^ ^ ^ ^ EXECUTIVE
WORLD HEALTH ORGANIZATION
EB49/30
ORGANISATION MONDIALE DE LA SANTÉ
13 D e c e m b e r
1971
BOARD
INDEXED
Forty-ninth
Session
Provisional
agenda item
2.10
P R O G R A M M E RΠV I E W :
NUTRITION
:0NTENTS С Page Introduction 1.
2.
The nutritional
4.
Protein-calorie malnutrition
3
1.2 1.3 1.4 1.5
Xerophthalmia Nutritional anaemias Endemic goitre Other nutritional conditions
6 8 9 10
WHO assistance
A s s e s s m e n t of n u t r i t i o n a l status and e p i d e m i o l o g i c a l s t u d i e s A s s i s t a n c e in the o r g a n i z a t i o n of s e r v i c e s and of p r e v e n t i v e p r o g r a m m e s Training in nutrition Resources
•
11 11 14 17 19
3.1 C o - o r d i n a t i o n w i t h o t h e r u n i t s of W H O 3.2 C o - o r d i n a t i o n w i t h i n t e r n a t i o n a l a g e n c i e s of the U n i t e d N a t i o n s s y s t e m . • 3.3 ‘ C o - o r d i n a t i o n w i t h the International U n i o n of N u t r i t i o n a l Sciences • • .
19 19 22
The Protein Advisory Group
23
• • • •
E s t a b l i s h m e n t and e a r l y f u n c t i o n of P r o t e i n A d v i s o r y G r o u p T e r m s of r e f e r e n c e Functioning Recent PAG activities Recent developments in the United Nations concerning the protein and PAG
•
Protein-calorie malnutrition Nutrition and infection A n t h r o p o m e t r y as r e l a t e d to n u t r i t i o n a l Hypovitaminosis A Anaemias Tropical sprue Endemic goitre Rickets B u d g e t of r e s e a r c h p r o g r a m m e
Possible
Annexes
lines of future action
23 23 24 24
problem
The research programme 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9
6.
11
i n t h e f i e l d of n u t r i t i o n
Co-ordination
4.1 4.2 4.3 4.4 4.5
5.
3
situation in the world and p r e v e n t i v e m e a s u r e s
1.1
2.1 2.2 2.3 2.4
3•
2
25 26
• « • • • • status
•
27 28 29 29 30 31 31 32 32 32 35
page
2
INTRODUCTION T
In J a n u a r y 1 9 6 5 , the D i r e c t o r - G e n e r a l s u b m i t t e d a r e p o r t on the O r g a n i z a t i o n s n u t r i t i o n p r o g r a m m e to t h e E x e c u t i v e B o a r d ( t h i r t y - f i f t h s e s s i o n ) . The report was p u b l i s h e d in t h e W H O C h r o n i c l e ( 1 9 6 5 , 兰 ， 3 8 7 - 3 9 6 , 4 2 9 - 4 4 3 and 4 6 7 - 4 7 6 ) and as a b o o k l e t in the same y e a r . N o w , s e v e n y e a r s l a t e r , t h e D i r e c t o r - G e n e r a l h a s the p l e a s u r e to s u b m i t to the E x e c u t i v e B o a r d a n e w r e p o r t , e m p h a s i z i n g the m o s t r e c e n t d e v e l o p m e n t s in t h i s f i e l d . During the past seven years substantial additional information has been obtained, both o n t h e e x t e n t of n u t r i t i o n p r o b l e m s and o n p o s s i b l e a p p r o a c h e s to t h e i r s o l u t i o n . In r e c e n t y e a r s p u b l i c o p i n i o n has been p r e s s i n g u p o n g o v e r n m e n t s and i n t e r n a t i o n a l o r g a n i z a t i o n s the n e e d to i n t e n s i f y efforts against m a l n u t r i t i o n . Governments are i n c r e a s i n g l y aware of the seriousness of the s i t u a t i o n , and their representatives have d i s c u s s e d t h e p r o b l e m in the g o v e r n i n g b o d i e s of m a n y of t h e s p e c i a l i z e d a g e n c i e s of t h e U n i t e d N a t i o n s s y s t e m and a l s o in t h e E c o n o m i c and S o c i a l C o u n c i l a n d G e n e r a l A s s e m b l y of the United N a t i o n s . W h i l e i n t h e p a s t t h e p r o f e s s i o n a l p e o p l e m a i n l y i n v o l v e d in n u t r i t i o n w e r e m e d i c a l and a g r i c u l t u r a l , at p r e s e n t m a n y others are also deeply concerned : e c o n o m i s t s , p l a n n e r s , s o c i o l o g i s t s , and o t h e r s . T h e r e a s o n f o r t h i s i n c r e a s e in i n t e r e s t c a n b e e x p l a i n e d n o t o n l y in t e r m s of t h e c o n t i n u i n g g r a v i t y of the p r o b l e m , w h i c h w a s n o t less s e r i o u s 10 o r 2 0 y e a r s a g o , b u t b e c a u s e o f t h e r e a l i z a t i o n t h a t i t is v e r y d i f f i c u l t t o a c h i e v e a n y s o c i o - e c o n o m i c development w i t h human resources seriously handicapped by the biological consequences of malnutrition. M a l n u t r i t i o n is n o t o n l y a h e a l t h p r o b l e m ； i t is a l s o a p r o b l e m of human d e v e l o p m e n t , with all the consequences that this implies for socioeconomic progress. This
report presents WHO activities
1.
The nutritional
2.
WHO assistance
3.
situation
in t h e w o r l d a n d p r e v e n t i v e
in t h e f i e l d of
nutrition.
Co-ordination.
4.
The Protein Advisory
5.
The
6.
Possible
research
Group.
programme.
lines of
future
in n u t r i t i o n u n d e r
action.
the following headings : measures.
THE NUTRITIONAL SITUATION From priority
IN T H E W O R L D A N D P R E V E N T I V E
MEASURES
the i n t e r n a t i o n a l point of v i e w , the following four conditions (Fig.
deserve
the
highest
1).
(a) p r o t e i n - c a l o r i e m a l n u t r i t i o n , b e c a u s e of its h i g h m o r t a l i t y r a t e , its w i d e and the i r r e v e r s i b l e p h y s i c a l and (sometimes) m e n t a l d a m a g e it m a y cause;
prevalence
(b) x e r o p h t h a l m i a , because of its c o n t r i b u t i o n to the m o r t a l i t y of m a l n o u r i s h e d children, its relatively wide prevalence and the dramatic irreversible damage (blindness) it causes； (c) n u t r i t i o n a l a n a e m i a s , because of their w i d e d i s t r i b u t i o n , their c o n t r i b u t i o n mortality from many other conditions and their effects on w o r k i n g capacity; (d)
e n d e m i c g o i t r e , b e c a u s e of its w i d e
to
distribution.
In s o m e m o r e l i m i t e d a r e a s o f t h e w o r l d , o t h e r n u t r i t i o n a l p r o b l e m s s u c h a s b e r i - b e r i , pellagra or rickets may warrant a high priority, but on a world-wide basis the above-mentioned seem the most important. 1.1
Protein-calorie malnutrition
(PCM)
W h e n the i n c r e a s e in food p r o d u c t i o n d u r i n g the last 10 y e a r s is a n a l y s e d in r e l a t i o n to demographic c h a n g e s , it appears that the quantity of food produced in d e v e l o p i n g countries has increased annually by 2.6 per cent., which barely keeps pace with the population growth. Even more important than the average quantity of food available per caput is its unequal d i s t r i b u t i o n among the d i f f e r e n t socio-economic groups of the p o p u l a t i o n . These facts explain the great m a g n i t u d e of the problem of calorie and p r o t e i n d e f i c i e n c y in the w o r l d . P C M is p r i n c i p a l l y a p r o b l e m of i n f a n t s and y o u n g c h i l d r e n u p to five y e a r s of a g e i n t h e d e v e l o p i n g c o u n t r i e s of t h e w o r l d . Since these countries contain nearly three-quarters of the w o r l d ' s t o t a l p o p u l a t i o n , p r o t e i n m a l n u t r i t i o n is r i g h t l y c o n s i d e r e d a p r o b l e m of global importance. A review of the literature on the p r e v a l e n c e of p r o t e i n - c a l o r i e m a l n u t r i t i o n in y o u n g c h i l d r e n (0-5 y e a r s of a g e ) p r e p a r e d by W H O in 1966 i n d i c a t e d , for the y e a r s 1 9 5 2 - 1 9 6 6 , that the r a n g e of s e v e r e P C M w a s 0 . 1 - 10 p e r c e n t , and t h e r a n g e of m o d e r a t e P C M 4.4 - 57 p e r c e n t , in the 33 community surveys analysed, w h i c h covered 26 c o u n t r i e s . A similar review in 1 9 6 9 for t h e y e a r s 1 9 6 6 - 1 9 6 9 i n c l u d e d s u r v e y s c o n d u c t e d in 24 c o u n t r i e s and g a v e r a n g e s of 0 . 5 - 7.6 p e r c e n t , for severe PCM and 4.4 - 43.1 per c e n t , for m o d e r a t e P C M (Table 1 ) . M o s t o f t h e s u r v e y s i n c l u d e d i n t h e s e t w o r e v i e w s c a n n o t b e c o n s i d e r e d as f u l l y r e p r e s e n t a t i v e of the c o u n t r y i n w h i c h they w e r e carried o u t , b u t their results g i v e at least a rough idea of the e x t e n t of P C M in t h e areas c o n c e r n e d . If o n e a s s u m e s , w h i c h s e e m s r e a s o n a b l e , t h a t on an a v e r a g e t h r e e p e r c e n t , of t h e c h i l d r e n b e t w e e n 0 and 5 y e a r s of a g e . i n d e v e l o p i n g c o u n t r i e s , s u f f e r from s e v e r e p r o t e i n - c a l o r i e m a l n u t r i t i o n and 20 per c e n t , from m o d e r a t e m a l n u t r i t i o n , t h e n u m b e r s i n v o l v e d w o u l d b e a p p r o x i m a t e l y 11 m i l l i o n and 7 6 m i l l i o n respectively. R e g i o n a l d i f f e r e n c e s in t h e p r e v a l e n c e of e a c h of the two e x t r e m e forms of severe PCM (kwashiorkor and m a r a s m u s ) should also be taken into consideration (Table 2 ) . T h e i n t e r - r e l a t i o n s h i p of d i e t a r y factors i n the e t i o l o g y of P C M h a s b e e n s t u d i e d by the 1
Food and Agriculture Organization
(1970) The state of food and a g r i c u l t u r e ,
1970,
Rome • 2 Bengoa, J. M. (1970) Recent trends in the public health malnutrition, W H O Chronicle， 24, 552.
aspects of
protein-calorie
TABLE
Region
1.
PREVALENCE OF SEVERE AND FORMS OF PCM (1966-1969)
N o . of countries
Africa Latin America Asia
Total
TABLE 2.
MODERATE
P e r c e n t a g e of cases Moderate PCM Severe PCM
0.5-7.6
12
0.5-4.1
4.4-32.0
4
1.4-2.9
16.0-43.1
24
0.5-7.6
4.4-43.1
REGIONAL DIFFERENCES
Percentage
.
5.6-27.2
8
IN T H E P A T T E R N O F PCM
of c a s e s c l a s s i f i e d
(HOSPITAL
as:
Country
Percentage of c a s e s less than one year of a g e
kwashiorkor
marasmus
3
97
-
83
Iran
33
66
-
45
Jamaica
32
34
34
52
Jordan
24
15
61
45
55
-
South Africa (Johannesburg)
96
4
-
48
Sudan
92
8
-
50
Thailand
44
46
10
18
Chile
(Santiago)
Senegal
(Dakar)
unspecified
CASES)
Fig. 1 Priorities among nutritional conditions
Feasibility of Prevention
Conditions
Extent
PCM
參
•
•
參
•
參
參
Xerophthalmia
• •
Nutritional Anaemias
Endemic goitre
Social Significance
參.
參
• WHO
High m
Ш "S
二
M
Low
10578
FIG. 2 WEIGHT AND INFECTIOUS D I S E A S E S IN A GUATEMALAN VILLAGE CHILD
S9X ZI 1H0I3Ï
Source ；
Mata»
I — I . , U r r u t i a , J . J . a n d G o r d o n , J . E . ( 1 9 6 7 ), T r o p , g e o g r . M e d . , 19, 2 4 7
1
Joint FAO/WHO Expert Committee on N u t r i t i o n , in its eighth r e p o r t . There has been a t e n d e n c y to o v e r - e m p h a s i z e the i m p o r t a n c e of e i t h e r p r o t e i n or c a l o r i e d e f i c i e n c y a l o n e , w h e r e a s in fact the two almost always occur t o g e t h e r . S e v e r e P C M , if u n t r e a t e d , is f a t a l . Even in c h i l d r e n treated in hospitals the m o r t a l i t y m a y be as h i g h as 4 0 p e r c e n t . Children w h o survive suffer from impaired growth and possibly mental retardation. C h i l d r e n w i t h m i l d and m o d e r a t e PCM grow at a rate lower than n o r m a l . T h e d e g r e e of m a l n u t r i t i o n d i m i n i s h e s as the g r o w i n g c h i l d b e c o m e s c a p a b l e of c o n s u m i n g and assimilating the adult diet. The frequency of d i a r r h o e a l and r e s p i r a t o r y illnesses also d e c r e a s e s as c o m p a r e d w i t h t h e e a r l y y e a r s of c h i l d h o o d . T h e o n s e t of P C M in i n f a n c y and e a r l y c h i l d h o o d is of c o m p l e x e t i o l o g y . Studies supported b y W H O i n d i f f e r e n t c o u n t r i e s of t h e w o r l d , s u c h as G h a n a , G u a t e m a l a , I n d i a , J a m a i c a a n d U g a n d a h a v e p r o v e d b e y o n d d o u b t t h a t p r o t e i n m a l n u t r i t i o n is not‘merely a lack of p r o ^ e ^ n b u t t h a t 9 it is p r e c i p i t a t e d by the i n t e r a c t i o n b e t w e e n i n f e c t i o n and i n s u f f i c i e n t f o o d . Other s t u d i e s suggest that the stage for t h e development of PCM in infants and y o u n g c h i l d r e n is set even before birth. A b r i e f d e s c r i p t i o n of t h e e v e n t s l e a d i n g to P C M is n e c e s s a r y in o r d e r to u n d e r s t a n d its n a t u r a l h i s t o r y and to a p p r e c i a t e the c o m p l e x i t y of the p r o b l e m of its prevention. T h e average b i r t h - w e i g h t of infants in m a n y d e v e l o p i n g c o u n t r i e s is lower than d e v e l o p e d c o u n t r i e s , and t h e r e are reasons to b e l i e v e that the d i f f e r e n c e is not of o r i g i n , b u t that an i m p o r t a n t c a u s e is m a t e r n a l m a l n u t r i t i o n . In years. the age p o o r in weaning
in genetic
r u r a l a r e a s in d e v e l o p i n g c o u n t r i e s , c h i l d r e n are b r e a s t - f e d u p to the a g e of two H o w e v e r , the a m o u n t of b r e a s t m i l k b e c o m e s i n s u f f i c i e n t for the i n f a n t ' s n e e d s at of a b o u t f i v e m o n t h s . The supplementary foods then added to the diet are very often p r o t e i n and g i v e n in i n s u f f i c i e n t q u a n t i t y , o w i n g to t h e u n a v a i l a b i l i t y of a p p r o p r i a t e foods or to the lack of m o n e y to buy those a v a i l a b l e .
