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Progress achieved in the field of nutrition
under the new institutional arrangements
ACC/SCN series of nutrition summaries for
policy-makers
Endemic
goiter
Nutritional
anemia
Progress achieved in the field of nutrition under the new institutional arrangements
Report of the ACC to the United Nations Economic and Social Council
I. HARMONIZED POLICIES OF UNITED NATIONS ORGANIZATIONS FOR COLLABORATING WITH DEVELOPING COUNTRIES IN IMPROVING THE STATE OF NUTRITION
Introduction
1. A statement on institutional arrangements relating to nutrition (E/5805), submitted to the Council at its sixty-first session by the Administrative Committee on Co-ordination (ACC), provided a broad outline of the nutrition problem, noted that the recommendations of the World Food Conference contained in its resolution V appeared to offer a valid basis for coherent action to promote durable solutions to those nutrition problems, and contained several recommendations concerning institutional arrangements. Action on those proposals was deferred to the sixty-third session.
2. At that session, after considering a supplementary statement from ACC (E/5968), which elaborated upon or modified the original proposals, the Council adopted resolution 2107 (LXIII), requesting ACC, inter alia, "To implement the proposals [relating to institutional arrangements in the field of nutrition] ... and to report to the Economic and Social Council :.. on the progress achieved in this field under the new arrangements."
3. The present report is submitted in response to that request and is intended to assist the Council in its deliberations on the matter.
Review of the Nutrition Problem
4. Malnutrition continues to be a major world problem, affecting upwards of 500 million people-a number that is increasing daily. It contributes to about half of the approximately 15 million deaths of infants and young children annually in developing countries; it reduces the present and future potential of human beings by its effects on the physical and mental development of children and the working capability of adults; and it contributes substantially to the perpetuation of the hardships and misery that confront the poorest strata of the population in developing countries. Malnutrition is not only a consequence of unsatisfactory social and economic development but is also a major contributing factor.
5. While increased food production is essential for meeting nutritional needs and must be promoted vigorously, increased production will not of itself meet those needs unless it is associated with a more equitable distribution of benefits and the alleviation of the disease load that inhibits the effective use of food by the human organism. Thus, even a substantial improvement in gross national product per capita income may not necessarily result in a significant decrease in malnutrition unless it involves an increase in the income of the lower socio-economic groups. Both explicit attention to nutrition and explicit actions are required if the problem is to be reduced and ultimately eliminated.
6. In the past, the response to the problem has been inadequate, being limited in both conceptual scope and coverage. Rarely have the actions undertaken been within the context of a strategy looking at over-all need or with sufficient resources and commitment.
7. Because nutrition cuts across sectors, government administrations have generally not been organized so as to provide a strong focal point for nutrition Policies and programmes that produce a substantial impact on nutritional status (e.g., agricultural, price and trade policies) have usually been developed without taking nutritional considerations into account. The result in most countries has been nutrition "by happenstance".
8. The work of the United Nations system in relation to needs has run into most of the difficulties encountered by Governments. Fortunately, the situation is now beginning to change, and as awareness of the importance of the problem in developmental as well as human terms has grown, the prospects of achieving improvements have become more favourable.
9. At the global level, it is becoming increasingly apparent that both the knowledge and the resources are available to achieve a significant reduction in the major forms of malnutrition prevailing in developing countries. This will entail pursuing specific nutrition interventions and integrating nutritional considerations into development policies and programmes. In this connexion, special attention will need to be directed towards policies and programmes that are closely related to food availability and consumption, such as pricing policies, agricultural investment allocations and trade policies. Decisions on the appropriate policy mix, the types of intervention, programme content, and resource requirements will need to reflect the specific nature and extent of a country's malnutrition problems.
Summary of Required Actions at the National Level
10. While the Governments of both developed and developing countries will need to assume their appropriate responsibilities if malnutrition is to be reduced and eventually eliminated, a specific responsibility for dealing with nutrition problems clearly rests with the countries in which such problems occur.
