “bottom-up” information for improving the intervention design even after it has been initiated. It is useful to make “hidden hunger” as overt as possible to individuals so that they fully appreciate benefits of the intervention and to reinforce positive behaviour through a monitoring program.

One focus, to unify all the comments is the question -how can we best support national programmes to reduce micronutrient malnutrition? Given that unifying theme, we suggest four categories of support for reducing micronutrient malnutrition. The first is technologies and methods, which we have divided into two categories: (A) applying existing technologies and methods, and (B) developing new technologies and methods. The second topic is training. The third category - monitoring and evaluation - also involves methods in the sense of advising on their use. The fourth category is in the realm of offering advice, watching out for certain things, and advocacy.

Before we get into discussing the details of those four categories, we want to present some common themes that ran through the various presentations. The first is that there are an array of alternative interventions; no one type of intervention would solve the problem by itself in any one country, and we need to identify the optimal combination of interventions to fit specific circumstances. The interventions that were mentioned most often were supplementation, fortification, dietary diversity which is related to a food based strategy, and nutrition education.

There was perhaps a gap here - there was not much discussion of the factors that promote or constrain dietary diversity. To develop that a bit, we could take the question that was often raised - why don't people eat green leafy vegetables when they are available? Often it was mentioned that there were cultural beliefs and attitudes that prevented the consumption of these foods and the need for nutrition education. This needs to be better understood, and taken account of, in designing interventions.

Two other factors may warrant more attention. The first is food prices; for example, the prices of green leafy vegetables. Economists have found that people have a habit all over the world that when the price goes up their consumption goes down. Two specific studies are relevant. A well known one, in the economics literature from an Indonesian national sample household survey, showed that when the price of vegetables went up, the intake of vitamin A went down, and the incidence of morbidity went up. There is a much less well known study that I (Bouis) did in the Philippines that basically showed the same relationship. So prices are a very important factor in constraining or promoting the consumption of micronutrients.

But if one was going to put one factor at the top of the list, that factor would be income. Looking at households, with (say) $500 per capita per year, their diets are much more diverse than households at $100 per capita per year. Once income is considered, you introduce a whole myriad of possible interventions. It matters how household incomes increase - there is an array of policy interventions that governments have. They can introduce irrigation systems, they can build infrastructure, they can do research on developing new agricultural technologies. The effects of structural adjustments discussed this morning are very relevant here.

The second common theme is that there are important complementarities in treating iodine, vitamin A and iron deficiencies simultaneously. The populations at risk overlap; as do the functions of organisations involved in the implementation of interventions. Similarly, there is an overlap in the lack of access to health facilities of populations at risk. And there are complementarities in the intakes of the various micronutrients - for example, higher vitamin C intake promotes the absorbability of iron.

The third common theme was that an optimal strategy would be multi-sectoral. Within governments those responsible for health and nutrition need to cooperate with the agricultural ministries and also trade ministries. In the private sector, it is important what farmers do, what food processing and marketing companies do, and also what the medical profession does.

And finally, the fourth theme was that we need to find sustainable solutions. It does not do any good to do something that lasts for a couple of years and then disappears.

Now we turn to the four categories of support to programmes, summarised in table 1.

The first area concerns sharing of technology and methods. Here, as elsewhere, we are looking for multiple solutions and options, rather than single approaches; looking for multi-sectoral interventions rather than single-sector interventions; and looking for sustainability. One area for support is in assessment methods. These include epidemiological methods, such as sampling and survey designs, data management, and data interpretation. They also include reaching agreement on core indicators, on the criteria by which those indicators would be evaluated, and on the cut-offs used, so that we can speak a common language on the prevalence and the trends in micronutrient status. There is also a need for sharing information, supporting countries, and developing laboratory methods that are useful and practical. That means the methods themselves; laboratory management; and, very importantly, quality control. We need comparability of results hence a lot of attention to quality control. This is a role for technical support to countries.

Table 1. Components of Support to Countries

1. Sharing of Technologies and Methods

A. Application of Existing Methods
1. Assessment Methods:
Epidemiologic methods: sampling; survey design; data management; data interpretation.

Laboratory methods: analysis methods; laboratory management; quality control.

Programme evaluation methods: formative and process evaluation; focus on problem solving(cost/effectiveness) more than on optimisation; link measures of program implementation (process) with measures of outcome.

Qualitative evaluation methods: attitudes; participation of community in interventions; changes in dietary practices, etc.

2. Intervention Methods:
Dietary diversification strategies: modify food choices; increase availability; improve storage/preparation; utilise multisectoral resources e.g. extention workers, health workers, teachers.

Supplementation: community-based; targeting to risk groups; treatment e.g. vitamin A in acute infection.

Fortification methods/technologies: salt; grains; sugar; condiments, etc; linkage with industry.

Public health measures/environmental health; immunisation; ORT; anti-parasitic measures.

B. Research and Development of New methods/technologies
1. Emphasis on applied research and development needs
2. Investigate what works, what doesn't
2. Human Resource Development
A. Provide Training in:
1. Assessment/Information systems
2. Laboratory management
3. Program management
4. Communications/social marketing
5. Food technology/fortification
B. Develop Curriculum/materials/guidelines

C. Community-level training/empowerment

D. train/utilise multisectoral human resources

3. Monitoring and Evaluation
A. Assess initial prevalence and progress toward goals. Subtopic: need to go beyond clinical indicators.

B. Helps to identify target population

C. Mid-course corrections in intervention design

D. What are consequences for household resource allocation?

4. Advocacy (linked to sustainability)
A. Momentum generated by initial success

B. Involving the community which then gives its support

C. Support of national government:

(i) are human resources available?;
(ii) will ministries cooperate?;
(iii) legislation, regulation, enforcement.
D. Multi-lateral and bi-lateral agencies - information.

Another important area concerns programme evaluation methods. Beyond assessing status, we need to evaluate what's happening to programmes - how are they functioning - both formative and process types of evaluation. We need economic evaluation to look at the cost implications of programmes. We also need to look at issues that are behavioural in nature. We need to understand the coverage of programmes, but also the factors that affect the participation of communities in these programmes, and why or why not there is participation and adapting or adopting of interventions at the community level. So there is a whole range of assessment methods that need to be shared and developed. Support needs to be provided in evolving these assessment methods.

There is a variety of methods required to carry out interventions. Dietary diversification strategies have a whole range of approaches that might be used to modify food choices, to increase the production and availability of food, or to improve storage and preparation. Thus there are technologies and methods that underlie the accomplishment of these intervention strategies, and information and technology that needs to be shared in this regard. Also, there is a need to look for diverse approaches to how these strategies are applied, with not just people from one sector (such as health workers), but calling on a variety of sectors such as agricultural extension workers, other community level workers, educators, school teachers, and others to help in the promotion of dietary diversification. In a given country, one or another of these infrastructures may be more widespread and viable, and we should look to utilize what is in place and what is practical.

Supplementation methodologies have also been mentioned on many occasions. The emphasis has been on some strategies which are community-based, although we have heard concerns about broad based community supplementation and how practical and feasible it may be. We need to share this kind of experience. It may be applicable in some places and not in others. Targeting of supplementation strategies to risk groups may work better, depending on the particular environment. Also, there may be situations where therapeutic supplementation (for example, vitamin A in measles) may be relevant. Rather than considering supplementation as a good strategy or a bad strategy in general terms, this should be seen to depend on the need and what you are trying to do.

Fortification is among the most striking of the areas where technology has a major role to play, and we have heard a number of comments in regard to the application of methods in this area. A lot of attention has been given to the use of salt as a vehicle. There are many technical problems involved in applying that intervention, but there have also been many practical solutions found to them. We need to share those solutions, and promote ways of communicating what is known about these technologies, so that we put in place what is known, even as we develop new technologies.

Basic grains offer a variety of opportunities for fortification. Sugar is another vehicle for fortification, with different methodological problems. We have heard about the use of condiments like MSG. A very important point concerns the linkage with industry in regard to fortification. Industry's skill and expertise, experience, and there working in the market place in a sustainable way, are absolutely critical success factors for fortification to go forward. There is a tremendous amount of technical knowledge within industry with which we need to work constructively. A good example is the meeting on salt fortification in Africa that was held last year - this was extraordinarily useful in arriving at a good consensus for action based on salt fortification.

