PROGRAME NEWS

INTERAGENCY

UNICEF - WORLD BANK
Turning the Tide: The New Challenge
for Nutrition

A Synthesis of Findings from the World Bank-UNICEF Nutrition Assessment

In 1999, the World Bank and UNICEF joined forces to review past collaboration with a view to improving the future. This joint assessment comprised reviews of portfolios, policy analyses, country case studies, and consultations with Bank and UNICEF staff along with selected external experts. The aim was to provide a fresh perspective on the global effort to address malnutrition, with a particular focus on the roles of the two agencies in shaping this agenda and its implementation. The study attempted to understand how policy change in nutrition happened, what influenced these processes, and what lessons could be learned from them.

Key findings:

Nutritional status is improving slowly in some regions, but progress has stagnated in others.

Per capita spending on nutrition is generally low and poorly targeted nutrition expenditures by the two agencies are also low in relation to the size of the problem.

Beyond the nutrition community, knowledge about the problem, its consequences and relevance to poverty and other human development goals is fragmented, and inconsistently applied advocacy has not been effective.

There is broad consensus on key interventions, and on success factors for successful implementation, but few large scale sustained programmes. Process is key and has been neglected; multi-sectoral pre-packaged interventions do not work.

Rigorous evaluations demonstrate impact, but the evidence base is small.

Capacity to tackle malnutrition is often the limiting factor for accelerating progress. Nutrition is often marginalized and decentralization has provided both opportunities and challenges.

Key recommendations:

Reframe the nutrition issue; position it squarely on the poverty and human development agenda.

Emphasise information for decision making and the capacity to measure and evaluate.

Strengthen capacity to achieve this agenda. Capacity in nutrition in all agencies needs significant strengthening. Stakeholders involvement needs to be maximized and partnerships forged.

Increase nutrition-relevant public expenditures to achieve this agenda.

Global Alliance for Improved Nutrition (GAIN)
(Gates Foundation, USAID, CIDA,
Private food companies, the World Bank,
UN agencies and NGOs)

GAIN is new. Plans for a launch mid this year are in the making. GAIN is an alliance of public and private sector organizations seeking to save lives and improve health through the elimination of vitamin and mineral deficiencies. GAIN will support developing countries in their effort to implement locally developed food fortification strategies. Organizations working in developing countries will receive grants in support of country-based initiatives for food fortification based on comprehensive national nutrition strategies. GAIN partners include bilateral donors, foundations, multilateral agencies, developing countries, private sector companies, NGOs and academic institutions. GAIN will combine the strengths of public and private sector organizations to mobilize private industry, donors and foundations and to tap the expertise and resources of the corporate sector in technology transfer, business development, trade and marketing. GAIN will also work with multilateral agencies to set international standards and establish systems for quality assurance and control. At the moment, GAIN is funded mainly by the Bill and Melinda Gates Foundation. Total grant funds for the first year are estimated to be about $20 million. The executive director and the location of the secretariat are expected to be announced in early 2002.

More information is available at www.gainhealth.org

ADB

Asian Development Bank

Almaty Forum 2001: Improving Nutrition of Poor Women And Children In Central Asia and Neighboring Countries

Participants from six neighbouring Central Asia countries attended a regional round table on salt and wheat flour fortification in October 2001.They agreed on the following set of principles, strategies and actions (to be supported by the Japan Fund through 2002):

We recognize:

that in recent years the nutritional status of women and children in our region has deteriorated badly with negative consequences for children, families and countries - iodine and iron deficiencies are the most serious, but other essential nutrients also need to be addressed;

that the damage to the learning capacity of our children from iodine deficiency in pregnancy is irreversible;

that iron deficiency is causing serious damage to social and economic development through poor pregnancy outcomes, impaired cognition especially in young children, reduced work capacity and increased morbidity from infectious diseases;

that zinc deficiency is associated with lowered immunity, slower growth and increased risk of heavy metal poisoning in contaminated environments;

that folic acid deficiency in pregnant women contributes to congenital abnormalities of the central nervous system of the newborn and is an independent risk factor for coronary heart disease; and

that thiamin, riboflavin and niacin are removed during the milling of grain along with most iron and folic acid contributing to micronutrient malnutrition among populations whose diets are heavily dependent on bread and other flour-based foods.

that the addition of potassium iodate to all salt sold for human nutrition is a well established method for eliminating iodine deficiency as a societal problem;

that the freely available Knowledge, Attitudes and Practice (KAP) Komplex formula, developed by the Kazakh Academy of Nutrition for Central Asia, is an appropriate and safe basis for wheat flour fortification to prevent deficiencies of thiamin, riboflavin, niacin and folic acid and reduce iron and zinc deficiencies;

that people of the region should have access to affordable, safe, and efficacious fortified foods as a permanent commitment to the elimination of micronutrient malnutrition;

that there are no capacity constraints for private producers to achieve significant progress in providing affordable fortified salt and flour to consumers in the region;

that the consequences of not implementing fortification programs at national level will be poor child development, low educational achievement of children, and decreased earnings and economic growth; and

that the initiative, supported by the Japan Fund, will contribute to fulfilling commitments made by the participating governments to the universal protection of children.

that all salt for human consumption will be fortified with potassium iodate and, to the maximum extent achievable, wheat flour will be fortified with micro-nutrients using the KAP Komplex formula.

that food laws and regulations be reviewed and amended to ensure they support and enable the addition of all essential micronutrients in appropriate food carriers;

that public policies and regulations that constrain or impede investment in food fortification to reduce micronutrient malnutrition be reviewed and amended and that all nations collaborate to produce uniform or consistent standards based on international best practices that will facilitate the trading of foods;

that customs protocols and trade regulations be revised or enacted to ensure the import and export of certified and safe fortified foods at agreed levels of fortificants;

that the cost of food fortification be ultimately borne by the producer and the consumer, but a transition period of cost-sharing between the public and private sectors may be necessary;

that efforts be continued to inform the public of the benefits of fortified salt and flour to the learning and earning capacities of the region's children and that the interests of NGOs, especially women's federations and consumers' rights unions, be fully included in future activities jointly conducted by the nations; and

that food fortification be a part of a comprehensive strategy of anemia prevention and control that includes supplementation, dietary diversification, breastfeeding promotion and other public health measures.

National actions to achieve this will require the following coordinated actions at national and local levels:

Pass and effectively implement mandatory salt iodization laws in all countries and move forward flour fortification laws as required.

Urge the elimination of tariffs and value-added taxes on inputs to fortification and fortified food products, imported or domestically processed, to promote sustainability.

Avoid excessive price increases for fortified products that may discourage consumers.

Initiate cost-sharing by public and private sectors of the costs of producing fortified salt and flour and strengthen the capacity of the private sector to be fully self-reliant shortly after the two year project completion.

Establish a monitoring framework to assess progress in the percent of salt and wheat flour fortified during production and to assess the percentage of families with access to fortified food products.

Integrate fortification programs into national strategies and policies to reduce poverty, raise the quality of human resources and support the survival, growth, psychosocial and cognitive development of all children, especially those of early ages.

Promote an expanded public sector-private sector dialogue on fortification of salt and cereal flour and organize advocacy events to increase program and donor support.

Develop and implement a communications strategy and campaign to raise public awareness and improve the child caring skills of parents on the importance of fortified salt, wheat flour and wheat flour products and promote increased consumer demand for these products. These activities will be led by nongovernmental organizations in collaboration with the private sector, national experts, the media, local authorities and communities.

Promote mechanisms to exchange information and experiences within and across the countries of the project using the world wide web and other modern communication tools.

Obtain, update and disseminate information on the prevalence of micronutrient deficiencies by including micronutrient-related data collection in Demographic and Health Surveys, Multiple Indicator Cluster Surveys and other nutrition, health and education surveys.

Develop a framework for drafting and proposing harmonized regional and international trade standards and guidelines for fortified foods.

Develop regional activities such as roundtables, joint reports and inter-country training focusing on legislation, communications strategies and partnerships among the civil society and the private and public sectors.

Demonstrate through regional policy dialogue to economic planning agencies and the general public the large economic damage caused by poor nutrition and the proven low-cost solutions available to the region.

Advocate for greater resources mobilization by governments from domestic budgets, public and private, and strategic investments from development partners, and share country experience in regional fora.

Review and recommend financial and capacity building incentives to sustain food fortification and its expansion to other essential foods widely consumed by the poor.

Set up sentinel sites in at least three project countries to monitor progress of continuing efforts to fortify all salt and wheat flour.

Create communication mechanisms, including a web site, that allow project countries to share advocacy, technical and promotional activities among themselves and with the global community.

