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Nutrition and Food Aid
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The Nutrition Transition

Nutrition and Food Aid

Highlights of the Symposium held at the ACC/SCN 19th Session.

Food aid provides a direct contribution to improving nutrition. In fact, food aid is the largest externally available resource directly applicable to nutrition, amounting to over $2 billion per year.¹ There is long experience in applying food aid, in the UN context through the World Food Programme, and this experience raises a number of nutrition issues. The SCN decided that at its 19th Session, hosted by the World Food Programme in Rome in February 1992, the annual Symposium would be on the topic of "Nutritional Issues in Food Aid". The proceedings of this Symposium have just been published by the SCN (see inside front cover of this issue of SCN News).² Here we summarize some of the main points.

The Symposium was opened by James Ingram, then Executive Director of the World Food Programme, and was chaired by Judit Katona-Apte, Senior Programme Advisor at the World Food Programme. The Symposium was organized into three sets of topics. Public works as a nutrition intervention was introduced by Joachim von Braun of IFPRI. Issues to do with supplementary feeding of young children were covered in papers presented by George Beaton (University of Toronto, Special Advisor to SCN), Juan Rivera (Institute of Nutrition of Central America and Panama), and Philip Musgrove of the World Bank. The SCN returned then to the issue of nutrition of refugees, which had been highlighted in previous sessions, with a third section of the Symposium on this topic, introduced by Mike Toole of CDC. All these themes sought to provide an update of recent knowledge, relevant to improving the nutritional impact of food aid.

The scope ranged from use of food aid in development - "through some three billion dollars worth of development resources that provide food aid to more than 80 million people, WFP tackles the root cause of hunger and malnutrition - namely poverty" as stressed by Mr Ingram in his keynote address, to emergency relief: "WFP's relief work counted for just under half of all shipments of WFP food aid in 1991, to bring succour to 21 million people". One overall conclusion, introduced by Judit Katona-Apte whose article appears in the SCN publication, was that "food by itself can contribute significantly to improving the health and nutritional status of people... to withstand infections better and recover more quickly... pregnant and nursing mothers who receive proper nourishment have healthier babies. Children are better able to learn when they're properly fed. Workers can be more productive if they eat a sound diet. However, as emphasized throughout, food aid is far more effective when combined with other inputs, particularly financial and technical assistance". The first topic, concerning public works as a nutrition intervention, illustrates this point.

Public Works to Improve Nutrition

"By supporting appropriate interventions and instruments, food aid can play a role in promoting food and nutrition security and in reducing poverty. Food aid can be used both to increase demand for food (by backing higher employment policies) and to decrease the cost of production (by supporting labour-intensive investment)", Dr von Braun stated in his introduction. Public works programmes have been widely used, particularly in Asia, to improve food security. Indeed, supporting public works is probably one of the more effective uses of food aid for improving food security. It is important to emphasize that public works can be supported either by cash or by food, both approaches when properly designed and managed helping to improve nutrition. "Whether wages should be in the form of cash or kind (food) depends on local circumstances relating to the risk of market failure" according to von Braun.

The importance of public works in providing for food security was well illustrated in the case of Botswana, described by Mrs T C Moremi, of the Botswana government. Here, a significant part of the population was protected from the effects of prolonged drought through cash-for-work projects. Mrs Moremi explained that Botswana opted for cash-for-work projects because the markets functioned well, and "we thought that in the end it was better not to have parallel food distribution programmes running". However, it is acknowledged that under different circumstances using food directly for payment may have advantages.

The end result of using food aid to support food-for-work or cash-for-work is similar: increased food availability for those employed in the public works schemes thus supported. The two routes for using food aid in this way are illustrated in figure 1. In addition, food aid can be used to protect food supplies when wages are in the form of cash, if this is sufficiently extensive to expand demand for food.

Public works programmes improve welfare in a number of ways, importantly including: increasing income through wage employment in the short run: insuring against risk, particularly when public works are designed as employment guarantee schemes with low wage rates; and employment and income effects from assets created, and improvement in human resources in the long run -this would include through improved nutrition. "Combined, these three effects simultaneously address both transitory and structural food security problems of the poor" said von Braun. In particular, the employment guarantee schemes in India have been widely viewed as an effective buffer against acute food shortage. China has expanded public works programmes enormously during the 1980s. Certain African countries have also used emergency public works to improve food security in times of shortage - including Zimbabwe and Ethiopia, as well as Botswana.

Figure 1 - Two Ways of Using Food Aid for Public Works

One important feature of properly designed public works, in relation to poverty alleviation with low administrative cost, is their capacity to be self-targeting. "At properly defined wage rates, the working poor identify themselves by turning up at public works schemes. The self-targeting feature of public works programmes only operates effectively with an appropriate (low) wage rate policy and a flexible absorption of applications without rationing workplaces" said von Braun. This feature also leads to the possibility of using public works as a test for the actual need for emergency employment programmes. Labour-intensive public works programmes thus also can provide for food security monitoring information themselves, from the extent to which workers enrol in these programmes.

On the other hand, as von Braun as well as the discussants emphasized, public works programmes are not always straightforward to design and manage, and require a significant input of non-wage resources. Issues such as land ownership need to be carefully considered. Non-labour costs may be up to 50% in road construction projects, for example, or lower in other schemes such as forestation or anti-erosion. It is here in particular that coordination with other inputs is valuable. At the same time, the design and management of projects is crucial, and often overlooked, for the public works to be a worthwhile and sustainable investment. There was wide agreement that simply providing employment with little attention to the product was clearly wasteful. Public works projects, even in emergencies, need to be implemented with the same management criteria as other development projects.

At the same time, optimizing the nutritional benefit of the increased food consumption brought about by effective labour-intensive works projects may require complementary inputs, for example in health and sanitation. Moreover, problems of displacing labour, and effects on child care, need to be taken seriously.

In the discussion, Jens Schulthes of the World Food Programme emphasized that the potential of public works programmes was enormous, and providing an important possibility for investment. "Only about 20% of the food aid today is targeted, and out of that about half goes to direct feeding schemes. You can see that food-for-work schemes at the moment take up less than 10%. Retargeting to public works schemes should be feasible, and would have a big effect". In conclusion, Schulthes emphasized that public works, which have had a big effect in India for example, in guaranteeing employment, need to be more widely used. "In Africa, where this is now most needed, there is little yet of the required administrative infrastructure. I think this is where we have to concentrate".

Drawing on experience from Botswana, Mrs Moremi (Coordinator of Rural Development) stressed their generally successful experience in guaranteeing employment and supporting food security through widespread public works schemes. Nonetheless, it should be remembered that "quite a lot of female-headed households who are among the poorest groups, as well as the aged and the disabled, may together account for something like 25% of the absolute poor (in Sub-Saharan Africa), and are simply not able to participate in public works because they do not have time or they do not have the labour". According to Simon Maxwell, who summed-up the discussions "the first conclusion is that... there is enormous scope, and we ought to pursue it. The second conclusion is that food aid can play a very large role in supporting public works, both directly through food-for-work, and indirectly through monetization. A third conclusion is ... that we should not underestimate the real practical problems. In practice public works are extremely demanding in terms of preparation and design... and cash is crucial".