Communications is another area where the application of methodologies can be useful. First, at the global level, we have heard some discussion of a micronutrient information system, which should be practical and give basic information quickly on what is happening in micronutrient malnutrition.

There is also a vastly important area of social marketing, and how we communicate with the public and with consumers; there are methods to achieve this, and approaches that need to be shared and understood.

A particular point to stress, as we heard from Dr Scrimshaw this morning, concerns investigating weekly dosages of iron, and seeing whether this could improve iron status. That kind of practical applied research - to look at what works and what doesn't - is extraordinarily important.

Training is another broad area of need. Perhaps there are several functions within this context. Developing guidelines that can be broadly useful and are practical in terms of approaches and methodologies can be useful for countries, who look to groups such as this for guidance as to ways that can be considered. Providing courses and workshops can address a variety of needs, that include training and assessment information systems, laboratory management training, programme management, communications, and social marketing and food technology and fortification. All of these areas that correspond to interventions and supporting activities need corresponding course work, and they need curriculum developments and materials. We have heard comments this morning by Dr Masimba (OAU) in regard to the need to incorporate into training nutrition information and concepts, and a public health and socially conscious approach to understanding of problems - this is needed in technical training, medical training and training of health and other professionals.

There is an important role, of course, for information transfer and technology transfer, but the mode of that training should be more in the line of positive reinforcement of what is known, of sharing experiences, of bringing together people from different perspectives and different disciplines so they can look for the complementarities that exist and help to select among alternatives rather than giving the impression that 'we know what needs to be done and here it is'. With this way we can avoid the kind of fragmentation of knowledge that was mentioned by Dr Masimba this morning, and rather bring an integration of information and technology to solve practical problems.

Now to turn to monitoring and evaluation, and advocacy (sections 3 and 4 of table 1). The first purpose of monitoring and evaluation is to assess the initial prevalence of the malnutrition and then to monitor progress towards goals - how bad is the problem and what kind of progress are we making with the interventions. Data may need to go beyond clinical indicators and to use more biological indicators, which are becoming cheaper to use now that methodologies have been developed. The advantages are that these biological methodologies are more precise, which allows us to use a smaller sample size, and they can account for morbidity and mortality problems where there are no clinical signs or malnutrition. This helps to identify target populations.

It was mentioned that we can use households as the basis of surveys, or clinics or schools. Using clinics and schools leads to bias; higher income groups tend to have more access to clinics and to attend schools more. Household surveys are more representative, and better for targeting by socio-economic status.

Another value of monitoring and evaluation is for mid-course corrections in intervention design. This can apply to household resource allocation. It may be found that demands have been placed on the household, by the project design, that the household may not be able to or willing to provide. For example, clinic attendance may turn out impractical because of travel and time burdens on the mother. Another value of studying household resource allocation is to assess some second round effects. For example, if the intervention reduces morbidity, then the household may spend less on medical care, so what do they spend the money on? Do they then spend the extra money on more food, for more education? Do they invest it in their farms?

Similarly, time allocation patterns may be affected. Parents do not have to spend as much time caring for children; children may go to school more often; and so on. Showing such full economic benefits then gets us into the area of advocacy - the information can be used as part of an advocacy programme. Momentum is generated by demonstration of initial successes: a successful iodine programme can possibly generate support later on for iron and vitamin A programmes. Moreover, it is important to involve the community in the intervention, for them to give support to the programme.

In terms of support of the national government, we have to be careful that the human resources would be available. These are often already pretty much fully utilized. When we introduce new programmes - are the people there with the extra time and training to implement the programmes? We have to ask whether ministries can cooperate, and that cooperation has to be developed.

Finally, what is the role of multilateral and bilateral agencies? They can provide information, as discussed here. They provide resources and money, but we have to be careful - especially if the main impetus for intervention comes from the outside agencies - that when they withdraw their support the interventions continue. So, we have to be careful that the primary momentum for the interventions comes from within the countries themselves.

Howarth Bouis is at IFPRI, 1200 17th Street, N.W., Washington, D.C., USA

Frederick Trowbridge is at CDC, 1600 Clifton Road, N.E., Atlanta, Georgia, USA.

THE NEED FOR A “LIFE-STAGE” APPROACH TO MICRONUTRIENT INTERVENTIONS - A Comment on Micronutrient Intervention Strategies ACC/SCN Micronutrient Forum, Geneva, February 1993

Lindsay H. Allen, presently at the Department of Nutrition, University of California, Davis, CA 95616-8669, was formerly at the Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269-4017

A perspective on the question of which micronutrients are needed, and how to deliver them, is inherently accepted by many participants in this forum. I believe it needs stating overtly. I can best illustrate my point by using pregnant and lactating women, and their infants and young children, as an example. We are all agreed that these are important target groups.

In this view of the problem, individuals in poor regions of the world obtain most of their dietary energy and protein from a few “core”, staple foods, which are usually cereals and legumes. Cereals and legumes have a low content of most vitamins, and while their mineral content may appear to be reasonable, bioavailability will be poor due to food constituents such as phytates and fiber. As households' resources improve, micronutrient-rich fruits and vegetables, and perhaps more importantly dairy and other animal products, are added to the staple. Thus, many households in poor areas are likely to be consuming adequate amounts of energy and protein from staple foods, but inadequate amounts of vitamins and bioavailable minerals. Micronutrient malnutrition, because of poor dietary quality, occurs even in the face of adequate energy and protein intakes. It will also, of course, occur where there is an inadequate quantity of food. It is much more widespread than protein-energy malnutrition.

When women subsist on such diets prior to pregnancy, they enter pregnancy with low stores and intakes of multiple micronutrients. Anemia develops frequently, but other nutrient deficiencies undoubtedly exist - it is just that we don't usually measure them. Fetal uptake and storage of many of those micronutrients will also be low so that the infant starts early life with low stores. To this is added the problem that the concentration of nutrients such as vitamin A, and water soluble vitamins, is likely to be suboptimal in breastmilk. There are good reasons for the present policy of advising breastfeeding for the first 6-12 months of life, but are we sure that infants so fed will receive adequate amounts of vitamins and minerals, if the diet of their mother is poor?

Within 3-4 months of birth, until about 21 months of age, growth-stunting is found almost universally in poor regions of the world. It is now recognised that, without doubt, children who are growth-stunted have functional impairments which are persistent, often to adulthood. Growth-stunting occurs even in infants who are completely breastfed. Some, but as presently understood, not all, of the stunting is often caused by diarrhea. The infant with diarrhea may have anorexia, with a negligible intake of both macro- and multiple micronutrients. It will also incur major fecal losses of zinc, copper, and fat soluble vitamins in severe cases, as well as other nutrients.

A recognised but as yet unquantified problem is that of undiagnosed, asymptomatic, subclinical infections by bacteria and parasites, often resulting in bacterial overgrowth. Micronutrients such as vitamin A, iron, carotene, vitamin B12 and others may be chronically malabsorbed for long periods of time starting within a few months of birth.

Then a suitable weaning food must be found. Frequently, home- or locally-prepared weaning foods are cereal-based and very low in micronutrients. Stunting continues, and anemia develops - along with further deficits in multiple micronutrients, most of which are not usually measured in prevalence studies. Programs that have focussed on the use of cereals during diarrhea at this age have undoubtedly saved many lives, but many probably don't replete micronutrient stores or improve longer-term growth.

Based on this scenario, how much will feeding more green leafy and yellow vegetables really help? Perhaps they will improve vitamin A status, if they are well-targeted (and in the case of leafy greens, well-disguised?). Will they improve iron status? There is little information on this; we may be adding oxalates and fiber as well as vitamin C. What about the other micronutrients likely to be deficient by this age?

In this Forum we have accepted that single or complementary (1-3 nutrient) supplements should be regarded as a short-term solution to severe deficiency situations. However, it is more than likely that a pregnant or lactating woman and her child will be deficient in more than 1-3 nutrients. “Food-based” strategies such as introducing green leafy vegetables and fruits will not fill the whold micronutrient gap. Moreover, such foods must be integrated into the usual diet, and intervention efforts must “fit” with what is normally available, consumed, and recommended.