11. National Governments have an opportunity to reduce the severity and dimension of their nutrition problems by adopting a series of actions that are largely interrelated, including the introduction of food consumption and nutritional goals into their development programmes; the establishment of national strategies and programmes to meet these goals; the appraisal of the nutritional consequences of policies that may have a bearing on food consumption; the implementation of specific interventions with an emphasis on particular problems or on population groups at high risk; and the establishment of a strong focal point in the Government to achieve all these things.
Supportive Actions by the United Nations System
12. To support such action by Governments, the executive heads
of the United Nations organizations participating in the
Sub-Committee on Nutrition have agreed:
(a) To recommend, where this is not already the case, that the
improvement of nutrition as an explicit goal be included in the
medium-term and long-term plans of their organizations and to
develop a strategy to achieve this;
(b) To investigate opportunities for contributing to the
improvement of nutrition within their existing programmes;
(c) To assist countries, where their organizations are
co-operating in relevant development programmes:
(i) To assess at an early stage the probable nutritional impact
of such programmes on the population, especially on those groups
most at risk;
(ii) To introduce, when appropriate, nutritional components in
the goals, processes and indicators of these programmes;
(iii) To develop or expand direct nutrition intervention
programmes;
(d) To review administrative arrangements and resource
availabilities within their own organizations to meet the above
needs;
(e) To take every opportunity to bring to the attention of member
Governments the significance of nutrition as a development issue;
(f) To foster increased co-operation between their organizations
at the country level.
13. ACC has also asked its Task Force on Long-Term Objectives and its Task Force on Rural Development to ensure that nutrition concerns are integrated into their activities.
14. It is suggested that the Council may wish to draw the attention of bilateral aid agencies to the foregoing decisions, since they might wish to follow a similar approach in the programmes in which they are collaborating.
15. The steps outlined above reflect the general conviction on the part of ACC that the problem of malnutrition can be controlled, as well as a commitment for action on a systematic and sustained basis. Through these actions, which reflect the assignment of the same priority and importance to nutrition within the organizations as is expected of member countries, ACC believes that the United Nations system will be able to play an effective role of leadership in resolving one of the most serious and intolerable problems facing the international community.
Independent Review
16. The proposals made by ACC in 1977 for institutional arrangements relating to nutrition2 included a suggestion that an independent review of the evolution of the nutrition problem and the "state of the art" be made every two or three years by a small expert group (E/5968, pare. 10). In view of the extent to which the subject of nutrition is being dealt with in the mid-decade report being prepared for the World Food Council's fifth session, in 1979, and in the study Agriculture Towards 2000, to be published this year by the Food and Agriculture Organization of the United Nations (FAO), an independent review at this stage would appear to duplicate some of the work referred to above. The considerable expert and financial resources required would not appear to be justified. ACC intends, therefore, to postpone this independent review.
II. ACTIONS OF THE ACC SUB-COMMITTEE ON NUTRITION AND ITS ADVISORY GROUP ON NUTRITION
17. The Sub-Committee held its first meeting in September 1977. Its small secretariat became operational in mid 1978 and the fifth session took place at Geneva from 26 February to 2 March 1979.
18. The Sub-Committee appointed at its second session an Advisory Group on Nutrition, consisting of eight individuals from different disciplines with experience in the improvement of nutrition in developing countries. This Group is providing a general scientific input on which many of the Sub-Committee's conclusions are based. In addition, it is treating a number of specific questions referred to it or to which it wishes to draw attention.
19. Interested bilateral aid agencies now regularly attend meetings of the Sub-Committee. The resultant exchange of information and joint discussions are contributing towards a harmonization of plans and activities, an avoidance of overlapping and a mutual understanding of strengths and limitations.
20. To enrich further the deliberations of the Sub Committee and its Advisory Group, a few individuals from institutions active in nutrition in developing countries are also invited to attend each session in the light of their experience in respect to items on the agenda.