"Beyond this, the scope of public works needs to be looked at carefully. Questions include: exactly which works?" stressed Maxwell "this needs review in terms of labour intensity, nutrition impact, long-term employment effects, etc. Decisions need to be made concerning the type of public works, roads, forestry projects, erosion control, school buildings and health centres, etc. A further step needed is to substantially increase the amount of food used to build public works. Finally, there is a lot we still need to know, particularly on the choices: maybe you cannot have supplementary feeding and food-for-work, so we need better information on relative costs and benefits of these different interventions".

Supplementary Feeding

One major use of food aid is in supplementary feeding of vulnerable groups - for example in 1990/91 this amounted to some 200 million dollars per year, about 25% of WFP's expenditures. The second part of the Symposium addressed a number of issues concerning how to get maximum nutritional benefit from these resources. The first issues concern both the expected benefit, and which age groups to target. The important background here is that for many years preventing growth failure has been seen as the major objective of supplementary feeding, but many programmes have not been very effective in reaching this. Now it is becoming clear that preventing growth failure is not the only benefit, and moreover that this growth failure occurs at an age much earlier than programmes had hitherto been primarily targeted at. This crucial question was first addressed by George Beaton, of the University of Toronto and Special Advisor to the SCN.

An important earlier review of the effectiveness of feeding programmes for young children in developing countries had been completed in 1982 by Beaton and Ghassemi, for the SCN³, and one major conclusion quoted again was: "The general impression gained from that review is that food distribution programmes directed toward young children, as (then) being operated, are rather expensive for the measured benefit. However, the reviewers remain unconvinced that the benefit usually measured, physical growth and development, is either the total benefit to the family and community, or the most important benefit..." Since that time, a number of advances have been made. First, as mentioned above, the timing of growth failure is much better understood now. Second, the complex of disadvantages associated with growth failure is now clearer - including lowered immunity and hence increased morbidity and mortality, physical activity, and psychological development. Third, the very long-term effects of early malnutrition on educability and intellectual development are now becoming established.

Growth failure provides a marker of situations in which a number of aspects of functional development have been impaired. "However," as Dr Beaton said in his introduction "while these different failures may stem from the same cluster of environmental deprivations, it does not follow that they are linked through the same physiological processes, and hence that correction of growth failure will necessarily confer the same benefit as addressing the original causal situation - or that the other aspects of functional development might not be influenced without evidence of a growth response." Nonetheless, as emphasized in comments by Dr Martorell, "the massive growth failure that occurs in early childhood and at no other period in life is a marker of functional impairment in a number of other domains... I also believe that in preventing this massive growth failure through diet and health interventions, we will prevent most of these associated effects". This reemphasizes that intervening at the age at which growth failure is most active is of primary importance. The ACC/SCN Statement agreed at the meeting elaborates on this topic, and is included in box 1.

Growth failure is most active between six and around 24 months of age (see figure 2), and this age range provides a "window of opportunity" for prevention. Results of studies which have led to establishing this rather specific age of growth failure, measured usually in terms of length increment, were presented in some detail by Dr Beaton. Three lines of evidence all pointed to the same conclusion. First, observation of patterns of spontaneous growth faltering in developing countries - data from India, China, Uganda and a number of other countries were quoted - all showed clearly that this growth faltering began at around six months, and was generally complete by around 18-24 months. Second, rapid secular trends in reduced growth faltering observed in China illustrate clearly that this difference occurs in, again, the same period of around 6-24 months. Thirdly, recent carefully designed supplementation trials, as well as reexamination of older data from these, have shown that the major effect in preventing growth failure is in this same early period.

Box 1 ACC/SCN Statement on the Benefits of Preventing Growth Failure in Early Childhood Growth in young children tends to falter very early in many developing country populations, usually beginning by four to six months and ending by two to three years of age. This growth failure is often pronounced, so that by three years of age the size of the majority of children is outside the normal range expected in a well-nourished, healthy population. Once this faltering has occurred, linear growth tends to resume at a rate similar to that observed for children of that age in healthy populations. The growth failure which occurs in young children is only one result of the common combination of inadequate child feeding, high rates of infection, and poor child care. It is now realized that there are other very important effects that need to be prevented. Small size indicates other risks, such as reduced nutrient stores, depressed immunocompetence, increased severity of infections, and poor motor and mental development. It is also a marker of risk of long-term functional impairment, including poor educational and intellectual performance. Among the direct consequences of early growth failure are very short stature and reduced lean body mass in the adult, characteristics which constrain reproductive performance in women and work capacity and productivity in adults engaged in hard physical labour. Attention to child feeding, the control of infections, and good care results in improvements in child growth and other crucial functions. Specifically, some significant recent evaluations have shown that supplementary feeding programmes, where enough food is delivered to and consumed by young children in need, are effective in: - preventing growth failure; - protecting against the negative effects of diarrhoeal diseases on child growth; - improving educational performance, in later years. Programmes that integrate interventions designed to attack the multiple causes of growth failure are most effective in improving child growth. These programmes can be viewed as investments in the future, for they lead to adults with a greater capacity for healthy, productive lives. Interventions that prevent growth failure in early childhood, it is now clear, can be expected to have a range of important short- and long-term benefits. Extracted from: ACC/SCN (1993) (see endnote 2)

Figure 2 - LENGTH INCREMENTS BY AGE IN BOYS (cm / 3 months)

Extracted from: ACC/SCN (1993), p.45 (see endnote 2)

Food supplementation in pregnancy and lactation should be aimed at benefiting the mother herself, as much as the infant in utero or at the breast. Women in developing countries face major responsibility for the health and wellbeing of the household, and inadequate food intake undoubtedly has a negative impact on the mother. In particular, there is now good evidence that the supplementation of pregnant women in severely constrained settings can improve intra-uterine growth and birthweight; although the effects are small, they do appear to have an impact on infant morbidity and survival. Thus, in a sense, the opportunity for protecting infant growth and development also exists before birth. "If once we accept this argument, then we must also accept the logical argument that we should be concerned about the adequacy of food intake of girls before pregnancy begins", says Beaton. Thus the inter-generational effect of small babies becoming small adults and having small infants needs to be interrupted at several stages.⁴

Establishing that the age range of around 6-24 months is the period of active growth failure goes a considerable way towards explaining the often negative findings in the review of feeding programmes ten years ago: most of these programmes reached children of two years and older. The overall conclusion here then is that "one should no longer feel doubtful about the potential impact of supplementation programmes on growth... the effect is concentrated in the 'window of opportunity' of 6-24, or possibly 36 months old" as summarized by Dr Martorell. We should not be reticent in laying out the benefits to be expected from preventing this growth failure: in sum, better health, better individual development, happier people, higher educational attainment: better "human capital".