It is important, therefore, to focus on “food-based” strategies that add as many micronutrients as possible to the diets of women and young children. This should be done as part of an overall plan that is integrated with: management of non-pregnant, and then pregnant and lactating women (who may benefit from most multi- vitamin mineral supplements as part of perinatal health care); breastfeeding policy vs the adequacy of micronutrients in breastmilk (how do lactating women and their infants benefit from micronutrient supplements?); the types of weaning foods that are available, used and recommended (can multiple micronutrients be added to local cereal-based gruels? Is powdered milk a possible medium?); and foods available to, and preferred and consumed by the young child.

The “life stage” approach to micronutrient interventions has the potential benefits of: i) targeting appropriate nutrients to individuals at nutritionally-vulnerable periods of their life; ii) complementing normal dietary practices; and iii) fitting into an integrated health care, nutrition delivery and education system. A similar approach can be used for other nutritionally-vulnerable population groups.

PROGRAMME NEWS - MICRONUTRIENTS

The information here, which is in the usual format of SCN's “Programme News”, focuses in this issue on agencies' and organizations' activities in micronutrient deficiency control. The material is edited largely from verbal presentations at the Micronutrient Forum, plus some distributed printed material. It aims to give a brief overview of agencies' interests - more detail can be obtained by contacting the sources directly.

CDC (Centers for Disease Control)

CDC is collaborating closely in training and applied research with the Program Against Micronutrient Malnutrition (PAMM) at the Centre for International Health, Emory University, Atlanta.

The Division of Nutrition of CDC is actively involved in developing an iron initiative that will be directed at the very serious and continuing iron deficiency problem that exists in the United States, illustrating that micronutrient deficiency problems should not be thought of as being confined exclusively to the developing world.

As part of this initiative CDC is supporting the production of a report by the National Academy of Sciences that will provide an overview of public health strategies to address iron deficiency. Attention will be paid to the interaction of iron deficiency with lead toxicity. Exposure to environmental lead is a greater problem when the exposed individuals are iron deficient, because the absorption of lead is facilitated by the iron deficiency (when iron deficiency occurs, absorption of other divalent ions is facilitated).

Research that is being done in conjunction with this programme will test the effects of intervention with a coated iron tablet - a technique initially developed and tested in Jamaica.

CDC will be both distributing the tablets and monitoring the progress of the project through the United States primary health care system. In this case, it will be through the maternal and child health clinics, and the W1C programme (Special Supplemental Food programme for Women, Infants, and Children) activities.

(Source and contact for further information: Dr F Trowbridge, Director, Division of Nutrition. Centers for Disease Control, Mailstop #K-24, 1600 Clifton Road, N.E., Atlanta, Georgia 30329, USA. Tel: (404) 488 4721 Fax: (404) 488 4479)
FAO

FAO has been involved since 1986 in the control of micronutrients, especially through its vitamin A programme (see SCN News No.8, p.38), the main strategy of which is promotion of the food-based approach to the problem.

However, FAO is not limiting its projects only to activities aimed at increasing the production and the consumption of micronutrient rich foods, it is also running nutrition education projects - one is currently taking place in Sahel - aimed at increasing awareness of the micronutrient deficiency problem. In another project currently underway in Nepal, FAO is working with the Ministry of Agriculture, and also with the Ministry of Health, Ministry of Education and Ministry of Local Development, to increase awareness of and better inform people about the problem.

In the near future, FAO hopes to hold a meeting in Rome to prepare the guidelines for the implementation of food-based strategies at country level with a view to helping countries to implement the activities proposed in the ICN plan of action.

(For further information please contact: Director, Food Policy and Nutrition Division, FAO, Via delle Terme di Caracalla, 0100 Rome, Italy. Tel: (396) 5797 3330 Fax: (396) 5797 3152)
HKI (Helen Keller International)

Helen Keller International (HKI) looks forward to continuing its twenty year effort in the control of micronutrient deficiency. Building on its pioneering work in the area of vitamin A deficiency and blinding xerophthalmia, HKI is anticipating increased programmatic activity with wider applications in iodine and iron deficiencies. The HKI micronutrient programme will include continued emphasis on technical assistance to governments and NGOs, advocacy for micronutrient issues, child survival programmes and operations research.

Recently, HKI, in cooperation with UNICEF and the Government of Yemen, assisted in an assessment of several thousand children, gathering information of the vitamin A, thyroid and iron status of this group. This successfully demonstrated the ability to expand the assessment methodology used for vitamin A status. In Bangladesh, HKI has organized a Nutritional Surveillance Programme which utilizes NGOs to gather data and has successfully proven its usefulness following recent flooding. In the past year, HKI has assisted a number of NGOs in assessment techniques through the VITAP programme. HKI is committed to continuing to assist an even larger number of NGOs (indigenous and international) and governments in performing assessments for micronutrient disorders. New techniques, like dietary recall are beginning to provide valid data at greatly reduced cost, and HKI will continue to test these techniques.

Just as importantly, HKI is anxious to expand its intervention strategies to include all micronutrients. There is no reason to assume that social marketing techniques, like those we have developed in Indonesia, or Burkina Faso, cannot be adapted to address iodine and iron deficiency. Training skills similarly can be used in a number of interventions. We are especially concerned with determining the impact and effectiveness of community health workers in delivering a more complicated nutritional message.

HKI's experience in capsule delivery systems, like those in Bangladesh and Indonesia, has application in a number of other areas. Fortification, when successful, offers a cost effective method of reaching those at high risk for micronutrient deficiencies. HKI is currently working to develop a number of foodstuffs fortified with vitamin A, and perhaps eventually the other micronutrients.

In summary, HKI is enthusiastically pursuing a number of strategies to combat micronutrient deficiencies. Two decades of experience with many assessment, monitoring and intervention strategies has taught us the need to remain flexible and imaginative in creating programmatic solutions based on sound scientific research and public health principles.

(For further information please contact: HKI, 90, Washington St., New York, NY 10006, USA. Tel: (212) 943 0890 Fax: (212) 943 1220)
IAEA

The IAEA is supporting a number of research programmes in the area of human nutrition. All of these programmes involve some aspect of the use of isotopes or radiation (however, this component is sometimes only a relatively small one). The main mechanisms of support are:

(1) coordinated research;
(2) technical cooperation (including fellowship training and training courses); and
(3) analytical services (particularly relating to analytical quality control).
Current Activities Relating to Trace Element Nutrition

With respect to iron nutrition, a Coordinated Research Programme (CRP) is being supported in 11 countries on the bioavailability or iron and zinc from different diets. With respect to iodine nutrition, extensive activities are being supported in Asia and Latin America involving the use of radioimmunoassay for monitoring neonatal hypothyroidism.

With respect to trace elements in general, a study was conducted in collaboration with WHO on trace elements in human milk in 6 countries and the results were published in 1989. More recently, studies have been conducted in 16 countries on dietary intakes of a large number of essential and toxic trace elements. Some results have been published and a more detailed report is in preparation. Another current programme (in collaboration with WHO) is concerned with assessing nutritional and environmental exposure to mercury in selected human populations.

During the past year a global database on human daily dietary intakes of nutritionally important trace elements was completed and an evaluation of these results is due to appear in the report of the WHO/FAO/IAEA Expert Consultation on Trace Elements in Human Nutrition (in press).

Some of the above-mentioned programmes are supported by work in the IAEA's Analytical Laboratory in Seibersdorf, which also runs an extensive programme of analytical quality control services (AQCS). The current AQCS programme makes available a variety of food-based reference materials for trace elements, organic micro-contaminants, and radionuclides; many of these are relevant in different kinds of nutritionally-related research programmes. The IAEA also maintains a computerized database of such reference materials, which it is planning to update during 1993 in collaboration with UNEP.

Future Activities Relating to Trace Element Nutrition

Most of the above-mentioned programmes will continue during 1993-94. A new CRP is expected to start during 1993, in collaboration with WHO, on Comparative International Studies of Osteoporosis Using Isotope Techniques (details available on request). Trace element studies are included as one part of the protocol for this CRP. A Regional Training Course for English Speaking African Countries on Isotope Techniques in Human Nutrition Research is due to be organized during 1993, which is expected to deal extensively with iron nutrition.

