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An international workshop on Nutritional Surveillance, convened by the United Nations Administrative Committee on Co-ordination Subcommittee on Nutrition (ACC/SCN), was held in Cali, Colombia, 14 - 17 July 1981. The following excerpts from the report of this meeting assess the current understanding of the nature, process, and uses of national nutritional surveillance programmes - listing a number of issues to be addressed.
1. What Is Nutritional Surveillance?
By analogy with the surveillance and successful control of infectious disease in human populations, the World Food Conference in 1974 recommended the establishment of surveillance systems for nutrition. They defined the function of such systems as monitoring " the food and nutrition conditions of the disadvantaged reference groups of the population at risk, and [providing] a method of rapid and permanent assessment of all factors that influence food consumption patterns and nutritional status." The application of the systems, as in the case of disease surveillance, is to facilitate decisions that will lead to improvement and prevent deterioration of the nutritional status of populations. The nutritional status of populations is conditioned by many factors, including social and economic ones, as well as health, environment, and the availability of food. Therefore, the range of decisions that should be influenced by nutritional surveillance activities could be related to the concerns of many different areas of activity and sectors of government.
Nutritional status data are the core of nutritional surveillance and are commonly accepted as indicators of social, economic, and health conditions. They can be used as objectives for the improvement of the nutrition of populations and to monitor the progress of social and economic development.
However, surveillance need not necessarily be complex or require the routine collection of a very large range of new data. The amount of information required will depend on the nature of the problem and the range of policy alternatives and resources available. In addition, efficient design of the system will ensure the maximum use of all relevant existing sources of data. Commonly, it will be necessary to collect data on nutritional status. These may be, for example, body weight and height measurements that are relatively simple and cheap to obtain.
2. What Indicators Are Likely to Prove Useful?
For convenience, the wide variety of indicators that may prove useful can be classified as:
a. "leading," for measuring both immediate vulnerability and resources, mainly agricultural, rainfall, food storage levels, and others;
b. "concurrent," for determining current food availability, related to flow data such as wages, prices, income, household food stocks, change in dietary patterns; and
c. "outcome," for assessing the effect of past and continuing shortfalls in food availability, including harvest yields, morbidity, mortality, and nutritional status.
Some of these indicators may not be quantitative but still be reliable, such as farmers' perceptions of the next harvest as being good, average, or poor. Although anthropometry is not always of major use in early-warning systems, these data, especially in a time series, may still prove valuable, particularly when effectively linked in a fast and efficient way to decision-making. All indicators would have to be timely and practical. Trigger levels derived from them should not be too sensitive, for this would be costly and lessen credibility. On the other hand, if they are either too vague or too stringent, this might lead to hardship or to ignoring a developing problem.
The institutional and administrative details of early warning systems very much depend on local circumstances. Lower-level responses are likely to be faster than systems requiring central action.
3. What Are the Uses of Nutritional Surveillance?
Nutritional surveillance systems can be used for planning, for management and evaluation of programmes and projects, and for giving advance warning of nutritional emergencies for the initiation of action.
The potential users are therefore the ministries, departments, and institutions responsible for relevant action in these areas. For example, the Family Allowance Programmes (Asignaciones familiares) in Costa Rica are using nutritional status data for planning supplementary feeding programmes The first user in Kenya is the Food and Nutrition Planning Unit in the Ministry of Economic Planning and Development. This unit is beginning to use nutritional criteria for assessing several programmes, including those in rural development. In Ethiopia, the Food and Nutrition Surveillance Programme was developed following the severe droughts of 1973 and 1974 by the Relief and Rehabilitation Commission for giving early warning of the effects of drought.
In some cases-for example in Botswana, Lesotho, and Costa Rica-nutritional status data are used for screening the child population for malnourished individuals requiring special care as well as for supplying data to the surveillance system.
4. What Are the Steps to be Taken in the Evolution of a Nutritional Surveillance System?
A number of essential steps and processes in the development of a nutritional surveillance system are outlined here in a linear sequence that illustrates some of the logical connections between the steps. In practice, the sequence may need to be varied to fit the actual circumstances; and, in addition, some of the steps will need to be repeated as further information progressively becomes available.