Include micronutrient malnutrition issues into the agenda of regional expert group consultations such as associations of paediatricians, nutritionists and reproductive health specialists.

Prepare progress reports toward elimination of micronutrient malnutrition to the Regional Health Ministers Council.

AUSTRALIA

Primary Prevention Section, Commonwealth Department of Health and Aged Care

In August 2001, the Australian Health Ministers Conference endorsed the national public health nutrition strategy, Eat Well Australia and its indigenous component, the Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan. The document together with its four priority action areas - maternal and child health, minorities’ nutrition, vegetable and fruit consumption and healthy body weight - will guide public health nutrition action at the national level over the next ten years.

A number of initiatives have already begun under these four priority areas. Under the maternal and child health priority area, a review of the national dietary guidelines, including those for children and adolescents, and for infant feeding is under way and due for release in mid 2002. Children in rural and remote areas, in socio-economically disadvantaged and minority communities will benefit from funds totalling AU$15 million provided under the National Child Nutrition Program. The issue of overweight and obesity is being tackled through the development of clinical guidelines for the prevention, management and treatment of overweight and obesity and by increasing the awareness of these issue among key stakeholders and organizations. The priority area of vegetable and fruit consumption has been boosted by the appointment of a national program manager to facilitate and coordinate the national efforts of industry, health and other relevant sectors in this area. Guidelines for promoting increased consumption of vegetables and fruit are being developed. Finally, an example of work towards improving nutrition for indigenous Australian communities is the development of an indigenous food selection guide based on the national food selection guide, the Australian Guide to Healthy Eating.

Contact: Kathleen Graham: kathleen.graham@health.gov.au
http://www.health.gov.au/pubhlth/strateg/pp/index.htm

BASICS II

Workshop on Post-NIDs Vitamin A Supplementation Options in Africa sponsored by BASICS II and MOST, The USAID Micronutrient Program

Broad-based vitamin A supplementation was launched over the past several years in many countries by linking vitamin A capsule distribution with National Immunization Days (NIDs). These activities have been well accepted and have consistently achieved high coverage rates among children. However, NIDs are being progressively phased out in many countries as the incidence of polio declines giving rise to an urgent need to develop and institutionalize alternative strategies to sustain the delivery of vitamin A to children six to 59 months. To date, many countries have explored different mechanisms to deliver vitamin A independently of NIDs and there are promising results. (For more information, see Twice-yearly Vitamin A Supplementation: Time for Action, at www. mostproject.org). At this workshop, held in Senegal in June 2001, discussions on 'special child health weeks' and other ways of achieving outreach by district health teams were discussed to sustain high rates of vitamin A supplementation. The workshop brought together government nutrition, immunization, and maternal-child health specialists and their counterparts from BASICS and MOST offices in Benin, the Democratic Republic of Congo, Ethiopia, Ghana, Madagascar, Niger, Nigeria, South Africa, Senegal, Uganda, and Zambia. During the workshop, MOST and MOH staff in Zambia and Ghana shared their recent child health week experiences which achieved vitamin A supplementation coverages of over 80%. At the end of the meeting, participants issued the Goree Declaration affirming their commitment to eliminating vitamin A deficiency and recommending that countries adopt more sustainable alternatives to NIDs. “The rationale behind this declaration is to draw the attention of our decision makers to the need to make child health routine services more active and systematic and to reach the unreachable,” said Albertha Nyaku, MOST field co-ordinator in Ghana. Goree

Declaration (Excerpted)

Considering that vitamin A is essential for building resistance against infectious diseases, and is vital for protecting the vision of individuals, critical for child survival, and that

Vitamin A supplementation has been proven to reduce under five mortality, reduce mortality from measles and reduce mortality from diarrhoea: all children under-five should be covered with adequate vitamin A particularly in Africa where efforts to reduce high childhood mortality have been difficult and have not achieved desired results.

Although activities for vitamin A supplementation have been successfully implemented in our countries and have resulted in an average 80% coverage (using a campaign approach), despite the development of ad-hoc policy guidelines, protocols, and tools; the training of thousands of implementers and volunteers; the mobilization and sensitization of communities to the importance of vitamin A; the strengthening of local level structures and support systems; and the building of a network of partners including the private sector and the media: there still remain gaps that should be filled, support systems need to be consolidated and gains achieved in high coverage need to be sustained in order to realize the full benefits of reducing childhood mortality in Africa.

Further, the passive routine supplementation through health care delivery systems and the low exclusive breastfeeding rates have resulted in very poor national child health indicators, severe vitamin A deficiency and high levels of morbidity and mortality among under five children in our countries. Infants up to six months are not well covered and lactating mothers have low vitamin A intake. Many communities have no access to health centres. Therefore: with NIDs being phased out and not being really sustainable because of high resource needs, we need to adopt more sustainable alternatives including setting aside special days and weeks for active outreach activities to bring child health services - including vitamin A supplementation - closer to the communities.

We, the undersigned participants from 11 African countries urge governments, donor agencies, NGOs, political and community leaders, and others who are committed to improving child health in Africa to take the following urgent actions: Adopt policies and implement guidelines based on experience from our countries that focus on organizing Child Health Weeks or Days that will help increase immunization coverage, increase growth promotion activities, increase prenatal iron/folic acid supplementation, increase de-worming, increase malaria control activities, increase HIV awareness creation, and increase vitamin A supplementation.

Ciro Franco, MOST The USAID Micronutrient Program: cfranco@istiinc.com

FIVIMS

Food Insecurity and Vulnerability Information
and Mapping Systems

As one of the key steps towards achieving the 1996 World Food Summit (WFS) goals, the Plan of Action called for the establishment of an inter-agency programme to be called Food Insecurity and Vulnerability Information and Mapping Systems (FIVIMS). FIVIMS is now well established and has members representing international and bilateral donors, technical UN agencies and NGOs. The Inter-Agency Working Group on Food Insecurity and Vulnerability Information and Mapping Systems (IAWG-FIVIMS) is supported by a Secretariat housed in FAO in Rome. FIVIMS seeks to increase awareness of the interrelationship of food security issues with other issues at the national and international level. It also seeks to improve the co-ordination and communication amongst agencies working in food security and poverty alleviation.

At the international level, FIVIMS implements diverse activities in support of national information systems so that they become part of an international information exchange network. At the country level, FIVIMS works with a network of information systems that gather and analyse relevant national data concerning food insecurity and vulnerability. The principle behind FIVIMS is that improved information can be effectively used in support of efforts geared towards reducing malnutrition.

The involvement of civil society in national FIVIMS is critical to achieve sustainable reductions in the numbers malnourished. Civil society organisations often hold valuable information on the incidence/prevalence of malnutrition and the location of vulnerable groups, in addition to carrying out activities in support of poverty and food insecurity alleviation. To be successful, a national FIVIMS needs to empower civil society to participate in gathering information on food insecurity, to better understand the implications of the information gathered and to use the information to carry out actions that address the underlying and basic causes of malnutrition. Ideally, civil society is an active participant in the FIVIMS process, not a passive recipient of improved information and better designed information gathering tools. However, their current level of involvement in national FIVIMS in most countries needs to be increased.

One of the crucial elements promoted by FIVIMS national programmes is the decentralisation of information gathering systems. This allows for improved representation of civil society both in data analysis and in formulating recommendations related to food security in many local contexts. FIVIMS is firm on the notion that it is not enough to improve the quality of information overall. Mechanisms to incorporate the views and decisions of civil society need to be streamlined as well.

In Kenya and Bangladesh FIVIMS activities have been incorporated into two key UN initiatives, namely the Common Country Assessments (CCA) and the UN Development Assistance Framework (UNDAF). With FIVIMS national and sub-national data inputs, these national documents will be integrated into an existing institutional mechanism. The FIVIMS Secretariat, the FAO Representation in the country and the national FIVIMS coordinator are involved A workshop on the design and implementation of a national FIVIMS for China was held in late November 2001. The workshop defined the most suitable format, participating agencies and end users for China. The role of civil society in the Chinese FIVIMS was also covered.

A meeting of national nutrition coordinators took place in Grenada in November 2001. This meeting, hosted by the Caribbean Food and Nutrition Institute, focused on the development of country-specific plans for technical co-operation to support national food and nutrition programmes. The final day of the conference was dedicated entirely to FIVIMS and the development of a workplan for a FIVIMS programme in the Caribbean.