(For further information please contact: R M Parr, Section of Nutritional and Health-Related Environmental Studies, International Atomic Energy Agency, PO Box 100, A-1400 Vienna, Austria. Tel: 43 1 2360 1657 Fax: 43 1 234564)
ICCIDD (International Council for Control of Iodine Deficiency Disorders)

Expansion is evident in national programmes throughout the world supported by regional and global activities. The momentum generated from the 1991 Montreal Conference “Ending Hidden Hunger” has been increased by the ICCIDD working closely with UNICEF and WHO and interested bilateral agencies (Holland, Sweden, Australia, Switzerland, Belgium). The World Bank is also now supporting IDD control programmes within its country nutrition programmes. Particular impact has been made in Indonesia and China.

Notable features of the past year have been -

· The increase in political support for national programmes by the 45th World Health Assembly (Geneva 1992) and the FAO/WHO International Conference on Nutrition (Rome 1992).

· The new emphasis on salt iodisation. This has included the new alliance between the ICCIDD and the major salt producers of the world (IAAIDD), and the two major regional salt iodisation workshops in Africa-Botswana (Anglophone) and Senegal (Francophone) supported by CIDA and UNICEF. These workshops had been very successful and rapid progress was being made by Southern African countries. In West Africa there had been substantial impact in Nigeria.

· In Europe, the Report on the 1992 ICCIDD/UNICEF/WHO Meeting on Iodine Deficiency in Europe is about to appear. It is now agreed that there are 200 million still at risk of IDD. What is needed is political will to overcome the problem. Ministries of Health and Industry and other decision makers need to be also aware of the great cost of IDD - recently estimated by insurance companies in Germany to be $800m per year for the investigation of iodine deficient goitre and its complications. The hazard of further catastrophies like the Chernobyl disaster of 1986 make correction of iodine deficiency urgent due to the increased radiation uptake associated with this condition.

· Middle East (Eastern Mediterranean) A WHO/UNICEF/ICCIDD Regional Meeting has just been held in Alexandria (25-29 April 1993). It was attended by representatives from 12 countries who reported good progress with national IDD control programmes. A Communication Workhop was held, led by Ms N Chawla (India), Mr R Tyabji (UNICEF Yemen) and Professor Ling (USA).

(For further information please contact: Dr Basil S Hetzel, Executive Director, ICCIDD, c/o Health Development Foundation, 8th Floor, Samuel Way Building, Women's and Children's Hospital, 72, King William Road, North Adelaide, 5006, Australia. Tel: 61 8 204 7021 Fax: 61 8 204 7221)

IFPRI

Food Policy and Agricultural Technology to Improve Diet Quality and Nutrition

Nutrition Research Within the CGIAR The International Food Policy Research Institute (IFPRI), one of eighteen international research organizations which comprise the Consultative Group on International Agricultural Research (CGIAR), undertakes research, primarily from an economics perspective, to assist policymakers in developing countries to increase food production and improve food consumption and nutrition among the poor. The main focus of research at most Centers in the CGIAR, however, is development of improved crop varieties, which increase the food supply and so lower food prices, and which raise farm profits and rural employment. Lower food prices and increased rural incomes are perceived as the major contributions of past CGIAR activities to improve nutrition in developing countries.

Recently IFPRI has been designated to take the lead in coordinating nutrition-related activities within the CGIAR. A large part of that effort will be organized around a new five-year project, Just initiated, funded by the Office of Nutrition of the United States Agency for International Development (USAID). The focus of the project will be to explore cost-effective alternatives within the CGIAR for increasing micronutrient intakes.

Strategies for Improving Micronutrient Intakes

There are two broad strategies which the CGIAR can pursue in the area of nutritional improvement. The first broad strategy might be characterized as a business-as-usual approach to nutrition in which social scientists and nutritionists focus on the interaction of the technologies provided by the Centers, household resource allocation, and health, nutrition, and other policies implemented by national governments. For example, adoption of micronutrient-rich food production technologies which are the focus of research at specific Centers (e.g., vegetables, livestock) will presumably raise some farm incomes, alter the way that these households organize their time, and modify food consumption patterns, among other changes, all of which will differentially impact the nutritional status of mothers, children, and other family members. At a regional level, employment patterns may be affected and the prices of micronutrient-rich foods will decline, affecting micronutrient intakes and nutrition even in non-adopting households.

Adoption of modern food staple crop technologies, which in general are not rich sources of micronutrients, will also impact household resource allocation and regional employment and food consumption patterns, but in a different way. Which specific production technologies will have the greatest impact in reducing micronutrient deficiencies? Among a host of other factors, the answer will depend on the extent to which mothers are involved in farm work to produce these crops, the extent to which households sell what they produce or consume their own production, and how food consumption patterns of non-producing households are affected by changes in food prices and incomes.

The second broad strategy is to enhance the micronutrient content of crops through plant breeding, agronomic practices, and food processing. Plant breeding, which may be viewed as a form of fortification, has tremendous potential for improving micronutrient intakes. There are, however, a daunting number of technical questions to be answered before investing substantial resources in such a strategy.

What is the probability of success of breeding for a nutrient-dense crop variety, for example an iron-dense wheat variety? How long will it take and how much will it cost? If breeding is successful, will the nutrient-dense genotype be low-yielding, or will it have unacceptable consumer characteristics, resulting in lower profits as compared with present varieties and thus reducing adoption by farmers? If the profitability and adoption barriers are overcome at the farm level, to what extent will the additional micronutrients in the seeds be bioavailable after being consumed? Assuming that bioavailability is enhanced, to what extent will micronutrient deficiencies be improved, given the variety of food consumption patterns and food demand behaviours of low income groups in poor countries? Finally, what are the functional consequences, in terms of human health and economic outcomes, of these improvements?

Before pursuing either or both strategies within the CGIAR to improve micronutrient deficiencies, it is essential to take into account alternative interventions, outside the purview of the CGIAR, which may be more cost-effective. If better solutions lie outside the scope of CGIAR activities, then the appropriate response would be for the CGIAR simply to continue with its traditional focus on raising farm incomes and lowering food prices. For example, iodization of salt appears to be a proven, low-cost intervention which is being implemented in developed as well as developing countries. Other major interventions apart from fortification outside of the purview of CGIAR activities are supplementation, disease reduction, and nutrition education. Rather than a single intervention precluding others, it may turn out that there are strong complementarities between these alternative interventions and CGIAR activities.

Identifying Specific Research Activities

The complexity of the issues raised above conditions how the project will be organized and implemented. The first two years will involve a process of identification and selection of specific research activities to be implemented in the final three years of the project. Five papers will be major inputs into that decision-making process. These papers not only will review the existing literature, but will also involve new analysis of existing data. To the extent that appropriate information is available, these papers will provide:

(i) an overview of the extent of micronutrient deficiencies in developing countries by geographic location, their functional consequences, and the socio-economic characteristics of populations suffering from these deficiencies;

(ii) information on the specific dietary sources of micronutrients by geographic location and by socio-economic group, and an analysis of the factors (e.g. income, food prices, education) that drive household-level demand for these foods;

(iii) information on the intra-household distribution of these foods and the factors (e.g. income-control, education, gender) that drive this distribution;

(iv) a review of the cost-effectiveness of past supplementation, fortification, disease reduction, nutrition education, and home gardening interventions in reducing micronutrient malnutrition, and prospects for the development of new low-cost technologies in these areas; and

(v) an evaluation of the probabilities of success of breeding for micronutrient-dense varieties by crop within the CGIAR, and recommendations for the sequence of specific steps that would need to be taken to develop such varieties; similar evaluations in the areas of farming systems, agronomic practices, and food processing technologies.

