Fondation Charles Léopold Mayer pour le Progrès de l'Homme
Réseau "Agricultures Paysannes, sociétés et Mondialisation" (APM)

Proposals for the 21st century

Food, nutrition, public policies

Final version, March  2002

Prepared by Geneviève Le Bihan, Francis Delpeuch, Bernard Maire 

Institut de Recherche pour le Développement
Unité R106 Nutrition, Alimentation, Sociétés
Montpellier, France

History of this report

It was during the World Food Summit in 1996 that Pierre Vuarin of the “Agricultures Paysannes, Sociétés et Mondialisation” (APM) network of the Fondation Charles Léopold Mayer pour le Progrès de l’Homme (FPH) and Francis Delpeuch, Researcher in Nutrition at the Institut de Recherche pour le Développement (IRD) had their first discussions concerning nutrition and public policy.

Five years later, the idea has come to fruition with the publication of this report “Food, Nutrition and Public Policies”, prepared by three public nutrition experts: Geneviève Le Bihan, Francis Delpeuch and Bernard Maire.  It benefits from their professional experience and networks in both developing and industrialised countries, as well as their links with the wider international scientific community. It forms part of a series of complementary reports that are related to food and nutrition: sustainable agriculture, food security, health, water, biodiversity and genetically modified organisms, international business trade, training community leaders1 and so on. 

This report Food, Nutrition and Public Policies has already been presented and discussed in several differing contexts:

•	Meeting of the APM network at Castielfabib (Spain), May 2001;
•	World Forum of Food Sovereignty, Havana (Cuba), September 2001;
•	European meeting “Another diet is possible” at Teruel (Spain), September 2001;
•	Conference “Savoirs Partagés” at the Agropolis museum, Montpellier (France), November 2001;
•	World Citizen Assembly at Lille (France), December 2001;
•	World Social Forum at Porto Alegre (Brazil), January 2002;
•	Conference of the Institut Français pour la Nutrition (IFN) at Paris (France), May 2002;
•	World Food Summit at Rome (Italy), June 2002.

It has been reviewed by several experts, to whom the authors are extremely grateful: Hélène Delisle, Professor of Nutrition, University of Montreal (Canada); Tim Lang, Professor of Food Policy, Thames Valley University, London (UK); Rebecca Norton, Nutrition Specialist for La Fondation Terre des Hommes, (Switzerland); Souleymane Seck, Deputy of the National Assembly of Senegal and retired Vice-Chancellor of L’Université Internationale Senghor d’Alexandrie of Egypt. We are equally grateful to Marie-Lise Sabrié, Scientific Writer at the IRD (France) for her precious advice and suggestions and to Michelle Holdsworth, lecturer in human nutrition, University of Nottingham (UK) for her help with the english version.

Introduction

Today more than half the world population suffers from one form or another of malnutrition, deficiency diseases and/or diseases caused by over-nourishment. Despite considerable effort and a certain amount of progress, the goals that were defined at international summits during the 1990s to reduce malnutrition in the world are far from being attained. In addition, the gap between rich and poor globally and within countries is widening, and this further worsens the nutritional and sanitary status of the poor.

Scientific research has revealed the enormous toll malnutrition levies on human development and on the development of societies as a whole. Everything points to the fact that progress towards more equitable and more sustainable development  will depend on how families, governments and the international community deal with questions concerning nutrition and food in coming decades. Awareness of the stakes involved is gradually increasing but many politicians and economists are still not well enough informed. Nor has enough progress been made in informing and mobilising citizens. Agriculture and agri-food industries continue to produce food without paying sufficient attention to its long-term implications for health, while the health sector has to pay for diseases caused by inadequate diet. These different modes of production and consumption call into question respect for environmental goals e.g.  sustainability and biodiversity of the entire food system.  To this we must add the uncertainty surrounding globalisation and climatic change.

The complex causes of nutritional problems, and their interrelationship with political, socio-economic, environmental factors and with the management of resources, suggest that we need to look beyond a conventional medical approach and the search for one-off solutions. These approaches have shown their limitations in reducing malnutrition, although of course the promotion of breastfeeding and the fight against micronutrient deficiencies have started to prove their worth and should be continued and strengthened.

However, a different approach is possible: a wider-ranging and necessarily more complex approach in which the first step is to consider nutritional well-being as the central concept in our way-of-life, modes of production and consumption. This entails re-thinking the theoretical and practical basis of many policies and actions. It implies adhering to a trend that has been emerging over the past few years: to consider questions of nutrition in terms of human rights, and accepting the idea of a new paradigm for world agriculture.

This approach will confront conflicting interests in as much as considerable change must happen in all parts of the food chain. It will inevitably have to overcome much resistance.

The basis for a new approach to public nutrition

•	The right to adequate nutrition;
•	Priority given to defining policies integrating nutritional well-being, environmental concerns and social justice; 
•	The mobilisation of individual citizens and/or communities for changes in production methods and in the adoption of a more balanced diet and healthier lifestyle. This requires continuous information and education campaigns;
•	A new paradigm for world agriculture: the promotion of durable food systems that favour nutrition, health and well-being;
•	A guarantee of nutritional quality of food that respects different cultures and food preferences; 
•	Improvement in the status of women, literacy education and help in entering the labour force;
•	Good nutritional status of pregnant women and young children as a pre-condition for the development of society;
•	Nutritional surveillance at the population level to obtain objective data for monitoring and decision-making;
•	Scientific research directed towards solving nutritional problems at the population level;
•	Training professionals in this new way of thinking.

Proposals2

•	Towards effective nutrition policies

-	Develop an effective advocacy to persuade decision-maker; particularly those outside the field of nutrition in the strictest sense of the word, i.e. economists, politicians, legislators, and representatives of agriculture, the agri-food sector, distribution, catering, and the environment;
-	Organise national workshops to define nutrition policy; these should bring together decision-makers, researchers with those directly involved, i.e. producers, manufacturers, distributors and consumers;
-	Continue and strengthen programmes that have proved effective; such as the promotion of exclusive breastfeeding, the timely introduction of adequate complementary foods and prevention of micronutrient deficiency;
-	Introduce legislation and/or other measures to encourage respect of the right of the individual to food and nutrition. The first step could be the adoption of the “International Code of Conduct on the Human Right to Adequate Food";
-	Strengthen regulations concerning agricultural and industrial food production to ensure food is of satisfactory quality - from the point of view of nutrition, hygiene and flavour - while at the same time respecting the environment;
-	Strengthen regulations on labelling of foods to ensure the consumer has access to objective information;
-	Tighten controls on food advertising particularly that aimed at children;
-	Tax food products with low nutritional value; this could take the form of a small tax to generate funds for preventive actions and/or for the promotion of health or a larger tax to discourage the consumption of these products. It could also take the form of lowering VAT on products that are to be promoted for their nutritional value;
-	Develop an environment that encourages physical activity; adapt the infrastructure in the different public places the population uses for travel, work and leisure; 
-	Create jobs for specialists in public nutrition; in their position as members of a central administration, these people can form multi-disciplinary teams to facilitate a global, integrated approach;
-	Create university courses in public nutrition; at PhD level they should be multi-disciplinary;
-	Reinforce further education programs in public nutrition for professionals engaged at all levels and in particular those employed in the health, food, and education sectors;
-	Introduce nutritional surveillance at the national or regional level depending on the political and administrative structure of the country concerned;
-	Introduce monitoring procedures to ensure the right to food and nutrition is fulfilled. 

•	Towards commitment of the agricultural and agri-food sectors to the production of quality food:

-	Diversify agricultural crops to encourage production of foods rich in micronutrients – vegetables, fruit, pulses – while respecting the environment and food safety regulations;
-	Introduce nutritional quality objectives in industrial production and institutional catering – less salt, sugar and  fat, and more micronutrients and dietary fibre; 
-	Develop a more effective conservation and processing sector, to improve availability, accessibility and the food price-quality ratio;
-	Continue nutrient fortification of food products while paying particular attention that those in need consume these foods, and that the fortified foods are well integrated in local eating habits; 
-	Encourage the manufacture of complementary foods to breastfeeding by small local enterprises in countries with limited resources; 
-	Produce food labelling that is objective, complete and easy to understand;
-	Promote the introduction of good practice charters and moral commitment in educational material produced by the agri-food industry; 
-	Facilitate access to professional education and training by women employed in the agricultural and food sectors. 