Contact: Annalea.Jenny: annalea.jenny@fao.org
http://www.fivims.net

THE UN SYSTEM'S FORUM FOR NUTRITION

Publications - December 2001

http://acc.unsustem.org/scn

available for download from our website

REPORTS ON THE WORLD NUTRITION SITUATION

Fourth Report on the World Nutrition Situation: Nutrition Throughout the Lire Cycle, January 2000

Third Report on the World Nutrition Situation, December 1997

Update on the Nutrition Situation, 1996: Summary of Results for the Third Report on the World Nutrition Situation, late 1996

Update on the Nutrition Situation, November 1994-

Second Report on the World Nutrition Situation Volume II, Country Data, March 1993

Second Report on the World Nutrition Situation, Volume I, Global and Regional Results, October 1992

Supplement on Methods and Statistics to the First Report on the World Nutrition Situation, December 1988 (out of print)

First Report on the World Nutrition Situation, November 1987 (out of print)

NUTRITION POLICY DISCUSSION PAPERS

Nutrition and HIV/AIDS by P Piot, S Monico, O Saasa, S Gillespie, L Haddad, R Jackson, P Dlamini, E Marum, R Nduati, P Mwalari and L Thairu, October 2001 (NPP No. 20)

What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions by L Alien and S Gillespie, September 2001 (NPP No. 19)

Low Birthweight - Report of a meeting in Dhaka, Bangladesh, June 1999 by J Pojda and L Kelley, September 2000 (NPP No. 15)

Challenges for the 21^st Century: A Gender Perspective on Nutrition Through the Life Cycle by P James_; S Smitisiri, P Pinstrup-Anderson, R Pandua-Lorch, C Murray, A Lopez & I Semega-Jenneh, April 1998 (NPP No. 17)

Nutrition and Poverty by S Gillespie, N Hasan, S Osmani, U Jonsson, R Islam, D Chirmulay, V Vyas & R Gross, November 1997 (NPP No. 16)

How Nutrition Improves by S Gillespie, J Mason, R Martorell, July 1996 (SOA No. 15)

Controlling Vitamin A Deficiency by S Gillespie and J Mason, January 1994 (SOA No.14)

Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing

Countries by G Beaton, R Martorell, K Aronson, 5 Edmonston, G McCabe, AC Ross, B Harvey, December 1995 (SOA No. 13)

Nutritional Issues in rood Aid by J Katona-Apte, J von Braun, G Beaton, J Rivera, P Musgrove and M Toole August 1993. (SOA No.12)

Nutrition and Population Links - Breastfeeding, Family Planning and child Health by S Huffman, R Martorell, K Merchant, R Short, P Ramachandran, M Labbok, B Edmonston, and B Winikoff, May 1992 (SOA No. 11)

Nutrition-Relevant Actions - Some Experiences from the Eighties and Lessons for the Nineties by S Gillespie and J Mason, October 1991 (SOA No. 10)

Controlling Iron Deficiency by S Gillespie, J Kevany, and J Mason, February 1991 (SOA No. 9)

Managing Successful Nutrition Programmes Edited by J Jennings, S Gillespie, J Mason, M Lotfi and T Scialfa, October 1990 (SOA No. 8)

Appropriate Uses of Child Anthropometry by G Beaton, A Kelly, J Kevany, R Martorell, and J Mason, December 1990 (SOA No. 7)

Women and Nutrition by J McGuire, B Popkin, M Chatterjee, J Lambert, J Quanine, P Kisanga, 5 Bajaj, and H Ghassemi, October 1990 (SOA No. 6)

Malnutrition and Infection - A Review by A. Tomkins and F. Watson, October 1989 reprinted June 1993 (SOA No, 5)

Women's Role in Food Chain Activities and their Implications for Nutrition by G Holmboe-Ottesen, O Mascarenhas and M Wandel, May 1989. (SOA No. 4) (out of print)

The Prevention and Control of Iodine Deficiency Disorders by BS Hetzel, March 1998, reprinted June 1993 (SOA No. 3)

Delivery of Oral Doses of Vitamin A to Prevent Vitamin A Deficiency and Nutritional Blindness by K West Jr and A Sommer, June 1987 reprinted June 1993 (SOA No. 2)

Nutrition Education: A state-of-the-art review by RC Hornik, January 1985 (SAO No. l) (out of print)

SCN NEWS - A periodic review of developments in international nutrition compiled from information available to the ACC/SCN, published twice yearly. Contains features, news and views, programme news, and reviews of publications (Distributed free of charge)

SCN NEWS No. 23 December 2001 Civil Society and the UN System: debate in the food security arena,

SCN NEWS No. 22 July 2001 Nutrition Goals and Targets. (out of print)

SCN NEWS No. 21 December 2000 Nutrition and the Environment, (out of print)

SCN NEWS No, 20 July 2000 Nutrition and Agriculture.

SCN NEWS No. 19 December 1999 Nutrition and Healthy Ageing.

SCN NEWS No. 18 July 1999 Human Rights & the Right to Adequate Food: SCN's 26^th Symposium Report.

SCN NEWS No. 17 December 1998 Nutrition and HIV/AIDS including HIV, Infant Feeding Micronutrients in HIV Transmission.

SCN NEWS No. 16 July 1998 Nutrition of the School-aged Child: A summary of Working Group discussions, Oslo 1998, Abstracts from the Symposium on Challenges for the 21 st Century: a Gender Perspective on Nutrition through the Life Cycle.

SCN NEWS No. 15 December 1997 Effective Programmes in Africa for Improving Nutrition, the 10 th Annual Martin J. Forman Lecture: How are we doing in International Nutrition?

SCN NEWS No. 14 July 1997 The Nutrition Challenge in the 21st Century: What Role for the United Nations? Meeting the Nutrition Challenge: A Call to Arms; Update on the Nutrition Situation, 1996 Poor Nutrition and Chronic Disease Part II; Effective Programmes in Africa for Improving Nutrition.

SCN NEWS No. 13 late 1995 Interview with Dr Abraham Horwitz, SCN Chair, 1986~1995; Behavioural Change and Nutrition Programmes; Poor Nutrition and Chronic Disease Part I.

SCN NEWS No. 12 early 1995 The Role of Care in Nutrition - A Neglected Essential Ingredient; Summary of findings from the recently published ACC/SCN "Update on the Nutrition Situation, 1994" Specific Deficiencies Versus Growth Failure: Type I and Type II Nutrients; and Enrichment of Food Staples Through Plant Breeding. A New Strategy for Fighting Micronutrient Malnutrition, (out of print)

SCN NEWS No.11 mid 1994 + Maternal and Child Nutrition.

SCN NEWS No.10 late 1993 Nutrition and food Aid, Nutrition and Human Rights, The Nutrition Transition.

SCN NEWS No.9 mid 1995 Focus on Micronutrients. (out of print)

SCN NEWS No.8 late 1992 Highlights of the World Nutrition Situation, food Prices and Nutrition, Food Security and Nutrition 1971-91-Lessons Learned and Future Priorities, Long-Term Effects of Improved Childhood Nutrition.

SCN NEWS No.7 mid (1991 Refugees Nutrition Crisis, breastfeeding birth Spacing and Nutrition, Community-based Development - From a Programme Towards a Movement, Micronutrient Intakes, Incomes and Prices. Supplement: Some Options for Improving Nutrition in the 1990s - Reviews experience of policies and programmes, and grouping nutrition issues, leads to identifying options as building blocks for future action.

SCN NEWS No.6 late 1990 Preventing Anaemia, Policies to Improve Nutrition - what Was Done in the 80s, Weaning foods-New Uses of Traditional Methods, (out of print)

SCN NEWS No.5 early 1990 Nutrition and School Performance, Uses of Anthropometry, Malnutrition and Infection (Part II), Flows of External Resources for Nutrition, (out of print)

SCN NEWS No.4 late 1989 Update on the Nutrition Situation, Women and Nutrition, Malnutrition and Infection (Part I), Targeted food Subsidies, (out of print)

SCN NEWS No.3 early 1989 Does Cash Cropping Affect Nutrition?, Nutrition in Times of Disaster.