Project Design and Organization

Our intention is that these papers will identify gaps in knowledge and areas of key concern, which in turn will point the way toward high pay off research projects. Separate funding has been designated for research under the two broad nutritional improvement strategies discussed above. The projects involving social scientists and nutritionists are envisioned as tri-lateral collaborative efforts between IFPRI, another CGIAR Center, and a national research institution. Typically, these projects would involve household surveys, with some households adopting a CGIAR technology and perhaps receiving a specific nutritional intervention, and other households serving as a control group. Data would be collected on a wide range of economic and nutrition variables. Projects on the breeding/agronomic practices/food technology side of the project would be bilateral collaborative efforts between a CGIAR Center and a national research institution.

Guidance for this project in its first two years will be provided by an advisory committee. The committee consists of persons who have been involved in solving food, nutrition, and agricultural problems in developing countries, and represents such disciplines as agronomy, plant breeding, nutrition, and economics.

An initial planning workshop will be held toward the end of this year or early next year to be attended by the advisory committee and an interdisciplinary group of scientists from IFPRI, other CGIAR Centers, and national research institutions. Initial work on the five papers outlined above will be presented. Preliminary proposals will be discussed, although new proposals may be developed after this first workshop. Finalized proposals will be reviewed by the advisory committee before a second workshop to be held in early-to-mid 1995. The five finalized papers will be presented at that second workshop and decisions will be made as to specific research activities to be undertaken in the final three years of the project.

Representatives from organisations involved in funding and implementing projects aimed at reducing micronutrient deficiencies also will be invited to participate in the workshops. In part, this is to ensure coordination of research under this project with work being undertaken by other organisations. However, the project has been structured administratively so as to allow expansion of the number of research activities during the final three years through direct participation of these donor and implementing organisations in the project.

(IFPRI's intention is to seek advice as widely as possible during this planning phase. Those who have suggestions, who want to learn more about the project, or who would be interested in attending the workshops (some funding for this is available for persons from developing country institutions), can write to the project director, Howarth Bouis, at IFPRI, 1200 17th St. N.W., Washington D.C. 20036-3006. Tel: 202-862-5641; Fax: 202 467 4439)
The Micronutrients Initiative

The Micronutrients Initiative (MI) is a new organization. It emerged as various donors and governments and some other groups all saw the need over the past few years to accelerate, expand and strengthen programmes to overcome micronutrient malnutrition. The World Summit for Children in New York, 1990 and the Ending Hidden Hunger Conference in Montreal (1991) as well as the International Conference on Nutrition in Rome, 1992 all served to strengthen the realization that programmes to overcome micronutrient malnutrition really need to be catalyzed.

The objectives of MI are to assist countries to identify problems, analyze and articulate needs, formulate programme proposals and establish collaboration with the providers of the required support; to increase international awareness and commitment; and to act as a focal point for fund raising, information and international dialogue.

MI seeks to promote intersectoral collaboration in addressing the problem of micronutrient deficiencies. Emphasis is placed on facilitating dialogue between the policy, community and research sectors, and in promoting coordinated programme design at the country level. Whenever possible, it encourages linkages between programmes directed at vitamin A, iodine and iron deficiencies. The MI also facilitates the integration of work in regions and countries in the areas of supplementation, food fortification and consumption patterns.

At national and regional levels, the MI focuses its efforts on feasibility studies, operational research, programme design and evaluation, capacity-building, information systems, and communications.

At the international level, the MI works closely with FAO, UNICEF, WHO, bilateral agencies, NGOs, technical agencies and the multilateral banks to promote implementation at national levels of micronutrient interventions. The MI works with the UN ACC Subcommittee on Nutrition (ACC/SCN), the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), the International Vitamin A Consultative Group (IVACG), the International Nutritional Anaemia Consultative Group (INACG), and the Group for the Control of Iron Deficiency (GCID).

The MI is overseen by a Steering Committee and is guided by an External Technical Advisory Group. The Executive Director of the MI reports to donors through the Steering Committee which establishes guidelines and reviews progress of the MI. The External Technical Advisory Group validates the scientific, technical and economic appropriateness of activities, identifies and advises on new opportunities, and reviews research and development needs. The Advisory Group is interdisciplinary in nature with representation from the nutritional, health, agricultural, social and management sciences. The MI is housed in the headquarters of the International Development Research Centre (IDRC) in Ottawa, Canada, and is financed by CIDA, IDRC, UNDP, UNICEF and the World Bank.

(For further information please contact: Executive Director, The Micronutrients Initiative, IDRC, PO Box 8500, 250 Albert Street, Ottawa, Canada, K1G 3H9. Tel: (613) 236 6163. Fax: (613) 238 7230)
The Nutrition Foundation

The Nutrition Foundation, Inc. is a division of the Human Nutrition Institute of the International Life Sciences Institute (ILSI). ILSI is a public non-profit scientific foundation established in 1978 to advance the understanding and resolution of scientific problems in nutrition, toxicology, and food and environmental safety. Headquartered in Washington, D.C., ILSI has branches in Argentina, Australia, Brazil, Europe, Japan, Mexico, North America and Southeast Asia.

Both the Human Nutrition Institute and its Nutrition Foundation division have been active in micronutrient malnutrition. The Nutrition Foundation serves as the secretariat for the International Nutritional Anaemia Consultative Group (INACG) and the International Vitamin A Consultative Group (IVACG) through a cooperative agreement with the US Agency for International Development. The most recent INACG publication is “Combatting Iron Deficiency Anaemia through Food Fortification Technology.” and the most recent vitamin A publication is “Nutrition Communications in Vitamin A Programmes, a Resource Book.”

Ongoing activities of INACG include the submission of a toxicology monograph on sodium iron EDTA to the Joint FAO/WHO Expert Committee on Food Additives (JECFA). Iron EDTA provides iron in a more bioavailable form for food fortification, thus requiring less iron to be added to the food.

The Nutrition Foundation and the Human Nutrition Institute have also been actively involved in promoting coordination of efforts among the three micronutrients. In late 1992, the Institute co-sponsored a workshop, “Coordinated Strategies for Controlling Micronutrient Malnutrition” with the Program Against Micronutrient Malnutrition and the US Centers for Disease Control. Through the Nutrition Foundation, representatives of INACG, IVACG, and ICCIDD have met to discuss ways programs at the developing country level might be more effectively coordinated. A joint mission is being planned to test whether or not such an approach is feasible and useful.

(For further information please contact: Dr Suzanne Harris, Executive Director, The Nutrition Foundation, 1126 16th Street, N.W., Washington D.C. 20036. Tel: (202) 659 9024. Fax: (202) 659 3617)
PAMM (Program Against Micronutrient Malnutrition)

The Program Against Micronutrient Malnutrition (PAMM) is a network of collaborating groups that is working towards the elimination of micronutrient malnutrition. The groups include participant countries, Emory University, the Centers for Disease Control and Prevention (CDC), the Task Force for Child Survival and Development, and a variety of other groups with complementary technical and programmatic strengths. The strategic focus of PAMM is to assist national governments to develop the capability to achieve and sustain the elimination of micronutrient malnutrition.

The goal of PAMM is to support the global effort towards the elimination of micronutrient malnutrition by the year 2000. The strategic plan developed by PAMM includes the following key components:

· Advocacy. Advocacy is the dynamic process of developing consensus and a mandate for action. It is essential for control of micronutrient malnutrition; those who are in a position to take action must be convinced that control of micronutrient malnutrition has merit. The value of micronutrient malnutrition control has been recognized by most of the heads of state or government. This recognition should be translated into clear and decisive agendas for action by policy-makers, legislators, producers, and consumers. Mechanisms for various groups to work together towards common goals is needed to avoid duplication of effort, geographic and programmatic gaps, and excessive reliance on short-term solutions. PAMM cooperates with other groups to work with national governments, the private sector, and consumers in this global effort.

· Interventions. Similarly, micronutrient malnutrition can only be controlled if effective and feasible interventions are implemented. Dietary diversification, fortification and supplementation have been shown to be effective when appropriately tailored to the conditions where deficiencies exist. Cultural, economic, geographic, climatic, and political conditions can influence the suitability of particular interventions or combinations of interventions. Interventions can be implemented separately or in combination. Short-term interventions that are easy to initiate but difficult to sustain might be coupled with longer-term interventions that are harder to initiate but more sustainable.