21. In its supplementary statement, noted by the Council in resolution 2107 (LXIII), ACC says that the Sub-Committee "would be a point of convergence in harmonizing the policies and activities in the United Nations system, particularly in accomplishing the objectives of resolution V of the World Food Conference" (E/5968, pare. 4). ACC can now report that there is substantial agreement among the agencies on the approach and policy to be followed in support of national actions in the field. A briefing document has been prepared on nutrition and on the appropriate lines of action that may be taken in different circumstances. It is designed to be used by all organizations concerned as a common element in the briefing of new staff, project personnel and consultants whose work will have a bearing on nutrition.
22. The Sub-Committee is examining a number of constraints on
more rapid progress in the field of nutrition and is endeavouring
to initiate measures to reduce them:
(a) A paper on the usefulness of global and national targets to
countries undertaking action in the nutrition field has been
prepared for publication in a professional journal, which will be
made available to national planners, through the resident
representatives of the United Nations Development Programme
(UNDP) and other channels;
(b) In order to enhance the information available to decision
makers, the possibility is being investigated of initiating a
professionally produced newsletter with bilateral support; the
Food and Nutrition Bulletin of the United Nations University is
being used to publish material prepared in connexion with the
work of the Sub-Committee and in addition publication has started
of a series of information leaflets on various nutritional topics
of importance to developing countries;
(c) After extensive examination by United Nations and bilateral
organizations it was decided at the fifth session of the
Sub-Committee that there was sufficient interest to start on a
trial basis a "Resource Identification Facility", the
object being to speed up project/programme preparation and to
enhance the flow of external support by facilitating the
collaboration of national authorities, bilateral or international
funding organizations and technical agencies from the earliest
preparatory stage at the country level;
(d) A shortage of personnel able to prepare and administer
nutrition activities was recognized as a major constraint and to
counteract this it was decided at the fifth session to give
priority to identifying and strengthening national institutions
so that they would be able to undertake the training, applied
research and advisory services required within their areas of
influence; initially special attention will be given to Africa;
(e) Participation of the community is essential for the success
of activities to prevent malnutrition. The Sub-Committee has
requested its Advisory Group on Nutrition to prepare a basis for
consideration at the sixth session of actions that can be
recommended
23. The Sub-Committee considers it important to give people in developing countries concerned with the planning and management of activities to improve nutrition an opportunity to elaborate what external support they would find most effective; a workshop for this purpose is due to be held in July 1979.
24. A consultative group on maternal and young child nutrition has been established as a task force of the AGN, and held its first meeting in February 1979. Its principal recommendations will be published and be used as an input to a high-level meeting on infant and young-child feeding to be convened by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) in October 1979. Immediately after that meeting, representatives from United Nations and bilateral organizations will discuss follow-up actions working group for the co-ordination of support by United Nations and bilateral organizations to national nutritional surveillance activities.
26. FAO has prepared guidelines for the introduction of nutritional considerations into rural development and agriculture programmes. These guidelines have been commented on by other agencies and are now undergoing field testing.
27. Other work has been concerned with analyses of different types of intervention in nutrition. A brief paper on nutrition in long-term objectives or strategies has been prepared for the ACC Task Force on Long-Term Objectives
28. The first item in the Sub-Committee's terms of reference concerns the implementation of the resolutions of the World Food Conference relating to nutritional improvement, and the Sub-Committee has helped ACC to respond to requests from the World Food Council in this field. ACC presented to the World Food Council at its fourth session, in June 1978, a brief report on actions to improve nutrition that could be taken in countries, especially in the field of agriculture (WFC/1978/5/Add.3). A second report is being presented to the World Food Council at its fifth session.
ACC/SCN series of nutrition summaries for policy-makers
The two short statements on "Endemic Goiter" and "Nutritional Anemia" appearing on pages 46 - 49 are the first of a series planned by the Administrative Committee on Co-ordination's Sub-Committee on Nutrition for policy-makers and others interested in short, authoritative summaries of major nutrition problems and their prevention. Single copies will be available without charge from Dr. H.J.L. Burgess, Secretary, ACC Sub-Committee on Nutrition, c/o Food Policy and Nutrition Division, FAO, Via delle Terme di Caracalla, 00100 Rome, Italy. The statements can be ordered in bulk at the prices indicated on the copy.