In u r b a n a r e a s i n d e v e l o p i n g c o u n t r i e s t h e s i t u a t i o n i s d i f f e r e n t . The breast-feeding period is becoming shorter and shorter and infants are b o t t l e - f e d with over-diluted m i l k p r e p a r a t i o n s in very unhygienic c o n d i t i o n s . M a n y i n f a n t s s u f f e r f r o m r e p e a t e d a t t a c k s of d i a r r h o e a b e t w e e n the ages of s i x and 24 m o n t h s . ‘ T h e y are also l i a b l e to s u f f e r from other c o m m o n d i s e a s e s such as m e a s l e s , w h o o p i n g cough and acute respiratory infections. It h a s b e e n e s t i m a t e d t h a t in d e v e l o p i n g c o u n t r i e s a c h i l d u p to t w o y e a r s of age is i l l for a b o u t 3 0 p e r c e n t , of t h e t i m e . An illustration of t h i s , not r a r e in d e v e l o p i n g c o u n t r i e s , is g i v e n in F i g . 2 . D u r i n g acute e p i s o d e s of i n f e c t i o n and c o n v a l e s c e n c e the feeding of i n f a n t s is e v e n restricted qualitatively and quantitatively than at other times, and this leads to the a g g r a v a t i o n of m a l n u t r i t i o n .
more
It s h o u l d t h u s b e c l e a r t h a t t h e r e a r e two e l e m e n t s in t h e d e v e l o p m e n t of s e v e r e and m o d e r a t e m a l n u t r i t i o n in infants and young c h i l d r e n . O n e is t h e d e f i c i e n c y of c a l o r i e s , p r o t e i n and some other essential nutrients and the s e c o n d , equally i m p o r t a n t , is infection and its effects. T h e a t t a c k o n the p r o b l e m of P C M h a s t h e r e f o r e to b e in t w o d i r e c t i o n s at o n c e . F i r s t , feeding d u r i n g w e a n i n g and for two years t h e r e a f t e r h a s to be improved in o r d e r to e n s u r e that c h i l d r e n receive adequate amounts of nutritious f o o d . Second, health conditions have to be so i m p r o v e d that the risk of i n f e c t i o n is r e d u c e d to a m i n i m u m . 1
Joint F A O / W H O Expert C o m m i t t e e on N u t r i t i o n , eighth r e p o r t , Wld Hlth O r g , techn. R e p ,
1971, No.
Ser,
477.
2 N u t r i t i o n and i n f e c t i o n , r e p o r t of a W H O Expert C o m m i t t e e , W l d H l t h O r g , t e c h n . R e p . 1965, No. 314. 3 S c r i m s h a w , N . S . , T a y l o r , С. E . & G o r d o n , J . E . ( 1 9 6 8 ) I n t e r a c t i o n s o f n u t r i t i o n a n d infection, WHO Monograph Series No. 57.
Ser.,
and and
P C M is o f t e n a s s o c i a t e d w i t h o t h e r n u t r i t i o n a l d e f i c i e n c i e s s u c h as a n a e m i a d u e to i r o n f o l a t e d e f i c i e n c y , x e r o p h t h a l m i a , and k e r a t o m a l a c i a resulting from vitamin A deficiency ariboflavinosis.
E v i d e n c e h a s b e e n a c c u m u l a t i n g i n r e c e n t y e a r s that m a l n u t r i t i o n in the f i r s t y e a r of l i f e , if s e v e r e enough to retard p h y s i c a l g r o w t h m a r k e d l y , m a y c a u s e m e n t a l i m p a i r m e n t . If the d e p r i v a t i o n is s e v e r e and p r o l o n g e d and o c c u r s d u r i n g the first m o n t h s of life, r e t a r d a t i o n of b r a i n d e v e l o p m e n t and f u n c t i o n m a y be so s e v e r e that it c a n n o t be c o m p l e t e l y c u r e d by nutritional rehabilitation. Many non-nutritional factors also influence mental development. At present there are n o t e n o u g h d a t a to i d e n t i f y the p a r t i c u l a r c o n t r i b u t i o n s of n u t r i t i o n a l and n o n - n u t r i t i o n a l f a c t o r s t o d e f e c t i v e m e n t a l functions、：following m a l n u t r i t i o n . B o t h t y p e s of f a c t o r p r o b a b l y have effects that are independent but that interreact.^ It is n o t n e c e s s a r y to u n d e r l i n e the g r e a t s o c i a l s i g n i f i c a n c e of this p r o b l e m , w h i c h deserves further s t u d y . T h e p r i m a r y c a u s e s of P C M c a n o n l y be o v e r c o m e by g e n e r a l e c o n o m i c and s o c i a l d e v e l o p m e n t and a co-ordinated approach in agriculture, education, social services and public h e a l t h . T h e r e is n o s i m p l e s o l u t i o n to the problem of PCM; many approaches have to be explored t o m e e t t h e r e q u i r e m e n t s of d i f f e r e n t c o u n t r i e s and of r u r a l and u r b a n a r e a s . More costb e n e f i t s t u d i e s are n e e d e d of the d i f f e r e n t m e a s u r e s a v a i l a b l e . N e v e r t h e l e s s , it is at p r e s e n t p o s s i b l e to i m p l e m e n t a s e r i e s o f a c t i v i t i e s i n t h e h e a l t h s e c t o r w h i c h w i l l p e r m i t a t l e a s t to r e d u c e t h e m o r t a l i t y and the l a s t i n g e f f e c t s of P C M . T h e s e a c t i v i t i e s , w h i c h c o u l d form part of a c o m p r e h e n s i v e p r e v e n t i v e p r o g r a m m e , are s e t o u t i n T a b l e 3, w h i c h is b a s e d o n t h e r e p o r t of the r e c e n t J o i n t F A O / W H O E x p e r t C o m m i t t e e o n Nutrition.1 It s h o u l d b e s t r e s s e d t h a t t h r e e m a i n c o m p o n e n t s s h o u l d b e t h e b a s i s o f M C H a c t i v i t i e s in the c o n t r o l of P C M , namely: -nutrition -control -family 1•2
of i n f e c t i o u s
diseases
planning.
Xerophthalmia
The c l i n i c a l l y d e m o n s t r a b l e signs of vitamin A d e f i c i e n c y in m a n are u s u a l l y designated as xerophthalmia. Vitamin A deficiency affects mainly infants and young children. Its i m p o r t a n c e as a p u b l i c h e a l t h p r o b l e m h a s b e e n u n d e r l i n e d in s e v e r a l of the r e p o r t s of the J o i n t F A O / W H O Expert C o m m i t t e e on N u t r i t i o n , and in the second of these reports it was r e c o m m e n d e d that a s u r v e y of the p r o b l e m of n u t r i t i o n a l d i s o r d e r s of the e y e be c a r r i e d o u t in d i f f e r e n t p a r t s of the w o r l d . In 1 9 6 2 and 1 9 6 3 t h r e e c o n s u l t a n t s w e r e r e c r u i t e d t o v i s i t s e v e r a l c o u n t r i e s of South and E a s t A s i a , W e s t A s i a , countries in A f r i c a bordering on the Sahara and Latin America. E v i d e n c e of the e x t e n t of the p r o b l e m w a s s o u g h t by v i s i t s to h e a l t h d e p a r t m e n t s , h o s p i t a l s , institutions for the blind and o p h t h a l m o l o g i s t s , examination of r e p r e s e n t a t i v e g r o u p s of c h i l d r e n , e v a l u a t i o n of n u t r i t i o n s u r v e y s and c e n s u s e s , e t c . The information collected was thought sufficiently complete to show that vitamin A deficiency c o n t r i b u t e s s i g n i f i c a n t l y to b l i n d n e s s in B r a z i l , C a m b o d i a , C e y l o n , E g y p t , El S a l v a d o r , H a i t i , India, Indonesia, J o r d a n , L i b y a , P a k i s t a n , S u d a n , Syrian A r a b R e p u b l i c , U n i t e d Republic of Tanzania and Viet-Nam.
1
Joint FAO/WHO Expert Committee
S e r ” 1971, No.
477.
o n N u t r i t i o n , E i g h t h r e p o r t , W l d H l t h O r g , t e c h n . Яер.
TABLE 3. L e v e l s of I
II
OBJECTIVES AND ACTIVITIES
intervention
GENERAL
IN T H E C O N T R O L OF PCM
T o e s t a b l i s h a food and n u t r i t i o n p o l i c y , to d e v e l o p a g r i c u l t u r e , to expand e d u c a t i o n , to i m p r o v e e n v i r o n m e n t a l s a n i t a t i o n , and to r a i s e s t a n d a r d s of l i v i n g .
Health
promotion
protection
(a) Improvement of nutrition or maintenance of nutritional status
(b) Control of infectious diarrhoeal diseases
(c) M i n i m i z i n g the effects infectious diseases
and
of
Establishment of an i n t e r m i n i s t e r i a l food and nutrition board Food production programmes, including developm e n t of agricultural i n d u s t r i e s Fundamental education Socio-economic measures directed towards the less privileged g r o u p s , and the d e v e l o p m e n t of opportunities for employment Policies on food prices and m i n i m u m w a g e s 1. Measures directed towards pregnant and lactating women (education, d i s t r i b u t i o n of supplements, etc.) 2. Promotion of breast feeding 3• D e v e l o p m e n t of low-cost w e a n i n g foods 4. M e a s u r e s to improve family d i e t s , i n c l u d i n g food d i s t r i b u t i o n p r o g r a m m e s 5. Education on n u t r i t i o n , in c o - o p e r a t i o n w i t h h e a l t h and a g r i c u l t u r a l e x t e n s i o n s e r v i c e s , s c h o o l s , and social and h o m e e c o n o m i c s services 6. Expansion of immunization p r o g r a m m e s 7. Promotion of h y g i e n i c food p r e p a r a t i o n and personal hygiene 8. Promotion and p r o v i s i o n of m o r e s u i t a b l e domestic utensils for the preparation of infant foods and for feeding i n f a n t s . 9. D e v e l o p m e n t of p r o g r a m m e s for the e a r l y rehydration of young children w i t h d i a r r h o e a 10. Development of supplementary feeding programmes during epidemics 11.
Treatment and
rehabilitation
CHILDREN Activities
Objectives
SPECIFIC
Health
IN Y O U N G
De-worming of heavily
infested
P e r i o d i c s u r v e i l l a n c e of risk
the
children
population
(e) Improved treatment and early and c o m p l e t e r e h a b i l i t a t i o n , of moderate and severe cases of malnutrition
13. A m b u l a t o r y t r e a t m e n t ； n u t r i t i o n a l rehabilitation services 14. Hospital treatment 15. Follow-up care, through supplementary feeding and nutrition education
Его办9/3〇
12. at
раоче 7
(d) Early detection and managem e n t of m i l d cases of m a l n u t r i t i o n
A t the end of 1963 an e p i d e m i o l o g i c a l study w a s set u p in Jordan by W H O . It i n c l u d e d a f i e l d i n v e s t i g a t i o n and a s t u d y of p a t i e n t s a d m i t t e d to a h o s p i t a l for x e r o p h t h a l m i a . A total of 1180 c h i l d r e n u n d e r s i x years of age w e r e s u r v e y e d . A p r e v a l e n c e of e i g h t per c e n t , of m i l d to m o d e r a t e x e r o p h t h a l m i a w a s found in the c h i l d r e n e x a m i n e d , the peak i n c i d e n c e b e i n g b e t w e e n 30 and 40 m o n t h s of age; this probably indicates that the infants were born w i t h low vitamin A reserves. In a s u r v e y c a r r i e d o u t o v e r a 1 0 - y e a r p e r i o d in o n e e y e h o s p i t a l i n E a s t J a v a , I n d o n e s i a ( 1 9 5 8 - 1 9 6 8 ) , x e r o p h t h a l m i a w a s f o u n d to b e the c a u s e of b l i n d n e s s in 5 0 to 60 c e n t , of the cases among p r e s c h o o l c h i l d r e n .
per
A p o p u l a t i o n i s c o n s i d e r e d a t r i s k o f d e v e l o p i n g v i t a m i n A d e f i c i e n c y w h e n 15 p e r c e n t , or m o r e of the individuals have serum values less than 20 mcg/lOO m l , or five per c e n t , or 1 m o r e less than 10 mcg/lOO m l . P e r s o n s w i t h less than this last v a l u e are likely to h a v e s i g n i f i c a n t l y d e p e l e t e d l i v e r s t o r e s and c a n b e c o n s i d e r e d as p o t e n t i a l c l i n i c a l c a s e s . WHO has also undertaken some research, particularly related xerophthalmia.
to the prevention
of
A n E x p e r t G r o u p on Hypovitarainosis A w a s c o n v e n e d in the A m e r i c a n R e g i o n in 1968 to p r o p o s e recommendations for preventive programmes. The Group recommended t h a t 1 0 0 0 0 0 IU o f w a t e r m i s c i b l e v i t a m i n A be a d m i n i s t e r e d o r a l l y once to four times a y e a r for at least two years to all p r e s c h o o l c h i l d r e n from the third m o n t h of life o n w a r d s i n areas w h e r e a v i t a m i n o s i s A is a public health problem. The Group also suggested that lactating women be given one oral d o s e o f 1 0 0 0 0 0 IU o f w a t e r - m i s c i b l e v i t a m i n A i m m e d i a t e l y a f t e r d e l i v e r y t o p r o t e c t t h e c h i l d d u r i n g the first w e e k s of l i f e . H i g h e r d o s e s of v i t a m i n A are a d m i n i s t e r e d at p r e s e n t in I n d i a , and it is p r o b a b l e that W H O w i l l c o n v e n e a n o t h e r c o n s u l t a t i v e g r o u p i n t h e S o u t h E a s t A s i a R e g i o n i n 1 9 7 2 to r e v i e w the p r e s e n t situation of the p r e v e n t i o n p r o g r a m m e . A n i m p o r t a n t c o n t r i b u t i o n from t h e I n s t i t u t e of N u t r i t i o n of C e n t r a l A m e r i c a and P a n a m a ( I N C A P ) to the p r e v e n t i o n of x e r o p h t h a l m i a is a s t u d y s h o w i n g t h e f e a s i b i l i t y of f o r t i f i c a t i o n of s u g a r w i t h v i t a m i n A . I t i s o b v i o u s t h a t , t o o b t a i n an i d e a l a n d l a s t i n g s o l u t i o n o f t h e p r o b l e m , t h e s e m e a s u r e s should be c o m p l e m e n t e d by changes in the p a t t e r n of a g r i c u l t u r a l p r o d u c t i o n and appropriate educational efforts. 1•3
Nutritional
Megaloblastic
by
anaemias
anaemias
N u t r i t i o n a l m e g a l o b l a s t i c anaemia is u s u a l l y d u e to an i n s u f f i c i e n t i n t a k e of f o l a t e . L i t t l e p r e c i s e i n f o r m a t i o n is available on the i n c i d e n c e of m e g a l o b l a s t i c anaemia in developing countries; n e v e r t h e l e s s , in some areas of India, for i n s t a n c e , it has b e e n shown that m e g a l o b l a s t i c anaemia affects 20 to 50 p e r c e n t , of p r e g n a n t w o m e n a t t e n d i n g h o s p i t a l c l i n i c s . Iron-deficiency
anaemia
Of the various c r i t e r i a for i r o n - d e f i c i e n c y a n a e m i a , the m e a s u r e m e n t of the h a e m o g l o b i n c o n c e n t r a t i o n in the b l o o d is the one m o s t f r e q u e n t l y u s e d in p r e v a l e n c e s t u d i e s . Informat i o n c o l l e c t e d from s u c h s t u d i e s and from n u t r i t i o n s u r v e y s in d i f f e r e n t p a r t s of t h e w o r l d • 2 shows how widely prevalent iron-deficiency anaemia is. 1
P A H O / W H O E x p e r t G r o u p o n H y p o v i t a m i n o s i s A i n t h e A m e r i c a s , R e p o r t , W a s h i n g t o n , РАНО
Scientific Publication N o . 198,
1970.