•	Towards social mobilization3

-	Involve the local community in the development and implementation of action plans for nutrition: this involvement is key if interventions are to be sustainable; 
-	Reinforce the capacity for the analysis of nutritional problems with respect to their dimension, trends, and causes; 
Mobilise consumers: strengthen nutrition education programmes and information campaigns to raise awareness and educate the public; 
Mobilise young people: choose schools as sites for nutrition education programmes; involve young people in programmes to improve lifestyles and consumer behaviour not only aimed at themselves but also at other people; 
Mobilise women: use of participatory methods as a means of increasing women’s access to resources that will allow them to retain their primary role in food security and care of the family;  
-	Develop community volunteers programmes in countries with limited resources where nutritional problems are widespread among women and young children. The volunteers can help in locating and caring for pregnant women, the aim being to prevent foetal malnutrition; volunteers can also take part in nutrition education and the promotion of physical exercise. 

Findings

Persistent and emerging nutritional problems 

Two types of major nutritional problems exist throughout the world, those that continue despite efforts to overcome them and emerging problems. As mentioned in reports by the United Nations sub-committee on nutrition and the World Health Organisation (WHO), different problems can be distinguished:
•	Foetal malnutrition: 30 million babies are born in the developing countries with low birth weight, that is 24% of annual births; 
•	More than 150 million children under five years of age are still stunted and/or are underweight; 
•	More than 250 million adults, particularly women, in developing countries suffer from malnutrition that results in underweight; 
•	Two billion people of all ages suffer from varying degrees of micronutrient deficiency, particularly iron, vitamin A, iodine and zinc; 
•	Diet-related non communicable diseases (NCDs) – obesity, non-insulin dependent diabetes, cardio-vascular diseases, certain form of cancer – are either emerging or rapidly increasing in a number of developing countries;
•	300 million adults already suffer from obesity and almost a billion are overweight. Child obesity is on the increase in many countries. 

Consequently one half of the world population suffers from one form or another of malnutrition. 

Despite progress in certain fields, overall trends are unfavourable and inequality is on the increase

There has been some progress, particularly in reducing iodine deficiency (thanks to universal salt iodisation),  clinical vitamin A deficiency and the treatment of severe infant malnutrition. Progress has also been made in reducing the proportion of preschool children presenting underweight or stunting, and this has decreased everywhere except in sub-Saharan Africa, although progress remains slow. On the other hand, there has been an increase in specific problems linked to a particular situation or to particular populations.  Examples include those who suffer from AIDS (in certain populations this has a huge impact on food security and on the future of orphans), refugees and displaced persons, and old people in the context of an aging population. 

In addition to these considerations, more and more countries have to face two types of problems at the same time, both of which have a significant impact on both public health and on development: nutritional problems connected with deficiencies – malnutrition in children under 5, micronutrient deficiencies – and NCDs: one of the most remarkable examples of this being what the WHO has named the “global obesity epidemic”. The emergence and growth of NCDs is closely linked with urbanisation and changes in lifestyles and diet. The stage of advancement of this nutritional transition varies with country. In some emerging countries with intermediate incomes, NCDs are more widespread than infectious diseases and malnutrition caused by deficiencies, although the latter have not yet completely disappeared. Deficiency diseases are starting to reappear in industrialized countries, particularly in eastern and central Europe. 

In addition, the gap between rich and poor is widening both in the world as a whole and also within countries, which worsens the nutritional status of the poorest segments of the population. It has also become clear that overweight and underweight can co-exist within the same family: around 10% of families in Brazil, China and Russia are affected, particularly in urban environments.  

The challenge is thus to reduce the number of deficiency diseases while at the same time limiting the emergence of NCDs, particularly in contexts where resources are limited and among disadvantaged populations. However, up to now, these problems have frequently been treated separately.

It is now generally accepted that the majority of major nutritional problems are related .  Malnutrition often begins during the foetal stage, and, depending on conditions, may continue throughout the individual’s life, particularly in girls and women, who subsequently give birth to babies presenting intrauterine growth retardation. Acceptance of a “life-cycle” approach to nutrition (see Figure 1) opens the way for new policies and new strategies. In addition, a number of scientific studies have shown that malnutrition during the foetal stage and infancy increases the likelihood of developing NCDs as an adult. This susceptibility is increased by changes in lifestyle and in eating habits linked to economic development and urbanisation.

Figure 1: Nutrition throughout the life cycle

Huge consequences for societies 

Over the last two decades, advances in knowledge have led to a re-assessment of the importance of nutrition and diet for health, well-being and development.  Research has shown that the consequences of malnutrition, and in particular, of moderate forms of malnutrition and micronutrient deficiencies are considerably more serious than had previously been thought in terms of their impact on society. Social and economic costs are enormous: increased mortality and morbidity, reduced physical and mental development, and reduced capacity for learning and work. WHO has established that half the deaths of children under 5 are linked with malnutrition (of which 40% with moderate forms of malnutrition) associated with various infections. Iron deficiency is one of the main causes of maternal mortality. Iodine deficiency is the primary cause of mental retardation in the world.

Malnourished individuals have less chance of obtaining a basic education and satisfactory social skills and of contributing to the well-being of their family, the development of their community and of their country. This counteracts efforts to reduce poverty.

By increasing morbidity and mortality, malnutrition also considerably increases the cost of health. This is particularly disquieting in the context of the rapid emergence of NCDs in developing countries, as managing these diseases is very costly. Finally, the fact that nutritional problems are inter-generational underlines the long-term consequences of inadequate nutrition.

These findings all underscore the fact that significant progress in human development can only take place if major nutritional problems are made top priority.

The fact that some progress has been made (see above) can be attributed to agreements reached by the international community during the 1990s at a series of international meetings: World Summit for Children, organised by UNICEF in 1990, the International Conference on Nutrition, (ICN), organised by FAO/WHO in 1992, and the World Food Summit, organised by FAO in 1996. The ICN world declaration thus emphasised that “nutrition is an essential factor in development, given that a healthy, well nourished and educated population is the best basis for the promotion of a nation's economic growth”.

However, many key political and economic figures are still not convinced despite: the attempt by the ICN to promote a comprehensive approach; national nutrition action plans drawn up by many countries; and international initiatives in, for example, the promotion of breastfeeding, or the fight against micronutrient deficiencies. Regardless of the world declaration at the ICN, nutrition and food are still widely considered by decision-makers simply as by-products of economic growth and agricultural production.

Also the process of informing and mobilising citizens has been unsatisfactory. In addition  to this slow rate of progress there are uncertainties about the effect globalisation and trade liberalisation may have on the nutritional status of populations and on the sustainability of the food system in a wider context.

Thus a comprehensive approach is even more vital than in the past. What is required now is to rise above traditional approaches, and above all, to stop looking for exclusively medical solutions; instead nutrition must be acknowledged as a human right and integrated at the heart of agricultural production systems. In this sense, the crises that are presently occurring in the food system may provide an ideal opportunity to progress and undertake the necessary changes in our production systems.

Complex and multifactorial causality calls for a comprehensive approach and numerous interventions at all levels 

In 1990, UNICEF drew up a conceptual framework of malnutrition in young children. Different forms of this scheme have been widely adopted by the international scientific community. It clearly illustrates the complexity of the causes of malnutrition (see figure 2), i.e. the systemic nature of food, health and care in the causal relationships that result in malnutrition; the number and the diversity of factors – political, economic, social, cultural, religious – that can limit the use of resources at different levels; and, as a consequence, the range of sectors concerned by nutrition: obviously health, but also and equally significant, agriculture, economics, industry and commerce, legislation, environment, and so on.

	Source: ACC/SCN, 2000

Research has also shown how important it is to take into account factors that influence food and nutrition security and how they interact at different levels, and particularly at the level of the household, while at the same time not losing sight of the global perspective.

Poverty is both a cause and a consequence of malnutrition. However, economic growth does not necessarily result in a rapid improvement in nutritional situation, and nutrition may not improve at all with increased income. This was demonstrated by a comparative analysis in countries where there had been a significant decrease in underweight in young children. The allocation of resources and whether resources are fairly distributed plays a crucial role, as was clearly shown in one of the poorest states in India, Kerala, where sanitary and nutritional conditions are now better than other regions of the country, thanks to the introduction of social, educational and health policies.

Food security, i.e. access to adequate, nutritive food, is an obvious precondition for healthy nutrition. Agricultural policies have a major role to play in this connection, on the condition that they integrate nutritional well-being as an objective, which, up to now, has rarely been the case4. 