SCN NEWS Nos.1 and 2 March 1988 Vitamin A Deficiency, Urbanization, World Nutrition Situation, Economic adjustment. (out of print)

REFUGEE NUTRITION INFORMATION SYSTEM

RNIS Reports on the nutrition situation of refugee and displaced populations - issued every three months with an interim electronic mail update when warranted Special supplements on the anthropometric assessment of the nutrition status in emergency situations of adolescents and adults are also available

COUNTRY CASE STUDIES

Brazil: The improvement in Child Nutritional Status in Brazil: How Did it Occur? by RF Junes & CA Monteiro, September 1993

Egypt: Review of Trends, Policies and Programmes Affecting Nutrition and Health in Egypt (1970-1990) by H Nassar W Moussa, A Kamel & A Miniawi, January 1992 (out of print - but photocopy available)

India: Nutrition in India, by V Reddy, M Shekar, P Rao & S Gillespie, December 1992 (out of print - but photocopy available)

Indonesia: Economic Growth, Equity and Nutritional Improvement in Indonesia, by IT Soekirman, GS Idrus Jus'at & F Jalal, December 1992. (out of print - but photocopy available)

Tanzania: Nutrition-Relevant Actions in Tanzania, by FP Kavishe, April 1993) (out of print - but photocopy available)

Thailand: Nutrition and Health in Thailand: Trends and Actions, by Y Kachondham, P Winichagoon & K Tontisirin, December 1992 (out of print - but photocopy available)

Zimbabwe: Nutrition-Relevant Actions in Zimbabwe, by J Tagwireyi, T Jayne & N Lenneiye. December 1992 (out of print - but photocopy available)

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ICCIDD

International Council for the Control of Iodine
Deficiency Disorders

Innovative partnerships: role of civil society in IDD elimination activities in India

The iodization of salt, while undoubtedly a simple technique for an immeasurably important social benefit, is only the first step towards the goal of IDD elimination. Many other steps are needed before IDD can be prevented from making a comeback.

Historically, in India, there have been three main professional interests in the elimination of IDD: the government, medical professionals and researchers working in the field of IDD and in the salt industry. These three stakeholders need the participation of others. The success of the programme calls for participation from NGOs, from the grassroots level, and from ordinary people, who have the most to win. Commitment to and ownership of the solution to the IDD problem by this wider network of stakeholders is essential.

To understand how civil society is best involved as a stakeholder in the formulation of health programmes, one needs to look at the world in which policies are made. First, the problem has to be recognized as a public health problem. Then, one has to assess the information available nationally, as well as the values and beliefs of the population. Next, one has to understand the formal and non-formal structure of decision-making that will be called upon to take action. All these factors influence the final decisions made. Informal networks and coalitions of stakeholders are, therefore, an important part of the decision making process.

The International Council for Control of Iodine Deficiency Disorders (ICCIDD) in close partnership with the All India Institute of Medical Sciences, UNICEF and the Micronutrient Initiative (MI), have played a significant role in strengthening IDD elimination efforts made by the government and iodized salt producers in India. In its work, ICCIDD has forged a collaborative partnership with a network of NGOs all over the country. Schools are also enlisted for monitoring the programme. This article documents the efforts of ICCIDD to collaborate with two national level non-governmental organizations, the Bharat Scouts and Guides and the Voluntary Health Association of India.

In 1997-98, ICCIDD used these two channels to collect information about iodised salt availability, pricing and its use from all the districts of the country. These collaborators were requested to ask their district people to collect and dispatch salt samples for analysis. Almost 500 districts in the country received letters seeking cooperation. Booklets and pamphlets on IDD were also mailed to them. Each NGO selected was sent ten prepaid self-addressed envelopes which contained a ziplock polythene bag for sending the salt samples from the field to the ICCIDD laboratory in Delhi. Each district sent 20 samples from retail shops, ten urban and ten rural. All NGOs were also sent iodine testing kits so they could obtain immediate results and use the information to organize and plan needed community education activities.

A total of 147 NGOs and 39 sub-units of Scouts and Guides participated; 2100 samples were received. More than half of the samples from NGOs and the scouts and guides tested adequate for iodine content by the kit (63% and 56% respectively). By titration, 51% of the NGOs and only 15% of the scouts samples tested adequate. As regards prices, iodized salt prices ranged from three to seven Rupees as opposed to one to three for un-iodized salt.

This experience showed that partnership with NGOs to collect data regarding iodized salt is feasible and effective although there were some non-responders. The partnership now needs to be strengthened and enlarged so that a nationally representative sample can be used, to assess availability of iodized salt at retail and household level.

The effort described here is important, but has to be complemented with efforts to better understand the demand and supply issues involved in salt iodization.

Creating demand requires improving community perceptions, proactive education, exposure to more and better media messages and more supportive legislation. Education has to be directed to schools, health providers, traders, salt manufacturers, consumer organizations and others.

Discussions and interviews with communities in many localities are needed to determine people’s knowledge, attitudes, practices and behaviour about the problem of iodine deficiency and to explore perceptions about the importance of regular consumption of iodized salt. This has often been neglected. On the supply side, one has to focus on salt producers’ (and associations of salt producers) economic and social incentives and their need for technical support.

Transport costs are a key factor and need to be addressed as a priority. The government and international agencies need to continue contributing resources and expertise to ensure that salt production is of the highest quality.

The creation of demand for iodized salt and the provision of an adequate supply of iodized salt are thus necessary, but not sufficient, for IDD elimination programmes to succeed. Good data are also needed to track progress and to influence decision makers. NGOs, can be good providers of such data and can also be involved in lobbying.

A strategy for the good management of sustained IDD elimination should, therefore, focus on:

Continuous political and financial commitment

Clear communications strategies involving professionals and the public

Persistent quality control processes to assure a high quality product, i.e. appropriate iodine levels

Monitoring and tracking biological progress with respect to IDD status

Ensuring that the management process is in place to carry out these activities

Contact: Chandrakant S. Pandav: pandav@iccidd.ernet.in

IFAD

International Fund for Agricultural Development

IFAD launches new website:
Gender and Household Food Security
www.ifad.org/gender

With the financial support from the Government of Japan, IFAD launched a new website dedicated to issues of gender, household food security and nutrition. All the IFAD regional divisions and the office of evaluation collaborated in identifying and selecting relevant source materials.

The purpose of the site is to communicate IFAD's policies, strategies and accumulated knowledge to the public, IFAD staff and partners. The site contains operational tools developed by IFAD to address gender, nutrition and household food security (HFS) issues in its projects and programmes. The website also contains published materials, new documents and a series called Learning Notes. The Learning Notes have been prepared specifically for the website based on original field research and evaluation reports, as well as on the IFAD Rural Poverty Report 2001 (see SCN News 22, p.55). The site provides a space for posting future publications and outputs from the regional gender programmes, as well as on-going work on HFS and nutrition.

The website is also available as a CD-ROM for distribution to projects in the field or areas where internet access is problematic.

IFAD hosted a workshop on Malnutrition in Developing Countries: Generating Capabilities for Effective Community Action in Fiuggi, Italy in September 2001

The following is a summary of conclusions and recommendations: Malnutrition and poverty:

Chronic malnutrition is inextricably linked to endemic poverty and gender discrimination.

Measures of chronic malnutrition among children and women are included in international development goals, and should be included in the evaluation of development interventions.

A key indicator is stunting (height-for-age) among children, using international references.

Measures of chronic malnutrition should be complemented with qualitative information and other quantitative data on income, education and gender. Responsibility for action:

Adequate nutrition is a human right, and states are responsible and accountable for eliminating malnutrition.

Community action is critical for generating the capabilities to fight malnutrition and poverty.

Communities should lead the process of identifying causes of malnutrition, propose solutions and take actions.

Community-based organizations should be the key actors supported by NGOs, national governments and the international community Next steps:

Strengthen inter-agency collaboration: include malnutrition and rural development in country-level planning such as the UN Development Assistance

Raise the profile of nutrition linkages to poverty reduction and gender discrimination at international, national and project level (promote increased development assistance, research and information exchange).

Recognise and build on the existing capabilities of community based organizations to address malnutrition.

Create a network to review and share lessons learned.

Initiate demonstration projects that primarily focus on effective community action in reducing malnutrition.

IFPRI

International Food Policy Research Institute

IFPRI tackles measuring childcare and feeding practices

The role of care in critically influencing child nutrition, health, and development has received increasing attention in the last decade. In the early 90s UNICEF took a lead role in articulating a conceptual model of child welfare that includes care, and in promoting the important role of care in nutrition programmes. However, progress in identifying tools to measure care has been slow because of the lack of simple, valid, and reliable measurement tools. With financial assistance from the Food and Nutrition Technical Assistance (FANTA) project, IFPRI is beginning to sort out these methodological and measurement issues.

Measuring hygiene

Using interviews and recall methods to measure hygiene practices is discouraged, because responses tend to be biased towards over-reporting of good practices. This happens because most populations have at least a minimum knowledge of what good hygiene practices should be, so they tend to report good practices even if they do not apply them. Observational methods are preferred although these are subject to problems of reactivity, i.e. people will behave differently in the presence of an observer. Reactivity decreases after one day of observation. Some researchers recommend discarding data obtained on the first day. Repeated observations also help address the common problem of day-to-day variability in hygiene behaviors.

An increasingly popular alternative to structured observation techniques is the use of spot-check observations. These consist of observing a pre-determined list of aspects and conditions at one point in time during a home visit. Spot check observations are much less time consuming, less costly and are not subject to reactivity. Additional research is needed to validate these methods.