2 Nutritional 1968, No.
405.
a n a e m i a s , R e p o r t o f a W H O S c i e n t i f i c Groujb.
Wld Hlth Org, techn. Rep,
Ser,,
I n A f r i c a 6 t o 17 p e r c e n t , o f m e n a n d 1 5 t o 5 0 p e r c e n t , o f w o m e n ( B a n t u s o f Africa excepted) have been found iron-deficient. In c h i l d r e n u p t o t h e a g e of 15 frequency of anaemia varies between 30 per c e n t , and 60 p e r c e n t , and still h i g h e r h a v e b e e n r e c o r d e d in c h i l d r e n b e l o w the age of s e v e n .
South the figures
In S o u t h A m e r i c a ， w h e r e s e v e r a l s u r v e y s h a v e b e e n c o n d u c t e d r e c e n t l y , t h e p r e v a l e n c e i s e s t i m a t e d to r a n g e f r o m 5 p e r c e n t , to 15 p e r c e n t , f o ç m e n and f r o m 1 0 p e r c e n t , t o 35 p e r cent, for women. T h e p e r c e n t a g e of c h i l d r e n r e p o r t e d as a n a e m i c v a r i e s b e t w e e n 15 p e r c e n t , and 5 0 p e r c e n t , in m o s t of the s t u d i e s , w h e r e a s it r a n g e s from 15 p e r c e n t , to 4 0 p e r c e n t , in samples from the g e n e r a l p o p u l a t i o n (all c a t e g o r i e s and age groups taken t o g e t h e r ) , the highest values being found in hookworm-infected areas. The prevalence of iron-deficiency anaemia has also been estimated at about 20 per in N o r t h A m e r i c a , m a i n l y among the poorest sections of the p o p u l a t i o n .
cent.
In A s i a , a b o u t 10 p e r c e n t , of m e n s u f f e r f r o m i r o n - d e f i c i e n c y a n a e m i a , w h e r e a s i n w o m e n the p r e v a l e n c e i s m o r e t h a n 2 0 p e r c e n t ” and as h i g h as 4 0 p e r c e n t , in p r e g n a n c y . In c h i l d r e n , s e v e r a l s u r v e y s i n d i c a t e a p r e v a l e n c e of a b o v e 5 0 p e r c e n t , a n d t h e e x t r e m e l y h i g h f i g u r e of 92 p e r c e n t , h a s b e e n r e p o r t e d in c h i l d r e n b e l o w two y e a r s of a g e . In the M i d d l e E a s t , 25 to 7 0 p e r c e n t , of c h i l d r e n and about 2 0 to 25 p e r c e n t , of p r e g n a n t w o m e n have been found to have low haemoglobin levels. In E u r o p e , t h e p r e v a l e n c e a m o n g w o m e n seems to b e s o m e w h e r e b e t w e e n 10 p e r c e n t , and 25 p e r cent.； c a r e f u l s t u d i e s c a r r i e d o u t i n S c a n d i n a v i a h a v e s h o w n t h a t 3 t o 6 p e r c e n t , of adult males are i r o n - d e f i c i e n t . In a l l c o u n t r i e s , p r e g n a n t w o m e n a n d i n f a n t s b e t w e e n s i x a n d 1 8 m o n t h s o f a g e a p p e a r to b e t h e m a i n g r o u p s at r i s k . In W H O - s p o n s o r e d s t u d i e s i n d i f f e r e n t p a r t s of t h e w o r l d , the p e r c e n t a g e of p r e g n a n t w o m e n w i t h a n a e m i a r a n g e d f r o m 21 p e r c e n t , to 8 0 p e r c e n t , and the p e r c e n t a g e w i t h iron d e f i c i e n c y w a s s t i l l h i g h e r (40 p e r c e n t , to 99 p e r c e n t . ) w h e n s a t u r a t i o n of t r a n s f e r r i n b e l o w 15 p e r c e n t , w a s u s e d as a c r i t e r i o n f o r t h e d e f i c i e n c y . T h e p r e v e n t i o n of n u t r i t i o n a l a n a e m i a s is n o t an e a s y u n d e r t a k i n g . of action are discussed in the section dealing w i t h r e s e a r c h . 1.4
Endemic
The
possibilities
goitre
Endemic goitre is a deficiency disease which occurs in people of all a g e s . The largest goitres and the m o s t serious complications are commonly found in adults, but the p a t h o l o g i c a l changes begin in childhood. Iodine deficiency constitutes the m a i n etiological factor of endemic goitre, but goitrogenic substances and genetic factors m a y also play a r o l e . Endemic goitre affects m o s t of the d e v e l o p i n g countries, but its p r e v a l e n c e considerably, both between and within countries.
varies
A l t h o u g h the m e t h o d s for the p r e v e n t i o n of e n d e m i c g o i t r e h a v e b e e n k n o w n for s e v e r a l d e c a d e s , the interest of governments in setting up national p r e v e n t i v e programmes is 1 relatively recent. WHO published a monograph on endemic goitre in 1960 and recently two 2 seminars have been held, in A M R O and S E A H O ^ r e s p e c t i v e l y , to d r a w the a t t e n t i o n of g o v e r n m e n t s a g a i n to t h i s p u b l i c h e a l t h p r o b l e m . In r e c e n t y e a r s РАНО h a s d e v e l o p e d a g o i t r e c o n t r o l and r e s e a r c h p r o g r a m m e i n L a t i n A m e r i c a . The whole problem of endemic g o i t r e and its prevention were extensively studied by a Scientific Group in 1969.^ 1
World
Health Organization
(1961) Endemic
. g o i t r e , W l d H l t h O r g . M o n o g r . Ser.， 44•
2
/ • S e m i n a r i o sobre y o d i z a c i o n d e la sal p a r a p r e v e n c i ó n d e l b o c i o e n d e m i c o , S a l t a , Argentina, 21-26 de junio de 1965, Informe final, Washington, Pan American Health Organization. 3
R e p o r t of a s e m i n a r on g o i t r e c o n t r o l , N e w D e l h i , 3 0 O c t o b e r - 4 N o v e m b e r
Delhi, World Health Organization
Regional Office for South-East
Asia.
1967,
New
B e s i d e s t h e c l a s s i c a l p r o g r a m m e s of s a l t i o d i z a t i o n w h i c h h a v e b e e n w i d e l y u s e d in t h e c o n t r o l of endemic g o i t r e , iodized oil has been used in some countries on an e x p e r i m e n t a l s c a l e w h e n s a l t i o d i z a t i o n p r o v e d to b e u n p r a c t i c a l . Assistance has been provided for the e s t a b l i s h m e n t of a r e f e r e n c e laboratory and training c e n t r e for iodine d e t e r m i n a t i o n s in endemic goitre prophylaxis in Santiago, Chile. 1•5
Other nutritional
conditions
R i c k e t s does not r e p r e s e n t a m a j o r p u b l i c health problem in m o s t countries of the w o r l d , o w i n g to t h e w i d e s p r e a d u s e of v i t a m i n D f o r p r e v e n t i o n and t r e a t m e n t . However, severe forms of rickets are common in certain countries, particularly in the Middle East and North о Africa. In 1 9 6 5 , s u r v e y s u n d e r t a k e n w i t h W H O a s s i s t a n c e p r o d u c e d e v i d e n c e of s e r i o u s r i c k e t s i n c h i l d r e n b e t w e e n t h r e e a n d 18 m o n t h s (3 p e r c e n t , t o 1 0 p e r c e n t . ) i n N o r t h A f r i c a . S c u r v y is now v e r y r a r e , but m i l d v i t a m i n С d e f i c i e n c y is still f r e q u e n t limited areas.
seasonally
in
P e l l a g r a p e r s i s t s in s o m e v u l n e r a b l e g r o u p s such as p r e g n a n t w o m e n , t o d d l e r s , and p a t i e n t s with tuberculosis. It i s o f t e n f o u n d i n a s s o c i a t i o n w i t h a h i g h a l c o h o l c o n s u m p t i o n i n m a i z e eating countries.
some
Beri-beri in adults has almost disappeared, but infantile beri-beri is still reported areas in A s i a .
in
F i n a l l y , o t h e r n u t r i t i o n c o n d i t i o n s such as l a c t a s e d e f i c i e n c y , f a v i s m , and o b e s i t y m a y h a v e a p u b l i c health s i g n i f i c a n c e in certain c o u n t r i e s . The epidemiological aspects and n u t r i t i o n a l i m p l i c a t i o n s of these c o n d i t i o n s d e s e r v e further s t u d y . 1.6 In s u m m a r y , d e v e l o p i n g c o u n t r i e s a r e a t p r e s e n t c o n f r o n t e d w i t h a g r o u p o f s e r i o u s nutritional problems. T h e r e are no i n d i c a t i o n s that as a w h o l e m a l n u t r i t i o n in y o u n g children (particularly PCM) has much improved during the past 20 years. The fall in mortality in y o u n g c h i l d r e n is n o t i n i t s e l f a g o o d i n d i c a t o r of i m p r o v e m e n t in n u t r i t i o n ; it is p r o b a b l y m o r e d u e to some specific public h e a l t h action and m e d i c a l care than to any s i g n i f i c a n t i m p r o v e m e n t s i n the s t a n d a r d of l i v i n g . In t h e a d v a n c e d c o u n t r i e s , 3 0 o r 4 0 y e a r s a g o t h e f a l l in m o r t a l i t y w a s r e l a t i v e l y s l o w , b u t the d e c l i n e w a s p r o b a b l y d u e m o r e to the r a i s i n g of s t a n d a r d s of living than to public h e a l t h a c t i o n . ^ W h i l e , as far as m o r t a l i t y rates are c o n c e r n e d , t h e g a p b e t w e e n t h e d e v e l o p e d and t h e d e v e l o p i n g c o u n t r i e s is n a r r o w i n g , t h e g a p b e t w e e n s t a n d a r d s of l i v i n g d o e s n o t f o l l o w the same trend and seems d e s t i n e d to grow w i d e r . H o w e v e r , it cannot be denied that there h a v e been some positive g a i n s . Mention should b e m a d e of the virutal e r a d i c a t i o n of some d e f i c i e n c y diseases such as s c u r v y , p e l l a g r a and beri-beri; the i n c r e a s i n g c o n t r o l of s o m e c o m m u n i c a b l e d i s e a s e s that are i m p o r t a n t f a c t o r s in p r e c i p i t a t i n g severe m a l n u t r i t i o n , e . g . , m e a s l e s and malaria； a n d , in p a r t i c u l a r , the awaren e s s a t h i g h p o l i t i c a l l e v e l s and in p u b l i c o p i n i o n of the s e r i o u s n e s s of the s i t u a t i o n , w h i c h p r o b a b l y m e a n s that m o r e r e s o u r c e s w i l l b e d e v o t e d to s o l v i n g p r o b l e m s of n u t r i t i o n in the future. T h e r e c e n t d i s c u s s i o n s at the E c o n o m i c and S o c i a l C o u n c i l and G e n e r a l A s s e m b l y of t h e U n i t e d N a t i o n s o n t h e p r o t e i n c r i s i s i n d i c a t e t h e p r e s e n t i n t e r e s t o f a l l g o v e r n m e n t s in the proper n u t r i t i o n of their growing p o p u l a t i o n s . 1
Pan American Health Organization
Publication, No.
(1969) Endemic goitre, Washington
(Scientific
193).
2
Joint FAO/WHO Expert Committee on Nutrition, Seventh Report (1967) Wld Hlth O r g , techn. Rep. Ser,, N o . 377; FAO Nutrition Meetings Report Series, No. 42. 3
B e n g o a , J . M . ( 1 9 7 1 ) N u t r i t i o n a l s i g n i f i c a n c e of m o r t a l i t y s t a t i s t i c s . In: Proceedings o f W e s t e r n H e m i s p h e r e N u t r i t i o n C o n g r e s s I I I , M i a m i B e a c h , F l o r i d a , 1 9 7 1 (in p r e s s ) .
2.
WHO ASSISTANCE
IN T H E F I E L D O F
NUTRITION
W H O h a s very s p e c i f i c r e s p o n s i b i l i t i e s in the field of n u t r i t i o n . Because of the extent of t h e p r o b l e m of m a l n u t r i t i o n , W H O a s s i s t a n c e , w h i c h is m a i n l y r e l a t e d to a c t i v i t i e s c o m i n g u n d e r the r e s p o n s i b i l i t y of h e a l t h services, is c l o s e l y c o - o r d i n a t e d w i t h the w o r k of o t h e r i n t e r n a t i o n a l o r g a n i z a t i o n s , in p a r t i c u l a r FAO and U N I C E F . R e q u e s t s from g o v e r n m e n t s to W H O for a s s i s t a n c e in the field of n u t r i t i o n c o v e r main areas : 2•1
Assessment
of n u t r i t i o n a l
status and epidemiological
three
studies
The main methods used are anthropometry, clinical examination and biochemistry, within the c u l t u r a l a n d s o c i o - e c o n o m i c context of the p o p u l a t i o n . They are usually c o m p l e m e n t ed by food c o n s u m p t i o n s u r v e y s c o n d u c t e d w i t h the c o - o p e r a t i o n of F A O . Some standardization of methods has been obtained
following two WHO
publications.