Many other factors influence the process of improving nutrition such as the status of women in society and their access to education, the fertility rate, the extent of infectious disease, governmental commitment locally and nationally to questions of health and nutrition, the organisation of primary healthcare. These issues must be addressed as a whole, at different levels, as part of a comprehensive approach.

Impact of current social trends on food and nutrition 

Many contemporary phenomena have a direct or indirect influence on food and nutrition in populations: growth and aging of the population, urbanisation and industrialisation, globalisation, environmental problems and climate change. To a greater or lesser extent these factors can induce a change in lifestyle and eating habits.  They can lead to a decrease in physical activity, due to mechanisation and motor transport that is not offset by an increase in leisure-time physical activity or sport. These phenomena also encourage increasing dependence on food produced by others (consumption of own produced food is falling), increasing consumption of manufactured foods that provide energy but have low nutritional value (the agri-food industry increasingly produces foods that contain high levels of fat, salt and sugar, , are easy to transport, easy to prepare, and cheap); and increasing consumption of foods of animal origin. There is also a decrease in the transfer of culinary know-how and traditions anchored in different cultures, and particularly in regions where diets are known to be ‘protectors’, for example the Mediterranean diet in southern Europe. This phenomenon contributes to an overall loss in culinary and dietary diversity.

Over the last few decades economic growth in most countries has contributed to an improvement in the nutritional situation through a relative increase in income which has increased variety of the diet, an improvement in sanitary and social structures. However, this situation was recently jeopardised by the economic crisis that hit many countries in South-East Asia and South America. Indonesia is one example, where micronutrient deficiencies have started to reappear. High inflation, high unemployment rates and a decline in purchasing power resulted in a reduction in the ability of families to buy foods such as, eggs, meat and milk, which are rich in micronutrients but expensive. This resulted in a reduction in supplies of iron and vitamin A. Supplementation and fortification programs are proving difficult to maintain. In Africa, policies that were introduced to solve the financial crises that occur more frequently – particularly structural adjustment programmes – can partially explain the deterioration in the nutritional situation, especially among small children. These programs have also contributed to an increase in malnutrition among urban populations, which had previously been less affected. Besides, development aid has reached its lowest level in 20 years (as a percentage of Gross National Product of donor countries).  This aid, still often managed by donor countries, has not always contributed to real development of the countries concerned.  

Neither have Eastern European countries been spared. After the change in regime at the beginning of the 1990s, Russia, formerly a food exporter was obliged to import one third of its food requirements. The financial crisis that led to devaluation of the rouble severely limited the country’s capacity to import; as a result, Russia had to request food aid from the international community. In Western Europe, poverty is increasing and appears to be becoming established among a significant section of the population, which has a predictable impact on its nutritional status. There is an obvious need for measures to alleviate the social and sanitary effects of financial crises.

However, the present economic situation alone cannot explain the fact that half the world population suffers from nutritional problems. For this reason the UN sub-committee on nutrition tried to analyse why we are still so far from achieving the objectives fixed during the ICN summit for a reduction in malnutrition. Five basic factors were identified:

•	“The lack of a locus within many countries for highly motivated academics and non-governmental organisations (NGOs) to interact with political leaders and decision-makers, and thereby help drive forward a nutrition initiative;  
•	The frequent failure of health and agricultural sectors to combine forces to ensure coherent plans of action; 
•	Within-country rivalries: these may be amplified by selective support of specific national programs by charities, NGOs, bilateral and UN organizations; 
•	The failure of some major financial institutions to follow the World Bank initiatives which require intersectoral measures to improve food security and human health when developing plans for economic reform and development;
•	The failure of political leadership in many countries to realise the possibilities of making rapid improvements by prioritising nutrition when allocating national resources.” 

Food policies to date are only weakly linked to population nutrition

In the past, state policies and development programs in agriculture, economics, education, industry and commerce, generally did not include nutritional objectives. This was notably the case in western industrialised countries, but also for developing countries. A study conducted in the 1980s in twenty-one developing countries showed that in none of the countries concerned did food policies have an explicit nutritional objective.  Nevertheless, the idea of food policies is not a recent one, but dates from the 1950s, when policies were mostly quantitative (producing enough food), all based on the same model of increased production, improved agricultural productivity and supply of cheap food.  

This state of affairs can be explained by suffering caused by famine or food shortages and some governments favouring policies of increased production. Since, attention has moved towards food supply to low income groups, resulting in production of low price policies. Lastly the successive difficulties encountered sometimes by producers, sometimes by distributors have favoured the expansion of a policy of increased plant yields and animal breeding, aided by technological progress and a tightening control at a national level on the whole food system. Consequently, countries have become influenced by lobbyists from all sides, and have not always responded by changing policy, despite the often harmful consequences to the environment.  

Such a model has not only had a major impact on the nutritional situation of countries and population health care expenditure, but also on the environment. Yet it is clear that even if critics have questioned this model following a series of food scares, in practice the situation has not changed much: countries are rare that have a comprehensive food and nutrition policy that is coherent and integrated. In Europe, only Norway and Finland had implemented explicit nutrition policies, based on the relationship of nutrition with non-communicable disease. Nevertheless, since 1951, the FAO/WHO Nutrition Expert Committee suggested that excessive intakes of particularly sugar and fat could lead to serious forms of malnutrition.  This idea, novel at the time, did not receive much support and underwent much resistance, as it was far from post-war nutritional concerns of forming long lasting agriculture and agri-food industries in western countries.  

In 1990, the WHO working group on diet, nutrition and prevention of chronic disease, focussed on the appropriateness of this question in Europe: “Agricultural and economic policies linked to those of the European Economic Community are not necessarily compatible with the current notion of diet and health”.

However, agriculture and agri-food industries continue to produce food without paying sufficient attention to its long-term implications for health, while the health sector has to pay for diseases caused by inadequate diet. Nor, as a general rule, is the consumer consulted. In Europe, a certain awareness and mobilisation has been emerging as a result of problems caused by bovine spongiform encephalopathy, dioxin, GMOs, quality of drinking water and so on. These phenomena do not appear to have substantially affected eating habits for the moment. However there is a rising trend in appreciating the importance of eating well and at the same time preserving the ecosystem.  

In industrialized countries the budget allocated by the state for preventive and education programs is often ludicrously low in comparison to the sums spent by the agri-food industry on advertising. In the USA for example, 4 billion dollars are spent each year to advertise fast food, soft drinks, snacks, sweets, and breakfast cereals as compared to just 333 million dollars spent on nutrition education. Which demonstrates how much influence the agri-food industry can have in changing the eating habits of the population.

Framework for a new approach to nutrition

As one can see, the focus of nutrition policies does not reflect scientific evidence or knowledge.  Historical trends and pressure from a range of lobbyists seem to have a strong influence. Innovative nutrition policies require change in all parts of the food chain, and will have to overcome strongly conflicting interests. To be effective these changes will require sharing of information and a strong commitment from a large number of key players. The obstacles to change in all parts of the food chain will need to be identified.  

It would be impossible to develop all the issues concerned, but some aspects of this new approach will be tackled below:

Public nutrition

Public nutrition is an approach where solving nutritional problems requires an analysis of the situation and its causes at a population level.  This requires an inter-disciplinary and inter-sectorial approach, and this is in the public interest. This approach fits in well with the concept of nutrition as a human right. Public action should be understood to include actions taken “by members of the public” and not only “for the public”. As in the human rights approach, each individual is an active member of society who claims his or her rights, and the responsibility for fulfilling these rights is found at all levels of society.  

It has been clearly demonstrated that “top-down” strategies imposed on the community do not work. Approaches based on the needs of the community, or on the rights of the community, have a much better chance of success. This underscores the importance of reinforcing local strategies and local players, and of designing programmes to build up local capacities, thereby ensuring improved analysis of the extent, trends, and causes of the nutritional problems and identification of interventions that are appropriate to available resources.

Thailand is frequently cited as having obtained the most spectacular results in reducing the prevalence of stunting in preschool children. Many circumstances came together that helped the project succeed: political commitment, specific objectives, good planning of strategies and programmes, sustainable action, systematic surveillance in the framework of sanitary infrastructure, and mobilisation of the general public. Participation by community volunteers was one of the main factors responsible for the success of the project (Brief “Community volunteers in Thailand”)

Norway provides a further example of a public nutrition approach. In the 1960s, Norway had a very high mortality rate due to coronary disease that was increasing rapidly. In 1974, a National Nutrition Council was established to develop a policy to promote healthy lifestyles and to create the environment needed to facilitate this. The policy, which resulted in a significant reduction in the problem, involved the active participation of people at all levels of society: consumers, producers, the agri-food industry, and professionals in the health and education sectors (Brief “Food and nutrition policy in Norway”).