Measuring feeding practices

Child feeding practices (i.e. breastfeeding and complementary feeding) are usually measured by maternal recall. However, there is little empirical evidence of the reliability and validity of maternal recall for measuring these practices. Recall errors are likely, especially when long recall periods are involved and when recall periods vary widely between respondents (e.g., when mothers of all children under five years of age are asked to recall early breastfeeding behaviors). This can be avoided by restricting the sample to mothers of children within a narrower age range (< 12 months, for example). Another approach is to use longitudinal studies, but these are not always feasible and tend to be costly. Recall bias may also occur, especially following educational interventions, when individuals know what the desired answer is. Such bias can be minimized through careful questionnaire design and by dissociating the survey process (evaluation) from program implementation. This can be achieved by using different teams of field workers.

Measuring caregiver-child interactions during feeding

The importance of the non-dietary aspects of child feeding, which include a variety of caregiver-child interactions, is now increasingly recognized. Interactions include responsive feeding, encouragement to eat, response to poor appetite, and adaptation of feeding to the child’s developmental stage. Structured observations are the method of choice for measuring these interactions. Various measurement scales have been developed, though not yet validated. Experience with survey approaches is very scanty; it is probable that many aspects of these interactions, especially those related to maternal involvement, will never be amenable to survey assessment. However, IFPRI experience in Accra suggests that simple questions can capture some aspects of caregiver-child feeding interactions. For example, attempts to operationalise and measure child appetite have been successful and it appears that maternal perceptions of infant and young child appetite are valid and useful. A simple analogue approach (i.e. asking the mother to rank her child’s appetite on a scale compared to other children the same age) has proven to be a useful tool.

Additional considerations for programming and research

A recurrent theme in IFPRI’s review is that good (or bad) practices tend to cluster, both within dimensions of care (such as hygiene or feeding) and across dimensions. Also, there seems to be a threshold or a minimum number of good practices necessary for health benefits to accrue to the child. Therefore, composite indices or summary measures that combine various practices in one index seem promising. Limited experience suggests that hygiene indices from spot check observations, and feeding indices using a variety of child feeding indicators measured through recall, can be constructed and are useful to study associations with child nutritional outcomes.

Program planning and design should be preceded by qualitative work in order to provide well-grounded and detailed knowledge of practices, relevant norms and potential constraints to the adoption of good practices. In addition to guiding program design, this information should be used to inform the selection of indicators and of monitoring and evaluation methods.

The use of mixed methods (combining qualitative and quantitative approaches) is also recommended both at the planning stage and during monitoring and evaluation in order to maximize opportunities to confirm findings.

Contact: Marie Ruel: m.ruel@cgiar.org

ILSI

International Life Sciences Institute

Forging effective strategies to combat iron deficiency

More than 200 participants from 45 countries attended a 3-day international conference in Atlanta to discuss strategies to address the world's most common nutritional deficiency: lack of adequate iron. The conference, held in May, 2001, was sponsored by ILSI, Centres for Disease Control and Prevention (CDC), the MI and Emory University.

Country-level experiences were reported describing successful efforts to improve iron status. The importance of effective communications with policy makers and consumers was stressed, as was the need to form partnerships and to utilize multiple strategies adapted to the needs of specific populations. Research is needed that addresses not just what to do, but also how to do it well. This implies a need for funding program evaluation activities. Some significant successes and promising new intervention approaches were reported. For example, the introduction of iron-fortified formula was shown to have a significant impact on the iron status of infants from low-income families in the United States. A highly effective program of fortification and supplementation has been implemented and sustained over many years in Chile. In China, a promising intervention is being field tested using iron-fortified soy sauce, and recent studies in Vietnam suggest that iron fortified fish sauce can have a positive impact on iron status. Effective, broad-based community interventions for iron deficiency were reported in Thailand.

The concluding session of the conference considered key action steps needed to address iron deficiency, as follows:

1. Government and non-governmental organizations, multi and bilateral agencies, the private sector and civil society need to recognize the health and economic consequences of iron deficiency and prioritize its alleviation as a major public health initiative by allocating appropriate resources.

2. National governments have an economic, social and moral obligation to implement and support the effective and affordable measures now available for prevention of iron and related micronutrient deficiencies.

3. Piecemeal and pilot efforts alone are insufficient. Culturally appropriate interventions must be multifaceted, e. g. integrating fortification of cereal flours and other foods with preventive multi-nutrient supplementation of vulnerable groups complemented by dietary diversification and public health measures.

4. Prevention and control programs of iron, folate and other appropriate micronutrients should be implemented in all developing countries by fortification of cereal flours and other suitable vehicles and by the supplementation of infants and children, adolescent girls and women of childbearing age, especially during pregnancy. Such programs can provide substantial health, social and economic benefits. Abstracts of the papers presented in the plenary, concurrent and poster sessions of the conference can be ac- cessed via the ILSI website at www.projectidea.ilsi.org Publication of the conference proceedings is planned.

INACG

International Nutritional Anaemia Consultative Group

The International Nutritional Anemia Consultative Group (INACG) is delighted to welcome Dr. Olivia Yambi, Regional Nutrition Advisor for UNICEF to the INACG Steering Committee. Dr. Yambi brings with her years of experience and dedication to the goal of eliminating micronutrient deficiencies.

INACG is planning a one-day symposium to immediately follow the 21^st IVACG meeting scheduled for February or March of 2003 in Morocco. INACG has released a call for abstracts for the symposium and will be accepting abstracts though 31 May 2002. The symposium will provide participants an opportunity to share expertise on program implementation and research dedicated to significantly reducing iron deficiency and iron deficiency anemia in the world.

Poster topics should be related to anemia, iron deficiency, iron deficiency anemia and cover:

infectious diseases (e.g. malaria, HIV/AIDS)

reproductive health

interventions (supplementation, food fortification and dietary modifications) and their effect on health outcomes, in particular, child development, including foetal growth, childhood growth, and mental and physiological development

integration of control programs with other public health interventions.

IVACG

International Vitamin A Consultative Group

IVACG has issued a call for abstracts for its next international meeting in Morocco. The tentative theme is

Improving the Vitamin A Status of Populations. IVACG will be accepting abstracts through 31 May 2002.

Abstracts for oral and poster presentations describing new data on the following topics are welcome:

successful interventions to prevent and treat vitamin

delivery of vitamin A supplements: Innovative delivery methodologies, alternative delivery systems, costs

food-based strategies to reduce vitamin A deficiency: effectiveness of dietary diversification, successful local initiatives with food fortification, increasing the vitamin A content of foods (genetically modified foods through traditional breeding or biotechnology-derived processes)

behavioural changes, from theory to practice, strategic approaches that work at the community level using supplements or food-based activities

new assessment methods to identify vitamin A deficiency and evaluating programme effectiveness

efficacy of multiple micronutrients delivered through supplements or food fortification: Biological interactions, stability, public health impact

Contact: Veronica Triana: vtriana@ilsi.org http://inacg.ilsi.org

ISPN

International Society of Public Nutrition

On August 28 2001 at the Vienna International Convention Centre, The International Society of Public Nutrition was launched. Dr Aaron Lechtig was asked to take charge of the Secretariat.

The Society will deal with issues of policy-making and programme development as they influence problems of human nutrition, such as:

nutrition and human rights (the right to food, health and care),

implications of recent advances in biotechnology for public nutrition,

development of human resources for policy making and for program development in nutrition,

comprehensive public nutrition planning and programming involving agriculture, education, industry, energy, economics, health, community development and other sectors,

programme implementation issues from their design to their evaluation as related to public nutrition interventions, and

translation of research findings into policies and programmes.

Contact: Aaron Lechtig: alechtig@terra.com.pe

IUNS

International Union of Nutritional Sciences

A small group of public health and nutrition scientists and advocates, met at the Rockefeller Centre, Bellagio, Italy in August 2001 under auspices of the IUNS. The purpose of the meeting was to further understand the nutrition transition and discuss ways to push forward both research and program and policy work. The meeting was organized by Barry Popkin of the University of North Carolina at Chapel Hill. Participants drafted this Declaration.

Bellagio Declaration
Nutrition and Health Transition in the Developing World:
The Time to Act

The control and prevention of undernutrition is unfinished work in many countries. At the same time, nutrition-related chronic diseases are now the main causes of disability and death, not only globally but also in most developing countries.

Evidence presented at our meeting supports and reinforces evidence already accepted by the World Health Organization and many national governments that proves that the patterns of disease throughout the developing world are rapidly changing.