1,2
During the last few years further advances have been made which will permit comparative studies among different countries and systematic surveillance of the population. WHO has already standardized for computer processing the forms used in a n t h r o p o m e t r i c studies• It will also standardize the forms and codes used in other surveys. A successful attempt at doing this has already been made in East Africa by WHO staff. In N o v e m b e r 1971 a m e e t i n g o r g a n i z e d by P A H O / W H O t o o k p l a c e in B u e n o s A i r e s discuss this subject.3 It w i l l b e f o l l o w e d b y t r i a l s i n t h e f i e l d .
in order
to
During the past six years, W H O has provided assistance for nutrition surveys to about 2 0 countries and in six of them (Brazil, Cambodia, Kenya, Libya, Madagascar and P a k i s t a n ) WHO h a s h e l p e d in setting u p laboratories of n u t r i t i o n b i o c h e m i s t r y . In a d d i t i o n to the overall a s s e s s m e n t of n u t r i t i o n a l status, g o v e r n m e n t s request W H O a s s i s t a n c e for specific conditions, in p a r t i c u l a r for endemic g o i t r e . During recent years, assistance has been provided to Burma, Ecuador, Fiji, Ghana, Indonesia, Iraq, Kenya, Malaysia, Nepal, Philippines and Thailand. I n s u c h cases, W H O assistance is provided through shortterm consultants. 2.2
A s s i s t a n c e in the o r g a n i z a t i o n of services and of preventive This covers a series of activities which vary according Such activities can be grouped under two main
programmes
to local
conditions.
headings:
1
World Health Organization (1963) Expert Committee on Medical Assessment Status, Wld Hlth Org, techn. Rep. S e r ” No. 258.
of
Nutritional
2 Jelliffe, D . B . (1966) The Assessment Geneva, Wld Hlth Org. Monogr, Ser., N o . 53.
of the N u t r i t i o n a l Status of the
Community,
3 PAHO/WHO Standardizing Methodology and Computer Analysis Status, Buenos Aires, Argentina, November 1971.
for A s s e s s i n g
Nutritional
2.2.1
Integration
of nutrition activities
in b a s i c h e a l t h
services
1
During a meeting of W H O regional nutrition a d v i s e r s special attention was given to this topic. It w a s felt t h a t i n t e g r a t i o n s h o u l d b e a c h i e v e d at t h e l o c a l l e v e l , t a k i n g i n t o account the population to be covered and the resources available. H o w e v e r , it w a s a l s o felt t h a t in g e n e r a l t e r m s it w o u l d b e p o s s i b l e t o d i s t i n g u i s h t h r e e l e v e l s of n u t r i t i o n programmes： minimum, medium and optimum. T a b l e 4 summarizes the type of a c t i v i t i e s at each l e v e l . The a c t i v i t i e s h a v e to be adapted to local conditions, but the m a i n principle is to integrate n u t r i t i o n a c t i v i t i e s w i t h i n the routine b a s i c h e a l t h services and not to o r g a n i z e i n d e p e n d e n t activities. T h e s u b j e c t w a s a l s o d i s c u s s e d i n РАНО a n d w i l l b e t h e t o p i c o f a s e m i n a r t o b e o r g a n i z e d b y A F R O in 1972. W H O a s s i s t a n c e h a s b e e n provided recently in this field to Algeria, Brazil, Columbia, the Dominican Republic, Ecuador, Haiti, Kenya, the Libyan Arab R e p u b l i c , M a l a y s i a , Peru, the U n i t e d Republic of T a n z a n i a , V e n e z u e l a and Z a i r e . O n e of the m o s t satisfactory developments in recent y e a r s h a s b e e n the setting u p of a n u t r i t i o n u n i t in p r a c t i c a l l y all the m i n i s t r i e s of h e a l t h in developing c o u n t r i e s with the assistance of W H O . T h e c o m p o s i t i o n of such units varies from country to country, but in m o s t cases they are h e a d e d by a m e d i c a l nutritionist trained by W H O . The units are responsible for the d e v e l o p m e n t of n u t r i t i o n activities in the health sector in c o - o r d i n a t i o n with the other ministries concerned. W H O h a s a l s o p r o v i d e d a s s i s t a n c e to about 15 c o u n t r i e s for the e s t a b l i s h m e n t of n u t r i t i o n 4 rehabilitation centres J， T h e s e c e n t r e s a i m at t h e r e h a b i l i t a t i o n , at low c o s t , of c h i l d r e n suffering from second and third degree malnutrition and at the nutritional education of mothers They are integrated in basic health services. 2.2.2
National
food and nutrition
policies
T h e b a s e s f o r t h e h i g h p r i o r i t y 油ich W H O , F A O a n d U N I C E F g i v e t o t h e e s t a b l i s h m e n t n a t i o n a l f o o d a n d n u t r i t i o n p o l i c i e s are： (a) the recognition development, and
of the impact of n u t r i t i o n a l problems on social and
of
economic
(b) the fact that the causal factors of nutritional problems are economic, agricultural, health and educational; this r e q u i r i n g a j o i n t a p p r o a c h t o t h e p l a n n i n g and e x e c u t i o n of food and nutrition policies. M o s t national programmes aim at increasing or improving food production and consumption. T w o m a i n f a c t o r s p r e v e n t success： (1) the lack of a clear formulation and a biological o r i e n t a t i o n of n a t i o n a l f o o d and n u t r i t i o n p o l i c i e s , a n d (2) t h e l a c k of c o - o r d i n a t i o n in a l l phases of the programmes.
1
M e e t i n g of R e g i o n a l A d v i s e r s in N u t r i t i o n , G e n e v a ,
document
9-19 June 1970.
Report.
WHO
NUTR/70.8.
о РАНО T e c h n i c a l C o n f e r e n c e 17-21 June, 3 4
1968.
on Nutrition Activities
РАНО S c i e n t i f i c P u b l i c a t i o n N o . 1 7 9 ,
Bengoa, J. M .
(1967) Nutrition Rehabilitation
a practical guide to combating malnutrition
working conference
on nutritional
Appleton-Century-Crofts,
New York,
rehabilitation 1970.
in Local H e a l t h Services,
Washington,
1969.
Centres, J. Trop. Ped.,
in the preschool
or mothercraft
child.
13,
169.
Report of
centers, Bogota, March
a 1C69.
TABLE 4.
MINIMUM
NUTRITIONAL ACTIVITIES
PROGRAMME
IN P E R I P H E R A L B A S I C H E A L T H
MEDIUM
PROGRAMME
SERVICES
O P T I M U M PROGRAMME
Nutritional surveillance
Clinic： o b s e r v a t i o n of PCM w e i g h t for a g e c l a s s i f i c a t i o n ( u n d e r 5) H o m e v i s i t s : o b s e r v a t i o n of PCM or: c h e c k for s i g n s of l o c a l l y m o s t i m p o r t a n t d e f i c i e n c y (for i n s t a n c e v i t a m i n A ) and t r e a t
C l i n i c : w e i g h t for a g e serial records Home visits: o b s e r v a t i o n of PCM, follow-up C h e c k for s i g n s of o t h e r
Additional: P e r i o d i c s c r e e n i n g o f pre一school p o p u l a t i o n w e i g h t for a g e r e c o r d s S c r e e n i n g for H b of m o t h e r s a n d i n f a n t s S c r e e n i n g for x e r o p h t h a l m i a a n d o t h e r d e f i c i e n c y c o n d i t i o n s k n o w n t o b e of h e a l t h importance locally D i e t a r y h i s t o r i e s of v u l n e r a b l e g r o u p s ?
Nutrition education
A d v i s e m o t h e r s (ad h o c ) on supplementary feeding and weaning, especially quantities and frequencies If n o n - c e r e a l s t a p l e , a d v i s e on local protein sources (advise on g r e e n s )
Additional: a d v i s e m o t h e r s on c o m p l e m e n tary f o o d s , a m o u n t s a n d preparation
Additional : advise mothers routinely on principles of child feeding and diets during pregnancy and lactation at clinic and home visits
C o n t r o l of infectious diseases
I m m u n i z a t i o n of c h i l d r e n a t clinic whenever possible A d v i s e on food a n d fluid intake during infectious events, especially d i a r r h o e a - a d v i s e on s a n i t a tion in t h e h o m e e s p e c i a l l y for infant food; c h e c k any recent deaths
I m m u n i z a t i o n of a l l c h i l d r e n that c a n b e r e a c h e d Simple oral rehydration s e r v i c e , a l s o for h o m e u s ©
Full immunization programmes, home sanitation Oral and intragastric rehydration station, r e f e r r a l p o s s i b i l i t y for s e v e r e c a s e s
Nutritional supplements
D i s t r i b u t i o n to p r e g n a n t w o m e n v i t a m i n A to n e w b o r n s and i d e n t i f i e d c a s e s of n i g h t blindness/xerophthalmia; available s u p p l e m e n t a r y foods ( p r o t e i n r i c h ) to y o u g c h i l d r e n / i n f a n t s
P r e v e n t i o n p r o g r a m m e for i r o n d e f i c i e n c y a n a e m i a in p r e g n a n c y . V i t a m i n A to n e w b o r n s a n d deficiency cases, milk powder or o f t e n s u p p l e m e n t s t o m o d e r a t e PCM w i t h a d v i c e on u s e .
P r e v e n t i v e p r o g r a m m e for i r o n d e f i c i e n c y anaemia P e r i o d i c a d m i n i s t r a t i o n of v i t a m i n Л to infants and pre-school children Supervised supplementary feeding programme w i t h c h e c k s on d e v e l o p m e n t .
R e f e r m o d e r a t e c a s e s of PCM for n u t r i t i o n a l r é c u p é r a t i o n a n d e d u c a t i o n p r o g r a m m e , if available. Refer severe cases to h o s p i t a l or h e a l t h c e n t r e ward
D e v e l o p m e n t of f u l l n u t r i t i o n a l r e c u p e r a t i o n and education services with referral and f o l l o w - u p system
Nutritional recuperation
A P A H O / F A O m e e t i n g h e l d in W a s h i n g t o n in 1969 d e f i n e d food and n u t r i t i o n policy as the f o r m u l a t i o n and e x e c u t i o n of a series of m e a s u r e s that tend to ensure the o p t i m u m n u t r i t i o n a l status of the entire population. It w a s r e c o m m e n d e d t h a t s u c h a p o l i c y b e e s t a b l i s h e d a s a n i n t e g r a l p a r t of the n a t i o n a l p l a n s for e c o n o m i c a n d s o c i a l d e v e l o p m e n t , a n d e x e c u t e d t h r o u g h co-ordinated sector p r o g r a m m e s . ^ B e s i d e a d v i c e to c o u n t r i e s t h r o u g h W H O n u t r i t i o n a d v i s e r s a n d n u t r i t i o n i n s t i t u t e s , t h e q u e s t i o n of d e f i n i n g f o o d a n d n u t r i t i o n n a t i o n a l p o l i c i e s is a l w a y s g i v e n e m p h a s i s in j o i n t FAO/WHO training programmes and seminars. In 1 9 7 0 and 1971 ad h o c c o u r s e s on food and n u t r i t i o n policy and planning w e r e organized in B e i r u t in co-operation w i t h FAO and UNICEF; a n a t i o n a l food and n u t r i t i o n seminar was h e l d in Cyprus in 1971. A s e r i e s of seminars a r e u n d e r p r e p a r a t i o n by FAO, P A H O / W H O and U N I C E F in L a t i n A m e r i c a , to take place in 1972, 1973 and 1974. T h e d i f f i c u l t y of the subject is d u e to d i f f e r e n c e s of o p i n i o n on the content of such food and n u t r i t i o n p o l i c i e s , and p a r t i c u l a r l y to the resist a n c e e n c o u n t e r e d in o b t a i n i n g s a t i s f a c t o r y c o - o r d i n a t i o n a m o n g t h e n a t i o n a l a g e n c i e s i n v o l v e d . F i g . 3 indicates, in a summary form, the aspects to b e considered in defining a food and n u t r i t i o n policy and, in particular, makes a distinction between direct and indirect intervention programmes. A g r e a t d e a l of c o n f u s i o n a b o u t t h i s q u e s t i o n s t i l l p e r s i s t s . The recent conference on n u t r i t i o n , n a t i o n a l d e v e l o p m e n t and planning organized by the Department of N u t r i t i o n and Food S c i e n c e , M a s s a c h u s e t t s Institute of T e c h n o l o g y in B o s t o n in October 1971 to w h i c h W H O m a d e several contributions, reflects the differences of opinion between economists, planners and nutritionists. However, a definitive step forward was that for the first time people with different backgrounds m e t together and compared their approaches to nutrition problems. Many e c o n o m i s t s think that raising the income of the p o o r w o u l d b e sufficient to a t t a i n b e t t e r nutrition. Nutritionists believe that, although this assumption may be correct, a large p r o p o r t i o n of t h e u n d e r n o u r i s h e d c a n n o t e x p e c t to i n c r e a s e their incomes enough w i t h i n their l i f e t i m e to m e e t even m i n i m a l n u t r i t i o n a l s t a n d a r d s . D i r e c t intervention to improve nutritional h e a l t h is one w a y of a t t a c k i n g this p r o b l e m . We must identify and implement those p r o g r a m m e s of d i r e c t i n t e r v e n t i o n w h i c h w i l l both improve the situation of the present generation and offer improved prospects for development. 2•3
Training
in
nutrition
W H O h a s g i v e n very h i g h p r i o r i t y to the training of p e r s o n n e l in the field of n u t r i t i o n , p a r t i c u l a r l y of m e d i c a l n u t r i t i o n i s t s , p u b l i c h e a l t h n u t r i t i o n i s t s , n u t r i t i o n b i o c h e m i s t s a n d dieticians but also in general of public health personnel. In f a c t , s o m e t r a i n i n g i s c a r r i e d out in nearly a l l WHO n u t r i t i o n p r o j e c t s . WHO activities 2.3.1
in this field may be described under four
Establishment During the
of c u r r i c u l a and o r g a n i z a t i o n
headings:
of a c a d e m i c
education
last five y e a r s , three m e e t i n g s h a v e been o r g a n i z e d
on this s u b j e c t :
- a c o n f e r e n c e on n u t r i t i o n e d u c a t i o n in s c h o o l s of m e d i c i n e and s c h o o l s of p u b l i c h e a l t h i n L a t i n A m e r i c a , in W a s h i n g t o n in 1 9 6 6 , w i t h t h e U n i t e d S t a t e s A g e n c y f o r I n t e r n a t i o n a l D e v e l o p m e n t and the U n i t e d S t a t e s N a t i o n a l I n s t i t u t e s of H e a l t h ; 1 P a n A m e r i c a n H e a l t h O r g a n i z a t i o n ( 1 9 7 0 ) E l e m e n t s of a food a n d n u t r i t i o n p o l i c y L a t i n A m e r i c a , W a s h i n g t o n (РАНО S c i e n t i f i c P u b l i c a t i o n N o . 1 9 4 ) .
in
2 Food and Agriculture Organization of the United Nations nutrition policy, Rome (FAO Nutritional Studies, N o . 2 2 ) .
(1969) M a n u a l on food
and
FIG. 3.
THE ORGANIZATION OF PROGRAMMES HAVING MAJOR
INFLUENCES ON
OVER-ALL SOCIO ECONOMIC
Increase in Purchasing
Labour and Social Welfare
NUTRITION
DEVELOPMENT
Family Power
Increase in L e v e l of General Education
Education
C o n t r o l of Infections
Health
Diminished Stress
Finance Action
Transport
Human
Beings
Improved Individual Food Consumption
C o l l e c t i o n of information, Research, Training
丨0Э
Community Development
NOIEHVNIaë
Industry
Attainment and Maintenance of H e a l t h
on
Action
on Improved Availability of Food
Foods
Trade
Agriculture and Rural Development
Land Reform, Food Commodities Trade
Food
V RESPONSIBLE
V
MINISTRIES]
PROGRAMMES OF DIRECT INTERVENTION
V FOOD AND NUTRITION
OBJECTIVES
1СЛ
EM办 9/ЗО
arbitrary.
V
PROGRAMMES OF INDIRECT INTERVENTION
page
N o m e n c l a t u r e of m i n i s t r i e s is
Import-Export Policy
-
a c o n f e r e n c e on the training of public h e a l t h n u t r i t i o n i s t - d i e t i c i a n s , in 1966; and
-
j o i n t l y w i t h U N I C E F , a seminar on the teaching of n u t r i t i o n c o u n t r i e s , in T u r k e y in 1 9 7 0 .