In Europe, it was only recently that a twofold movement has emerged, on the one hand in the fifteen countries that make up to the European Union, and on the other, thanks to an initiative by the WHO Regional office for Europe, which groups more than 50 countries. The two movements are closely linked. The aim is to draw up food and nutrition policies to protect and promote health and reduce morbidity linked to food, while at the same time contributing to socio-economic development and a sustainable environment. Decision-makers who draw up national plans have accepted these arguments, but others involved remain to be convinced: farmers, the agri-food industry, distributors, consumers, and so on. (Brief “Food and nutrition policy in Europe: a reference framework for the region”)

From human rights to the right to food and nutrition 

Even if economic growth does play a crucial role in development, it is clear that it cannot suffice on its own, and an awareness is starting to emerge that true development is the combined result of economic growth and human development. At the end of the 1990s, recognition of the failure of the approach based exclusively on “economic growth” led to the emergence of a “human rights” approach to development.
 
National governments and other bodies have the obligation to respect, protect and fulfil rights facilitate and provide) (Brief “Right to breastfeeding”). They must do everything in their power to fulfil these obligations through legislative or other measures. Up to the present, the concept of accountability and obligation was rarely taken into consideration in development strategies; even though it plays a key role in ensuring actions are both effective and transparent.

This approach is also important in the current context of globalisation, where economic and market forces predominate to the detriment of individual well-being. Thus, even though globalisation appears to be inevitable, the human rights movements, among others, can influence the course of events. Respect of human rights could lead to the creation of a context and a framework to facilitate good governance (transparency, participation and accountability).
 
The debate on food as one of the basic human rights is by no means new, and the right to adequate food is the most frequently cited right in solemn official declarations, but it also the right that is most frequently abused5. More recently, discussions have focused on the right to nutrition, or more precisely, the right to food, health and care (see conceptual framework on malnutrition in figure 2) for good nutrition.

Approaching the problem from the point of view of human rights has consequences both for the analysis of the situation and for planning policies and programmes. Any analysis of the situation must be completed by an analysis of potential obstacles to fulfilling the right to adequate food at household, national and international levels. This will allow those responsible for the obstacles to be identified and the obstacles removed; to achieve this, we have to try to understand why duty bearers seem to be incapable of fulfilling these rights; and finally we have to plan action to give duty bearers the capacity to respect and fulfil them. Strengthening the capacities of duty bearers - responsibility, authority, resources, communication and decision-making - is an integral part of the human rights approach.
 
It is also essential to select indicators to monitor this approach. The fulfilment of human rights calls for the achievement of objectives and simultaneously the creation of a morally acceptable process, and quality monitoring is the part of this process for which the fewest indicators exist.

Women: at the heart of nutrition policy 

Improving their position, literacy and participation in the labour market 

Women represent a vital resource both from a biological standpoint (cf. figure 1 “nutrition throughout life), a social standpoint (women are generally responsible for caring for children), and an economic standpoint, and in particular with respect to household food security. Consequently any action to improve the situation of women by starting with their nutritional status cannot fail to benefit both them and their children in the short, medium and long term.
 
Education plays a fundamental role in the development of both the individual and society. But while concrete progress has been made in enrolling children in school, in some countries the percentage of enrolled children remains low, particularly that of girls. A study carried out in 60 countries showed that schooling of girls plays a determining role in the long-term reduction of malnutrition in young children. Taken as a whole, adult literacy education has progressed, but nevertheless remains lower for women. The same phenomenon can be observed in access to professional training even in sectors where women are employed in enormous numbers, as in agriculture and trade. This is of particular concern since the level of education of women is a decisive factor in the health and nutrition of the family.
 
Despite the crucial role played by women, in many countries their position is far from satisfactory. For this reason, facilitating access of women to education, improving their status by granting them power, and facilitating their entry in the labour market should be core components of any new plans to eliminate maternal malnutrition, such as foetal malnutrition. It is crucial that women are involved in income-generation project with the aid of “micro-credit”.  All of this implies introducing new legislation to ensure progressive changes towards the sharing of rights, responsibility and workload between men and women, and ending sexual discrimination. Women must be integrated in the decision-making process at the local, national and international level (Briefs “Increasing women's involvement in community decision-making:  a means to improve iron status in Peru”; “Mobilisation of women by ABESF for the improvement of diet and nutrition in Burkina Faso”).

Although it is indispensable to integrate women in development projects, particular care must be taken to not add to women’s workload and work schedules as these are often already overloaded, the main risk being that their involvement is to the detriment of the care they provide young children, with negative repercussions for nutritional status and development. Some projects have shown that it is possible to avoid these problems, including measures aimed at pregnant and lactating women, such as developing crèches at work and breastfeeding breaks.

Prevention of foetal malnutrition  

Preventing foetal malnutrition consists of improving the nutritional status of girls and women and consequently newborns, and also increasing their physical and intellectual capacity and thus their capacity to be integrated into society. It also implies decreasing or even stopping the development of NCDs in adulthood. As is true for nutrition in young children, the nutritional status of women should be considered a precondition and key indicator of development.

Actions aimed at improving the nutritional status of girls and pregnant women should be national priorities. In Thailand, village volunteers locate pregnant women, supply them with food and supplements (iron and folic acid) and encourage them to go to the local health centre for medical surveillance during pregnancy. This project has demonstrated the capacity of a country to reduce maternal mortality and to improve the nutritional status of pregnant women and, as a result, of their future children. However, intrauterine growth retardation is the result of complex interactions between many different causes, so these measures need to be conducted alongside other strategies e.g. reducing smoking by pregnant women, controlling parasitosis, infection, and finally reducing the workload of pregnant women. (Brief “Community volunteers in Thailand:  a key to the improvement of the nutritional situation through mobilisation of the community”).

Promote adequate feeding during the first year of a child’s life 

Breastfeeding and complementary feeding, which are important predictive indicators of nutritional status, health and the survival of infants and children, also contribute to the well-being of future generations. Breastfeeding is practised throughout the world but there is still room for improvement as far as the duration and approach are concerned: exclusive breastfeeding during the first 6 months (from birth on), followed by the timely introduction of a nutritive and healthy (free from pathogenic germs) complementary food, whilst continuing to breastfeed6.
 
Despite the recognized benefits of breastfeeding for mother and child, numerous cultural, social, economic and political barriers persist. Several programs have been started at local, national and international levels to promote breastfeeding, and progress has already been observed. Three international initiatives in particular have contributed to the promotion of breastfeeding: the “International code of marketing of breast-milk substitutes”, the Innocenti Declaration, and the WHO/UNICEF initiative “Baby-friendly Hospital”.
 
While it goes without saying that these actions should be continued and strengthened, other innovative ideas should also be discussed, such as breastfeeding promotion within the framework of other programmes than those primarily concerned with sanitary and nutritional questions, particularly in projects for sustainable human development, family planning and environmental conservation.

Home-prepared complementary foods should be recommended as long as enough time is available for their preparation and these foods are available. If manufactured complementary foods have to be used in contexts where resources are limited, small local agro-processing enterprises should be preferred for the production and distribution of these foods (Brief “Improving infant feeding in developing countries: a collaborative effort between NGOs and Research”).

Quality of the diet: the role of agriculture, the agri-food industry, the state and the consumer 

The relationship between diet and health is scientifically robust and changeable. Food produced must respect quality criteria permitting healthy diets for the population in the long term. In this context we will only be discussing the concept of quality from the standpoint of composition and nutritional balance and not sensory or hygienic quality.
 
The Green Revolution focused on an increase in cereal yields to provide sufficient calories for the world population. Though this policy did succeed in certain parts of the world, it had a further consequence in addition to its impact on the environment and that is a reduction in crop diversity and consequently on food diversity. In particular, there has been a significant decrease in the cultivation of pulses and vegetables, and this probably has contributed to the development of micronutrient deficiencies.

Several different strategies are currently used to combat this type of deficiency, particularly in international initiatives. These may be stand-alone or complementary strategies. Some standard approaches are supplementation or food-based, such as food fortification and the promotion of food diversity. These measures imply nutrition education of the populations concerned. (Briefs “Mobilisation of women by ABESF for the improvement of diet and nutrition in Burkina Faso”; “Increasing women's involvement in community decision-making:  a means to improve iron status in Peru”).