Changes in food systems and patterns of work and leisure, and therefore in diets and physical activity, are causing overweight, obesity, diabetes, high blood pressure, cardiovascular disease including stroke, and increasingly cancer, even in the poorest countries. Malnutrition early in life, followed by inappropriate diets and physical inactivity in childhood and adult life, further increases vulnerability to chronic diseases.

Evidence from many developing countries shows that nutrition-related chronic diseases prematurely disable and kill a large proportion of economically productive people - a preventable loss of precious human capital. This trend is also seen in countries where HIV/AIDS is a dominant problem. Four out of five deaths from nutrition-related chronic diseases occur in middle and low-income countries. The burden of cardiovascular disease alone is now far greater in India and in China than in all economically developed countries in the world put together. Low income communities are especially vulnerable to nutrition-related chronic diseases; they are not only diseases of affluence.

Obesity, itself a disease, is a predictor of more serious diseases. For most developing countries, current rates of overweight and obesity - most of all in children, young adults and women - predict rapidly increasing disability and premature death from nutrition-related chronic diseases. Social and economic changes, on a scale and speed unprecedented in history, have resulted in an epidemic of nutrition-related chronic diseases that must be contained.

Prevention is the only feasible approach to nutrition-related chronic diseases. The cost of their treatment imposes an intolerable economic burden on developing countries. There is an urgent need for governments - in partnership with all relevant constituencies - to integrate strategies that promote healthy diets and regular physical activity throughout life into all relevant policies and programmes including those designed to combat undernutrition.

Chronic diseases are preventable. This has already been demonstrated in a few developed countries. Their main determinants are smoking, inappropriate diets and nutrition, and a lack of physical activity. Exposure to these determinants is largely a result of political, economic and commercial policies and practices that reflect decisions made at national and transnational level.

Effective programmes and policies to counter these trends will include not only health promotion and education, but also community empowerment and actions to overcome the environmental, social, and economic constraints to the improvement of diets and a reduction of sedentary lifestyles. (Over a relatively short time span, Finland and Norway have succeeded in reversing extremely high levels of nutrition-related chronic diseases through comprehensive food policies and active community involvement).

Several examples of innovative and promising approaches in developing countries were presented at the meeting. These include: Promotion of daily physical activity through massive community participation in Brazil; protection of the healthy aspects of the traditional low-fat high-fibre diet in South Korea; selective price policies promoting the consumption of soy products in China; development of food-based dietary guidelines in several countries based on local disease patterns and available foods.

School-based programmes to promote healthy diets and physical activity are an especially important early opportunity for action. Examples are the national school food programme in Brazil that provides fresh unprocessed foods to school children and the new national physical activity program in Thailand.

Immediate action to control and prevent nutrition related chronic diseases is not only a public health imperative, but also a political, economic, social necessity. Successful programmes will have to be multidisciplinary and inter-sectoral, and will include government, industry, the health professions, the media and civil society, as well as international agencies.

We - a group of scholars and representatives of selected international organizations from Africa, the Middle East, Asia, Europe and the Americas - present at this meeting, provided ideas for pushing forth a broader public health agenda in this area. We pledge ourselves to be part of this process.

This Resolution was agreed at the Rockefeller Centre at Bellagio, Italy in August 2001. (Barry Popkin organized the meeting which was convened under the auspices of the International Union of Nutritional Sciences). The 25 papers from this meeting will be published in the February 2002 issue of Public Health Nutrition. They will also be available as pdf files on www.nutrans.org.

Contact: Barry Popkin: popkin@unc.edu or visit www.nutrans.org

LINKAGES

Training modules on breastfeeding and related topics developed by or with the assistance of the LINKAGES Project - USAID’s global breastfeeding promotion programme - can be adapted to support health facilities and community-based breastfeeding activities. They are designed to draw on the knowledge and experience of learners to engage them in the immediate application of skills through a mix of discussions, role plays, case studies, field visits, and “take home” action steps. The modules cover five topics.

Infant Feeding Basics Various modules introduce key concepts related to breastfeeding and complementary feeding. Examples are:

Freedom from Hunger and LINKAGES have field tested behaviour change modules in Madagascar and the Philippines for use in credit-with-education groups. These modules employ adult learning techniques to improve infant feeding practices.

In Ghana, LINKAGES field tested a ten-day course for facilitators of women’s groups. The course focuses on the methodology of mother-to-mother support groups.

In Madagascar, the Ministry of Health, UNICEF, WHO, and LINKAGES produced four practical modules for health personnel of Baby Friendly Hospitals. A discussion guide at the end of each module can be used at monthly meetings of hospital personnel.

A four-day module for training trainers of community volunteers concentrates on enhancing skills in identifying suboptimal feeding practices, negotiating new behaviours with mothers, and appropriately using IEC materials.

Infant Feeding in Emergencies LINKAGES collaborated with WHO, UNICEF, IBFAN, and the Emergency Nutrition Network in the development of a module for emergency relief staff designed to raise awareness of the importance of sound infant feeding practices in emergencies and to advocate for improved practices. A second module, under development, will emphasize practical measures to support breastfeeding women in emergency situations.

Maternal, Infant, and Young Child Nutrition These Essential Nutrition Actions training modules include six orientation sessions directed at six service delivery contact points: antenatal, delivery and immediate postpartum, postnatal, well-baby and immunization, sick child, and family planning services. The sessions inform, prepare, and motivate health workers to implement priority nutrition actions as part of their routine health contacts with women and children.

Contact: L Martin: lmartin@aed.org www.linkagesproject.org

PROGRAMME NEWS - we welcome items for inclusion under PROGRAMME NEWS - write to us at: accscn@who.int

MI

Micronutrient Initiative

The Micronutrient Initiative evolves into a new organization

On December 1^st 2001 the Micronutrient Initiative became a legally independent organization with an international Board of Directors. This step fulfils one of the goals set for the MI at the time of its inception as a secretariat within The International Development Research Centre in Ottawa in 1992.

Drawing on nine years of experience, the new MI will continue to operate with the same mandate, i.e. facilitating the expansion of food fortification and supplementation programmes in developing countries to eliminate micronutrient malnutrition. The change of status of MI will make it more responsive to the needs of its partners and enhance operational effectiveness. The new organization will operate through four regional units and a global programmes unit. These are highlights of the MI’s recent work:

Enhanced support for vitamin A supplementation programmes: during 2001 the MI provided more than half a billion vitamin A capsules through UNICEF, WHO and national governments to reach children and lactating mothers in 68 developing countries. Since 1996, more than 1.5 billion vitamin A capsules have been provided by the MI. In many countries supplements are integrated with national polio immunization campaigns. MI is now working towards the progressive integration of vitamin A supplementation using routine primary health care delivery mechanisms.

Strengthening national capacities to assess micronutrient status: the MI is working with Tulane University, CDC and research institutions from ten Asian, African and Latin American countries.

Support to the UNU Iron Deficiency Project Advisory Service (called IDPAS Iron World) to create a proactive network and a clearinghouse with information on the assessment and prevention of iron deficiency. The MI’s support allowed IDPAS to expand its international advocacy for developing an internationally accepted decade goal on iron nutrition that can guide countries in efforts to reduce the prevalence of iron deficiency anaemia.

Support to Tulane University for the creation and maintenance of a database on micronutrient deficiencies and control programmes in the developing world.

Creation of an educational computer module on iodine deficiency disorders. This module was completed in collaboration with McMaster University. The programme is to be used as an educational resource for public health professionals working on IDD control programmes.

In partnership with UNICEF and local salt producers, the MI is now scaling up the production of double fortified salt in Nigeria and Kenya. Sensory tests in the two countries have shown encouraging results. The MI’s technical consultants provide engineering services to salt producers to design and install fortification equipment.

Support for vitamin A fortification of sugar of India’s Targeted Public Distribution System which distributes food commodities to households below the poverty line.

Assistance to the Department of Nutrition in Nepal for the development of a national anaemia control strategy. Several initiatives on staple food fortification are also being pursued.

Assistance for the fortification of cooking oils in Bangladesh.

Technical and financial support to the Ministry of Agriculture in Brazil for flour fortification with iron. As a direct result of this project, iron fortification of wheat and corn flour is now mandatory in Brazil.

Technical and financial assistance to the South African National Fortification Task Force and the Ministry of Health’s Directorate of Nutrition for the establishment of mandatory micronutrient fortification of wheat flour and maize meal with vitamin A, thiamin, niacin, B6, iron, zinc and folic acid.

Contact: Ibrahim Daibes: idaibes@micronutrient.org www.micronutrient.org

UNICEF

Monitoring progress toward the World Summit for Children Goals

The World Summit for Children (WSC) has perhaps had the most systematic and rigorous follow-up and monitoring of all the major UN Conferences and Summits of the 90s.