2.3.2
Assistance
to training c e n t r e s or sponsoring
of
in the
in Caracas,
also
Mediterranean
courses
W H O f i n a n c i a l and t e c h n i c a l a s s i s t a n c e is p r o v i d e d to the Institute of N u t r i t i o n of C e n t r a l A m e r i c a and P a n a m a (INGAP), the C a r i b b e a n Food and N u t r i t i o n Institute, the N a t i o n a l I n s t i t u t e of N u t r i t i o n of India, H y d e r a b a d , and the u n i v e r s i t i e s of Ibadan, Bogotá and P u e r t o Rico. T h e c o u r s e s g i v e n by these d i f f e r e n t institutions are d e s c r i b e d in A n n e x 1 . WHO n u t r i t i o n i s t s p a r t i c i p a t e in the t e a c h i n g a c t i v i t i e s of the N u t r i t i o n Institute of Islamabad, ( P a k i s t a n ) , Recife, (Brazil) and the U n i v e r s i t y of D a k a r , ( S e n e g a l ) . Advisory services have a l s o b e e n provided to the schools of public health of Caracas, Sao Paulo and Bangkok, to the school of dieticians of Teheran, to the school of dieticians/public health nutritionists of A l g i e r s and to many such schools in Latin A m e r i c a , 2.3.3
Organization
of ad hoc training courses and
seminars
T h e s e courses and seminars aim at training personnel in one particular nutrition (e.g., PCM or goitre). D u r i n g the last six years the following
s e m i n a r s or c o u r s e s w e r e
- t w o regional seminars on applied nutrition programmes, India (1966) and in C o l o m b i a (1966);
subject
held:
in collaboration with FAO,
in
- f o u r regional or inter-regional seminars on PCM and on weaning problems, in Kenya (1969), T h a i l a n d (1971), Ethiopia (1969) and Algeria (1971), (the latter in co-operation w i t h FAO and UNICEF)； - t w o regional c o u r s e s on food and n u t r i t i o n policy and p l a n n i n g in Lebanon, w i t h FAO and U N I C E F ( 1 9 7 0 , 1 9 7 1 ) ;
in
co-operation
- o n e n u t r i t i o n c o u r s e a n d a n a t i o n a l food and n u t r i t i o n s e m i n a r in C y p r u s , a l s o in b o r a t i o n with FAO and UNICEF (1971). 2.3.4
Provision of
colla-
fellowships
T a b l e 5 gives a summary of trends in the award of n u t r i t i o n d o e s n o t i n c l u d e t h e f e l l o w s h i p s p r o v i d e d b y РАНО d i r e c t l y .
fellowships by W H O .
It
T h e n u m b e r of f e l l o w s h i p s a w a r d e d from the regular b u d g e t by the O r g a n i z a t i o n in the field of nutrition has nearly doubled during the last six y e a r s . At present, WHO awards about 70 fellowships per year, w h i c h represents about two per cent, of the total fellowships granted by the Organization. In f a c t , the O r g a n i z a t i o n h a s g r a n t e d fellowships on the b a s i s of m o s t of the r e q u e s t s made by the governments. Probably no m o r e than half of the personnel trained have a key p o s i t i o n in the n u t r i t i o n policy of the g o v e r n m e n t s c o n c e r n e d . M a n y , h o w e v e r , a r e in other key positions, w h i c h is not in itself an unsatisfactory situation, because of the influence they can exercise on nutrition policy.
TABLE
Years
2.4
AFRO
5.
WHO FELLOWSHIPS AWARDED
AMRO
SEARO
EURO
EMRO
IN T H E F I E L D O F
WPRO
NUTRITION
Total for all regions
%
of total WHO fellowships
1965
8
8
9
3
7
2
37
2.1
1966
10
9
9
2
5
4
39
1.5
1967
6
1
20
-
9
4
40
1.5
1968
15
6
8
4
6
6
45
1.4
1969
21
12
16
4
7
12
72
2.1
1970
21
18
13
3
5
8
68
1.7
Resources
For 1972, the regular b u d g e t of n u t r i t i o n is of the order of $ 169 0 0 0 for h e a d q u a r t e r s a c t i v i t i e s and $ 1 310 0 0 0 for r e g i o n a l a n d i n t e r - r e g i o n a l a c t i v i t i e s . Under other sources of funds the amount provided for 1972 totals $ 3 648 000 inclusive of UNICEF-assisted projects. The attached Table 6 shows the amounts provided for nutrition activities for the years 1963, 1966, 1969 and 1972. T h e n u m b e r of p o s t s for a c t i v i t i e s d i r e c t l y related to n u t r i t i o n p r o v i d e d for 1972 47 under the regular budget of which seven are established at headquarters and 40 relate the field whilst under other sources there are 228 posts.
is to
W H O is c o n f r o n t e d w i t h d i f f i c u l t i e s in the r e c r u i t m e n t of staff p a r t i c u l a r l y for field activities. Governments request personnel able to cope with all aspects of nutrition, including epidemiology, services, training and food and nutrition policy. There are few persons able to cover all these fields. T h e b e s t s o l u t i o n is t h r o u g h a team approach^ n o t only in the field of h e a l t h but a l s o in terms of c o - o p e r a t i o n w i t h FAO and other i n t e r n a t i o n a l organizations.. This has not been possible in m a n y instances, not only because of problems in i n t e r n a t i o n a l c o - o p e r a t i o n d u e to d i f f e r e n c e s in the system of b u d g e t i n g and r e c r u i t m e n t but also because of difficulties in obtaining a co-ordinated request to international organiz a t i o n s from g o v e r n m e n t s .
TABLE
6.
NUTRITION
ACTIVITIES
Estimated
Obligations
1963
1966
1969.
1972
US
US
US
US
$
$
$
$
HEADQUARTERS
Regular Other
budget
INTER-REGIONAL ~ P R O G R A M M E
Regular
95
667
131
526
168 816
75
145
95
667
131
526
168
316
AND
33
800
151
900
1 9 4 ООО
279
733
90
150
91
836
122
086
109
443
123
950
243
736
316
086
389
176
224
334
629
854
069
924
1 030
656
4 074
462
3 705
952
757
546
3 538
654
2 827 470
4 569
310
OTHER
ACTIVITIES
budget
sources
Sub-total
THE
145
sources
Sub-total
Other
75
REGIONS
Regular Other
budget
sources
Sub-total
4 298 796
4 335 806
TOTALS
Regular Other
Total
budget
sources
333 279
877
421
395 450
1 479
205
4 164 612
3 797
788
879 632
3 648
097
4 497 891
4 675 209
3 275 082
5 127
302
3.
CO-ORDINATION
WHO nutrition activities international organizations. 3.1
are co-ordinated within the Organization
C o — o r d i n a t i o n w i t h o t h e r u n i t s of
and with
other
WHO
M a n y of t h e a c t i v i t i e s of t h e N u t r i t i o n u n i t , as w e l l as t h e a c t i v i t i e s at r e g i o n a l l e v e l , are carried out in close co-operation w i t h other d i v i s i o n s and u n i t s , a m o n g w h i c h m a y be mentioned Maternal and Child H e a l t h , Health E d u c a t i o n , Cardiovascular D i s e a s e s , Dental H e a l t h , Occupational H e a l t h , Community Water Supplies and Sanitation, Education and T r a i n i n g , Food Additives, Health Statistics, Immunology, Mental Health, Parasitic Diseases, Programme Co-ordination, Programme Evaluation and Veterinary Public H e a l t h . A t t h e r e g i o n a l l e v e l , t h e r e is a l s o c l o s e c o - o r d i n a t i o n w i t h o t h e r a d v i s o r y s e r v i c e s , and at t h e c o u n t r y level t h e n u t r i t i o n staff is i n t e g r a t e d w i t h i n W H O teams to o b t a i n a common approach to the h e a l t h problems in the country or community concerned• C o - o p e r a t i o n w i t h o t h e r a c t i v i t i e s of W H O is a l s o of g r e a t i m p o r t a n c e in t h e t r a i n i n g of p e r s o n n e l and the W H O n u t r i t i o n staff is u s u a l l y involved in the t r a i n i n g a c t i v i t i e s of public health personnel• 3.2
Co-ordination with
3.2.1
international
Collaboration with UNICEF and
agencies of the United N a t i o n s
system
FAO
For many years, the three organizations have jointly developed nutrition projects, m a i n l y in the fields of applied n u t r i t i o n , the o r g a n i z a t i o n of t r a i n i n g courses and seminars and the d e v e l o p m e n t of p r o t e i n - r i c h f o o d s . They have also established the Protein Advisory G r o u p w h i c h , in v i e w of its p a r t i c u l a r i m p o r t a n c e , w i l l b e d i s c u s s e d in a s p e c i a l c h a p t e r (Chapter 4). 3.2.1.1 About allocation
Collaboration with
UNICEF
5 0 p e r c e n t . of t h e U N I C E F b u d g e t is d e v o t e d t o h e a l t h p r o g r a m m e s , a n d for n u t r i t i o n p r o g r a m m e s represents 13 per c e n t , of this b u d g e t .
the
U N I C E F ' s i n t e r e s t in n u t r i t i o n lies m a i n l y in the field of a p p l i e d n u t r i t i o n p r o g r a m m e s , feeding programmes, protein-rich foods, milk conservation and training activities # In a d d i t i o n t o t h e a b o v e p r o j e c t s , m a n y h e a l t h p r o j e c t s m e n t of b a s i c h e a l t h s e r v i c e s c o n t a i n an i m p o r t a n t n u t r i t i o n
like MCH programmes and component.
develop-
F o r s o m e y e a r s , the t e n d e n c y in U N I C E F h a s b e e n t o b r i n g t o g e t h e r in a s i n g l e p r o j e c t a c t i v i t i e s related to h e a l t h , a g r i c u l t u r e , e d u c a t i o n , social w e l f a r e , e t c . Such projects are called integrated or co-ordinated services for children. M o s t of them h a v e i m p o r t a n t h e a l t h and n u t r i t i o n c o m p o n e n t s of d i r e c t i n t e r e s t to W H O . 3.2.1.2
Collaboration with
FAO
A n agreement was reached between W H O and FAO in 1959 outlining the respective responsibilities of the two organizations in the field of n u t r i t i o n . O w i n g to t h e e x p a n s i o n of 1 n u t r i t i o n activities both in FAO and in W H O , this agreement w a s revised in 1 9 6 6 . In F A O , t h e e m p h a s i s i s o n n u t r i t i o n in r e l a t i o n t o t h e p r o d u c t i o n , d i s t r i b u t i o n a n d c o n s u m p t i o n o f 1
R e p o r t o f a n F A O / W H O i n t e r - s e c r e t a r i a t m e e t i n g t o d i s c u s s i n t e r - a g e n c y со—operation the field of food and n u t r i t i o n , R o m e , F e b r u a r y 1 9 6 6 .
in
food； in W H O it is o n n u t r i t i o n in r e l a t i o n to t h e m a i n t e n a n c e of h e a l t h a n d t h e p r e v e n t i o n of d i s e a s e . In p r o g r a m m e s f o r p r o m o t i o n of b e t t e r n u t r i t i o n t h e r e a r e t w o i n t e r d e p e n d e n t m a j o r c o m p o n e n t s w h i c h deal respectively w i t h (a) improvement in the q u a l i t a t i v e and q u a n t i t a t i v e p r o d u c t i o n and a v a i l a b i l i t y of f o o d , its u t i l i z a t i o n and the o r g a n i z a t i o n of a p p r o p r i a t e s e r v i c e s , and (b) t h e p r e v e n t i o n and c o r r e c t i o n of d e f i c i e n c y d i s e a s e s and the o r g a n i z a t i o n of services in the broad field of n u t r i t i o n in h e a l t h . B o t h t y p e s of a c t i v i t i e s n e e d b e p r o m o t e d c o n c u r r e n t l y so as to a c h i e v e t h e b e s t r e s u l t s in t h e i n t e r e s t of M e m b e r States. The co-operation between the two organizations has been progressively strengthened, both at the national and international l e v e l s . FAO/WHO inter-secretariat meetings are now f r e q u e n t l y h e l d in G e n e v a o r R o m e o r e l s e w h e r e , on t h e o c c a s i o n of t h e j o i n t t e c h n i c a l m e e t i n g s w h i c h g r e a t l y f a c i l i t a t e the c o - o p e r a t i o n of the twp o r g a n i z a t i o n s . The main joint activities are as follows: (a)
Joint expert committees and expert
Joint FAO/WHO Expert Committee on
groups
Nutrition
A l l joint activities are periodically reviewed by these expert committees, which been regularly convened every two or three years since 1 9 4 9 . T h e seventh session w a s held in Rome in D e c e m b e r 1966 and the eighth in Geneva November 1970. T h e eighth session focused its attention on food fortification and calorie malnutrition. Joint FAO/WHO Expert Group
on N u t r i t i o n a l
have
in protein-
Requirements
K n o w l e d g e of h u m a n r e q u i r e m e n t s for e s s e n t i a l n u t r i e n t s is n e c e s s a r y in o r d e r to be a b l e to a s s e s s t h e n u t r i t i o n a l a d e q u a c y of diets for growth in i n f a n t s , children and a d o l e s c e n t s , for the m a i n t e n a n c e of h e a l t h in adults of both sexes and for pregnancy and lactation in women. D u r i n g the last 1 0 y e a r s , F A O and W H O h a v e convened groups of e x p e r t s to d e f i n e h u m a n r e q u i r e m e n t s for t h e m a j o r e s s e n t i a l n u t r i e n t s and for energy： c a l c i u m (1961)； p r o t e i n (1963); vitamin A , thiamine, riboflavin and niacin (1965); ascorbic acid, vitamin D, vitamin B12, f o l a t e a n d i r o n (1969)； a n d e n e r g y and p r o t e i n ( 1 9 7 1 ) • Requirements for trace elements will be considered in 1973. T h e Joint Expert Group reports h a v e been w i d e l y used in m o s t countries to e v a l u a t e t h e n u t r i t i o n a l a d e q u a c y of l o c a l d i e t a r i e s in n u t r i t i o n s u r v e y s and to e s t a b l i s h targets for n a t i o n a l requirements of food d u r i n g food policy p l a n n i n g . (b)
Applied nutrition programmes
(ANP)
T h e s e can be defined as a co-ordinated educational a c t i v i t y of a g r i c u l t u r e , h e a l t h , e d u c a t i o n and o t h e r i n t e r e s t e d a g e n c i e s w i t h t h e a i m of r a i s i n g t h e l e v e l s of n u t r i t i o n of local p o p u l a t i o n s , p a r t i c u l a r l y mothers and children in rural a r e a s . Nearly 60 applied n u t r i t i o n p r o g r a m m e s h a v e been created in co-operation w i t h FAO and UNICEF d u r i n g the past 1 3 10 years. These programmes are periodically reviewed by the three o r g a n i z a t i o n s » as far as their approach, objectives and methods are concerned. W H O assistance in developing the programmes has been particularly A m e r i c a n countries, the Western Pacific Region and India.
important
1
Joint F A O / W H O T e c h n i c a l M e e t i n g on M e t h o d s of P l a n n i n g and E v a l u a t i o n Nutrition Programmes (1966) Wld Hlth Org, techn. Rep. Ser., N o . 340. 2
WHO/UNICEF Joint Health Policy Committee, February
in
Central
in A p p l i e d
1967.