· Evaluation and Surveillance. Evaluation to implement and surveillance to sustain effective interventions are also crucial to micronutrient malnutrition control. Formative evaluation can provide information to guide decisions on who, what, where, and how to implement interventions. For instance, quantitative information on how many are afflicted and where they are located can assist in targeting. Qualitative information on knowledge, attitudes and practices can assist in identifying and overcoming resistance to adopting new practices. Process evaluation can provide information on whether interventions are functioning as intended, and if not, how to fix them. Ongoing surveillance can be an effective means to systematically collect and disseminate such information. Summative or impact evaluation can provide information to guide new programs.

Training

PAMM offers training courses designed to assist national teams to acquire skills to work together to develop and maintain effective programs. These programs are interdisciplinary. Teamwork, collaboration, and integration are key elements of the training strategy. Participants from a variety of backgrounds work together through team-building exercises and technical training sessions to develop and plan programs that build linkages across disciplines. Three-month technical courses are offered simultaneously in:

· program management;
· information management;
· social marketing management;
· fortification management;
· information management; and
· laboratory management.
At the end of the three-month technical courses, senior level officials from the participant countries join the one week training course on:
· advocacy and policy
Ongoing Support

PAMM offers long-term technical assistance and collaboration with national programs. Training is only one component of a more comprehensive interrelationship between the PAMM participant countries, experts in specific micronutrients, and others working against micronutrient malnutrition. Key aspects of this ongoing support are:

· Initial and Continuing Site Visits. PAMM offers to visit countries interested in training to assess country-specific needs. PAMM also offers continued site visits after training to provide technical assistance to participant countries as needed. These visits are tailored to country-specific requests and needs.

· Annual Workshops. A two-week workshop is conducted each year for three years following the initial training. The workshop takes place in one or more of the countries in the PAMM network. For instance, the Indonesian Ministry of Health hosted the first PAMM workshop for all participants in the training courses. Just prior to the Indonesian workshop, Mahidol University, Iron and Iodine Projects, held a small workshop for program managers in Thailand. Annual workshops provide the opportunity to share program experiences, strengthen the international network, and refine technical skills. Participants identify topics for discussion, skills to improve with further training, problems encountered, new developments, and successful strategies. PAMM provides technical support to meet the needs expressed by the participants.

· Micronutrient Information Network. PAMM is developing a micronutrient information network (MIN). Its purpose is to facilitate communication between participant countries, PAMM, and other groups. The emphasis is on information to support micronutrient malnutrition control programs. AT&T has donated computer equipment for participant countries and PAMM.

· Laboratory Support. PAMM provides technical guidance to purchase the equipment necessary to establish a national laboratory similar to the laboratory used in the laboratory management training. Participants can elect to purchase this equipment at discount prices through PAMM, or choose an alternative better suited to their needs. Support will include purchase of the reagents needed for one year's work. The laboratory equipment is linked to a computer that rapidly analyzes data specific to micronutrient malnutrition. Ongoing quality assurance from a reference laboratory is also offered.

· Applied Research and Development. PAMM has already undertaken many activities to develop applied research and development to enhance micronutrient malnutrition control. The workshop on “Coordinated Strategies for Micronutrient Malnutrition Control” sponsored by the International Life Sciences Institute (ILSI) and PAMM in November 1991, identified technical gaps and research priorities for evaluation and surveillance, fortification, and dietary diversification. Furthermore, PAMM has:

a) developed a technical network of research groups;

b) defined issues needing research & development;

c) identified field sites for testing & development;

d) identified collaborating country participants to scale-up projects to nation-wide program; and

e) developed human resources to implement new techniques & methods through training.

Many of the groups in the technical network have long-standing applied research and development programs for micronutrient malnutrition control. Much of the research is proposed by institutions in countries where micronutrient malnutrition is a serious problem. This means that the research will be conducted in the most relevant settings. The link between regional research centers and national programs provides a direct mechanism to evaluate new developments in the conditions where the problems occur and interventions are implemented. The implementation and scaling-up experiences of these programs have potential for adaptation among similarly affected countries.

Furthermore, the training and ongoing support provide the means of developing human resources to take advantage of the latest most relevant developments.

(For further information please contact The Program Against Micronutrient Malnutrition (PAMM), Center for International Health, Emory University School of Public Health, 1599 Clifton Road, N.E., Atlanta, GA 30329, USA. Tel: (404) 727 5417. Fax: (404) 727 4590)
SIDA

About half of Swedish development assistance goes through the Swedish International Development Authority (SIDA). Most of SIDA's assistance is bilateral, direct to its 19 cooperating countries in the developing world. In the field of nutrition most of the support is of a capacity building or institution building nature, currently for Tanzania and Zimbabwe, In Zimbabwe, this had included support to the national IDD control program, including staff training.

In Tanzania, Swedish support laid the foundation for the national vitamin A deficiency and anemia control programs currently being funded by the World Bank. SIDA funds the short-term component of the IDD control program, distribution of iodized oil capsules to over 20 heavily affected districts.

In Bangladesh, SIDA has been funding 1/3 of the costs of the national universal vitamin A capsule distribution program via UNICEF since 1981 and has since 1989 supported a project in one district involving nutrition education and horticulture to improve vitamin A through the diet. A large quasi experimental evaluation of this approach has recently been completed. Small studies of constraints to the success of this program, including the role of dietary fat in carotene absorption and another of how to overcome practical constraints to home gardening are planned for later this year.

Small grants have been given as core support to ICCIDD and to WHO Africa for holding a workshop on iron deficiency in pregnancy. SIDA offered additional funds to ICCIDD earmarked for work on rehabilitation of those handicapped by IDD, however this was apparently not of interest to them. SIDA believes that there may be an ethical basis for asking those working on IDD surveys to also consider this aspect, since cretins and other may, as a result of such surveys, be subject to more discrimination from the community once outsiders have focused attention on these handicapped individuals.

Relevant training for several staff from both Tanzania and Zimbabwe at PAMM has been funded as well as research degrees for a few staff. At the Uppsala University International Child Health Unit, the Assistant Director of the MOH Nutrition Unit recently completed a Master of Medical Sciences degree on goiter palpation and urinary iodine excretion in a high prevalence region of the country. The Managing Director of the Tanzania Food and Nutrition Centre has been working on a PhD studying factors affecting the absorption of iodine from iodized oil capsules. Another Tanzanian is beginning a PhD on food fortification, probably vitamin A, but maybe also iron or vitamin C. Another is nearing completion of a PhD on IDD related to cyanide exposure from cassava. ICH is also studying methodological issues in iodized oil capsule distribution programs from epidemiological, economic and communication perspectives.

A major relevant interest to Sweden is breastfeeding. A large programme is being supported through INCAP for several years in Central America. SIDA has supported national breastfeeding promotion programs in Tanzania and Zimbabwe and provided minor assistance in Viet Nam. SIDA has been supporting protection of breastfeeding via the International Baby Food Action Network since 1980 and through various programs at WHO since the 1970s. Support has recently been provided to the World Alliance for Breastfeeding Action for a seed grant program to support grassroots groups in Africa and Asia who want to develop local approaches to provide support and assistance to working women to breastfeed more successfully.

The Natural Resources Division of SIDA has supported FAO and the Agricultural University in Uppsala for work on diet diversification through the promotion of local foods, often through the Forest, Trees and People programme. The role of diet diversification in household food security has received attention, mainly through farming systems research.

SAREC, the Swedish Agency for Research Cooperation with Developing Countries, has been one of the agencies supporting research on iron absorption. Many of you probably know of the research conducted over many years by the group including Hallberg, Rosander, Svanberg and others in Gothenburg. One Tanzanian has recently completed a PhD which included bioavailability of iron in fermented gruels. SAREC also funds a small project studying iodination of water. There are a number of Swedish agencies and businesses which have been working on iron fortification of cereals and weaning foods.

Another Swedish development assistance agency, BITS, supports technology transfer and training. It funded a scientific exchange program between ICH and Sudan for a decade and new programs of that type are now in operation with China and Pakistan. The program supported the PhD research of Mohammed El Tom on iodized oil capsules and his subsequent work on iodation of sugar.