Supplementation is efficient, but though it is cheap in terms of the cost of the treatment, in practice it requires both considerable infrastructure and manpower. The limitations of this approach became apparent during the recent economic crisis in Indonesia.

Food fortification may be pertinent and effective in certain contexts. However many countries are unable to make use of this approach as they do not have a sufficiently developed agri-food industry. In addition, food fortification is most beneficial if the fortified food is habitually eaten by those most in need. The choice of a food that is anchored in local eating habits can also avoid potentially damaging changes in eating behaviour. (Brief “Iron fortification of nuoc mam: a promising approach in the fight against iron deficiency in Vietnam”).

Agriculture has an important role to play in overcoming micronutrient deficiencies by facilitating food diversity (by producing vegetables, fruit and pulses) as well as through by developing varieties with high micronutrient levels and improved bioavailability. In practice, up to now, selection of varieties was based on criteria such as the suitability of the product for industrial processing or transport, and nutritional criteria were a minor consideration.

A new paradigm needs to be developed for world agriculture that will result in sustainable food systems that favour nutrition and health. Food and nutrition must become indisputable objectives in agricultural policies and production systems. To this end it is indispensable to establish channels of communication between the agricultural and nutritional sectors. This can and must be achieved  in harmony with the principles of sustainable agriculture7.  A new non-linear model linking agriculture, diet, health environment and society has been proposed redefining the contribution of agriculture to health.8

The proportion of manufactured products in overall food consumption is on the increase. As a result, the dominating role played by the agri-food industry in many societies is also increasing. There is a trend towards production of food with very high sugar, salt and fat contents (particularly saturated fats) while production of foods with high dietary fibre and micronutrient content often remains negligible. From a nutritional point of view, the former may provide a lot of calories, but the calories are “empty” and when consumed in excessive quantities, these foods are a major cause of the increase in NCDs in both the North and the South. 

It is thus indispensable to encourage the agri-food industry to reduce the levels of these food components. Legislation should be introduced to create nutritional quality charters in collaboration with manufacturers, consumers, distributors, sanitary authorities and farmers in the country concerned. This has already been done in Finland and the United Kingdom, where manufacturers have been asked to reduce, for example, the quantity of salt in manufactured food products.
 
Labelling is also very important. Labels often do not exist or are incomplete and legislation should be enforced to ensure the consumer has access to objective information9 about the composition of the food, without, however, going as far as claiming that the food constitutes a risk for health or protects against disease. There is a great risk when combining publicity slogans and nutrition education messages.

Stricter regulations should be introduced for advertising food products, particularly those aimed at children. Some countries have already prohibited commercials before, during and after TV programs for children. In other countries specialists in child obesity are asking for a ban or at least stricter control of the content and form of the message. Measures could also be taken with respect to educational material provided by the agri-food industry for consumer and health education. A charter should be drawn up describing good practices and deontological commitments.

Large scale retail distribution plays a very important role in many countries in supplying families with food; more than 80% of food products are now purchased in supermarkets and hypermarkets in many industrialised countries. Thanks to the influence it have on food systems, the environment, and on food consumption and health, this distribution represents a strategic link in the food chain and measures should be taken to encourage them to change their practices. An initiative of this type has been taken in the United Kingdom to measure and monitor the performance of supermarkets in the social, ethical and environmental fields. (Brief “Race to the Top”).

Although the subject of a lot of controversy in the United States and the United Kingdom, another possible measure is taxing products that are unhealthy10. Some people have suggested basing the tax on food on the content of specific fats that contribute to the development of cardiovascular diseases, but apparently it has been found easier to tax foods that are recognised to be of little nutritive value, such as soft drinks, sweets and confectionary, and savoury snacks. Legislation to this effect already exists in many states in the USA. Although the tax is small, the idea is not necessarily to directly reduce consumption but to generate funds to be used for prevention and health promotion (Brief “Small tax on certain products: a way to generate funds for the promotion of health”). Another possible solution is to reduce VAT on certain foods to be promoted for their nutritional value.
 
Lastly, in most countries, and at a local level, food conservation and processing methods, as well as marketing and distribution strategies need to be more far-reaching and adapted to improve availability, accessibility and food quality-price ratio. 

Consumer awareness, education and active participation in the move towards a balanced diet and a healthy lifestyle 

None of the above-mentioned measures concerning industrially processed food products will suffice on their own. They need to be integrated in a wide-ranging action plan that will necessarily include awareness-raising and education programmes aimed at consumers. The consumer should be encouraged to play an active role in the process, as demand is a very effective way of modifying supply. Raising awareness of the impact consumer choices and food habits can have on public health, the environment and agriculture, and of the need for their involvement as citizens is consequently of paramount importance. For this, it is becoming necessary to strengthen capacity to assess size, trends and causes of nutritional problems, particularly at community leader level11.  Despite this fact, few governments have really made an effort to achieve this objective. (Brief “National awareness and information campaigns”).

Nutrition education should enable individuals to acquire the competence and knowledge about food and nutrition they need to enjoy more freedom, to choose eating habits that are in harmony with their own cultural background and within existing socio-economic limits. Thus the objectives of nutrition education should go hand in hand with those of education and the promotion of health.

One ideal environment for health education in general and particularly nutrition education is the school. However, existing teacher training programmes and school curricula need adapting. School is also an ideal place to carry out supplementation or supplementary feeding programs that will have an immediate beneficial effect on learning capacity.

Promoting physical activity 
 
Even though the level of physical activity is still very high in some rural communities in developing countries, as we have already seen, in other populations many factors contribute to a decrease in physical activity, which is recognised as a key factor in the prevention of obesity, along with eating a healthy diet.

In order to change existing behaviours and attitudes, informing and educating the public is indispensable, but alone it cannot suffice. Information campaigns and education must be accompanied by other measures that facilitate daily physical exercise at work and at school. The first step is to include sufficient sport in the school curriculum (some people recommend one hour per day at primary school to encourage healthy habits in adolescence and subsequently in adulthood).  Local councils/municipalities and/or the government should favour means of transport other than private cars (e.g. public transport, cycling by building cycle tracks and creating footpaths) and provide sports facilities that are financially accessible for everyone.

Surveillance

Nutritional surveillance is now recognised as an integral component of nutrition policy. Changes that occur in food and nutritional situations, notably in the context of transition, are generally not well documented and this often means that timely decisions are not made. Surveillance can be defined as a continuous process of collecting and analysing pertinent information on the nutritional status of a given population and its main determinants for identified users. Nutritional surveillance is designed to be a flexible support tool for decision-making that can be used at different levels, i.e. local community or nationally. These different types of surveillance may serve different purposes. Particular attention must be paid to the specific needs of the users and the independence of those responsible for surveillance in addition to cost and sustainability (Brief “Nutrition barometer”).

Research and training of professionals 

Research is still required in many fields of nutrition. However, in the new field of public nutrition, research should focus on solving problems at the population level  and particularly the disadvantaged. It is essential to strengthen the links between research, action and professional training. Project evaluation must be made a priority. This implies a change in the way action plans are designed and applied: evaluation should be included at the design and funding stage, and priority should be given to information systems and monitoring.

Training of professionals in the field of public nutrition is also a priority and should be developed systematically and be multidisciplinary including: statistical analysis, epidemiology, communication, programme management, the science of nutrition, food and nutrition policies, concepts and methodology used in economics and social sciences. New curricula have already been proposed, and these can be used as a basis for designing training programmes adapted to specific regional and national needs.

Lastly, as previously highlighted, it is also necessary to train in public nutrition professionals of related fields, e.g. agriculture, food manufacturing, catering, education and health. In the health sector, training of professionals at all levels is essential before nutrition can be incorporated into health care, and especially in maternal-infant health care, within community health services.