4.1. Initial assessment of the problem on the basis of existing evidence. In most countries, sufficient data are available to allow a rough conclusion on the nature and extent of nutritional problems. There are three aspects to the problem that need to be described at this stage:
- Existence and type of malnutrition. Evidence for the existence of malnutrition might be found in analyses of food supplies, in clinic and hospital records, in previous nutrition surveys, and in historical accounts of famines. This may also allow identification of age and sex of those most affected.
- Who are the most affected? Population groups most affected need to be described in terms of geographic area, socio-economic status, types of production systems, and resources available, such as crop types, water resources, land tenure, etc. This kind of information may be found in national census reports; agricultural census and land use surveys; employment, income, and expenditure surveys; retail price reporting; local administration records; and research reports and publications.
- Causes and trends. A preliminary description should attempt to give an indication of probable immediate and underlying causes, and should also attempt to review trends over time in the size and nature of the problem.
4.2. Identification of the users of the system and their needs. Given a preliminary understanding of nutritional problems and their causes, some assessment of the likely extent to which actions may be modified or initiated to influence the nutrition situation must be made from discussions with priority users. This should indicate how nutritional surveillance information can contribute to better decisions, with respect to nutrition, by user institutions. This will help to define the purpose of the proposed surveillance system and lead to clearer specification of the information required. It will also suggest institutional mechanisms that may be suitable for providing this information in such a way that it is acted upon.
4.3. Appraisal of existing data systems and identification of needs. At this stage, a number of existing sources of data will have been identified and their adequacy for surveillance purposes will have to be assessed, so that a decision can be made as to the need for further development of the system. This may imply the rationalization or expansion of existing systems, as in Costa Rica, where data on the socio-economic conditions of families are being collected by simple additions to the questionnaire already in use by rural health visitors, and similarly in Kenya, where anthropometric data are being collected as part of the periodic household sample survey. Additionally, it may be possible to interlink existing data systems so as, for example, to standardize definitions and coding or even entire sampling frames. However, if these modifications will not provide an adequate basis for surveillance, new collection systems may have to be instituted. This process will require a series of dialogues, discussions, and workshops held between agencies and institutions concerned with the use of information as well as its production, and will include desk research and analysis.
The existing information may be found inadequate with respect to the assessment of nutritional status or the coverage of some population groups, distinguished by geographic location or socio-economic situation or who may be exposed to particular seasonal or other recurrent risks. It may therefore be necessary to conduct special studies in order to complete a satisfactory initial assess" meet.
4.4. Institutionalizing the surveillance system. Collation of data from existing sources, the management of additional data collection systems, and the processing, analysis, and presentation of surveillance data will be ongoing activities and will require a permanent institution with the financial and administrative responsibility and commitment this implies.
4.5. Cost and economic feasibility. With regard to cost, a distinction should be made between the resources needed for the initial steps of setting up the system and the requirements for continuous operation. Generally, the initial intensive phase will require special funds, while maintenance needs will be much more modest. Throughout the whole of the process of design and institution of the system, cost effectiveness must be kept in mind. At a number of stages the design of the system may need to be changed if its cost is not reasonable in relation to the resources involved in the planning decisions that are to be dependent on it.
4.6. Definition of outputs. Emphasis throughout has been upon the wide range of potential applications and functions of a surveillance system. The outputs of the system will accordingly vary in form and frequency. The precise nature of the outputs relevant to different institutions and uses should be elaborated through the processes of dialogue and discussion that have been referred to. Opportunities should be sought from the earliest stages, for the consideration by the users, of specimen outputs in the form of dummy tabulations, diagrams, maps, etc. This would provide valuable feed-back of responses by the decision-makers, planners, etc., about their own specific needs as the design of the system progresses. The institution responsible for nutritional surveillance should at ail times be sensitive to possibilities for disseminating newly available information in order to stimulate an extension of applications. it is therefore essential that interim results should be produced and made accessible to future users as early as possible. In addition, it is likely that responsiveness to nutrition issues will thereby be successfully promoted and reinforced. The nutrition information system project in Costa Rica issues a regular bulletin containing articles and discussions about the work of the project and displays of information. Such activities require the use of professional expertise in the area of communication.
As has been said, the sequence and intensity of these various steps and processes will vary widely with particular circumstances. However, the total time required before the regular production of outputs should not be underestimated and will largely depend on available resources.