Supplementation is Particularly Effective in Counteracting Growth Failure from Diarrhoea

Striking results have been found when the effects of supplementation on growth have taken account of diarrhoea. Three studies were described in some detail by Dr Juan Rivera, INCAP, based on work in Colombia, Guatemala, and Peru. These all showed, with some variation, an interactive effect of diarrhoea and food intake - that is that food is especially effective in counteracting diarrhoea. In all three cases, there was a much greater growth inhibitory effect of diarrhoea among children who were not receiving a supplement, or otherwise eating less. For example, in Bogota, Colombia, a five cm difference in achieved height by 36 months of age was found between those with and without the supplement and having the greatest degree of diarrhoea; while those without diarrhoea grew much the same either way. In the INCAP study, in Guatemala, a similar result was found, except that some effect of the supplement on growth was also found in those with less diarrhoea. This difference was ascribed to a lower underlying intake of energy in the latter study. Confirmatory results from observing usual energy intakes, diarrhoea incidence, and weight change, from studies in Peru, again showed a greater effect of diarrhoea in those with inadequate food intake (less than 75% of recommended intakes).

"A possible mechanism explaining the larger effects in children with diarrhoea is an increase in appetite immediately after the diarrhoeal episode" according to Dr Rivera. When appropriate foods are available to meet the increased appetite, the negative effects of diarrhoea on energy balance may be offset.

Other interesting conclusions from the studies, pointed out by Dr Martorell, were "first, growth rates after about three years of age were similar in the Guatemalan population to values found in well nourished populations". This links with other findings, that growth over longer periods (up to 18 years of age) in Guatemala was just a few centimetres less than seen in the United States - and in fact a little more than found in Mexican Americans growing up in the US.

These studies also reinforced the characterization of the first few years of life as the age of growth failure. The studies quoted by Dr Rivera showed that the supplement had no effect on growth rates after three years of age.

Related studies on long-term effects of improved childhood nutrition⁵ are also relevant in this context. Studies at INCAP had also shown that "improving the diets of young children in Guatemala had both an immediate payoff in terms of reduced prevalence of stunting, and also resulted in enhanced physical and intellectual status in adulthood".

Education and Weaning Food Supplements

The use of external food aid in supplementary feeding and weaning of young children poses some specific problems, brought out by Dr Ken Bailey of WHO and the AGN. One well known issue concerns the introduction of non-traditional foods, such as wheat, into many rural areas in Africa, which can induce a change in dietary patterns. This is particularly concerning when the food aid itself is only transitory. In the case of feeding young children - a point made later in the context of Latin America - it is often important to be aware that the problem is not so much a lack of food in broad terms, as constraints in the feeding and care of young children. "... my estimate is that food aid is often used in countries and even for vulnerable group feeding, where there is no real shortage of food", says Bailey.

Better use of local foods can be promoted by "making suitable weaning food mixtures locally, using appropriate technology in the form of simple equipment of existing machinery such as corn mills" according to Dr Bailey. "In a few countries, WFP is using local weaning food plants to produce mixtures of local beans and cereals, such as Weanimix in Ghana, Misala in Burundi and Likuni Pala in Malawi. WFP purchases these products locally and thus the possibility exists at least, to show the people the proportions used, and how to make these mixtures themselves using local cornmills."

This also emphasizes the need for targeting in terms of seasonality. It would be much better to provide food aid to needy families in rural areas during the pre-harvest season. This sensible idea is as yet not widely enough applied.

Feeding Latin America's Children

Turning to the practical application of food aid and supplementary feeding, experiences in Latin America were presented by Philip Musgrove of the World Bank.⁶ "More than US$1.6 billion is spent annually on 104 programs in nineteen Latin American and Caribbean countries to subsidize or provide food for people supposedly at risk of malnutrition. This amount constitutes only 0.2 percent of these countries' gross national product. If there is no double-counting, these programs reach more than 80 million people, or 21 percent of the population, at a cost of $20 per beneficiary or $4 per capita. Yet some 10 million children are malnourished, which suggests that the expenditures are poorly directed or ineffective. There is little hard evidence that these programs are preventing much malnutrition; even curative results are seldom measured. The effort is too small in some countries with great needs, while other countries have nearly eliminated malnutrition. Where coverage is high, programs - although generally targeted and with sensible criteria - do not always reach the neediest. They may also fail to provide enough food or to combine food with the health care and nutritional education necessary to attack all three root causes of malnutrition: poverty, disease, and ignorance. The evidence, limited mostly to program inputs rather than results, suggests that greater progress against undernourishment is possible even with current spending levels."

Overall, the programme participants (nearly 100 million people) are about half primary school children, and a quarter children under five. This amounts to around 54% of the under five population, and 65% of the total primary school population. "If the expenditures ($20 per beneficiary, or about $4 per caput) were concentrated on the nutritionally neediest one tenth of the population, that would mean a transfer on the order of $40 per beneficiary per year." Moreover, Musgrove concludes that "if the resources now being spent were concentrated on currently malnourished children... it seems plausible that malnutrition could largely be eliminated from the region." The range of expenditures per beneficiary varies from around $10 per year up to nearly $60 per year (e.g. in Peru or Jamaica). A figure of around $35-40 per year is taken as that likely to be effective - based in part on experiences in Chile, with the National Supplementary Food Programme. With a unit cost of $35, the 1.6 billion dollars spent on these programmes could adequately cover 47 million beneficiaries or about 56% of the present coverage.

Malnutrition has not been eliminated despite these programmes although the trend has generally been for improvement in the region.⁷ One reason is that the coverage of programmes is not necessarily related to need, both between countries and within countries. "At one extreme is Chile, where malnutrition has been reduced so far that current spending covers 70 times as many beneficiaries as there are malnourished children in the country" explains Musgrove. "At the other extreme are countries where current spending simply would not be enough. This is the case in Bolivia and Guatemala which could only provide (with current resources) for some three fourths of children in immediate need." But uneven coverage is only part of the story. "Ineffective use of resources within countries is the other reason why the substantial level of expenditure reported here has not succeeded in eliminating malnutrition". However, information on effectiveness of resource use is scarce. Impact evaluations are necessary, but rare. In fact, "most of the programmes reviewed here have never been evaluated". But those evaluations that have been undertaken have, unfortunately, shown that a number of programmes have had little effect. There are various reasons for this, among which is the "failure to measure preventive benefits... another is that rations are often too small to make much difference... and finally, failure may easily result from simple irregularity of operation that plagues many programmes".

In the ensuing discussion, introduced by Dr Eileen Kennedy from IFPRI, this question of level of supplementation was again raised - "from a low in Mexico of 140 kcals (per beneficiary per day) and high of slightly over 1000 in Costa Rica... it is unclear exactly how one decides where to set the level of supplementation...". "Recommendations on levels of micronutrients are also needed - in southwestern Kenya, holding total calories constant, a beneficial effect was found of increasing the percentage of animal protein in the diet. Thus in considering supplementation packages, we should not only be thinking about absolute levels, but also about quality issues, including micronutrients".

The issue of what the objective of supplementary feeding is - as introduced in earlier papers - returns in this context. As Musgrove put it: "the problem is this: turn it around, start at age ten and look back. At age ten, I want a healthy, normal size child that has already been in school for three or four years. Now, what is the best distribution of resources between the child's conception and its tenth birthday, to get there? This is what I think we do not know." Emphasis was placed on the point that non-food inputs are crucial - not only addressing poverty, but ill-health and educational issues. Many agreed that "in most programmes (not all) too much emphasis is on food, too little on the other inputs, and this tells you the direction to push in - move away from the present balance towards more health care and more education. But back to the objectives: try to figure out what the problem is before specifying the solution". (See also box 2.)