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Examples of “good” practice

•	Right to breastfeeding
•	Community volunteers in Thailand: a key to improving the nutritional situation through mobilisation of the community 
•	Food and nutrition policy in Norway: a public nutrition approach responding to rising coronary heart disease
•	Food and nutrition policy in Europe: a reference framework for the region
•	Increasing women's involvement in community decision-making: a means to combat anaemia in Peru.
•	Mobilisation of women by the ABESF for the improvement of diet and nutrition in Burkina Faso 
•	Iron fortification of nuoc mam: a promising approach in the fight against iron deficiency in Vietnam
•	Tracking supermarket progress towards a fairer and greener food system: the Race to the Top initiative in the United Kingdom 
•	A small tax on certain foods: a way to generate funds for the promotion of health 
•	National awareness and information campaigns 
•	Improving infant feeding in developing countries: a collaborative effort between NGOs and Research  
•	The nutrition barometer: an experience in nutritional surveillance in France

The right to breastfeeding

Breastfeeding is recognised as the ideal way to feed and care for infants; it benefits both psychomotor development of the infant and is good for the mother. For these reasons it should be considered the mother’s right as well as the child’s. 
Nevertheless this right is frequently violated: “medicalisation” of infant foods, promotion of breastfeeding substitutes by industry, failure on the part of society to help mothers breastfeed and work, and failure of the community to support breastfeeding.

The following table illustrates how the approach to breastfeeding as a right can be transformed into concrete commitments at different levels of society.

Breastfeeding rights: Duties and obligations at different levels of society

Duty or obligation	Household	Community	Government	
Respect	To understand that breastfeeding is best for both boys and girls	To assist in the promotion of breastfeeding	To constantly promote breastfeeding	
Protect	To avoid buying breast-milk substitutes	To inform people about the importance of breastfeeding	To protect people against misinformation
Establish appropriate legal measures	
Facilitate	To assist in housework during lactation	To assist in reducing the workload of lactating mothers	To provide basic mother and child health care
Encourage medical and paramedical staff to support breastfeeding	
Fulfil	To ensure that the lactating mother eats well and gets sufficient rest	To provide food to poor households with lactating mothers	To ensure household food security	
Adapted from Nutrition throughout the life cycle. 4th report on the world nutrition situation 2000: p55.

As can be seen, even though legislation and international and national action are extremely important, final success depends on the commitment made by individuals and communities to the right to breastfeed.

Latham MC. A mother's right to breastfeed: removing the obstacles. Food and Nutrition Bulletin, 1999;20(3):293-299
Other bibliographical references can be found in the general bibliography on the right to food and nutrition.

Community volunteers in Thailand: a key to the improvement of the nutritional situation through mobilisation of the community

In its fight against poverty, Thailand has adopted a strategy that aims to fulfil people’s basic needs and is founded on self-sufficiency. Including nutritional objectives in this strategy, and in primary health care and agricultural policies has helped achieve a significant reduction in malnutrition in children under 5 over the last two decades.

Besides political engagement and a multi-sectorial, integrated approach - both essential for programme sustainability and effectiveness – the emphasis was placed on mobilising communities and obtaining their active participation.

Community volunteers were selected and received basic professional training in nutrition, health and programme planning. The use of one volunteer (or ‘facilitator’) for 10 households allowed the scope and impact of the intervention to be maximised. 

The main tasks carried out by the volunteers were connected with prevention and the promotion of health. Prenatal surveillance was provided to ensure ideal bodyweight at birth, prevent micronutrient deficiencies and reduce maternal mortality. The volunteers played an essential role in locating pregnant women, distributing complementary foods, obtaining the mothers’ commitment to taking iron supplements and encouraging the women to make use of available health services.
 
A system was set up involving the health services, volunteers and the mothers mobilised by the volunteers to monitor child growth. Nutritional surveillance tools were developed and used at household and community levels.
Volunteer also helped set up nutrition education and communication programmes to encourage breastfeeding, the use of adequate complementary foods and satisfactory hygiene.

Active community participation allowed 95% coverage of vulnerable groups by mother and child health services.

Tontisirin K, Bhattacharjee L. Nutrition actions in Thailand -  a country report. Nutrition research 2001; 21:425-433
Tontisirin K, Winichagoo P. Community-based programmes: success factors for public nutrition derived from the experience of Thailand. Food and Nutrition Bulletin 1999;20(3):315-322

Food and nutrition policy in Norway: a public nutrition approach responding to rising coronary heart disease

In the 1960s Norway suffered from a high and rapidly rising mortality rate due to coronary heart disease. In 1975 the Norwegian parliament adopted an unprecedented food and nutrition policy aimed at adapting agricultural production to objectives for nutrition and health policy.  A National Nutrition Council was created to work on the following topics:
-	Self-sufficiency in the production of healthy food; 
-	Regional distribution of foods such as fruit and vegetables at constant prices; 
-	Campaign to reduce intakes of fats, particularly saturated fats, and to increase intake of polyunsaturated fat; 
-	Adaptating the health service to allow surveillance of coronary heart disease, hypertension and blood fat levels;  
-	Development of a culture favouring leisure-time physical activity and sport. 
  
This new policy was based on active participation by people at different levels of society: consumers, producers, the agri-food industry, distributors, health and education professionals and researchers.

Community mobilisation was very high, mainly as a result of municipal services that ensured the population had access to a balanced diet.

Emphasis was placed on informing and educating the public particularly through TV programmes, the distribution of educational material to the general public and to professionals, and training. The level of knowledge about food, nutrition and the relationship between food and health increased and resulted in an improvement in diet followed by a progressive reduction in fat consumption, particularly saturated fat, and an increase in polyunsaturated fat, which in turn, led to a reduction in cholesterol levels.
 
In addition to efforts concerned with food production and access to fruit and vegetables, certain foods were fortified and careful attention was paid to labelling.

A system of surveillance was set up to provide decision-makers with information concerning the monitoring of the food and nutrition situation and to modify objectives when necessary.
 
This policy resulted in a significant reduction in mortality due to coronary disease, which was reduced by half over a period of 20 years.

WHO, Regional office for Europe. European food and nutrition policies in action. Eds. Milio N., Helsing E. WHO regional publications, European series 73;1998:176p
WHO, Regional office for Europe. Comparative analysis of nutrition policies in WHO European member states. EUR/ICP/LVNG 01 02 01; 1998:75p

Food and nutrition policy in Europe: a reference framework for the region

European countries are not necessarily all at the same level when it comes to defining and implementing food and nutrition policies. Some countries have had functioning policies for years, while others are still at the stage of drawing up policies and collecting the necessary data. Still others have instigated a number of actions in the field of nutrition, but have not yet defined a general framework. In the last few years, a desire has been expressed to define a general regional framework to support and encourage government actions in favour of nutrition.

For this reason, the WHO Regional office for Europe produced a policy document and an action plan for nutrition in the European region for the period 2000-2005. It comprises three inter-linked strategies: (i) food safety, (ii) nutrition aimed at ensuring optimal health, and (iii) sustainable food supply. This action plan underlines the complementary roles played by different sectors in drawing up and applying policies to protect and promote health and reduce morbidity linked to food, while contributing to socio-economic development and a sustainable environment.

The European Union only very recently developed a policy and a specific action plan for nutrition. Despite this fact, certain European policies have already had an impact on nutrition via policies on: health, consumers, the internal market and industry, trade, agriculture, and research. 
A nutrition policy was defined with the following objectives:
-	To provide a safe and varied food supply, in sufficient quantities; 
-	To monitor nutritional status, food consumption and health status linked to nutrition;
-	To provide reliable and comprehensive nutrient information about food; 
-	To develop nutritional research and disseminate results to all member states; 
-	To train health professionals;
-	To support national nutrition policies. 

Close collaboration is envisaged between WHO and the European Commission around these topics. The creation of a nutrition task-force within WHO Europe is planned that would have the following responsibilities: facilitating collaboration between international agencies and European organisations, creating a forum for exchanges on nutrition and public health, making sure that development agencies work together to help countries, and strengthening political engagement in favour of food and nutrition. 

European Commission Employement and social affairs. Priorities for public health action in the European Union. 1999:182p
OMS, Bureau Régional de l'Europe. Les incidences de la situation alimentaire et nutritionnelle sur la santé publique: les arguments en faveur d'une politique et d'un plan d'action en matière d'alimentation et de nutrition pour la région européenne de l'OMS (2000-2005), 2000:18p
OMS, Bureau Régional de l'Europe. Santé 21 : Introduction à la politique-cadre de la santé pour tous pour la région européenne de l'OMS. Série européenne de la santé pour tous n°5, 1998:35p
Société Française de Santé Publique. Santé et nutrition humaine : Eléments pour une action européenne. Collection Santé et société 2000,10:52

Increasing women's involvement in community decision-making:  a means to improve iron status in Peru

This project is part of a multi-country study (Ethiopia, Kenya, Peru, Thailand, Tanzania) conducted by the International Centre for Research on Women. It is justified by the fact that, despite numerous interventions aimed at preventing micronutrient deficiencies, the prevalence is still high in many regions of the world. In order to increase the effectiveness of these measures, a better understanding is needed of the factors within the family that influence micronutrient status.  Recognition is also required of the fundamental role played by women in family nutrition, based on their earnings, the care they provide, and the production and preparation of food.