In 1998, UNICEF accelerated work to review the indicators, prepare data collection tools, line-up expert assistance and reinforce the political momentum required for this complex global undertaking. A high priority was placed on providing countries with data collection instruments of high technical standards as well as with direct assistance in data collection and analysis, at both country and regional level. The challenge was to ensure that the end-decade assessment was grounded in data that truly reflected the situation of the world's women and children and gave indication of the trends on which the 21^st century’s agenda for children has to be based.

For this assessment, UNICEF relied on Multiple Indicator Cluster Surveys (MICS) as the main data collection instrument. MICS is a household survey methodology that generates data on key indicators not adequately monitored by other data collection systems in use. It does so quicker and inexpensively. Working closely with other agencies, UNICEF harmonized MICS with other major survey programmes to generate comparable and complementary data, in particular with the USAID-sponsored Demographic and Health Surveys (DHS).

A technical manual was developed covering all aspects of survey design and implementation, including a model questionnaire, sampling, fieldwork, data collection, data processing, data analysis and report writing. In addition, standardised data processing programmes, as well as model reports were made available. To provide technical assistance in the implementation of the MICS surveys, UNICEF conducted a total of eighteen regional workshops in six regions. In addition, UNICEF is supporting countries to make the MICS data available for further analysis through the creation of micro datafiles.

MICS surveys were conducted in a total of 66 countries. An additional 35 countries obtained end-decade data from DHS and other national household surveys.

The MICS surveys were primarily implemented by government statistics agencies or ministries of health. The MICS surveys collected data not only on nutrition, health and education, but also on birth registration, living arrangements, water and sanitation, child work and knowledge and attitudes toward HIV/AIDS. MICS collected data on anthropometric indicators of child malnutrition, breastfeeding, complementary feeding, birth weights, vitamin A supplementation, and salt iodization.

A website (www.childinfo.org) was created to disseminate technical tools for the design and implementation of the surveys. In addition, the website contains UNICEF’s key statistical databases with detailed country-specific information that was used for the end-decade assessment. This major statistical and monitoring effort has resulted in a vast improvement in the quality and availability of data.

The MICS and DHS also for the first time calculated the percentage of births for which no weights were recorded or the mother did not recall the birthweight (more than two thirds of birthweights are either not recorded or not known). Available data on low birthweight are thus not representative of the population at large. A major effort is needed to ensure that all babies are weighed at birth and their birthweights are recorded.

In summary, one of the most important achievements of the end-decade review process has been an improved national capacity for data collection and analysis and the increased awareness of the importance of monitoring. This improved capacity plus the new and updated information challenges the international community to better use data to improve the condition of the world's children.

Contact: Tessa Wardlaw: twardlaw@unicef.org or
Krishna Belbase: kbelbase@unicef.org
www.unicef.org and www.childinfo.org

Mobilizing for Action on Infant and Young Child Feeding: Key Outcomes of the Easter and Southern Africa Regional Office (ESARO) Nutrition Network Meeting, Harare 15-19 October 2001

This four day network meeting focused on infant and young child feeding with sessions on the WHO/UNICEF global strategy, development of national policies, the Code, Baby Friendly Hospital Initiative, HIV and infant feeding, communications, and training. Field visits to baby friendly facilities, prevention of mother-to-child transmission project sites and code monitoring sites provided an opportunity to put theory into practice.

Most countries in the region have now been oriented on the new UNICEF/ WHO Global Strategy on Infant and Young Child Feeding. It was emphasized that implementation of the various elements of the strategy can proceed and does not have to await formal adoption by the World Health Assembly in May 2002.

Country teams made commitments to endorse the Global Movement for Children and to accelerate actions to improve infant and young child feeding. Specifically, the following commitments were made:

- All countries without written policies will work on developing policies and strategies on infant and young child feeding. Existing policies will be reviewed to assure they are comprehensive and up to date. New and updated policies will appropriately reflect infant feeding in the context of HIV/AIDS.

- All countries with draft legislation (the majority in the region) on Marketing of Breastmilk Substitutes will work to have these enacted into law by July 2002. Following the example of Zimbabwe, all countries with national laws will work on improving their enforcement. Local language translations of the International Code will be made available as needed.

- A re-assessment of existing Baby Friendly facilities will be undertaken.

- Large-scale orientation and training strategies on infant and young child feeding practices for different cadres will be developed in all countries.

These commitments call for concrete mechanisms of support by different regional bodies including UNICEF country offices and the Eastern and Southern Africa Regional Office. Among partners who committed support for the implementation of the new Infant and Young Child feeding initiative were the Commonwealth Regional Community Health Secretariat, The Regional Centre for Quality Health Care, WHO/AFRO and IBFAN Africa. UNICEF ESARO, in collaboration with UNICEF Headquarters as needed, will provide support on technical and financial resources mobilization. This is especially important given that the nutritional aspects of country programmes have been chronically under-funded and it has been difficult to raise funds to support infant and young child feeding in general.

There was very good exchange of country experiences. Critical to further sharing of lessons will be more systematic documentation and the sharing of best practices.

It was agreed that South Africa will host the Nutrition Network Meeting for 2002 and the theme will be Nutritional Care and Support in the Context of HIV/ AIDS. The theme of infant and young child feeding will continue to be on the agenda of the network meetings for the next 3 years.

WHO

Improving the management of severe malnutrition

An estimated 50 million children under five are severely wasted. They mostly live in 27 developing countries and they face a case-fatality rate of 30-50%. As described in these new WHO guidelines, with appropriate management this unacceptably high death rate can be reduced to less than 5%. WHO has completed the development and testing of a seven-module training course on hospital-based care to accompany recent manuals on assessment, management, and rehabilitation of severely malnourished children. Wide dissemination of the course, and training in its application, are among the next urgent steps. The completed modules are now available for distribution to institutions interested in conducting training to improve the case management of severe malnutrition.

Contact: Sultana Khanum: khanums@who.int

WHO and WFP work together to provide food aid in HIV/ AIDS

The third coordinating and planning meeting between WHO and WFP was held in November 2001 in an attempt to complement actions in the fight against HIV/ AIDS. Assisted by a contribution from the Italian government, the objectives of the current effort focus on achieving coordination in country level actions. The first planning meeting resulted in a Letter of Intent to this effect signed by both agencies. WHO will assist WFP to develop appropriate food packages for people living with HIV/AIDS, as well as providing other types of technical assistance, notably training for WFP staff and partners in the field. WFP is making the Vulnerability Analysis Mapping system (VAM) available to WHO for enhanced targeting of activities. Both organizations will prepare joint funding proposals. In addition, the ongoing activities in Mozambique, Rwanda, Tanzania, and Uganda will be documented to provide models for an expansion of this initiative in the near future.

Contact: Mirella Mokbel Genequand: mokbelm@who.int

Complimentary feeding

There is far less knowledge, experience and consensus about effective approaches to improve complementary feeding than there is in relation to breastfeeding. To address this imbalance, the WHO’s Department of Child and Adolescent Health and Development in collaboration with the Department of Nutrition for Health and Development, convened a global consultation on complementary feeding, December 10-13, 2001 in Geneva. Since a consensus had been reached earlier in the year on the optimal duration of exclusive breastfeeding, the need to move more energetically to increase understanding of how to promote better complementary feeding practices in developing countries is obvious. One of the main objectives of the consultation was to define key messages for programmatic approaches to improve complementary feeding. Kathryn Dewey and Ken Brown of the University of California/Davis presented an update on technical issues and implications for intervention programmes. Professor Brown noted that FAO, WHO and UNU are in the process of revising energy requirements (see p 17) in infancy based on new data from longitudinal studies of energy expenditure and body composition of USA children. Revised energy requirements for older children (12-23 months) are also being prepared. These new requirements will have an impact on recommended energy densities of complementary foods as well as feeding frequency. The consultation debated the value of a ten-steps approach for complementary feeding, akin to the ten steps to successful breastfeeding. The full report of the consultation will be issued shortly.