Additional summaries in this series are planned for future issues of the Food and Nutrition Bulletin.
The Problem and Its Causes
Thyroxine, the hormone produced by the thyroid gland, is essential for the physical and mental development of children, and it regulates energy expenditure. Iodine, a basic component of this hormone, is thus an essential nutrient for human beings, although the average daily requirement is only about 0.1 to 0.15 of a milligram. The iodine content in foods of both vegetable and animal origin is determined by the amount in the soil on which they are produced. In many areas of the world, mainly in mountainous regions, the soil and water are very poor in iodine; if the populations in these areas are dependent primarily on the foods produced locally, they may not have enough iodine in their diet.
In an effort to compensate for this deficiency, the thyroid gland enlarges so that it can utilize the available iodine more efficiently and produce enough thyroxine. This pathological enlargement of the thyroid gland is known as goiter, which presents as a swelling on the front of the neck. When it occurs in a significant proportion of people living in a circumscribed area, goiter is considered to be endemic. Although in some instances other factors may be contributory or principal causes, in most areas where endemic goiter prevails, the main cause is insufficient iodine intake.
The Consequences
It has been estimated that about 200 million people suffer from goiter. Where it is endemic the proportion of people actually affected varies with the degree of the iodine deficiency. Women, and particularly adolescent girls, are especially at risk because their iodine requirements are higher. The World Health Organization considers that endemic goiter is a serious health problem when, in a given area, more than 5 per cent of adolescent girls have goiter. In some highly endemic areas, up to 80 or 90 per cent of the total population may be affected.
Because the enlargement of the thyroid gland in goiter is actually a compensatory mechanism, people with this condition usually have normal thyroid function. If, furthermore, the goiter is not very large, health does not seem to be seriously affected. However, with severe, chronic deficiency, very large goiters develop. Not only do these alter appearance, but they can cause obstructive complications and there are indications of a greater risk of other thyroid diseases, including thyroid cancer.
Perhaps the most serious problem of iodine deficiency is its effect on fetal development It has been known for a long time that where goiter is endemic, there is often a higher than usual incidence of congenital cretinism and deaf-mutism. More recently it has been shown that children born of iodine-deficient mothers may have varying degrees of mental impairement, ranging from a very mild form, difficult to recognize, to blatant cretinism. Cretinism is relatively rare, thus of greater importance to the community is the much larger proportion of children born with a slightly diminished mental capacity.
The health consequences, as well as the social and economic repercussions of endemic goiter are, therefore, obvious, and may constitute a serious impediment to the development of the affected communities. The situation is all the more intolerable because effective, low-cost measures for control are available.
Control
The prevention of endemic goiter depends on ensuring that people obtain, through their diet or by other means, the iodine they lack. The problem may gradually be alleviated when, in the course of economic development, food sources become diversified and a large proportion of foods originate from soils richer in iodine. This process may take decades, and in most developing countries, particularly in areas of high endemicity, more active steps are necessary.
Two methods for direct intervention are available: the addition of iodine to salt, or periodic intermuscular injections of iodinated oil.
Salt Iodination
The addition of an iodine compound to common salt has been used in many countries to control endemic goiter. A great deal of experience is available on the most suitable forms of iodine, on the level of fortification required, on the processing indicated under different circumstances, and on costs. The advantages of salt as a vehicle are that it is consumed regularly by all the population; variations in the amount consumed are not large; it is frequently centrally processed, making iodination feasible; its colour, taste, and other characteristics are not altered.
In most instances where salt has been iodinated, its selling price to the public has not been altered, the relatively small increase in the cost (about one-half of one US cent per person per year) being borne by the government or by the producers. Salt iodination is, therefore, a very effective and efficient measure for the prevention of endemic goiter.
Intramuscular Injection
There are areas where iodination cannot readily be implemented, for instance, in isolated villages that obtain their salt from local mines or salt marshes; or where salt is produced by a large number of small producers and does not pass through central processing or marketing facilities. Under these circumstances, and particularly for populations with high endemicity, the second alternative for goiter control is the intramuscular injection in women of child-bearing age with a specially prepared iodinated oil.