(For further information please contact: Dr T Greiner, SIDA Nutrition Adviser, International Child Health Unit. Uppsala University, Entrance 11, 751 85 Uppsala, Sweden. Tel: 46 18 665937 Fax: 46 18 515380)
UNICEF

UNICEF is committed to working with all countries to achieve the three goals, for each of the micronutrients, by the year 2000. There is an agreement about to be launched to virtually eliminate iodine deficiency by the end of 1995. UNICEF will help to do this through its regular country programmes (in one hundred countries). The substantial resources required will come primarily from country programmes in some way. UNICEF is committed to developing national plans of action for the achievement of the goals of the World Summit for Children: it is anticipated in many respects that these plans of action will be closely linked to the plans of action for achieving the objectives of the International Conference on Nutrition.

The emphasis will be, as far as possible and in almost all respects, on developing a community based approach, working within the existing UNICEF programmes, strengthening present activities in community based health care for the support, protection and promotion of breastfeeding, the EPI programme and linking programmes to that as far as possible. UNICEF will not generally support separate vertical programmes.

At the international level, UNICEF will continue to support institutions which are developing approaches to training and improving monitoring and evaluation. UNICEF will continue to work closely with WHO in this respect. UNICEF will continue to support organizations such as PAMM and ICCIDD. UNICEF will also participate in the Micronutrient Initiative. UNICEF's work will continue in close collaboration with WHO (see WHO section below).

(For further information please contact: Dr D Alnwick, Senior Adviser, Micronutrients, Nutrition Cluster, Programme Division, UNICEF, 3, UN Plaza, New York. NY 10017, USA. Tel: (212) 326 7057 Fax: (212) 326 7336)
UNU

Anaemias, the great majority of which are due to iron deficiency, constitute the most universal and prevalent nutritional problem in the world. WHO estimates that 56% of pregnant women in developing countries and one-third of women of child bearing age and preschool children are anaemic. Most of the remainder are iron deficient with consequences ranging from higher reproductive losses, impaired cognition, reduced physical capacity, increased susceptibility to infection and higher morbidity from infectious disease. UNU and WHO have developed a master protocol for comparing the effectiveness of a weekly versus a daily iron supplement in anaemic pregnant women, in adolescent girls and in preschool children.

Four proposals in each category have been approved and support from various sources is pending. It is anticipated that these studies will begin soon providing initial information for policy decisions by mid-1994. If the results of these studies are positive, adoption of community- or clinic-based weekly iron administration could be universally recommended rather than daily supplementation. This would result in great savings and consequently allow much wider coverage of communities than at present. Widespread adoption of this approach might render it feasible to attain the goal of the World Summit for Children and the International Conference of Nutrition of reducing the prevalence of anaemia in pregnant women by one-third of the 1990 levels by the year 2000. It is therefore an operational research of crucial importance and urgency for the health of women and children.

(Source and contact for further information: Dr Nevin Scrimshaw, The United Nations University, Food and Nutrition Programme for Human and Social Development, Charles Street Station, PO Box 500, Boston, MA 02114-0500, USA. Tel: (617) 227 8747 Fax: (617) 227 9405.)
USAID

USAID supports activities addressing a broad range of nutrition concerns, focusing on diet quantity and quality. These include women's and infant nutrition, nutrition communications, and micronutrients. In the latter category, USAID has long standing programmes in vitamin A and iron; and, most recently, has begun activities in iodine in certain countries.

USAID has had a vitamin A programme and an iron programme in place since the mid-1970s - the vitamin A activities in fact began in 1965. Activities are carried out in USAID-supported countries, in collaboration with in-country counterparts, other donors or international organizations, and non-governmental organizations both US-based and indigenous. The programme supports applied research, including studies to increase the scientific basis for understanding the relationship between micronutrient deficiency and childhood morbidity and mortality, refinement of assessment techniques, especially trying to find appropriate low-tech ones, and testing out and evaluating innovative interventions for sustainable control of micronutrient deficiency.

Technical assistance and training is provided to determine location and extent of micronutrient deficiency, at national and sub-national levels; to assist countries in development of institutional capacity for sustainable programmes, and to determine appropriate intervention strategies, evaluation of their effectiveness, and documenting lessons learned. Training is undertaken to develop a cadre of qualified individuals in host countries to ensure sustainability of programmes. In this regard USAID recently supported the development of country reports for the ICN, information collection and dissemination through support of consultative groups such as IVACG and INACG, and development and publication of state-of-the-art documents on micronutrients. Support is given to international meetings and publication and dissemination of reports on experiences of programme implementation - such as compilation of home and community gardening experiences - in newsletters, such as the Xerophthalmia Bulletin, Vital News, and other publications.

To reach the goal of the elimination of micronutrient malnutrition USAID supports integration of micronutrient delivery systems with other child survival activities; targeting interventions to areas, communities, age groups and seasons of highest risk; and selection of complementary interventions to enhance sustainability and impact based on conditions unique in each programme situation, or each country, rather than dependence on a single intervention. USAID engages in agricultural food processing and other relevant areas, including in the private sector, to ensure adequate micronutrients in food supplies, and access to food by needy segments of the population, as well as continued research in support of programme and policy decisions.

In our future is a new project called OMNI. This is based on experience in specific micronutrient activities and eventually will be all-encompassing, although initially dealing with the Big Three of vitamin A, iron and iodine, building up as new information becomes available about other micronutrients.

USAID carries out activities through projects in specific countries. USAID depends on individual missions located in specific countries, when these agree for us to do activities there, and identify host country counterparts.

(For further information please contact: Office of Nutrition, USAID, 320 21st Street, N.W., Washington, D.C., 20523, USA. Tel: 703 875 4074 Fax: 703 875 7483)
Wageningen Agricultural University

The major activities related to micronutrient malnutrition in Wageningen Agricultural University (WAU) are in the Department of Human Nutrition but other departments, such as Food Technology, Agronomy, Human and Animal Physiology, and Extension Science also contribute to the effort. The International Agricultural Centre (IAC) has developed a strong programme of international courses including those in food science and human nutrition (ICFSN), and in recent years, more attention has been developed to micronutrient malnutrition. The various activities are described below.

Training courses

· International Course on Food and Nutrition Programme Management (IAC) (6-weeks course since 1984 with participants from micronutrient programmes such as vitamin A programme in Vietnam)

· Management training in vitamin A programme in Vietnam (WAU/IAC)

· Food fortification module of PAMM training since 1992 (IAC)

· Extension module (provisional) of PAMM training (IAC)

· Proposed 4-week courses on micronutrient malnutrition in ECSA countries, Indonesia and Eastern Europe based on earlier experience

· MSc training (WAU) has emphasis on micronutrients with many students carrying out projects in this area.

· PhD training: 7 PhD fellows working on micronutrient problems including three from overseas

Research (WAU)
· Prevalence studies (Tanzania, Ethiopia, Malawi and Vietnam)

· Studies on mechanisms in humans (Ethiopia and Indonesia) and appropriate animal models

- inter-relationships between vitamin A nutriture and infection/immunity
- inter-relationships between vitamin A and iron nutriture
· Studies on developing and evaluating intervention strategies
- effect of iron and/or iodine supplementation on increasing physical, mental and psychological performance of children in an iodine-deficient area (Malawi)

- factors influencing the effectiveness of oral dosing with iodized oil in increasing iodine status (Malawi)

- examining ways of increasing vitamin A and iron status using available and acceptable food sources (Indonesia and Vietnam)

· Work aimed at increasing the quality and compatibility of data on food composition
- in Europe: FLAIR Eurofoods-Enfant Project

- in ECSA countries and Vietnam: food tables produced

- worldwide: through INFOODS and FAO initiatives

Missions
· Evaluating the prevalence and severity of micronutrient malnutrition

· Assisting in the establishment and maintenance of projects/programmes to combat micronutrient malnutrition

· Evaluating the effectiveness and performance of projects/programmes

Collaboration
· Institutes/agencies in Africa, Asia and Europe (West and East)

· International agencies including EEC

· Industry

· Program Against Micronutrient Malnutrition

(For further information please contact: Dr C West, Department of Human Nutrition, Wageningen Agricultural University, PO Box 8129, 6700 EV, Wageningen, The Netherlands. Tel: 31 8370 82589 Fax: 31 8370 83342)

World Food Programme

Four types of interventions were identified during the ACC/SCN Micronutrient Forum for improving micronutrient malnutrition: (1) Dietary diversification, (2) Food fortification, (3) Pharmaceutical supplementation, and (4) Public health measures.