A workshop on the Interfaces between Agriculture, Food Science, and Nutrition, sponsored by the United Nations University and organized by the International Crops Research Institute for the Semi-arid Tropics (ICRISAT), the National Institute of Nutrition (NIN), and the Central Food Technological Research Institute (CFTRI), was held in Hyderabad, India, 10-12 November 1981.
In reviewing existing knowledge and evolving new strategies for co-ordinated action, the 38 participants from five countries, the sponsoring and organizing institutions, and the WHO discussed genetic improvement of nutritional quality, more effective use of grain legumes, better utilization of millet and sorghum (dry-land crops which meet the requirements of population with low income levels), the impact of agriculture on protein-calorie malnutrition, the designing of cropping systems for more efficient production, technology for processing to optimize yield and improved nutritional levels, improved methods of storage to prevent pest damage, and the use of solar energy in post-harvest processing.
At the end, a set of recommendations were made which will be included in the final report. It was agreed that the representatives from different countries would hold national workshops and seminars as a follow-up to the Hyderabad discussion in order to stimulate interdisciplinary dialogues and interdisciplinary research. The subject of redesigning training to provide human resources capable of interdisciplinary action was discussed. Some members went so far as to suggest the creation of an organization within Asia to ensure multidisciplinary interaction and exchange of information between institutions and individual members.
The full report of the workshop will be published in the near future. For further information about this workshop, please contact Dr. J.S. Kanwar, Director of Research, International Crops Research Institute for the Semi-arid Tropics, ICRISAT P.O., Patancheru 502 324, Andhra Pradesh, India.
A workshop on the Interfaces between Agriculture, Food Science, and Nutrition-the sixth in this UNU-sponsored series-was organized by the UN University and the International Center for Agricultural Research in the Dry Areas (ICARDA) in co-operation with the University of Aleppo, in Aleppo, Syria, 21-25 February 1982.
Emphasizing the importance of interdisciplinary efforts for the solution of food problems, the 60 participants from seven countries and five UN and international organizations discussed agriculture, food science, and human nutrition in their individual and related aspects and, as a corollary, sought to explore the possibilities of appropriate inter-institutional co-operation in the Middle East region. Individual presentations focused on specific research experience in the region-including nutritional goals for plant breeders with particular reference to food legumes of the ICARDA programme, breeding of food legumes with particular reference to chickpeas and lentils, and breeding for nutritional quality in cereals-as well as on broader considerations such as global perspectives of hunger and malnutrition, food policy and human nutrition, and perspectives for food production in the Middle East and North Africa. Bringing together these diverse aspects of the subject, group discussions pursued such topics as nutrition priorities in agricultural projects and plant breeding, and priorities in research on post-harvest and food processing problems.
The full report of this workshop will be available in the near future. For further information about the workshop or the report, please contact Dr. D. Nygaard, Head, Farming Systems Program, International Center for Agricultural Research in the Dry Areas, P.O. Box 5466, Aleppo, Syria.
The results of a collaborative international study on Rethinking Infant Nutrition Policy under Changing Socio-economic Conditions, completed by an ad hoc task force of the International Union of Nutritional Sciences, were presented at the International Congress of Nutrition in San Diego, California, USA, in August 1981, and are now available in two reports.
Funded by the development agencies of Norway (NORAD), Sweden (SIDA), and Denmark (DANIDA), the study had four decentralized sub-studies co-ordinated from the Institute for Nutrition Research, University of Oslo, Norway: three country case studies-carried out in Sri Lanka, Tanzania, and Brazil and an international questionnaire survey of milk-company advertising and promotion practices in the six WHO regions. The country studies were conducted by teams based at the Faculty of Medicine, University of Colombo, Sri Lanka; the Tanzania Food and Nutrition Centre, University of Dar es Salaam, Tanzania; the São Paulo Department of Health, São Paulo, Brazil; and the Center for Population and Family Health at Columbia University, New York, N.Y., USA. The international survey was conducted from the Division of Population, Family and International Health, School of Public Health, University of California, Los Angeles, Calif., USA.
The country studies included: national policy and national statistical analysis; survey of 200 mother-infant pairs in urban areas in each country, evenly divided between mothers who were formally employed and those who were not; field studies of retail markets, health services, and working places of urban mothers; group discussions with mothers; and case studies of individual mothers.