This single injection provides enough iodine to cover the needs of a person for a period of three to five years. The procedure is only indicated for populations with a high prevalence of endemic goiter. If the injection is given before or during early pregnancy, it reduces the risk of the iodine deficiency causing mental retardation in the offspring.
Giving an injection to every vulnerable member of the population every three to five years may not sound too difficult, but in fact this can impose a considerable strain on the limited resources of a developing country. Therefore, it should be used only as a temporary measure while problems in iodinating salt are being overcome.
Conclusion
Endemic goiter is a major problem seriously affecting the health and well-being of large population groups and limiting their potential for socio-economic development. In most countries it has not received the attention it deserves, probably because its effects are undramatic and the populations affected have lived with the problem for generations and accept it as inevitable.
It is important, therefore, that public health workers call the attention of their governments to this problem and solicit the active participation of other sectors such as planning, industry, commerce, and rural development in designing locally suitable control measures. The communities themselves should be motivated and involved so that the tangible result of their efforts encourages their participation in further developmental work.
The control of endemic goiter is an important means of alleviating human suffering and facilitating social and economic development at marginal cost.
What Is Nutritional Anemia?
The World Health Organization has defined nutritional anemia as a condition in which the hemoglobin content of the blood is lower than normal as a result of a deficiency of one or more essential nutrients, regardless of the cause of such deficiency. Malaria, schistosomiasis, and various other diseases can contribute to iron-deficiency anemia and several causes of anemia can coexist in an individual.
Nutritional anemia is the end-result of a severe nutrient deficiency, usually iron, less frequently folate, and rarely vitamin B12 . Hemoglobin concentration, by which anemia is diagnosed, is a relatively insensitive index, thus a person who is found to be anemic is already suffering from quite a marked degree of nutrient deficiency. Very severe anemia manifests itself clinically in pallor, anorexia, lassitude, dizziness, breathlessness, and edema and soreness of the tongue and mouth.
Harmful Effects of Anemia
From the public health and socio-economic points of view, anemia is important because it interferes with the sense of well-being of the individual, and reduces productivity and work capacity; it aggravates many other disorders; it contributes to the overall mortality associated with malnutrition, and, in the case of anemia in pregnancy, it poses a threat to the life and health of the mother at the time of delivery and contributes to low birth-weight and thus poor viability of the infant.
Some individuals can seemingly function normally with severe degrees of anemia, but most cannot. Even mild anemia impairs well being. For example, studies of sugarcane cutters in Guatemala, latex tappers and weeders in Indonesia, and tea-pickers in Sri Lanka have shown a direct relationship between hemoglobin concentration and work output.
Causes of Nutritional Anemia
Nutritional anemia may be caused by insufficient intake, poor absorption, or an increased requirement of one or several blood-forming nutrients.
Insufficient Intake
Insufficient intake of iron is chiefly observed in young children consuming dairy products or other foods of low iron content at a time when their requirements are relatively high for the rapid build-up of blood and tissues. It is also found among young women who voluntarily restrict their dietary energy intake for esthetic reasons, because iron and energy intake are roughly proportional. There are other instances of insufficient iron intake, but these are rather exceptional and are usually combined with other deficiencies such as occur in famines.
The intake of folate and vitamin B12 is usually sufficient in most diets, only becoming insufficient in the presence of special culinary or dietary practices. Overcooking of foods, especially vegetables, can cause folate deficiency, and complete avoidance of all animal products in the diet, as practised by some vegetarians, may lead to vitamin B12 deficiency.
Poor Absorption
The rate of absorption of iron is influenced by the dietary pattern and the level of iron stores in the body. It is increased by the presence of animal products in the diet, or of some other constituents such as vitamin C and some amino acids. The iron in vegetarian diets is usually poorly absorbed, and unless there are other factors present that enhance the absorption, iron-deficiency anemia will develop. This is probably why widespread and severe anemia is so frequently observed in some developing countries, such as those in Asia.