3 R e p o r t of t h e L a t i n A m e r i c a n S e m i n a r on t h e P l a n n i n g and E v a l u a t i o n Nutrition Programmes, Popayán, Colombia, 1966.
of
Applied
(c)
F e e d i n g of
workers
A s a f o l l o w - u p of the F A O / W H O seminar on industrial f e e d i n g in the N e a r E a s t h e l d in 1 A l e x a n d r i a in O c t o b e r 1 9 6 5 , an F A O / l L O / W H O e x p e r t c o n s u l t a t i o n on w o r k e r s feeding was held 1 i n R o m e in M a y 1 9 7 1 . R e c o m m e n d a t i o n s w e r e m a d © for f u r t h e r s t u d i e s on the e f f e c t of w o r k e r s f e e d i n g p r o g r a m m e s i n i m p r o v i n g h e a l t h a n d t h e w e l l - b e i n g o f w o r k e r s a n d of t h e i r f a m i l i e s , in r e d u c i n g l a b o u r t u r n o v e r , a b s e n t e e i s m , a n d a c c i d e n t s , and in i n c r e a s i n g p r o d u c t i v i t y • (d)
Codex C o m m i t t e e on Foods for Special D i e t a r y
Uses
F o l l o w i n g a r e c o m m e n d a t i o n s of the Codex A l i m e n t a r i u s C o m m i s s i o n (Joint F A O / W H O Food S t a n d a r d s P r o g r a m ) , a C o d e x Committee on D i e t e t i c Foods (later called Codex C o m m i t t e e on Foods for Special D i e t a r y U s e s ) w a s created in 1 9 6 6 . S i n c e t h a t t i m e , it h a s m e t © v e r y y e a r in G e r m a n y to d e f i n e s t a n d a r d s f o r v a r i o u s c a t e g o r i e s of foods： t h o s e w i t h l o w s o d i u m c o n t e n t and those for diabetics and for infants and y o u n g c h i l d r e n . W H O p a r t i c i p a t e s a c t i v e l y in the m e e t i n g s of this C o m m i t t e e . (e)
D i f f u s i o n of t e c h n i c a l
information on food and
nutrition
A J o i n t F A O / W H O / Q A U - S T R C F o o d a n d N u t r i t i o n Conunission f o r A f r i c a w h i c h w a s c r e a t e d i n 1963 c o l l e c t s , analyses and d i s s e m i n a t e s i n f o r m a t i o n on food and nutrition in A f r i c a and h e l p s t h e R e g i o n a l O f f i c e in co-ordinating a c t i v i t i e s in this f i e l d . The Secretariat, s i t u a t e d in A c c r a , p u b l i s h e s a b u l l e t i n w h i c h is d i s t r i b u t e d to m i n i s t r i e s , o r g a n i z a t i o n s and persons interested in food and nutrition p r o g r a m m e s . It is e n v i s a g e d t o c r e a t e a r e g i o n a l n u t r i t i o n d a t a s t o r a g e a n d a n a l y s i s c e n t r e i n Latin America. A joint P A H O / F A O c o n s u l t a t i v e m i s s i o n assisted the Government of A r g e n t i n a in 1 9 7 0 to p r e p a r e a p r e l i m i n a r y d e s c r i p t i o n of t h e f u n c t i o n s of t h e p r o p o s e d c e n t r e . F A O and W H O a l s o p u b l i s h b u l l e t i n s for g i v e n r e g i o n s , like " C a j a n u s " , w h i c h is by the Caribbean Food and Nutrition Institute. 3.2,2
Collaboration with the World Food
issued
Programme
T h e W o r l d Food P r o g r a m m e (WFP) was established in 1963 to u s e commodities contributed v o l u n t a r i l y by government for economic and.social d e v e l o p m e n t and emergency relief in 1 participating countries. W H O has co-operated w i t h the W F P ever since its i n c e p t i o n and, 1 a l t h o u g h it w a s i n i t i a l l y b e l i e v e d that the P r o g r a m m e s a c t i v i t i e s w o u l d b e m a i n l y in t h e field of n u t r i t i o n , over the y e a r s its o p e r a t i o n s h a v e e x p a n d e d to include o t h e r a s p e c t s w i t h i n the f i e l d of h e a l t h , such as m a l a r i a e r a d i c a t i o n , c o n t r o l of p a r a s i t i c d i s e a s e s , e n v i r o n m e n t a l h e a l t h , and the s t r e n g t h e n i n g of b a s i c health s e r v i c e s . T h e a v e r a g e v a l u e of c o n t r i b u t i o n s in t h e form of food and s e r v i c e s m a d e a v a i l a b l e to W F P r o s e from a b o u t 3 0 m i l l i o n d o l l a r s in 1 9 6 3 to a p p r o x i m a t e l y 1 3 0 m i l l i o n in 1 9 7 1 . At p r e s e n t , a l m o s t 1 0 per c e n t . of the W F P c o m m i t m e n t s are allotted to projects w h o s e m a i n o b j e c t i v e is h e a l t h p r o m o t i o n . T h e y m a y be c l a s s i f i e d in t h r e e d i f f e r e n t categories：
the
(a) P r o j e c t s for t h e d e v e l o p m e n t of h u m a n r e s o u r c e s w h e r e t h e food is u t i l i z e d for t h e s u p p l e m e n t a r y f e e d i n g o f c l e a r l y i d e n t i f i e d v u l n e r a b l e g r o u p s of p o p u l a t i o n ; (b) P r o j e c t s f o r c r e a t i n g or s t r e n g t h e n i n g t h e i n f r a s t r u c t u r e of h e a l t h s e r v i c e s w h e r e t h e o p e r a t i o n a l s a v i n g s a c c r u e d as a r e s u l t of the food aid a r e fed b a c k a s a l o c a l currency capital investment for building health centres, improving hospital food s e r v i c e s , e q u i p m e n t , h e a l t h f a c i l i t i e s , etc.； a n d 1
tion
c f . Fifteenth World Health Assembly：
WHA15.56.
(a) W o r k i n g Paper A 1 5 / p & B / l 3 A d d . 1 ;
(b)
resolu-
(с) Food assistance to develop specific health p r o j e c t s , such as environmental s a n i t a t i o n w h e r e food c o n s t i t u t e s partial p a y m e n t of the w a g e s of the w o r k e r s e m p l o y e d , o r c o m p e n s a t i o n of v o l u n t a r y w o r k e r s if t h e p r o j e c t is o p e r a t e d o n a s e l f - h e l p b a s i s . T h e f o l l o w i n g table (Table 7) shows the t y p e , n u m b e r and cost of W F P d e v e l o p m e n t with direct health objectives. TABLE
7.
WFP DEVELOPMENT PROJECTS DIRECT HEALTH OBJECTIVES
As Approved No.
at 15 September
projects US
$
WITH
1971
Under technical No.
US
scrutiny $
Health
promotion
42
109 230 0 0 0
5
11
6 4 1 000
School
feeding
57
227 453 0Ô0
3
3
592 000
60
64 7 9 3 0 0 0
5
1
350 000
59
91 558 0 0 0
4
7
671 000
Teaching institutions Com. housing development
projects
and
A l t h o u g h W F P food aid goes to d e v e l o p m e n t p r o j e c t s directed towards a v a r i e t y of aims,l so m a n y h a v e health implications that W F P now sends all its projects to W H O for technical scrutiny. T h e n e e d for a c t i v e p a r t i c i p a t i o n of W H O a d v i s e r s in t h e p l a n n i n g p h a s e of W F P aided projects has also been recognized. W h i l e W F P p r o j e c t s r e l y on F A O a d v i c e in m o s t of t h e i r n u t r i t i o n a s p e c t s , m a n y of t h e s e c o n c e r n W H O a l s o as p a r t of o u r w e l l - e s t a b l i s h e d c o - o p e r a t i o n with F A O in the field of n u t r i t i o n . T h e n u m e r o u s p u b l i c h e a l t h a s p e c t s of W F P p r o j e c t s are identified and taken care of w h e r e v e r possible as a joint effort of national authorities and WHO personnel. 3.2.3
Collaboration with other
international
agencies
A s p e c i a l m e n t i o n s h o u l d b e m a d e h e r e of W H O c o - o p e r a t i o n w i t h IAEA in t h e f i e l d of nutrition in research using radioisotopes (particularly as concerns food iron absorption), w i t h U N E S C O for n u t r i t i o n e d u c a t i o n , the d e f i n i t i o n of c u r r i c u l a in p r i m a r y s c h o o l s , e t c ” and w i t h ILO for industrial feeding programmes. Contacts have also been made with UNIDO. T h e s e various collaborative activities will p r o b a b l y increase in the f u t u r e . 3.3
Collaboration with the
I n t e r n a t i o n a l U n i o n of N u t r i t i o n a l
Sciences
ClUNS)
W H O e s t a b l i s h e d official relations w i t h the International Union of N u t r i t i o n a l Sciences in 1 9 6 9 . T h e c o - o p e r a t i o n b e t w e e n W H O and this U n i o n is e x c e l l e n t and W H O staff p a r t i c i p a t e a c t i v e l y in n i n e of its c o m m i t t e e s .
Some
h a v e b e e n a p p r o v e d in 84 countries： a b o u t 2 5 0 a r e f u l l y o p e r a t i o n a l at others being either completed or at some early implementation s t a g e .
500
on© time, the
any
4. 4.1
THE PROTEIN ADVISORY
GROUP
Establishment and early function of the Protein Advisory G r o u p
(PAG)
Concern in FAO, UNICEF and W H O for the problem of protein-calorie malnutrition as a primary factor responsible for the impaired g r o w t h and development of children in many d e v e l o p i n g c o u n t r i e s p r o m p t e d t h e s e a g e n c i e s to j o i n f o r c e s to d e a l w i t h i t . From the beginning it w a s recognized t h a t , in view of the high prevalence and the severity of PCM and the limited availability, the high cost and the economic restraints on the increased production of t r a d i t i o n a l p r o t e i n foods (milk, m e a t , eggs and f i s h ) , there w a s little l i k e l i h o o d that these needs could be met from such sources. T h u s it w a s a g r e e d that n e w or u n c o n v e n t i o n a l protein resources and processes needed investigation and development. Accordingly, early in w h a t c a m e to b e c a l l e d the P r o t e i n - r i c h F o o d s P r o g r a m m e , m a j o r a t t e n t i o n w a s g i v e n to t h e p o s s i b i l i t y of d e v e l o p i n g and testing s u b s t a n c e s w i t h w h i c h little prior e x p e r i e n c e existed in terms of their use as human food. The r e a l i z a t i o n that the d e v e l o p m e n t of satisfactory foods from u n c o n v e n t i o n a l sources of proteins would involve special problems in food safety, toxicology, processing and compatibility w i t h i n f a n t d i e t s , as w e l l as the n e e d to c o - o r d i n a t e the v i e w p o i n t s o f the a g e n c i e s o n t h e s e p r o b l e m s , led to t h e e s t a b l i s h m e n t b y W H O i n 1 9 5 5 o f a P r o t e i n A d v i s o r y G r o u p , w h i c h i n 1 9 6 0 was expanded into the tripartite FAO/WHO/UNICEF Protein Advisory G r o u p . PAG initially consisted of a small group of eminent clinical nutritionists and paediatricians, which provided a d v i c e o n the safety and n u t r i t i o n a l u s e f u l n e s s for infants and y o u n g c h i l d r e n of v a r i o u s protein foods and supplements. By 1964 increasing emphasis was b e i n g placed on the problems of the formulation and manufacture of new protein foods and food mixtures and on the necessary processing and quality criteria for n o v e l protein concentrates and s u p p l e m e n t s . Problems later e m e r g e d r e l a t i n g to p a l a t a b i l i t y , c o n s u m e r a c c e p t a n c e and m a r k e t i n g • Thus, the m e m b e r s h i p of PAG after 1965 included food technologists a n d , in recent y e a r s , specialists in industrial research, agricultural production and plant breeding, governmental food policies and regulations, and persons-concerned with food acceptability and marketing. 4.2
Terms of r e f e r e n c e of
PAG
PAG h a s f u n c t i o n e d in an a d v i s o r y c a p a c i t y to the D i r e c t o r s - G e n e r a l of FAO and W H O the Executive Director of U N I C E F . It i s r e q u i r e d b y i t s t e r m s o f r e f e r e n c e : (a)
to advise on the technical and r e l a t e d a s p e c t s of the joint F A O / W H O / u N I C E F
for improvement of protein
programme
nutrition;
(b)
to a d v i s e o n c u r r e n t p r o g r a m m e s and o n n e w a r e a s of
(c)
to p r o v i d e g u i d e l i n e s for the f o r m u l a t i o n of the b r o a d p r o g r a m m e s o f t h e
activity；
Nations system of organizations concerning the various aspects of the protein (d)
and
to d i s s e m i n a t e n e w i n f o r m a t i o n o n t h e p r o t e i n
United problem;
problem;
(e) to a d v i s e o n the i m p r o v e m e n t o f p r o c e d u r e s for p r o j e c t e v a l u a t i o n a n d studies； and (f) to a d v i s e o n s u c h m a t t e r s as t h e D i r e c t o r s - G e n e r a l of F A O and W H O a n d E x e c u t i v e D i r e c t o r o f U N I C E F m a y f r o m t i m e t o t i m e r e f e r to t h e G r o u p .
feasibility the
4.3 4.3# 1
Functioning A p p o i n t m e n t of c h a i r m a n and m e m b e r s of
PAG
The m e m b e r s of PAG a r e a p p o i n t e d , w i t h the a g r e e m e n t of the sponsoring a g e n c i e s , for two-year term.
a
The total membership is 12. In a p p o i n t i n g m e m b e r s , b r o a d geographical r e p r e s e n t a t i o n is an i m p o r t a n t c o n s i d e r a t i o n . ‘ A p p o i n t m e n t s a r e m a d e to p r o v i d e for c o n t i n u i t y and r o t a t i o n of m e m b e r s h i p , but it is a g r e e d that no i n d i v i d u a l s h o u l d s e r v e for m o r e than six y e a r s consecutively. The chairman is chosen from the PAG membership for a two-year period with the agreement of the sponsoring agencies. 4.3.2
Administration
FAO is at present administering PAG on behalf of the three sponsoring a g e n c i e s . G r o u p is s e r v i c e d by a s e c r e t a r i a t e s t a b l i s h e d on the premises of U N I C E F h e a d q u a r t e r s New York. Three professionals and four secretaries are employed full-time. 4#3,3
Funding
So f a r , the b u d g e t of PAG has b e e n shared equally by F A O , WHO and U N I C E F . annual contribution has been as follows: 1963 1964 1965 1966 1967
-
$ $ $ $ $
11 13 14 15 14
400 300 600 600 000
1968 1969 1970 1971 1972
-
$ $ $ $ $
20 38 48 48 54
W o r k i n g m e t h o d s of
The
WHO
000 400 333 333 333
It i s c l e a r f r o m t h e s e f i g u r e s t h a t t h e w o r k o f P A G h a s g r a d u a l l y e x p a n d e d . in the b u d g e t is a l s o i n d i c a t i v e of the i n t e r e s t taken b y W H O in the w o r k of the 4.3.4
The in
The increase Group.
PAG
The Group has been holding one meeting every y e a r , usually of five-day duration on r o t a t i n g b a s i s at the h e a d q u a r t e r s of the s p o n s o r i n g a g e n c i e s . It h e l d t h r e e m e e t i n g s the last two y e a r s . In v i e w of the i n c r e a s i n g n u m b e r of p r o b l e m s p l a c e d b e f o r e PAG by a g e n c i e s , it h a s b e e n r e c o m m e n d e d that two m e e t i n g s b e h e l d a n n u a l l y .
a in the
The annual a p p o i n t m e n t , on the r e c o m m e n d a t i o n of PAG of ad hoc w o r k i n g groups c o n s i s t i n g of international experts who may or may not be members of P A G , has become an effective procedure for a n a l y s i n g specific technical questions in greater depth than is possible at regular PAG meetings. A member of PAG usually serves as c h a i r m a n . A typical group consists of about five members (although a few supporting consultants may also be a p p o i n t e d ) and it is dissolved u p o n c o m p l e t i o n of the a s s i g n m e n t and submission of a r e p o r t . The ad hoc working group recommendations are taken up by PAG when formulating authoritative statements or guidelines dealing w i t h significant aspects of protein resources and related nutritional p r o b l e m s . 4.4
Recent PAG
activities
A list of PAG ad hoc w o r k i n g g r o u p s , PAG p u b l i c a t i o n s , statements and guidelines included in Annex
is
2.