The country-study results and policy conclusions are as follows:
1. The study found that (a) mothers' employment, either formal or informal, accounted for only a small portion of the wide-spread use of breast-milk substitutes; (b) laws protecting the opportunities of employed mothers to breast-feed covered only the formally employed women not the equally large number of informally employed mothers; (c) laws provided for daily breaks for breast-feeding and crèches at the work place in each country; however, these laws were rarely implemented both because of employee's reluctance and because of mothers' transportation difficulties and personal preferences.
Therefore, labour policies should bring mothers' reproductive child-rearing roles into closer harmony with their productive roles in developing economies. Policies should account for (a) mothers' desire to breast-feed; (b) mothers' desire to obtain and retain employment; (c) mothers' desire to breast-feed in or close to home; (d) the large proportion of mothers who are informally employed.
2. The study found that (a) national/international economic factors and economic policy responses in the three countries were important influences on the volume of importation or production and the prices of breast-milk substitutes; (b) the availability and affordability of products were often only coincidentally related to the real needs of mothers and infants; (c) the use of commercial breast-milk substitutes was associated with less complete breast-feeding and shorter duration of breast-feeding.
Therefore, foods such as breast-milk substitutes should no longer be considered as simple commodities to be exchanged in the market but should be carefully regulated in full accord with the basic needs of mothers and infants through explicit national nutrition policies.
3. The study found that (a) promotion of commercial breast-milk substitutes by multinational corporations has occurred for many decades in all three countries; (b) awareness of and loyalty to essentially identical brand-name name products were widespread in all three cities among all economic classes; (c) this exposure was among the influences on mothers' infant-feeding attitudes and practices.
Therefore, information on infant-feeding choices should come from sources that are informed about culturally appropriate feeding methods and are free from any commercial interest in the practices mothers select. The strongest national policies should be implemented in line with the WHO Code of Marketing of Breast-Milk Substitutes, which prohibits the commercial advertising and promotion of breast-milk substitutes either directly to the public or indirectly thorough health services,
Requests for the full report of the cross-national study may be made to:
Elisabet Helsing
Institute for Nutrition Research
School of Medicine
University of Oslo, Blindern
PO Box 1046
Oslo 3, Norway
The international survey report may be requested from:
D.B. Jelliffe
Division of Population, Family, and International Health
School of Public Health, UCLA
Los Angeles, Calif. 90024, USA
International course in food science and nutrition
A course in implementation of food and nutrition programmes is being organized by the Netherlands Foundation for International Co-operation (NUFFIC). This annual international post-graduate course in food science and nutrition will in 1983 emphasize the theme "Implementation of Food and Nutrition Programmes: Its Impact on the Health of Vulnerable Groups."
The course is designed to be of particular relevance to officials engaged in the formulation, administration, and implementation or evaluation of specific nutrition interventions that are targeted at definite population groups and that deal directly with local and/or donated food.
Attention will be given to the formulation, implementation, evaluation, and monitoring of programmes and projects aiming at the improvement of the nutrition and health status of vulnerable population groups, especially in developing countries.
Requirements for admission:
1. Academic degree (B.Sc. as a minimum), or its equivalent, in nutrition, food technology, home economics, medicine, or a related field of study.
2. Professional position with tasks related to the theme of the course and through which dissemination of the acquired knowledge is possible and can be expected.
3. Some years of practical experience related to the theme of the course.
4. Fluency in the English language.
Course period: January-June 1983.
Place: Wageningen, Netherlands.
Language: The course will be conducted in English.
Fellowships: The Netherlands Government has fellowship
programmes. The diplomatic representative of the Netherlands in
your country can give you more information.
Application: For further information about the course
programme and for application forms, contact the Netherlands
Embassy in your country or write to the course secretary at the
address below. The closing date for application is 15 September
1982.
Address: International Course in Food Science and
Nutrition
Lawickse Allee 11
6701 AN Wageningen
Netherlands
Tel.: 08370-19040
CORRECTION
Food and Nutrition Bulletin, vol. 4, no. 1 (Jan. 1982), p.7
It is regretted that, in publishing the article "Community-Level Nutrition Interventions in Sri Lanka: A Case Study" by H. C. Karunanayake, the following statement was inadvertently omitted: "The observations made and the views expressed in this article are those of the author and not necessarily those of the US Save the Children Sri Lanka Field Office."