Increased Requirements
The body's increased requirement for iron may be physiological or pathological. Normally, a certain percentage of women lose large quantities of blood during menstruation and, therefore, require higher amounts of iron. During pregnancy, folate and iron requirements are increased, becoming six times greater for a woman in the last three months of pregnancy than for a non-pregnant woman. As a consequence, women of reproductive age are especially vulnerable to iron and folate deficiencies. It is interesting to note that hormonal contraceptives tend to reduce the menstrual blood flow and thus the loss of iron; however, intrauterine contraceptive devices have the opposite effect. in certain pathological conditions, such as hookworm infestation, there may also be increased loss of blood and, therefore, of iron. This is, in fact, a major cause of anemia in most developing tropical and sub-tropical countries.
Prevalence
There are now about one billion women in their reproductive years; over two-thirds of them live in developing countries, and bear on average over twice as many children as do women in developed countries. At any given time roughly every sixth woman 15 to 49 years of age living in developing countries is pregnant, compared with about one in 17 in developed countries. From the information available, it appears that at least half of the non-pregnant women and nearly two-thirds of pregnant women have hemoglobin levels below those established by WHO as indicative of anemia. This makes a total of some 260 million anemic women in the developing world alone. The overall proportion of anemic women is highest in Asia and Oceania, followed in descending order by Africa and Latin America.
In developed countries, the prevalence of anemia ranges from 7 to 20 per cent in non-pregnant women and up to 35 per cent in pregnant women. The total female population between 15 and 49 years old in these countries is estimated at 275 million, of whom 16 million are pregnant at any given time. Assuming conservatively that 10 per cent of non-pregnant and 30 per cent of pregnant women are anemic, this would make an additional 31 million, bringing the world total (outside China) of anemic women between 15 and 49 years of age to 291 million.
Accurate information concerning the prevalence of anemia in children under school age is not available, but figures of 20 to 50 per cent have frequently been mentioned. Therefore, the total figure of anemic individuals may be around 500 million, and perhaps more.
Treatment
Treatment consists of administering iron compounds orally. Rarely is the anemia so severe that it requires emergency treatment, such as blood transfusion. Giving iron tablets is, as a rule, sufficient; but they must be taken two or three times a day for several weeks before the hemoglobin concentration is restored to normal levels. The length of administration is a major drawback to the treatment because motivation to continue medication is usually lacking in anemic individuals. Iron compounds for treatment of anemia should have high bioavailability, acceptability, and low cost. Reduced iron and ferrous sulfate meet these criteria. Iron is best absorbed when the stomach is empty; however, it is also then that it most frequently causes side-effects that constitute another drawback to the treatment. Most iron preparations currently used are accompanied by a high proportion of side-effects such as epigastric pain, heartburn, vomiting, constipation, or diarrhoea. There is an urgent need to develop more acceptable iron preparations that cause fewer or no detectable side-effects.
Prevention
The obvious approach is to increase the amount of iron and folate absorbed and to reduce blood losses. A change in dietary patterns, together with programmes to control parasitic diseases, are needed to achieve this objective. The increased consumption of iron-absorption enhancers, such as foods of animal origin, would help, but may not be immediately practical in some areas for cultural or economic reasons.
In the short term, and in emergencies, the distribution of iron supplements should be considered. The approach may be especially effective when it is directed toward well identified, easily reachable, vulnerable groups such as mothers during the second half of pregnancy. Side-effects and duration of administration are again drawbacks.
Another measure designed to improve the iron status of the total population is to fortify food with iron. The selection of the food vehicle and of the iron compound is critical. The food vehicle must reach the population at risk, and its flavour, colour, and texture must not be changed by the fortification process. Several have so far been identified for iron fortification: salt, wheat flour, milk powder, sugar, monosodium glutamate, and fish sauce. The iron compound must have a high bioavailability, be stable, and inexpensive. It has been difficult so far to meet all these criteria, and only a few fortification programmes have proved successful. Most have not been evaluated, and it is not certain that they are effective; this is especially true of some national programmes of fortification of wheat flour. More developmental research is urgently needed in this field.