In Peru the objective was to develop and test a nutritional intervention aimed at reducing anaemia in women of childbearing age in the immediate vicinity of Lima. The goal was to provide an alternative to vitamin and mineral supplements.

The intervention took place in the framework of community kitchens where groups of women collectively prepared meals (three meals a day for five days); the prepared food was consumed at home.

Participatory methods were developed to actively involve women members of community kitchens in the design, application and evaluation of this intervention.
During the design stage, staff and clients of the kitchens took part in workshops to identify potential food and institutional problems, and possible solutions. A diagnosis was made of tastes and food preferences as well as of the nutritional quality of the meals.

The intervention also had the effect of improving the service provided - the nutritive value of the meals, stock management, and hygiene during preparation.  It also stimulated demand by improving the quality of information and the women’s knowledge through nutrition education. Quality control was the responsibility of women who had been specially trained for the task, which improved acceptance of the kitchens by others inasmuch as “cooking for the poor” no longer necessarily implied “poor quality cooking”. The participatory approach and support from planners and sponsors guaranteed the sustainability of the programme.

The convincing results of this project – an increase in the availability and consumption of iron-rich foods and a decrease in cases of anaemia – were diffused and developed throughout the country and this experiment is now being replicated in many other community kitchens.

Carrasco Sanez N. et al. Increasing women's involvement in community decision-making:  a means to improve iron status. Research Report Series 1, International Center for Research on Women, 1998:28p

Site on line: http://www.icrw.org/

Mobilisation of women by the ABESF for the improvement of diet and nutrition in Burkina Faso 

The Burkina Faso Association for Social and Family Economics (ABESF) has been active since 1995 in raising awareness of the role played by social and household economy in the improvement of living conditions within the family and in society as a whole. The association mobilises the entire female population to take part at different levels in the activities it organises. The members are volunteers and work for the association during their free time. One of the guiding principles of the ABESF is that its activities depend on stimulating and exploiting local resources. ABESF involvement in two major projects connected with the fight against malnutrition in Burkina Faso is entirely based on this philosophy.

In the context of the fight against vitamin A deficiency, the ABESF is taking part in a pilot project to promote consumption of red palm oil (RPO), which is a source of vitamin A, in a region where it is neither produced nor customarily consumed. The goal was thus to get the population to consume a new food because of its nutritional qualities. Red palm oil is first purchased from women producers in the southwest of Burkina Faso, and women belonging village groups at the eleven pilot sites then sell it. The ABESF functions as local coordinator and is a participating member of the steering committee; it also helps with the practical organisation of promotional activities at the pilot sites. A total of seventeen facilitators are employed in the project and are responsible for contact with local populations who receive awareness raising and educational information.
This collaborative project involves the ABESF, their Canadian collaborators, the AEFQ (Quebec Association for Family Economy), a university structure in charge of the project (Department of Nutrition, University of Montreal) and researchers at the Burkina Faso Research Institute for Health Sciences and at the Institut de Recherche pour le Développement (IRD), France.
 
As part of the effort to improve the nutritional status of the population as a whole, a recipe book has also been published. A substantial part of the book is made up of recipes for traditional dishes that were selected from a total of 1020 collected all over the country and improved from a nutritional standpoint. In addition it contains chapters on subjects like the general principles of a balanced diet, simple procedures for processing and conserving local foods, rules for hygiene and food safety, advice on feeding infants and balanced menus for different regions of the country.

Up to now, 27 facilitators have been trained in fifteen provinces of Burkina Faso, and awareness programmes have been introduced in the 144 village women’s groups that presently belong to the network; altogether a total of 6 072 women are involved.  Creating the recipe book also provided the ABESF with the opportunity to collaborate with the staff of the departments of agriculture, health, research and social welfare.

Association Burkinabé d’Économie Sociale et Familiale. Guide d’animation sur la promotion de l’huile de palme rouge (10 histoires en images). Ouagadougou, décembre 2000.
Delisle H, Zagré N, Ouedraogo V. Marketing of red palm oil for vitamin A in Burkina Faso: A pilot project involving women's groups. Food and Nutrition Bulletin 2001, 22(4): 388-394.
Contact Hélène Delisle, delisleh@dsuper.net

Iron fortification of nuoc mam: a promising approach in the fight against iron deficiency in Vietnam

A national survey carried out in 1994-1995 by the Hanoi National Institute for Nutrition (NIN) showed that there was a high prevalence of anaemia throughout the Vietnamese population, particularly in women of child-bearing age, irrespective of whether they were pregnant or not, and in infants from the age of a few months. The main cause of this anaemia is nutritional, due to a problem of bioavailability of iron in the Vietnamese diet, particularly in rural areas where cereal-based diets contain high levels of iron-absorption inhibitors like phytates. The prevalence of iron deficiency anaemia and its many consequences for health led the Vietnamese government to include control of this nutritional deficiency among the objectives of its National Action Plans for Nutrition for the periods 1995-2000 and 2001-2002.
 
Several complementary strategies need to be combined to fight more efficiently against iron deficiency. These strategies include iron fortification of foods that are regularly consumed by the whole population and particularly by the poorest. Nuoc mam fish sauce offered the most appropriate medium, as several national surveys, including the national survey held in 2000, indicated it is  widely consumed on a daily basis in Vietnam..  The form of iron supplement selected, NaFeEDTA, has two advantages, it is organoleptically stable in nuoc mam and has satisfactory iron absorption properties, and in addition, it enables iron included in other components of the diet to be absorbed, particularly those containing high levels of food iron-absorption inhibitors.

The programme for iron fortification of nuoc mam began in 1998 with meetings attended by the Vietnamese Ministers of Health and Fisheries, representatives of two international organisations (WHO, UNICEF), representatives of a French institute for bi-lateral cooperation (IRD), representatives of the private sector, and one foundation: the International Life Sciences Institute (ILSI). A programme of this type required a series of different activities organised over a period of time:
-	Preliminary enquiries concerning the production of nuoc mam in Vietnam; 
-	A study to determine the level of iron absorption in nuoc mam consumed during typical Vietnamese meals; 
-	A study of the biological efficacy in Vietnamese women of childbearing age suffering from anaemia. Results of this study showed that regular consumption of nuoc mam fortified with 10 mg of iron per 10 ml of nuoc mam over a period of 6 months resulted in a significant improvement in the iron status and haemoglobin concentration in the subjects studied, and reduced the prevalence of anaemia and iron deficiency. 
-	A study of effectiveness in real conditions when fortified nuoc mam is made available to all the households in the Red River delta. This study, which starts in 2001, will last 18 months.   

In parallel with these studies, the NIN is working on proposals for regulations concerning the fortification of foods with micronutrients. This means that if the results of the effectiveness study are positive, the nuoc mam iron fortification programme can be extended to the whole country.

Contact :  Professor  Ha Huy Khoi, Directeur, Institut National de Nutrition, 48 Tang Bat Ho, Hanoi, Vietnam ; Jacques Berger, j.berger@fpt.vn

Tracking Supermarket Progress towards a Fairer and Greener Food System: the Race to the Top initiative in the United Kingdom

In many countries more than 80% of food products are now purchased in supermarkets and hypermarkets, which consequently play a very important role in the food system. Firstly they have a huge influence on the rural economy by setting standards for agricultural practice and by seeking ever greater efficiencies from the food chain in the name of the customer value, competition, and shareholder value. Their product range and geographical siting policies affect the health of our communities.

The objective of the Race to the Top initiative, which was developed by the International Institute for Environment and Development (IIED), is to benchmark and track the social, environmental and ethical performance of supermarkets in the United Kingdom, and thereby catalyse change within the agri-food sector and beyond.

A series of indicators have been identified that will allow annual assessment and monitoring of progress made by supermarkets over a period of five years. These indicators are organized in seven main areas: biodiversity and landscape, labour standards, animal welfare standards, public health, regional sourcing and local development, sustainable management and reporting, and terms of trade with primary producers.

The Race to the Top project:
-	Offers supermarkets independent evaluation of their actions in the social, ethical and environmental domain;
-	Transforms supermarkets into an educational platform for consumers by clarifying the link between the choice of product, retail policy, health and the food system;
-	Provides indirect support for producers by supplying information about relations between supermarkets and local or foreign producers;
-	Provides investors and decision-makers with information to help them make their decisions.