Nutrition of Refugees

Refugees are the most nutritionally vulnerable group in the world, by far, and their numbers are increasing fast. The refugees' nutrition crisis has been of major concern to the Sub-Committee, for example as described in SCN News No. 7, mid-1991. International refugees, and many internally displaced, are dependent upon food aid, so issues of protecting refugees' nutrition with food aid were of priority in the Symposium. The subject was introduced by Dr Mike Toole, of CDC Atlanta, who summarized the problem both in terms of malnutrition and mortality, and micronutrient deficiencies.

"The synergism between high malnutrition prevalence and increased incidence of communicable diseases explains much of the excess mortality in refugee and displaced populations" he said. Many studies have now shown that where acute malnutrition prevalences are low (e.g. less than 5% wasting) crude death rates (CDRs) tend to be similar to the host population, around 0.3/10,000/day. Refugee populations with malnutrition prevalences much higher, for example around 50%, experience crude death rates very much higher. These high prevalences of acute malnutrition are due to either quite inadequate food rations, high incidence of infections, particularly diarrhoeal disease in camps, and usually a combination of both.

"The importance of micronutrient deficiencies in refugee and displaced populations has only recently been extensively documented. In addition to deficiencies of vitamin A and iron... large epidemics of scurvy and pellagra have been reported in refugee populations during the past decade." The risk factors for, for example, scurvy and pellagra are now well understood, as indeed are the prevention measures. "Both protein-energy malnutrition and micronutrient malnutrition among dependent refugees can be readily prevented by the prompt provision of a basic food basket sufficient in quantity and quality," emphasizes Dr Toole. "The world's response to refugee and other international emergencies needs to be consistent, based on sound technical assessments, and systematically evaluated to ensure that food and other humanitarian assistance produces the desired impact on the affected population."

Box 2 "The other problem is that the people who defend these programmes politically do not always do so on nutritional grounds - they are just as likely to defend them on the basis of income distribution. In fact that's often the last resort. If you take a look at a long list of objectives that somebody would state for his programme and it was possible (with data) to go knocking them off one by one - say, well you say that the kids will grow faster but here's the data and they don't; and you say that they are going to stay in school longer, here's the data and they don't - when you get them all the way back in a corner, he will throw up his hands and say "but we redistributed income!" and he's got you there. This is a real serious problem - and it's the scoundrel's last resort. How do we value this? What is it worth to us - anything? If nothing then we should not allow this, but if it is worth something, we need a way of judging it compared to the other things that we are trying to accomplish. One of the advantages of claiming a long list of objectives is that you always have this escape. I think we have a problem of not having any idea how to value one objective versus another; we have something much worse than apples and oranges here. We have no notion in general, of whether it is worth more for a one year old to be the right size at age three or whether it is worth more for a seven year old to stay in school for another year. If somebody says "I'll give you what it costs to produce either of these results, but you can only have one of them" I think we have no idea what to do next." Extracted from: ACC/SCN (1993), p.80 (see endnote 2)

Comments were given by John Seaman, Save the Children Fund (SCF) UK, Basra Hassan, SCF Sudan, and Ms Rita Bhatia, UN High Commission for Refugees. The comments revolved substantially around issues of information and accountability: "...there is no system whereby anyone can be held accountable if the proper information is not available..." said Rita Bhatia. Such considerations contributed to a coalition of SCN members and NGOs beginning in September 1993 to systematically report on refugees' nutrition.

There were around 18 million international refugees, of whom approximately 13 million were living in camps in remote areas of Africa, the Middle East, and South West Asia. In addition, up to 20 million internally displaced persons were dependent on some kind of international food aid for their survival. These figures have only increased since then. To give a picture of the desperate nutritional deprivation of these people, many tragic stories can be told. Basra Hassan, a nutritionist with Save the Children Fund in Sudan, and herself a refugee from Somalia, told of outbreaks of anaemia in Somali camps from which many women died within 2 months of giving birth; leading to a programme of supplementation with liver on a daily basis for those who were strong enough to take it, others receiving iron injections.

She illustrated the dilemma of registration, from the refugees' perspective with a dialogue between two women. One went to a registration centre and when she came back she met another on the way: "Where are you coming from?" "I am coming from the registration centre." "What did you tell them?" "I told them about the members of the family." "How many?" "Nine" "You are foolish, you know. You are not intelligent enough. Why did you not double the number?" "I do not like lying and also it is against the religion." "Do you want to starve the children? There are times the religion allows you to tell lies when these things touch on your survival."

And she finished by saying "for refugees, the UN is their parent, particularly UNHCR and WFP people. They should think of themselves as the fathers of their families. A concerned father who left his children at home knowing that there was nothing left to feed them would think about and be very concerned about how he would feed his family, unlike a father who is not concerned. What is the use of a father who cannot feed his family?"

J.B.M.

1. From "Updated Report on the Estimation of External Resource Flows in Relation to Nutrition". ACC/SCN, 8 December 1993 (table 10). The 1989-91 figures were: WFP total funding $864 million; bilateral $1,292 million.

2. ACC/SCN (1993). Nutritional Issues in Food Aid. Papers from the ACC/SCN 19th Session Symposium. State-of-the-Art Series Nutrition Policy Discussion Paper No. 12, ACC/SCN, Geneva.

3. Beaton, G. & Ghassemi, H. (1982). Supplementary Feeding Programs for Young Children in Developing Countries. American Journal of Clinical Nutrition, 35, supplement, 864-916.

4. See ACC/SCN (1992). Second Report on the World Nutrition Situation. Volume 1, p.56-57; SCN News No. 5, Early 1990, p.19.

5. See SCN News No. 8, Late 1992, p10-12, "Long-Term Effects of Improved Childhood Nutrition"

6. Dr Musgrove's presentation was based on the World Bank publication "Feeding Latin America's Children" (Musgrove 1991); the text here is taken directly from the article published in January 1993 in The World Bank Research Observer, 8, 23-45 - reproduced with the permission of the World Bank.

7. See ACC/SCN (1992). Second Report on the World Nutrition Situation. Volume 1, p.34-38; SCN News No. 8, Late 1992, p1-3.

Nutrition and Human Rights

Although the idea that adequate nutrition should be regarded as a fundamental human right appears in many different contexts in international law - these are not binding in practice. George Kent, of the University of Hawaii summarizes the current situation.

1. Full address: Department of Political Science, University of Hawaii, Honolulu, Hawaii 96822, USA. Tel: 1 (808) 956 8743 Fax: 1 (808) 956 6877 E-mail: KENT@UHUNIX.UHCC.HAWAII.EDU

In the Convention on the Rights of the Child, which came into force in 1990, two articles address the issue of nutrition. Article 24 says that "States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health . . ." and shall take appropriate measures "to combat disease and malnutrition" through the provision of adequate nutritious foods, clean drinking water, and health care. Article 27 says that States Parties "shall in case of need provide material assistance and support programmes, particularly with regard to nutrition, clothing, and housing."