Below is a description of WFP involvement in these types of interventions for both development and humanitarian assistance type projects.

Dietary Diversification

Food aid distributed to a household has an income transfer value, thus it increases the overall availability of resources to the household. While increased income is not necessarily a sufficient condition for improved micronutrient nutrition, the poorest populations, those served by WFP, have high income elasticities for micronutrient-rich foods.

Breastmilk is a good source of micronutrients and WFP promotes breastfeeding in all its projects. A circular was distributed to all staff in August, 1990, noting the different ways food aid projects are instrumental in promoting breastfeeding.

Food Fortification

There are a number of ways that WFP-supplied food commodities provide micronutrients through fortification. First, many WFP commodities are delivered fortified; for example, several donors fortify with Vitamin A, such as the US who fortifies processed cereals, some Scandinavian donors fortify vegetable oil, and most donors fortify dried skimmed milk. Salt is fortified with iodine and blended foods are usually fortified with a variety of vitamins and minerals. WFP has a policy regarding vitamin A fortification of dried skimmed milk and is currently instituting one on iodine fortification of salt.

Supplementation

WFP has a comparative advantage in the logistical system it developed to bring food commodities to very large numbers of people on a regular basis. This system could also be used to distribute micronutrient-rich foods and pharmaceutical agents. In Paraguay, for example, it is used to distribute LUGOL for combatting iodine deficiency.

Many supplementary and therapeutic feeding programmes against micronutrient malnutrition in refugee and displaced person feeding situations are administered by NGOs and use WFP food aid for this purpose.

Public Health Measures

WFP provides support to the health sector several ways. Food aid is used as an incentive for women to attend health facilities, to benefit from health education classes, for compensating people to build infrastructure for sanitation purposes (e.g. latrines, water storage containers, waste disposal), and can be monetized for essential non-food inputs.

WFP's arrangements for reaching large numbers of individuals on a regular basis can be used for additional public health benefits. On the island of Rodrigues in Mauritius, for example, this system is used for a parasite infection control programme in the primary schools.

(For further information please contact: Ms Judit Katona-Apte, Senior Programme Advisor, World Food Programme, 426 via Cristoforo Colombo, I-00145, Rome, Italy. Tel: 396 5797 5804 Fax: 396 5797 5652)
WHO

All three deficiency disorders have been the subject of a number of resolutions of the World Health Assembly. At regional level, Member States in Africa, South-East Asia and other regions have already declared through several WHO regional committee resolutions their resolve to control or eliminate iodine deficiency disorders, vitamin A deficiency and nutritional anaemia.

WHO and UNICEF, having formulated and adopted the micronutrient goals for the 1990s then included these in the World Summit for Children convened in New York in September 1990 and attended by 71 Heads of State and senior policy-makers from 80 other countries. Then in October 1991, WHO and UNICEF convened the monumental Montreal conference “Ending Hidden Hunger”, a policy conference on micronutrient malnutrition. It brought together over 300 people - ministers, policy-leaders and scientists - from 55 countries, and representatives of over 50 intergovernmental organizations actively interested in collaborating to overcome micronutrient malnutrition. The momentum of these events were then fed into the International Conference of Nutrition convened by WHO and FAO in Rome, December 1992. The World Declaration and Plan of Action for Nutrition was adopted by acclamation on 11 December 1992 and all Member States participating at the Conference indicated their determination to work together to end the human tragedy of all forms of malnutrition. Both the Declaration and the Plan of Action provide substantial commitment and guidance for national action on micronutrient malnutrition.

Global Micronutrient Monitoring - the WHO Micronutrient Deficiency Information System (MDIS) For all 3 micronutrients - iodine (IDD), vitamin A (VAD) and iron (IDA), 3 linked databases have been established and are under development: prevalence data of IDD, VAD, IDA for all countries; control programme information, giving the status and progress of national control programmes; bibliographic reference database containing all published and unpublished reports that WHO can get access to.

The publication “Global Prevalence of Iodine Deficiency Disorders” is the first major output from MDIS. Similar publications for the Vitamin A Deficiency Situation, and for Iron Deficiency Anaemia, are likely to be ready later this year.

Similarly the structure and indicators for reporting on national control programmes are well under development.

The ultimate aim of MDIS is not just reporting at world forums on the current prevalence of micronutrient malnutrition, or on progress in national control programmes. Even more important is assisting countries to establish and operate their own effective micronutrient surveillance systems - so that governments can watch their own progress towards the goals of elimination, can regularly report on the populations still affected, and can monitor their own efforts at establishing adequate control programmes.

Joint WHO/UNICEF/ICCIDD Global Verification Commission for Elimination of IDD. Closely linked to national and global IDD surveillance is the possible development of a Global Verification Commission for Elimination of IDD.

It is still only under discussion, but the concept is similar to that of the Global Smallpox Eradication Commission and would allow for global recognition that a country had formally succeeded in reaching the criteria for sustainable elimination of IDD, and for reporting this to the World Health Assembly.

WHO'S Normative Role. So far some of WHO'S policy surveillance activities with respect to micronutrients have been summarized. Other normative functions include ensuring that relevant critical research is carried out, the results published, and transferred in utilizable form to strengthen national programmes for tackling micronutrient malnutrition. Recent examples of this sort of work include:

- The Joint WHO/UNICEF/ICCIDD Consultation on Indicators for Assessing IDD;

- The Joint WHO/UNICEF Consultation on Indicators of Vitamin A Deficiency;

- The Joint WHO/USAID/NEI Consultation on Vitamin A Mortality and Morbidity Studies;

- National Strategies for Overcoming Micronutrient Malnutrition.

The next such event is a planned consultation: Joint WHO/UNICEF/UNU/USAID Consultation on Iron Deficiency Anaemia.

Regional Action. The strength of WHO'S outreach and support to countries lies in its Regional Office network where WHO Regional Nutrition Advisers - and their field staff in some countries - provide technical support to the countries in their regions. This involves Regional (inter-country) support, workshops, micronutrient task forces, and then financial and technical support.

Support for National Micronutrient Programmes. By far the main emphasis, thrust and action output of the WHO Nutrition Programme - through its combined strength of headquarters, Regional Office and field support - is to support the development of national nutrition capabilities - and hence for micronutrients, to ensure each government and country can adequately tackle, reduce and eliminate micronutrient malnutrition.

With the added momentum, generated by the International Conference on Nutrition, WHO has focussed its attention on providing essential technical and catalytic support to the World's Least Developed countries. Some 86 countries have been identified as needing support for developing their national nutrition programmes. Fifty of these countries are “Least Developed Countries” including 28 in the African Region, 3 in the Americas, 5 in the Eastern Mediterranean, 6 in South East Asia and 8 in the Western Pacific. The majority of these have some form of widespread micronutrient malnutrition of moderate/severe degree.

WHO has received requests from 42 countries so far - for help in developing the national nutrition plans of action - many including a substantial micronutrient component. WHO has been able to provide funds so far to support 19 of these countries, and technical support to some others.

(For further information please contact: Dr G Clugston, Chief, Nutrition Unit, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 0456 Fax: 41 22791 0746)
World Bank

The World Bank is keen to promote work in developing countries on micronutrient malnutrition. The “Best Practices” paper on micronutrient malnutrition has therefore been drafted to promote its importance and provide technical information. This provides the basis for the first article in this issue.

The World Bank approved a special grant on micronutrients two years ago, which so far has helped to inaugurate the Micronutrient Initiative at IDRC in Canada. The World Bank also plans to provide support to ICCIDD and the PAMM programme.

In addition, the World Bank has project preparation work continuing in about a dozen countries in micronutrient malnutrition.

(For further information please contact: Dr J McGuire, the World Bank, 1818 H Street, N.W., Washington DC 20433. Tel: 202 473 3452 Fax: 202 477 0643)


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