Contact: Bill Vorley, International Institute for Environment and Development, 3 Endsleigh St, London WC1H 0DD, UK; bill.vorley@iied.org

A small tax on certain products: 
A way to generate funds for the promotion of health

In North America, where the consequences of an unbalanced diet and unhealthy lifestyles are so obvious, both the United States (nineteen states and towns) and Canada have introduced a tax on certain food products like soft drinks, sweets and confectionary and savoury snacks.  This is either in the form of a flat tax as a function of the volume purchased or as a percentage of the sales price paid by either the wholesaler or the retailer.

A tax on easily identifiable foods was preferred to a tax on foods that contribute to the development of coronary diseases due to the levels of certain types of fats they contain.

However, the agri-food industry and distributors are fighting back, and, in some states, have successfully lobbied the government to cancel the tax, usually with promises to build factories and create jobs.

Even very small taxes can generate respectable funds. In Arkansas, a 2% tax on 12-ounce cans (360ml) of soft drinks generates 40 million dollars per year, and in California a 7.25% tax on the same products generates 218 million dollars. In the US as a whole, approximately one billion dollars per year tax is collected on the range of products listed above.

Up to now, these revenues have been included in overall tax revenues and rarely allocated for a specific use. The challenge is thus to have this money allocated for nutrition education programmes and the promotion of physical exercise.

Estimates made in the United States have shown that a tax of 1% on cans of soft drinks, and a tax proportional to the weight of other types of products, would generate around 1.8 billion dollars per year. Since this tax is very small, it would not have a significant effect on price or on consumption and would consequently be acceptable to both consumers and manufacturers. In addition, studies have shown that if consumers are aware that the tax is used for their health, they accept it even more easily.

Jacobson MF., Brownell KD. Small taxes on soft drinks and snack foods to promote health. American Journal of Public Health 2000 90(6):854-857
Ismail AI, Tanzer JM, Dingle JL. Current trends of sugar consumption in developing societies. Community Dent Oral Epidemiol 1997;25(6):438-43
Marshall T. Exploring a fiscal food policy: the case of diet and ischaemic heart disease. BMJ 2000;320:301-305

 National awareness and information campaigns 

"National Salt Awareness Day" in the United Kingdom

CASH: Consensus Action on Salt and Hypertension brings together specialists concerned with salt and its effects on health. Its objective is to reach a consensus with the agri-food industry on the problems caused by excess salt intake and on a reduction in the amount of salt used in processed foods.

A national awareness day is organised each year with the support of the government and the Ministry of Health, and many other organisations concerned with disease prevention and promotion of health.
The objectives of the national awareness day are:
-	To remind people how much salt may be concealed in processed food and ready-to-eat dishes; 
-	To encourage the population to pay more attention to salt; 
-	To alert the population to the long-term dangers of too much salt and to the benefits to be obtained by reducing salt input. 

The action also aims to encourage the agri-food industry to reduce the quantity of salt in manufactured products and to ensure labelling of all products is clear to enable the consumer to calculate his or her salt consumption.
Many manufacturers have already started to reduce the quantity of salt used and National Salt Awareness Day gives them the opportunity to promote their ‘new’ range by offering samples of the products.

"National Micronutrient Day" in the Philippines

In the framework of activities to combat micronutrient deficiencies, many countries now organise awareness and information days.
In the Philippines, for example, several types of activities are organised: 
-	Distribution of micronutrient supplements (Vitamin A and iodine); 
-	Distribution of vegetable seeds and seedlings to encourage home cultivation;
-	Nutrition education; 
-	Tests of the iodine content of salt; 
-	Distribution of iodised salt to poor families; 
-	Promotion of fortified foods. 

The awareness day is widely covered by the media to encourage as many people as possible to take part.

Contact: Sue Wilkinson – CASH Project Co-ordinator. E-mail: s.wilkinson@sghms.ac.uk
Site on line: http://www.hyp.ac.uk/cash/presfeb.htm

Dela Cuadra AC. The Philippine micronutrient supplementation programme. Food and Nutrition Bulletin, 2000;21(4):512-514

Improving infant food in developing countries: 
A collaborative effort between NGOs and Research
In 1994 a partnership was established between a research and development organisation (IRD) and a development operator “Group for Research and Technological Exchange” (GRET) to conduct projects aimed at improving infant food.  At the present time two projects are underway: one in Madagascar (Nutrimad) and one in Vietnam (Fasevie) and others are in preparation for sub-Saharan Africa.
The two projects have the following features in common: 
-	To define the most appropriate conditions in each specific context for the production of complementary foods to breastfeeding.  This takes place after a stringent analysis of the: eating habits and nutritional status of young children; available supplies and food technology, as well as of the organisations involved, or that could be involved in interventions aimed at improving infant food; 
-	To draw up strategies to make these foods available to the largest possible number of infants and young children and to promote hygienic and safe food habits likely to reduce infant malnutrition;
-	To carry out studies, research and evaluation to capitalise on the results and experience gained during the course of the project;
-	To provide additional training either in the country concerned or in France for locally recruited personnel and partners;
-	To make available all tools, methodologies, facilities and procedures developed and evaluated within the framework of the project to national institutions, NGOs and the scientific community concerned with the improvement of infant food and with the nutritional status of children in developing countries. 

The strategies used differ depending on the context, for example, aid in the setting up of small production units for infant flours, using an extremely cheap extrusion process, and in the promotion of these products through nutritional education campaigns run by women’s networks in Vietnam.  Also nutrition education activities at celebrations and other public events.  Lastly, the promotion of improved recipes developed in collaboration with mothers in the children’s restaurants (Antananarivo) or with the help of volunteers (rural areas in eastern Madagascar)

These projects are carried out in collaboration with partner institutions (research institutes, universities), with NGOs and public services in the countries concerned. Financial support comes mainly from French community institutions in the framework of decentralized cooperation, the French Ministry of Foreign Affairs, the French UNICEF Committee, United Nations agencies, and various private institutions in the form of humanitarian aid, plus IRD funds. 
These projects are the subject of information and communication campaigns in France whose aim is to raise awareness of nutritional problems in developing countries. Plans are underway to create a web site to provide information on these activities (with articles written for the general public and periodical information bulletins) to ensure that the results and the experience gained is easily accessible to those interested.

Contact: treche@mpl.ird.fr  - goudeau@gret.org
Dossier: Les farines infantiles. Bulletin du Réseau TPA, mai 1998, n°15: 39 pages. http://www.gret.org/tpa/bulletins/bulletin15/tmbulletin15.htm (en français)
http://www.gret.org/tpa/bulletins/bulletin15a/b15ap12a.htmSite (in english)

The nutrition barometer: 
An experience in nutritional surveillance in France

 
In 1992 the French Committee for Health Education and other national institutions concerned with health problems designed a health surveillance mechanism called “The Health Barometer”. 

The main aim of this type of barometric inquiry is to regularly update information on the knowledge, attitudes and behaviour of the French population in health matters. These data allow a clearer definition of objectives for national prevention programmes, to delineate the focus of specific qualitative or quantitative studies, and also to undertake more targeted interventions for particular populations or regions.

Up to now the Health Barometers have addressed four different sectors of the population: adults, adolescents, family doctors and chemists.

Food as a topic is generally only tackled marginally by the Health Barometers. Recognising the importance food has for health, a barometer was specifically designed to cover the subject. This tool helps define future national programmes and consequently facilitates the development of a real policy for nutrition education. The first nutrition barometer was conducted in 1996 and the second in 2002.

The specific objectives of the nutrition barometer are:
-	To assess food quality and frequency of consumption;  
-	To determine the frequency and the structure of meals; 
-	To evaluate certain food behaviours linked to the cultural environment, e.g. attachment to tradition, social interaction and snacking.
-	To identify eating profiles in the population;
-	To raise certain subjects linked to the perception of food; 
-	To link nutritional variables to other healthy behaviours. 

In the framework of food and nutritional surveillance, nutrition barometers are useful tools particularly because they complement quantitative surveys with a qualitative perspective.

Baudier F, Rotily M, Le Bihan G, Janvrin MP, Michaud C. Baromètre santé nutrition 96. Ed. CFES, 1997:180p
Contact: www.cfes.sante.fr   -  philippe.guilbert@cfes.sante.fr