The rights idea was voiced frequently at the International Conference on Nutrition organized by the Food and Agriculture Organization of the United Nations and the World Health Organization and held in Rome in December 1992. In his address opening the conference His Holiness Pope John Paul II said "It is up to you to reaffirm in a new way each individual's fundamental and inalienable right to nutrition. The Universal Declaration of Human Rights had already asserted the right to sufficient food. What we must now do is ensure that this right is applied and that everyone has access to food, food security, a healthy diet and nutrition education."

In the conference's concluding World Declaration on Nutrition the nations of the world agreed that "access to nutritionally adequate and safe food is a right of each individual." However, there was nothing in the accompanying Plan of Action for Nutrition to elaborate that right, nothing providing for clear entitlements with effective accountability.

While the idea of the right to food appears in many different contexts in international law, most are not binding. In some cases, as in the International Covenant on Economic, Social, and Cultural Rights, the obligations are technically binding on the States Parties. However, because the obligations lack specificity and because there are no effective mechanisms for implementation and accountability, they are not binding in practice.

Several nations have articulated nutrition rights in some form in their laws. Cuba's constitution assures that "no child be left without schooling, food and clothing." The Italian, Spanish, and Greek constitutions assure a right to health. In many countries there is language referring to other sorts of assurances, such as the right to social security (as in the Netherlands and Spain) that can be interpreted as implying nutrition rights. In most cases, however, the assurances are vague and have not been enforced through the courts. There is practically no elaboration in detailed statutes of distinct nutrition rights, and no legal enforcement. Although there have been many expressions of concern, and many laudable anti-hunger programs at local, national, and global levels, the idea of the right has not yet been implemented.

On reviewing the hunger data, Philip Alston and Katarina Tomasevski observed that "these statistics make hunger by far the most flagrant and widespread of all serious human rights abuses." Alston (who presently chairs the United Nations Committee on Economic, Social, and Cultural Rights) added that "the right to food has been endorsed more often and with greater unanimity and urgency than most other human rights, while at the same time being violated more comprehensively and systematically than probably any other right." The idea that people should have a right to adequate nutrition is an old one, one whose vision has not been fulfilled.

New Initiatives

Local, national, and international nongovernmental organizations have been working on the problem of malnutrition in many different ways for decades. Now, for the first time, several have emerged specifically to press the view that people should be adequately nourished as a matter of human rights. During the International Conference in Rome in December 1992, several international nongovernmental organizations agreed to work together under the umbrella of the World Alliance on Nutrition and Human Rights. Its newsletter and other information on WANAHR can be obtained from the Secretariat at the Norwegian Institute of Human Rights, Gensen 18, N-0159 Oslo, Norway (Phone: 47 22 42 13 60; Fax: 47 22 42 25 42).

Several distinct but overlapping ways of dealing with nutrition as a human right have emerged. A comprehensive analytic approach has been developed by Asbjorn Eide, Arne Oshaug, and Wenche Barth Eide in their work at the Norwegian Institute of Human Rights and the Nordic School of Nutrition at the University of Oslo in Norway. It is based on a detailed analysis of the root causes of malnutrition. It treats the alleviation of malnutrition not as something held in isolation but as an integral part of the challenge of national development. Their analysis shows, in a matrix format, that there are specific national obligations to respect, protect, and fulfil the right to adequate nutrition. These obligations apply to food security, adequate care, and adequate prevention and control of diseases.

FIAN is the acronym for the Foodfirst Information & Action Network, an "International Human Rights Organization for the Right to Feed Oneself." It focuses on the international dimension, calling attention to what it identifies as violations of the right to feed oneself. Through its international newsletter and its chapters in several countries around the world, it organizes "FIAN Urgent Actions" to correct these violations. At the World Conference on Human Rights in Vienna in June 1993, FIAN took the lead in advocating an Optional Protocol to the International Covenant on Economic, Social, and Cultural Rights that would allow individuals to bring complaints to the United Nations Committee on Economic, Social, and Cultural Rights. The FIAN International Secretariat can be contacted at: PO Box 102243, D-Heidelberg, FR Germany. (Phone 49 62 22 50108; Fax 49 62 22 50107).

Several Task Forces under WANAHR pursue particular themes. The Task Force on the Use of Food as A Weapon of War or For Political Purposes promotes compliance with the prohibition of food deprivation as a method of war. It advocates a total ban on the withholding of food for political ends when it deprives needy people of food.

The Task Force on Monitoring and Implementation of the Right to Food, working closely with FIAN, is promoting three major types of activities. First, it proposes a meeting to further clarify the obligations of States Parties to the International Covenant on Economic, Social, and Cultural Rights. Second, with FIAN it is campaigning for the Optional Protocol to the covenant. Third, it proposes strengthened monitoring procedures in relation to the work of the United Nations Committee on Economic, Social, and Cultural Rights and the Committee on the Rights of the Child.

Another approach is promoted by the Task Force on Children's Nutrition Rights (of which the author of this article serves as coordinator). Its premise is that the idea of the right to adequate nutrition is likely to be more acceptable, more politically feasible, if it focuses on children. The Task Force encourages the organization of national workshops on the theme. Their purpose is to launch locally-based long-term campaigns to strengthen children's nutrition rights, giving attention both to their articulation in the law and the effective implementation of that law. Individuals from both governmental and nongovernmental organizations are invited to participate.

The first workshop was held in Guatemala in February 1993 and the second in Mexico in May 1993. Others are planned, and discussions are underway with potential organizers elsewhere. Organizers are being asked to invite individuals to their workshops who might arrange similar programs in other nations in their regions. Hopefully this will lead to an ongoing process of facilitation, networking, and learning. The Task Force is confident that this process will in time lead to increasing recognition of children's right to adequate nutrition.

The Task Force has been concerned with elaborating the conceptual bases for its work, especially to set its directions for the future. Some of these views are described in the following sections.

Rings of Responsibility

Our principal obligation toward children is to promote their development, understood as empowerment or increasing self reliance. The task is to help increase children's capacity to define, analyze, and act on their own problems. Who is responsible for carrying out these obligations? Many different social agencies may have some role in looking after children, but what should be the interrelationships among them?

As children mature the first priority is to help them become responsible for themselves. So long as they are not mature, however, children ought to get their nurturance from their parents. Failing that, they ought to get it from their local communities. Failing that, they ought to get it from the local governments. Failing that, it should come from their national governments. Failing that, they ought to get it from the international community. The responsibility hierarchy looks like this:

child
family
community
local government
state government
national government
international nongovernmental organizations
international governmental organizations

We can picture this as a set of nested circles, with the child in the centre of the nest, surrounded, supported, and nurtured by family, community, government, and ultimately, international organizations.

This is straightforward. The idea that needs to be added is that in cases of failure, agents more distant from the child should not simply substitute for those closer to the child. Instead, those who are more distant should try to work through and strengthen those who are closer to help them become more capable of fulfilling their responsibilities toward children. To the extent possible, local communities should not take children away from inadequate parents but should help parents in their parenting role. State governments should not replace local governments, but should support local governments in their work with children. The international community should help national governments in their work with children. To the extent feasible, those in the outer circles should try to empower those in the inner circles so that they can meet children's nutritional and other needs.