M a n y P A G s t a t e m e n t s a n d g u i d e l i n e s h a v e b e e n o f c o n s i d e r a b l e p r a c t i c a l v a l u e to W H O . The g u i d e l i n e s for human testing of s u p p l e m e n t a r y food m i x t u r e s , for i n s t a n c e , are c u r r e n t l y u s e d in the W H O r e f e r e n c e c e n t r e s for testing: the guidelines on protein-rich mixtures for
u s e as weaning foods are used by the WHO nutrition experts in the field in new weaning food programmes； the statement on amino-acid fortification of c o n t r i b u t i o n to this d i f f i c u l t q u e s t i o n . M e e t i n g s of some ad h o c g r o u p s , "feeding the preschool child" have proved invaluable and have provided WHO advice on the various aspects of this important q u e s t i o n . 4•5
Recent developments
in the United Nations concerning
the development of food is an important such as the one on with excellent
the p r o t e i n p r o b l e m and
PAG
T h e A d v i s o r y C o m m i t t e e o n t h e A p p l i c a t i o n of S c i e n c e a n d T e c h n o l o g y to D e v e l o p m e n t ( A C A S T ) g a v e c o n s i d e r a t i o n f o r t h e f i r s t t i m e to t h e p r o d u c t i o n a n d u s e o f e d i b l e p r o t e i n i n d e v e l o p i n g countries at its fourth and fifth sessions in 1966 and established an ad hoc Working G r o u p on P r o t e i n w h i c h p r o d u c e d a d o c u m e n t e n t i t l e d " I n t e r n a t i o n a l a c t i o n to avert the i m p e n d i n g p r o t e i n 1 crisis". The protein question was reviewed again at the twenty-second (1967) and twenty-third (1968) sessions of the United Nations General A s s e m b l y . In 1 9 6 9 the W o r l d H e a l t h A s s e m b l y w a s informed of the resolutions adopted by the Economic and Social Council and the G e n e r a l о Assembly of the United N a t i o n s . It a d o p t e d a r e s o l u t i o n ( W H A 2 2 . 5 6 ) on "co-ordination with the United Nations, the specialized agencies and the International Atomic Energy Agency and on increase in the production and u s e of edible piotein". The problem w a s kept under review in the United N a t i o n s and subsequently (1970) the General Assembly adopted resolution 2684 (XXV), the operative provisions of which requested the S e c r e t a r y - G e n e r a l "to p r e p a r e , w i t h the a s s i s t a n c e of i n d e p e n d e n t e x p e r t s and in c l o s e consultation w i t h the agencies and organizations of the United Nations family, a concise report on the p o s s i b l e elements of a broad statement of s t r a t e g y , as c o n t e m p l a t e d by the A d v i s o r y C o m m i t t e e on the A p p l i c a t i o n of Science and T e c h n o l o g y to D e v e l o p m e n t , s u g g e s t i n g the role of governments and the contribution of the United Nations system in closing the protein gap and i n c l u d i n g r e c o m m e n d a t i o n s r e g a r d i n g those p r o p o s a l s a l r e a d y put forward w h i c h a r e found to b e both desirable and feasible, together with an indication of the possible means of their i m p l e m e n t a t i o n " , a n d to r e p o r t t o t h e G e n e r a l A s s e m b l y a t i t s t w e n t y - s i x t h s e s s i o n t h r o u g h t h e Economic and Social Council. In r e s p o n s e to t h i s r e s o l u t i o n , the S e c r e t a r y - G e n e r a l c o n v e n e d a m e e t i n g o n 3 - 7 M a y 1 9 7 1 of a panel of experts on the p r o t e i n problem c o n f r o n t i n g the d e v e l o p i n g countries in N e w Y o r k . Specialized agencies were also represented at this meeting and their views were solicited in the p r e p a r a t i o n of the r e p o r t ^ w h i c h was s u b m i t t e d to the f i f t y - f i r s t session (July 1 9 7 1 ) of the Economic and Social C o u n c i l . The panel prepared a strategy statement on action to avert the protein crisis and t h e f o l l o w i n g r e c o m m e n d a t i o n s c o n c e r n i n g t h e m a c h i n e r y to b e s e t u p o r e x i s t i n g w i t h i n United Nations system: 1.
E s t a b l i s h m e n t of an i n t e r g o v e r n m e n t a l
2.
Creation of a special protein fund;
3.
E x p a n s i o n and strengthening of
made the
committee; and
PAG.
International action to avert the i m p e n d i n g protein c r i s i s . United Nations, New York, 1968, Publication No. E.68.XIII.2. 2 World H e a l t h O r g a n i z a t i o n , H a n d b o o k of r e s o l u t i o n s and decisions of the World H e a l t h Assembly and Executive Board, Eleventh edition, p . 102, Geneva, 1971• -
Strategy s t a t e m e n t on a c t i o n to avert the p r o t e i n crisis in the d e v e l o p i n g United Nations, New York, 1971, Publication No. E71.II.A.17,
countries.
I n a n a n n e x to t h e r e p o r t , t h e p a n e l o f e x p e r t s l i s t e d 1 6 e l e m e n t s ( s e e A n n e x 3 ) t o b e e s s e n t i a l i n o r d e r to a v e r t t h e p r o t e i n c r i s i s i n d e v e l o p i n g c o u n t r i e s .
of
It s h o u l d b e n o t e d WHO.
that more than half of these elements are directly related
considered
to the
work
A f t e r e x a m i n a t i o n of the report and of the c o m m e n t s m a d e by the A d m i n i s t r a t i v e C o m m i t t e e on Co-ordination (ACC) the Economic and Social Council adopted resolution 1640 (LI) on edible p r o t e i n in w h i c h , inter alia it r e q u e s t e d the a d m i n i s t r a t o r of U N D P to c i r c u l a t e the s u b s t a n t i v e p o r t i o n s o f t h e r e p o r t of t h e p a n e l to t h e r e s i d e n t r e p r e s e n t a t i v e s o f U N D P , " w i t h a v i e w to m a x i m i z i n g t h e i r e f f o r t s a n d c o l l a b o r a t i o n w i t h the v a r i o u s g o v e r n m e n t s , so t h a t this v e r y i m p o r t a n t p r o b l e m can be b r o u g h t m o r e forcibly to the a t t e n t i o n of the n a t i o n a l d e v e l o p m e n t p l a n n i n g officials at the highest possible level". The resolution urged that greater emphasis in meeting the protein problem be placed on national development planning and that the g o v e r n m e n t s of developed countries reinforce their support for programmes and projects dealing with this question, and recommended that appropriate United Nations organs and specialized a g e n c i e s p a r t i c i p a t e i n the F A O / W H O / U N I C E F P r o t e i n A d v i s o r y G r o u p i n o r d e r to b r o a d e n i t s activities. The e x p a n s i o n of that G r o u p to i n c l u d e all the o r g a n i z a t i o n s concerned w a s advocated. The r e s o l u t i o n c o n c l u d e d b y " r e q u e s t i n g t h e l e g i s l a t i v e b o d i e s o f U N I C E F , F A O , U N E S C O a n d W H O * a n d o t h e r a p p r o p r i a t e b o d i e s o f t h e U n i t e d N a t i o n s f a m i l y of o r g a n i z a t i o n s to i n c o r p o r a t e in their a g e n d a , as a major topic of c o n s i d e r a t i o n , at the earliest possible d a t e , the d i s c u s s i o n of the r e p o r t of the strategy statement for solving the protein gap as c o n t a i n e d in c h a p t e r s I, I I , III and the a n n e x of the r e p o r t of the S e c r e t a r y - G e n e r a l , a n d t h a t a p p r o p r i a t e e x p e r t s o f P A G b e i n v i t e d to p a r t i c i p a t e i n t h e c o n s i d e r a t i o n o f t h e s t r a t e g y before these bodies". It a l s o r e q u e s t e d P A G to s u b m i t to the a p p r o p r i a t e i n t e r g o v e r n m e n t a l b o d i e s of the United N a t i o n s system an a n n u a l report g i v i n g an analysis of the progress and p r o b l e m s e n c o u n t e r e d in the solution of the problem of the protein gap w i t h suggestions and options for possible courses of action by these intergovernmental b o d i e s . Following the adoption of resolution 1640 (LI) by the Economic and Social Council and d i s c u s s i o n s in A C C , several organizations or agencies of the United Nations system expressed their interest in associating themselves with PAG. PAG has b e c o m e an a d v i s o r y body to the U n i t e d N a t i o n s system and its terms of r e f e r e n c e (see paragraph 4 . 2 ) are under r e v i e w . The G e n e r a l A s s e m b l y of the U n i t e d N a t i o n s at its 1971 s e s s i o n h a d b e f o r e it the r e p o r t of the E c o n o m i c a n d S o c i a l C o u n c i l o n this m a t t e r a n d any a c t i o n it m a y t a k e w i l l b e r e p o r t e d to the Board.
5.
RESEARCH
PROGRAMME
Introduction T o c a r r y o u t an e f f e c t i v e p r o g r a m m e , a t h o r o u g h u n d e r s t a n d i n g of the e t i o l o g y and p a t h o g e n e s i s of n u t r i t i o n a l d i s e a s e s and trial of p r e v e n t i v e or therapeutic m e a s u r e s are n e c e s s a r y . T h i s is t h e aim of the W H O p r o g r a m m e of r e s e a r c h in n u t r i t i o n . The subjects selected for i n v e s t i g a t i o n are b a s e d o n the r e c o m m e n d a t i o n s m a d e by a g r o u p of c o n s u l t a n t s c o n v e n e d in 1 9 6 0 by the Director-General, by the Advisory Committee on Medical Research and by the Joint PAO/WHO Expert Committee on Nutrition. P r o t e i n - c a l o r i e m a l n u t r i t i o n , n u t r i t i o n a l anaemias and h y p o v i t a m i n o s i s A are conditions to w h i c h h i g h p r i o r i t y h a s b e e n a c c o r d e d i n the W H O n u t r i t i o n r e s e a r c h p r o g r a m m e . The r e l a t i o n s h i p b e t w e e n n u t r i t i o n and i n f e c t i o n is h i g h l y r e l e v a n t to the p r o b l e m of p r o t e i n c a l o r i e m a l n u t r i t i o n and c o n s t i t u t e s one e l e m e n t of the p r o g r a m m e . Rickets and endemic goitre h a v e r e c e i v e d a t t e n t i o n in v i e w o f t h e i r h i g h p r e v a l e n c è in s o m e a r e a s of the w o r l d and of the need for preventive m e a s u r e s . F i n a l l y , an a t t e m p t is m a d e to a s s e s s trends in the n u t r i t i o n a l s t a t u s of the w o r l d ' s p o p u l a t i o n - a field in w h i c h there is s t i l l a g r e a t n e e d to c o l l e c t more objective information.
5.1 5.1.1
Protein-calorie Protein
malnutrition
requirements
S t u d i e s h a v e b e e n c o n d u c t e d o r a r e u n d e r w a y w i t h W H O a s s i s t a n c e in J a m a i c a , G u a t e m a l a , L e b a n o n , S i n g a p o r e , the United States of A m e r i c a , E g y p t , N i g e r i a and C h i n a ( T a i w a n ) . They include : the d e t e r m i n a t i o n of the o b l i g a t o r y l o s s e s of n i t r o g e n in u r i n e and f a e c e s . These m e a s u r e m e n t s h a v e been u s e d by the E x p e r t C o m m i t t e e s on Protein R e q u i r e m e n t s w h i c h m e t 1 9 6 3 and in 1 9 7 1 as a b a s i s for the e s t i m a t i o n of p r o t e i n r e q u i r e m e n t s . It h a s b e e n r e c o m m e n d e d that m o r e i n f o r m a t i o n be collected on o b l i g a t o r y losses of n i t r o g e n in i n d i v i d u a l s of d i f f e r e n t ages and races;
in
the d e t e r m i n a t i o n of p r o t e i n r e q u i r e m e n t s in i n f a n t s , p r e s c h o o l age c h i l d r e n and y o u n g adults by the n i t r o g e n balance technique, u s i n g cow's m i l k , eggs and vegetable protein m i x t u r e s as t h e s o l e s o u r c e o f p r o t e i n s ; the c a l o r i e - p r o t e i n i n t e r r e l a t i o n s h i p . This question assumes a particular importance in v i e w of the low c a l o r i e intake of some y o u n g p o p u l a t i o n g r o u p s . Since the protein intake is barely sufficient or even insufficient, calorie deficiency has damaging consequences and r e s u l t s in an e v e n m o r e a c u t e s h o r t a g e of proteins； the p r o t e i n r e q u i r e m e n t s of p r e g n a n t and l a c t a t i n g w o m e n . G o o d n u t r i t i o n of the foetus a n d o f t h e i n f a n t d u r i n g t h e e a r l y m o n t h s o f l i f e h a s b e e n d e m o n s t r a t e d t o b e an e x t r e m e l y i m p o r t a n t f a c t o r in the o v e r a l l p h y s i c a l and m e n t a l d e v e l o p m e n t of the i n d i v i d u a l . T h e r e s u l t s of these studies h a v e been w i d e l y u s e d by the J o i n t FAO/WHO Ad H o c Expert C o m m i t t e e on Energy and Protein R e q u i r e m e n t s w h i c h m e t in R o m e in A p r i l 1 9 7 1 . This Committee m a d e r e c o m m e n d a t i o n s w h i c h w i l l g u i d e W H O in the p l a n n i n g of its f u t u r e p r o g r a m m e of r e s e a r c h in t h i s f i e l d . 5.1.2
C r i t e r i a for the d i a g n o s i s of p r o t e i n - c a l o r i e
malnutrition
A s e a r c h f o r s u f f i c i e n t l y s e n s i t i v e m e t h o d s to d i a g n o s e a n d e v e n q u a n t i f y t h e m i l d t o m o d e r a t e forms of p r o t e i n - c a l o r i e m a l n u t r i t i o n is b e i n g c a r r i e d o u t at I N C A P ( G u a t e m a l a ) . Two biochemical methods are tested (a) determination of the ratio between essential and non-essential a m i n o a c i d s in blood p l a s m a and (b) the c r e a t i n i n e / h e i g h t i n d e x w h i c h e s t i m a t e s the m u s c l e m a s s of an i n d i v i d u a l . Both m e t h o d s are s t i l l being e v a l u a t e d u n d e r e x p e r i m e n t a l c o n d i t i o n s to d e t e r m i n e t h e i r p o t e n t i a l v a l u e a n d a p p l i c a t i o n in t h e s t u d y o f p o p u l a t i o n g r o u p s . 5.1.3
Development
and u t i l i z a t i o n of n e w protein
resources
For the utilization of unconventional protein resources for h u m a n feeding, it is essential that their composition, safety and nutritive value warrant their use w i t h o u t r i s k . This is the c a s e of o i l s e e d p r o t e i n c o n c e n t r a t e s such as those from s o y b e a n s , g r o u n d n u t and c o t t o n s e e d . Some others such as sunflower are less wellknown; this is w i d e l y c u l t i v a t e d in s o m e p a r t s of t h e w o r l d a n d c o u l d c o n s t i t u t e an i m p o r t a n t s o u r c e o f p r o t e i n . R e s e a r c h on the s a f e t y , a c c e p t a b i l i t y , tolerance and n u t r i t i v e value of this protein c o n c e n t r a t e is therefore b e i n g s p o n s o r e d by W H O and c a r r i e d o u t in the U S S R . T o x i c f a c t o r s , s o m e t i m e s p r e s e n t in l e g u m e s , m a y c o n s t i t u t e an o b s t a c l e to t h e i r u s e in the manufacture of processed weaning foods. T h i s is the c a s e , for i n s t a n c e , w i t h b r o a d b e a n s , w h i c h a r e w i d e l y c o n s u m e d in the M e d i t e r r a n e a n a r e a and a r e r e s p o n s i b l e for o u t b r e a k s of f a v i s m , an acute h a e m o l y t i c p r o c e s s , e s p e c i a l l y in y o u n g c h i l d r e n . Research is at present being carried o u t in the N e t h e r l a n d s and in L e b a n o n to i d e n t i f y the f a c t o r s p r e s e n t in b r o a d b e a n s r e s p o n s i b l e f o r the d i s e a s e and w a y s and m e a n s of i n a c t i v a t i n g t h e m .