Contact: Dr. H. Troedsson, Director, Department of Child and Adolescent Health and Development. troedssonh@who.int

Pregnancy Intentions, Breastfeeding and Infant Health: Is there a causal relationship? Analyses of data collected in Ecuador and the USA have found an association between unplanned pregnancies (mistimed and/or unwanted) and suboptimal prenatal care behaviors such as smoking and alcohol consumption. These findings are consistent with recently published 1994 data documenting that women with unwanted pregnancies were significantly more likely to deliver low birthweight infants. A retrospective study conducted in New York and two analyses from Peru (1992) and Ghana (1993) indicate that women with unplanned pregnancies are more likely to breastfeed for shorter periods of time. This may be explained at least in part by studies that have identified low birthweight as a risk factor for suboptimal infant feeding practices. Thus, a potential pattern is emerging that justifies conducting longitudinal studies to test whether unintended pregnancies lead to low birthweight by increasing the chances of untimely prenatal care, and/or prenatal alcohol consumption and smoking. Low birthweight in turn is a risk factor for suboptimal breastfeeding practices. Both, low birth weight and lack of breastfeeding are well known risk factors for poor child health outcomes. Unintended pregnancies may thus be linked with a higher risk of child morbidity and mortality. The implications of this model are enormous from a public health point of view as in many places as much as half of all pregnancies are unplanned. Rafael Pérez-Escamilla: rperez@canr.uconn.edu

WORLD FORUM ON FOOD SOVEREIGNTY

Some 400 delegates from peasant and indigenous organizations, fishing associations, non-governmental organizations, social agencies, academics and researchers from 60 countries met in Havana in September 2001 to analyze the reasons why hunger and malnutrition grow every day throughout the world, why the crisis in peasant and indigenous agriculture, artisanal fisheries and sustainable food systems has worsened, and why the people are losing sovereign control over their resources. This Forum was convened in Cuba by the Cuban National Association of Small Farmers and a group of international movements, networks and organizations with the aim to collectively develop viable alternatives for action on a local, national and global scale, aimed at reversing current trends and promoting new policies that can guarantee a hunger-free present and future for all men and women of the world. The Final Declaration reads:

For the peoples’ right to produce food, feed themselves and exercise their food sovereignty.

Five years after the World Food Summit, seven years after the agricultural agreements of the Uruguay Round, and following two decades of the application of neoliberal policies, the promises and commitments made to satisfy the food and nutritional needs of all are far from being fulfilled. Actually, the economic, agricultural, fishing and trade policies imposed by the World Bank, IMF and WTO, and promoted by the transnational corporations, have widened the gap between the wealthy and poor countries and accentuated the unequal distribution of income within countries. They have worsened the conditions of food production and nutrition of the majority of the world’s people, even of some in the developed countries. As a consequence, the right to food and nutritional well-being enshrined in the Universal Declaration of Human Rights, is not guaranteed for the world’s poor.

The sustainability of food systems is not merely a technical matter. It constitutes a challenge demanding the highest political will of states. The profit motive has led to the unsustainability of food systems often surpassing the limits on production imposed by nature.

The hope for a new millennium free of hunger has been frustrated, to the shame of all humanity.

The real causes of hunger and malnutrition

Hunger, malnutrition and the exclusion of millions of people from access to productive goods and resources are not a result of fate, of geographical location or climatic phenomena. Above all, they are a consequence of deliberate policies that have been imposed by developed countries and their corporations to maintain and increase their hegemony within the current process of global economic restructuring.

In the face of the neoliberal ideology behind these policies we affirm that:

- Food is not a merchandise and that the food system cannot be viewed mainly according to a market logic.

- The liberalization of international agricultural and fishing trade does not guarantee the people’s right to food.

- Trade liberalization does not necessarily facilitate economic growth and the well-being of the poor.

- The underdeveloped countries are capable of producing their own food now and in the future if external constraints are lifted.

- The neoliberal concept of comparative advantage negatively affects food systems. The importing of cheaper food commodities leads to the dismantling of domestic production and the reorienting productive resources towards export crops for the First World markets.

- Peasant, indigenous farmers and artisanal fisherfolks are indeed able to meet the growing needs of food production. Intensive industrial agriculture and fishing are ill-suited to solve the world's hunger problems.

- Current efforts to privatize agricultural and fisheries natural resources are steps in the wrong direction.

- Privatization leads, among other, to massive migration to the cities and abroad supplying cheap labor to corporations and exacerbating urban unemployment.

- Transnational food models being imposed threaten the diversity of peoples’ food cultures.

- Developed countries use food as a weapon. We recognize the efforts of Cuba which, despite a four decades US blockade has managed to guarantee the right to food for all of its people.

- All of the above is taking place while we see a weakening of the real participation of the rural population in the discussion and adoption of public policies.

- Developed countries have reaped most of the benefits while the peoples of the Third World have seen a growth of their external debt and heightened levels of poverty and social exclusion. The international agricultural market is cornered by a small number of transnational corporations while dependence and food insecurity is the reality for the majority of the rural poor.

- A number of countries continue to heavily subsidize their export crops giving no protection to small farmers who produce for the domestic market.

- Neoliberal policies are promoting a process of forced deruralization.

- Artisanal fishing communities have been increasingly losing access to their own resources.

- Hunger and malnutrition are growing, not because of an absence of food, but rather because of an absence of rights.

In view of the foregoing, the participants in the World Forum on Food Sovereignty declare:

1. Food sovereignty is the peoples’ right to define their own policies and strategies for the sustainable production, distribution and consumption of food. This sovereignty centers on supporting small and medium-size producers; it respects farmers' own cultures and diversity and their own forms of fishing and agricultural production in which women play a fundamental role.

2. Food sovereignty is primarily oriented towards the satisfaction of the needs of the local and national markets.

3. The rights, autonomy and culture of indigenous peoples is a prerequisite for combating hunger and malnutrition as is the recognition of their right to autonomous control of their territories and natural resources

4. Food sovereignty further implies guaranteed access to safe and sufficient food for all individuals.

5. Food sovereignty implies the implementation of comprehensive land reform which will also give equal opportunities to women. It has to entail equitable access to land, water and forests, as well as to the means of production, financing, training and capacity building. Where needed, land reform is an obligation of national governments, but must be controlled by peasant organizations. We oppose the policies and programs for the commercialization of land promoted by the World Bank.

6. We support the Code of Conduct on the Human Right to Adequate Food (put forward for consideration at the upcoming World Food Summit: Five Years Later (WFS FYL) as an instrument for the implementation and promotion of this right.

7. We support the ratification and application of the International Covenant on Economic, Social and Cultural Rights (UN, 1966).

8. We support the adoption by the UN of an “International Convention on Food Sovereignty and Nutritional Wellbeing” to rule over decisions on an international food trade that serves human beings. [Food sovereignty does not mean autarchy, full self-sufficiency or the disappearance of international agricultural and fishing trade].

9. We oppose any interference by the WTO to unduly influence national food, agriculture and fishing policies. We categorically oppose its agreements on intellectual property rights over plants and other living organisms. WTO has to be kept out of food. 10. We propose the creation of a new democratic and transparent order for the regulation of international trade, the creation of an international appeals court independent of the WTO, as well as the strengthening of UNCTAD as a forum for multilateral negotiations on fair trade in food. At the same time, we propose the promotion of regional networking among producers’ organizations opposing the negative effects of the neoliberal practices depicted above. 11. We demand an immediate end to the unfair subsidies being given to agricultural exports in the North.

12. We condemn biopiracy and the patenting of living organisms, including the development of sterile varieties through genetic engineering processes. Seeds are the patrimony of all of humanity. The monopolization genetically modified organisms (GMOs) technologies represents a grave threat to the peoples’ food sovereignty. We demand a ban on open experimentation and marketing of GMOs until there is conclusive evidence of their impact (precautionary principle).

13. We oppose the imposition of food models alien to the food cultures of sovereign nations. Food sovereignty should be founded on diversified systems of production, based on ecologically sustainable technologies.

14. We consider the protection of the environment and biodiversity and of cultural diversity a priority.

15. We support the struggles of women for access to productive resources and for passing on their food cultures to their children.

16. Artisanal fisherfolks and their organizations are not to relinquish their rights to free access to inland and coastal fishing grounds and the establishment and protection of reserve areas for the exclusive use of artisanal fishing.

17. Food aid policies and programs must be reviewed. They cannot inhibit the development of local food production capacities. They should also not lead to dependence, to corruption, or to the dumping of foods that are harmful to health.

18. Food sovereignty can only be achieved, defended and exercised through the mobilization of all of society. It requires an effective democratization of decision-making and the development of national and international solidarity networks.

19. We condemn the US policy of blockading Cuba and other peoples and the use of food as a weapon of economic and political pressure against countries and popular movements.

20. Achieving food sovereignty and eradicating hunger and malnutrition are possible in all countries and for all peoples. We express our determination to continue struggling against the negative effects of globalization, maintaining and increasing our role as social mobilizers, building strategic alliances and adopting firm political agendas.

21. We propose declaring October 16 (known until now as World Food Day) as World Food Sovereignty Day.

22. FAO has to fully assume its mandate and responsibility to, in all fora including WTO, fight for the interests and right to food and nutrition of the poor.