The Principle

In the perspective of the Task Force on Children's Nutrition Rights, past efforts to ameliorate malnutrition have been valuable, but they have been matters of charity and chance, and not the implementation of real rights. True implementation of a right to something means not just providing some amount of that thing to some people; it means assuring that every individual who is entitled to it gets his or her full share of it. Adequate nutrition for children should be recognized as an assured, unqualified right.

Perhaps capable adults should not be cared for by the state, but few would argue that small children in crisis should be ignored. Certainly the responsibility for nourishing children falls in the first instance on the child's family, but the community and the government bear some responsibility as well. Childhood malnutrition is one of those issues for which there should be a recognized obligation of government to provide some sort of services. Thus there should be a recognized legal obligation of government to provide services to assure that every child is adequately nourished. This principle is the foundation of the Task Force's work.

The family and the community also have responsibility for assuring that children are adequately nourished. The point is that there should be a clear duty of government, enshrined in law, to do what needs to be done if the family's and the community's response is inadequate. If the principle is accepted, there will still be a need to discussion of the exact nature of the services and the conditions under which they must be provided. The services provided by government could take several different forms, including not only direct feeding programs but a variety of health and care services as well.

International Obligations

The international human rights instruments are concerned primarily with the responsibilities of States Parties to their own people, not to people elsewhere. Article 11 of the International Covenant on Economic, Social, and Cultural Rights does require States Parties individually and through international cooperation to take the measures needed to implement "the fundamental right of everyone to be free from hunger," so the language does in fact speak of international obligations. In practice, however, there is no clear duty with corresponding measures to assure accountability. There is no international history of case law with respect to the right to nutrition. There is no hard international law with respect to the right to nutrition.

In the Task Force's view, children of particular nations are also children of the world. The international community should take responsibility when national governments are unwilling or unable to fulfil children's most basic needs. Thus the principle applied within nations also should be applied internationally: There should be a recognized legal obligation of the international community to provide services to assure that every child is adequately nourished. There could be an international agreement that certain kinds of international assistance programs must be provided, say, to children in nations in which children's mortality rates exceed a certain level.

This international obligation to provide assistance should stand unconditionally where national governments, or more generally, those in power, consent to receiving the assistance. The obligation must be mitigated, however, where those in power refuse the assistance and delivering the assistance would require facing extraordinary risks.

Implementation Internationally

In advancing nutrition rights within nations it is wise to work with nutrition programs that are already in place. In many cases the rules under which people have access to these programs can be revised to guarantee that those who are most needy are assured of receiving services. Similarly, there already are institutional arrangements for dealing with nutrition issues at the global level. Their methods of work can be adapted to advance nutrition rights.

The most prominent International Governmental Organizations (IGOs) concerned with nutrition are the Food and Agriculture Organization of the United Nations (FAO), the World Food Programme (WFP), the International Fund for Agricultural Development (IFAD), the World Health Organization (WHO), and the United Nations Children's Fund (UNICEF). They are governed by boards of directors comprised of member states. Responsibility for coordinating nutrition activities among these and other IGOs in the United Nations system rests with the Administrative Committee on Coordination -Subcommittee on Nutrition (ACC/SCN). Representatives of bilateral donor agencies such as the Swedish International Development Agency (SIDA) and the United States Agency for International Development (USAID) also participate in ACC/SCN activities. There are also numerous international nongovernmental organizations (INGOs) concerned with nutrition.

The main role of the IGOs is not to deliver services directly but to help nations use their own resources more effectively. To the extent possible, they empower national governments to do what needs to be done. In much the same way, an increasing rights orientation among the IGOs would not require massive new international transfers of food. Their main function would be to press and help governments to adopt a nutrition rights approach in their own national programs, using the food, care, and health resources within their nations. For example, the World Food Programme could make it known that in providing food supplies for development it will favour those nations that are working to establish clear nutrition rights for the most needy in their nations. All of the IGOs could be especially generous in providing assistance to those nations that create national laws and national agencies devoted to implementing nutrition rights.

The IGOs could encourage and support nations in conducting national workshops on children's nutrition rights of the sort described earlier. With modest incentives, many might be willing to review their existing nutrition programs to determine ways in which the rules governing access to them could be improved through careful use of the law.

Currently, international assistance (including food aid, development aid, health services, and other forms of assistance) is intended to serve a very broad range of purposes. Only a small fraction of the total is intended to alleviate malnutrition directly. When wastage of different kinds is taken into account, the proportion of international assistance that is used to alleviate malnutrition directly is very small. When such assistance is provided it is usually in acute crisis situations such as famines, natural disasters, and armed conflicts. Most international assistance bypasses those who are chronically malnourished or reaches them only indirectly. The argument here is not that there should be massive increases of international assistance, but rather that there should be more systematic targeting to assure that extreme malnutrition is ended everywhere. International assistance programs would become more orderly and effective if they were based on the principle that under specified conditions the needy have a right to assistance.

As a minimum, it should be recognized that children everywhere have a right to adequate nutrition. Consequently, it should be recognized that national governments and the international community have positive duties to help fulfil that right. There is a great deal of work remaining to be done to articulate those rights in the law and to assure that the law is effectively implemented.

References

Alston, P. & Tomasevski, K. (eds.) (1984) The Right to Food. Martinus Nijhoff, Dordrecht, Netherlands.

Eide, A., Eide, W., Goonatilake, S., Gussow, J. & Omawale. (eds.) (1984) Food as Human Right. United Nations University, Tokyo.

Eide, A., Oshaug, A. & Eide, W. (1991). Food Security and the Right to Food in International Law and Development. Transnational Law & Contemporary Problems, 1(2), 415-467.

Kent, G. (1993) Children's Right to Adequate Nutrition. International Journal of Children's Rights, 1(2), 133-154.

UN (1989). Right to Adequate Food as a Human Right. United Nations, New York.

The Nutrition Transition

Large shifts in dietary composition are taking place in some lower income countries with important implications for health and development. Barry Popkin of the University of North Carolina at Chapel Hill presents evidence from selected countries.

Scientists have long recognized the importance of the demographic and epidemiological transitions in higher income countries and have more recently understood that similar sets of broadly based changes are occurring in lower income countries. What has not been recognized is that concurrent large changes are occurring in nutrition with equally important resource allocation implications for many low-income countries.

Two extant theories of change address key factors that affect and are affected by nutritional change. One relates to the demographic transition - the shift from a pattern of high fertility and high mortality to one of low fertility and low mortality (typical of modern industrialized nations). Even more directly relevant is the concept of the second theory of change, the epidemiologic transition, first described by Omran. The epidemiologic transition describes the shift from a pattern of a high prevalence of infectious diseases and malnutrition, resulting from pestilence, famine, and poor environmental sanitation, to a pattern of a high prevalence of chronic and degenerative diseases strongly associated with life style. A later pattern of delayed degenerative diseases has been more recently formulated. Accompanying this progression is a major shift in age-specific mortality patterns and life expectancy. The concepts of demographic and epidemiologic transition share a focus on the ways in which populations move from one pattern to the next. The framework for the nutrition transition mirrors these concepts of demographic and disease change.

Human diet and nutritional status have undergone a sequence of major shifts among characteristic states, defined as broad patterns of food use and corresponding nutrition-related disease. Over the last three centuries, the pace of dietary change appears to have accelerated to varying degrees in different regions of the world (see Popkin, 1993a). The concept of the nutrition transition focuses on large shifts in diet, especially its structure and overall composition. These dietary changes are reflected in nutritional outcomes, such as changes in average stature and body composition. Further, dietary changes are paralleled by major changes in health status, as well as by major demographic and socioeconomic changes. Modern societies seem to be converging on a pattern of diet high in saturated fat, sugar, and refined foods and low in fibre - often termed the "Western diet." At its most basic level, the changes presented here represent a simple imitation of the "Western diet" and there is little evidence yet to indicate what else is involved. As this author and others have shown, the nature and pace of change varies significantly and there are important differences in the food pattern changes; nevertheless the net effects on nutrient intake and nutritional status are similar.

Examples of these Transitions

The progress of dietary change throughout the world will not necessarily replicate the pattern of nutritional change that has occurred in high-income countries. Clearly, the patterns of dietary change over time and space that constitute the nutrition transition have occurred concurrently with demographic, socioeconomic, and epidemiologic changes. The long-term relationships among these factors are complex and heretofore unexplored. In the short presentation of data for one country and the discussion of relationships for others, we focus on results from surveys of individual and household diet and body composition since aggregate food supply data do not explain the nature of the distribution of food and can at best give us some sense of the trends in food availability or consumption (cf. Popkin, 1993a).

Western High-Income Model. The pattern of change in the United States appears to be one that has been followed often during the past century by other countries. This is a more gradual shift in the structure of diet toward what we define as the Western diet. There are significant differences in the food sources for various components of the diet and therein lie some important differences in the health implications of the dietary changes in each country. In no Western countries other than the Scandinavian ones has there been any systematic national effort to change the structure of diet.

Japanese and Korean Accelerated Model. Following World War II, dietary energy intake in Japan increased slowly toward a peak around 1970-75, whereas intake of animal products and fat increased continuously from 1946 to 1987. Obesity is increasing rapidly among the Japanese. Moreover there is evidence that fat patterning is very different with a much greater likelihood that the obesity is associated with greater visceral fat area. Moreover, much lower levels of BMI are associated with adverse coronary heart disease (CHD) outcomes. South Korea, another Asian country that achieved remarkably rapid economic growth during the last three or four decades, appears to be experiencing a change in dietary structure similar to that of Japan and is beginning to see problems of dietary excess appear.

Emerging Asian Models. China and Thailand are indicative of countries with recent economic and demographic change. The rapidity of the economic change and the resulting shifts in the structure of diet and the distribution of body composition patterns in China appears indicative of a pattern appearing in other Asian societies. Information presented next comes from the China Health and Nutrition Surveys (CHNS), a longitudinal survey designed to monitor these issues in China (for detail on the CHNS, see Popkin et al, 1993b).

Over the last decade, China has attained overall adequacy in diet and has seen a marked change in dietary structure. Included have been large increases in the dietary intake of edible oils, sugar, eggs, and dairy and meat products. While the traditional Chinese diet was felt to be a low-fat one, we now find a small proportion of the population following this traditional low-fat pattern and an ever-increasing proportion consuming more than 30% of their energy from fat. In figure 1 I show that this high-fat diet was significantly more common in urban and higher-income populations than in rural and lower-income ones. Moreover, between 1989 & 1991 we see large increases in the proportion of the higher income urban sample consuming a high fat diet and decreases in the proportion of adults consuming a low-fat diet among all income groups.

Figure 1. Percentages of Study Population with High (A) and Low (B) Energy Consumed from Fat, China: Adults (Aged 20-45), by Tertile of Household Income, CHNS 1989 and CHNS 1991.

Thailand is undergoing an economic transition about five years after China and at a slightly slower pace. It has achieved a rapid decline in the proportion of underweight children, partly through economic growth and partly through targeted nutrition and health actions. Yet, we are beginning to see increases in obesity in urban areas, not just in Bangkok, but also in other parts of the country which approximate in speed of change the increases in obesity seen in China.

Latin American Pattern. Brazil, Mexico, Colombia, Chile, and Argentina are some of the countries in the Americas where problems of excess have begun to dominate. At the national level there is not a food security problem and even most of the low-income populations in these countries do not face problems of dietary deficit. In this region, where patterns of dietary change have been much slower, we have begun to face the problem of obesity and other problems of dietary excess among not only the rich but also the poor (cf. Popkin, 1994). For instance, there has been a large increase in the proportion of obese Brazilians between 1974-75 and 1989 and the largest increase has been among the lower income groups. In fact, the situation in many areas approximates that of the United States where the poor suffer more from problems of dietary excess than do the rich, and noncommunicable diseases and mortality from cardiovascular and other diseases is greater among the poor.

Government and Nutrition Professional Responses: What Can Be Done?

The nutritional and health communities need to consider how to respond to this emerging crisis. Ideally, we should be prepared to prevent the undesirable dietary changes and the related chronic disease patterns before they reach the level of the higher income countries. To do this, we must ensure that as with China and some of the other countries noted in this brief overview, we examine survey data beyond national averages to understand the segments of the population who are at risk. Aggregate data will hide the true problem far more in lower income countries where the overall national averages found in food balance sheets belie the extent of the problem. One of the more profound points is the feeling that the emergence of these new problems of excess threaten support for control of the problems of deficit and that the nutrition community must keep its focus on only problems of undernutrition. Most nutrition professionals working in lower income countries have focused their careers on problems of poverty and undernutrition and this represents a most important and difficult topic to address. At the same time, the response should not be one of attempting artificially to magnify the problems of deficit which will distort resource allocation and may actually hurt the poor.

It is possible to use the concern for both under- and overnutrition to craft a joint set of messages. It is becoming increasingly clear that there are common underlying sets of concerns that can unite nutritionists to push for selected common nutritional objectives. Among these are the promotion of the consumption of carotene and breastfeeding. Prevention of xerophthalmia and increased consumption of antioxidants combine to give advocates of prevention of under- and overnutrition a common goal. The same is true for the promotion of breastfeeding though this is not the place to list the increasing understanding of the role of breast-feeding in the prevention of chronic diseases and the enhancement of growth and development.

While there may be a perceived short-term competition for resources to solve problems of dietary deficit and excess, we must not ignore the role of nutrition in chronic diseases because the long-term effects of failure to act are potentially serious. A failure to articulate the role of nutrition in coronary heart disease, cancer, and other problems associated with dietary excess will lead to increased likelihood that medical interventions will dominate all treatment, and prevention will take a backseat. One example is the recent 1993 World Development Report on health which focuses on a range of interventions for addressing problems of deficit and excess. A wide range of public health interventions was discussed for the prevention of undernutrition and various communicable diseases. Problems of dietary excess and overnutrition were largely ignored. The result was a listing of chronic disease-oriented interventions that focus almost entirely on medical interventions and exclude the role of food and nutrition policies and other education interventions related to nutrition.

The other side of the coin is the need to adjust our understanding and prioritization of scarce nutrition resources to changes in need. Professionals and programs focused on problems of deficit must be adjusted as the nature of the problem occurs or we may actually hurt those who are in need. Chile is an important example.¹ There has been a significant shift in the problems and needs in Chile. Today, only a small segment of the population suffers from malnutrition. To assist this target population would require a new set of more focused programs and a new type of surveillance system. Fewer resources might be needed but they would need to be much more closely targeted. Rather than adjust to the new reality, there has been an effort in Chile to revise criteria for providing food program resources to those preschoolers whose anthropometric status places them minus one standard deviation below the growth curve for weight or height for age rather than the previous minus two standard deviation units (that is one rather than two Z-scores below the reference median used to define undernutrition). This would provide resources to a larger population but there is considerable concern that the result will be to use scarce resources for those not in need rather than to develop a more precise focus.

China faces a similar problem to that of Chile. In the past China has not had poverty alleviation programs per se. Rather, economic development was viewed as the engine to eliminate poverty. For much of the population this has worked admirably. At the same time, information presented here documents an emerging problem among the Chinese low-income population that requires new and targeted assistance to help them take advantage of the tremendous economic and social changes shaping China during the 1990s.

How nutrition ultimately adjusts to this set of changes that are rapidly coming to the lower income world will to a large extent affect its role. There is a considerable need to develop a set of cost-effective programs and policies to address these problems of dietary excess. Yet without experimentation and evaluations, we have little to offer to provide preventive low-cost solutions to problems higher income countries have also not systematically succeeded in tackling. Two sets of efforts provide a starting point-the Scandinavian countries and China.

Program and Policy Arsenal. Ideally, we would like to have a set of options for addressing problems of excess similar to those used to battle deficit and to be able to combine them to fit the needs of each country. We are at far too early a stage in the process; too few countries have tried to address problems of excess. As the China figures show, we must work on solutions that let us consider both problems of deficit and excess, in particular if increasing polarization occurs as it may in many countries with development.

The effect of the changes in diet and physical activity in China has been a significant change in adult body composition. The proportions of adults aged 20-45 years in different weight categories, according to the level of household income, are shown in figures 2 and 3. During 1989-1991, a decline in proportion underweight was observed among those in the middle- and high-income tertiles, while there was an increase in underweight among those in the lowest income tertile. This increase in proportion underweight among low-income adults is particularly noteworthy.

During the same period, there was an increase in proportion overweight in middle and upper income groups (see figure 3). The largest increase in proportion overweight was observed among the middle-income sample. Elsewhere we have shown that the changes in physical activity and diet (both energy and the proportion of energy from fat) were significantly associated with body mass index (Popkin et al., in press). Thus, polarization of nutritional problems are emerging in China. Increasingly, it appears that the earlier equal distribution of nutritional problems is being replaced by a situation where problems of excess and deficit are found among the rich and poor, respectively.

The Scandinavian country that has most systematically merged health and agricultural concerns into an effective nutrition policy is Norway (Oshaug, 1992). Norway began to be concerned with reducing dietary fat in the 1960s and developed the Norwegian National Nutrition Policy in 1976, formally linking economic and agricultural policy with nutrition and health (Milio, 1990). The results are impressive: Norway has stimulated research on breeding cows for lower-fat milk; denied consumer price subsidies when sugar import prices soared in the mid-1970s; increased consumer subsidies for skim milk more than for whole milk, for poultry more than for pork, and for fish more than for beef; and implemented a set of producer subsidies to favour fish production over beef production. Thus research and price policy have been used actively. As noted above, the results were dramatic, including a large change in the proportion of whole and reduced-fat milk, rapid increases in the consumption of poultry, and changes in the amount of edible fat and the proportion of margarine and light margarine. Milio hypothesizes that a systematic nutrition information policy directed at producers, government and private organizations, and consumers (along with significant agricultural policy changes) has been a key factor in Norway's dietary changes of the past decade.

Through debate, the Norwegian model developed a national consensus and several coordinating bodies, one of which became the active group to lead the changes in legislation, regulations, and education policy. Although Norway's National Nutrition Council had been established in 1946, the major breakthrough was creation of a national expert committee that established and publicized the linkage between diet and coronary heart disease. This began a series of national meetings and attempts to implement new dietary guidelines. The Ministry of Agriculture finally developed a White Paper in 1975 that led to the significant shift in government policy (Milio, 1990).

Figure 2 - Percentages of study population underweight By income tertiles (low, middle, high) China, 1989-1991

Underweight = BMI < 18.5

Figure 3 Percentages of study population overweight By income tertiles (low, middle, high) China, 1989-1991

Overweight = BMI > 25.0

Future needs. We are a long way from understanding the effectiveness of the array of food price policy, regulations, and other tools for addressing the problems of the nutrition transition. Aside from the Scandinavian countries, few countries have systematically tackled these problems over the past two decades and the China experience is too new to be able to use that to draw any conclusions. This is not a reason to argue for inaction but rather to imply that solutions will not be easy to develop and adequate evaluation must accompany them. While it will be difficult for many agencies and professionals who have focused our careers on problems of hunger and deficit to deal with these newly emerging problems, it is very important that we begin to work out ways to address these problems.

1. This example is based on thoughtful communication with Francisco Mardones (World Bank) and Reynaldo Martorell (Emory University). No readily available published material exist on this shift.

Dr. Popkin is Professor of Nutrition at the University of North Carolina at Chapel Hill. His current research focuses on the patterns and determinants of the nutrition transition and the relationship of social change and nutritional change.

Acknowledgement

The author acknowledges his collaborators in the CHNS, in particular Dr. Ge Keyou with whom he has prepared related research on obesity, and the National Institute of Health (NIH) (P01HD28076-01) for its support of his research.

References

Milio, N. (1990). Nutrition Policy for Food-Rich Countries: A Strategic Analysis. The Johns Hopkins University Press, Baltimore.

Oshaug, A. (1992). Towards Nutrition Security. Country paper for Norway for the International Conference on Nutrition. University of Norway Institute for Nutrition Research, Oslo. pp. 1-99.

Popkin, B. (1993a). Nutritional Patterns and Transitions. Population and Development Review 19(1), 138-157.

Popkin, B., Keyou Ge, Fengying Zhai, Xuguang Guo, Hiajiang Ma, & Namvar Zohoori. (1993b). The Nutrition Transition in China: A Cross-Sectional Analysis. European Journal of Clinical Nutrition, 47, 333-46.

Popkin, B. (1994). The Nutrition Transition in Low Income Countries: An Emerging Crisis. Presented at the Symposium "Diet and Chronic Diseases in Countries in Socio-Economic Transition" Experimental Biology Conference, April 24-28 1993, Anaheim.

Popkin, B., Paeratakul, S., Fengying, Z., Keyou, G. Dietary and Environmental Correlates of Obesity in a Population Study in China. Obesity Research, in press.