A t I N C A P , i m p r o v e m e n t of the p r o t e i n q u a l i t y of the d i e t is a m a j o r t o p i c of r e s e a r c h . S t u d i e s a r e c o n d u c t e d o n e x p e r i m e n t a l a n i m a l s a n d c h i l d r e n to d e t e r m i n e the n u t r i t i v e v a l u e of g e n e t i c a l l y improved v a r i e t i e s of c o r n , p r i n c i p a l l y those c o n t a i n i n g the o p a q u e - 2 g e n e . It h a s b e e n d e m o n s t r a t e d that t h e s e h i g h l y n u t r i t i o u s v a r i e t i e s o f c o r n c a n be u s e d in t r a d i t i o n a l culinary p r e p a r a t i o n s , such as " t o r t i l l a s " . V a r i o u s forms of e n r i c h m e n t to i m p r o v e the p r o t e i n q u a l i t y of t r a d i t i o n a l f o o d s h a v e a l s o been i n v e s t i g a t e d . Studies have been completed on the f o r t i f i c a t i o n of grain p r o d u c t s w i t h s y n t h e t i c amino acids or p r o t e i n c o n c e n t r a t e s , or both. T h e f i r s t p r a c t i c a l u s e of these s t u d i e s h a s been the f o r t i f i c a t i o n of I n c a p a r i n a w i t h lysine in G u a t e m a l a . 5.1.4
T e s t i n g of f o o d
mixtures
W i t h i n the framework of the i n t e r n a t i o n a l F A O / W H O / U N I C E F p r o t e i n - r i c h food p r o g r a m m e , a n u m b e r of p r o t e i n - r i c h food m i x t u r e s have been d e v e l o p e d and are being d i s t r i b u t e d throughout the w o r l d as w e a n i n g or supplementary f o o d s . Before these food m i x t u r e s are accepted for d i s t r i b u t i o n to the p u b l i c it m u s t be a s c e r t a i n e d that they are s a f e , n u t r i t i o u s and a c c e p t a b l e for human feeding. An elaborate testing procedure has been developed which includes human t e s t i n g in the final s t a g e . W H O is a s s u m i n g r e s p o n s i b i l i t y for the l a t t e r . Human testing i n c l u d e s the testing of a p r o d u c t for a c c e p t a b i l i t y and tolerance and the study of its n u t r i t i v e v a l u e by m e a n s of g r o w t h s t u d i e s , n i t r o g e n b a l a n c e a s s e s s m e n t s and o t h e r b i o c h e m i c a l tests in children. T h e m e t h o d o l o g y of the t e s t i n g is c o n s t a n t l y r e v i s e d in the light of the e x p e r i e n c e gained. In 1 9 6 6 t w o f o o d m i x t u r e s , C S M ( s o - c a l l e d b e c a u s e i t c o n t a i n s c o r n , s o y a a n d s k i m m i l k p o w d e r ) a n d S u p e r a m i n e (a f o o d m i x t u r e d e v e l o p e d i n A l g e r i a w h i c h c o n t a i n s h a r d w h e a t , c h i c k p e a s , l e n t i l s , s u g a r and skim m i l k ) w e r e tested in c h i l d r e n in A l g e r i a . L a r g e quantities of the f o r m e r m i x t u r e are b e i n g d i s t r i b u t e d t h r o u g h o u t the w o r l d by U N I C E F . S i n c e 1 9 6 7 five i n s t i t u t i o n s , l o c a t e d r e s p e c t i v e l y in C h i l e , C h i n a ( T a i w a n ) , E t h i o p i a , G u a t e m a l a , a n d I n d i a h a v e a g r e e d to c o l l a b o r a t e w i t h W H O in the p r o g r a m m e of h u m a n t e s t i n g . A c c e p t a b i l i t y a n d t o l e r a n c e t e s t s h a v e b e e n c o n d u c t e d s u c c e s s f u l l y i n E t h i o p i a (in a n i n s t i t u t i o n ) a n d i n I n d i a (in a v i l l a g e u n d e r n o r m a l e n v i r o n m e n t a l c o n d i t i o n s ) . Growth s t u d i e s are done in C h i n a (Taiwan) on infants and in C h i l e on p r e s c h o o l - a g e c h i l d r e n , and n i t r o g e n b a l a n c e studies are being performed in G u a t e m a l a . M o r e than 20 food m i x t u r e s h a v e been tested so far, m o s t of them s u c c e s s f u l l y . Some of them are p u r e l y e x p e r i m e n t a l , others are produced and m a r k e t e d on a large scale or are on the point of being so. 5.1.5
Nutrition and mental
development
W H O is supporting a study in Mexico on this important topic: the p r o j e c t has for objectives to d e t e r m i n e the r e l a t i o n s h i p s b e t w e e n m a l n u t r i t i o n , s o c i o - e c o n o m i c c o n d i t i o n s , i n t e l l e c t u a l l e v e l a n d s c h o o l i n g p e r f o r m a n c e in c h i l d r e n a g e d s e v e n to e i g h t y e a r s . Another large-scale s t u d y i s b e i n g c o n d u c t e d a t I N C A P in G u a t e m a l a t o e v a l u a t e t h e e f f e c t s o f f o o d s u p p l e m e n t a t i o n and m e d i c a l care on the physical growth performance and mental development of young c h i l d r e n . 5.2
Nutrition
and
infection
Investigations have been conducted w i t h W H O assistance in G h a n a , G u a t e m a l a , Israel and India. W h i l e one of t h e s e s t u d i e s w a s of an e x p e r i m e n t a l n a t u r e and d e a l t d i r e c t l y w i t h the e f f e c t s of a s c a r i s i n f e s t a t i o n in c h i c k e n s on the a b s o r p t i o n and u t i l i z a t i o n of n i t r o g e n from the i n t e s t i n a l tract, two o t h e r s w e r e c o n c e r n e d w i t h the c o n s e q u e n c e s of the u r b a n i z a t i o n process on the frequency of infectious diseases and of cases of m a l n u t r i t i o n . The fourth deals with the effects of food supplementation and/or comprehensive medical care, including c o n t r o l of infections on the growth and development of preschool-age c h i l d r e n .
A t INCAP, the e f f e c t of i n f e c t i o n s , p a r t i c u l a r l y of the g a s t r o - i n t e s t i n a l tract, on infant growth is being s t u d i e d . This investigation is being expanded to include the effects of intestinal flora as a w h o l e . T h e study has already resulted in s i g n i f i c a n t o b s e r v a t i o n s r e g a r d i n g the i m p o r t a n c e of e n v i r o n m e n t a l i m p r o v e m e n t and of s p e c i f i c p r o t e c t i v e m e a s u r e s against various infectious d i s e a s e s in improving the n u t r i t i o n a l status of c h i l d r e n . I n 1 9 7 1 , a c o n s u l t a t i o n w a s h e l d a t W H O t o p r e p a r e -plans f o r a c o l l a b o r a t i v e s t u d y o n t h e effects of malnutrition on the immune response. This study should provide some information of a practical nature concerning the implementation of immunization programmes during childhood in p o p u l a t i o n groups w h e r e m a l n u t r i t i o n is p r e v a l e n t . 5.3
Anthropometry
as r e l a t e d
to n u t r i t i o n a l
status
T h e l o n g - t e r m o b j e c t i v e of this study is c o n t i n u o u s s u r v e i l l a n c e of the n u t r i t i o n a l s t a t u s of the w o r l d ' s p o p u l a t i o n by the u s e of selected i n d i c a t o r s . It is e x p e c t e d t h a t , by c o n d u c t i n g p e r i o d i c s u r v e y s in p o p u l a t i o n g r o u p s s e l e c t e d a c c o r d i n g to g e n e t i c and s o c i o - e c o n o m i c c r i t e r i a in a l a r g e n u m b e r o f c o u n t r i e s , it w i l l be p o s s i b l e to e x p a n d p r o g r e s s i v e l y k n o w l e d g e of the trends of the n u t r i t i o n a l situation in large areas of the w o r l d . The methodology of these s u r v e y s , a s p r e p a r e d b y W H O w i t h t h e a s s i s t a n c e of: a c o n s u l t a n t , w a s t e s t e d i n a p i l o t s t u d y in Y u g o s l a v i a in 1 9 6 8 . S i n c e t h e n t h e m e t h o d o l o g y h a s b e e n r e v i s e d a n d a manual"^ p r o v i d e s g u i d e l i n e s f o r t h e conduct of anthropometric surveys. These are applied in several countries of the W e s t e r n Pacific Region. Some data h a v e already been collected and are being processed at p r e s e n t in WHO. 5.4
Hypovitaminosis
A
T w o research p r o j e c t s on the prevention of vitamin A d e f i c i e n c y w e r e c o n d u c t e d in J o r d a n (1963一1965) and in India ( 1 9 6 5 - 1 9 6 6 ) . In e a c h c a s e y o u n g c h i l d r e n r e c e i v e d o r a l l y a s i n g l e l a r g e d o s e o f v i t a m i n A ( 5 0 . 0 0 0 to 1 0 0 . 0 0 p g of v i t a m i n A ) . In J o r d a n , n o v i s i b l e c h a n g e i n the s e r u m levels of v i t a m i n A could be d e t e c t e d in the treated c h i l d r e n as c o m p a r e d w i t h the c o n t r o l s , n o r w a s t h e r e any d i f f e r e n t in the g r o w t h r a t e or in the f r e q u e n c y o r g r a v i t y of illnesses. In I n d i a , 2 5 0 0 c h i l d r e n b e t w e e n o n e a n d f i v e y e a r s o f a g e r e c e i v e d o n c e a y e a r a s i n g l e d o s e ( 5 0 0 0 0 一 1 0 0 ООО p g ) o f t h e p r e p a r a t i o n o f v i t a m i n A . A t the outset of the study eight to 10 p e r c e n t , of t h e c h i l d r e n s h o w e d o c u l a r s i g n s of v i t a m i n A d e f i c i e n c y . Taking into c o n s i d e r a t i o n the n u m b e r of children in each age-group w h o had xerosis of the c o n j u n c t i v a and B i t o t ' s s p o t s at the time of c o l l e c t i o n of the b a s e l i n e d a t a , the e x p e c t e d p r e v a l e n c e r a t e s of these two c l i n i c a l signs w e r e w o r k e d out for the n u m b e r of c h i l d r e n followed u p d u r i n g the first two years of the trial. It w a s o b s e r v e d t h a t t h e a c t u a l n u m b e r o f s u b j e c t s w h o s h o w e d the s i g n s d u r i n g the f o l l o w - u p w a s c o n s i d e r a b l y lower than the e x p e c t e d n u m b e r , and it w a s also significant that not a single case of keratomalacia was seen. H o w e v e r , studies by S . Pereira in South India w i t h a small w e l l - c o n t r o l l e d group of children have shown that increased serum levels of vitamin A were not maintained for more than 1 3 w e e k s w i t h o r a l d o s e s o f 1 0 0 0 0 0 yig v i t a m i n A p a l m i t a t e . The determination of the p e r i o d i c i t y of v i t a m i n A a d m i n i s t r a t i o n thus r e m a i n s for the m o m e n t an o p e n q u e s t i o n and m o r e investigations are n e e d e d .
Nutritional status of populations : a manual on anthropometric Document WH0/kuTR/70.129. WHO, Geneva, 1970.
appraisal of
trends.
5.5
Anaemias
T h e v a r i o u s aspects of this programme of research w e r e reviewed by a W H O s c i e n t i f i c group 1 i n 1 9 6 7 a n d a m e e t i n g o f i n v e s t i g a t o r s i n 1 9 7 1 ( r e p o r t to b e p u b l i s h e d ) . Three joint c o n s u l t a t i o n s w e r e also h e l d w i t h IAEA and some o f the investigators c o n c e r n i n g that p a r t of the r e s e a r c h p r o g r a m m e w h i c h deals m o r e s p e c i f i c a l l y w i t h iron absorption and iron fortification of food. Prevalence
studies
Surveys h a v e been c o n d u c t e d in A r g e n t i n a , B r a z i l , C o l u m b i a , G u a t e m a l a , India, Israel, M e x i c o , P e r u , P o l a n d , V e n e z u e l a , on s a m p l e s of p r e g n a n t a n d n o n - p r e g n a n t w o m e n in the r e p r o d u c t i v e age and adult m e n . I r o n d e f i c i e n c y a n d i r o n d e f i c i e n c y a n a e m i a w e r e f o u n d to b e f a i r l y f r e q u e n t in w o m e n and e s p e c i a l l y in p r e g n a n t women； f o l a t e d e f i c i e n c y w a s a l s o f r e q u e n t l y observed in the l a t t e r . In o n e s u r v e y i n I n d i a a l m o s t 1 0 0 p e r c e n t , o f p r e g n a n t w o m e n w e r e found to be iron deficient and approximately 50 per c e n t , of these were also folate d e f i c i e n t . A h i g h p r e v a l e n c e of i r o n d e f i c i e n c y in i n f a n t s a n d y o u n g c h i l d r e n h a s a l s o been o b s e r v e d in some other surveys. In c o n n e x i o n w i t h t h e s e c o l l a b o r a t i v e p r e v a l e n c e s t u d i e s , t w o r e f e r e n c e c e n t r e s h a v e b e e n e s t a b l i s h e d r e s p e c t i v e l y in L o n d o n and S e a t t l e , W a s h i n g t o n , U n i t e d S t a t e s o f A m e r i c a , to s t a n d a r d i z e m e t h o d s of m e a s u r e m e n t of h a e m o g l o b i n , i r o n , serum t r a n s f e r r i n , vitamin B12 and r e d - c e l l and serum f o l a t e . S t a n d a r d i z a t i o n of the m e t h o d o l o g y w a s r e q u i r e d to o b t a i n a c c u r a t e and c o m p a r a b l e data in all these studies. Iron a b s o r p t i o n and
availability
A s a l r e a d y i n d i c a t e d , this is a j o i n t I A E A / W H O p r o g r a m m e w h e r e i n W H O s u p p o r t s s t u d i e s in S w e d e n , S w i t z e r l a n d , T h a i l a n d , U n i t e d States of A m e r i c a and V e n e z u e l a . T h e a m o u n t of iron a b s o r b e d by the b o d y d e p e n d s on s e v e r a l f a c t o r s , i n c l u d i n g the t o t a l a m o u n t in the d i e t , its a b s o r b a b i l i t y and the r e g u l a t i o n of its a b s o r p t i o n by the b o d y . F a c t o r s a f f e c t i n g the a f f i n i t y of p r o t e i n s for iron and h e n c e the a v a i l a b i l i t y of the in f o o d s t u f f s h a v e b e e n s t u d i e d in S w i t z e r l a n d by i m m u n o c h e m i c a l m e t h o d s .
latter
T h e a b s o r p t i o n of i r o n from v a r i o u s f o o d s h a s been s t u d i e d in the U n i ted S t a t e s of A m e r i c a and Venezuela. In t h e f i r s t s t u d i e s t h e f o o d s w e r e b i o l o g i c a l l y t a g g e d w i t h i s o t o p i c i r o n a n d f e d to n o r m a l and i r o n - d e f i c i e n t s u b j e c t s , and the a b s o r p t i o n w a s d e t e r m i n e d f r o m t h e a m o u n t of r a d i o a c t i v i t y in the r e d - c e l l m a s s two w e e k s l a t e r . The subjects w e r e d i v i d e d into two g r o u p s - n o r m a l and iron d e f i c i e n t - e m p l o y i n g the c r i t e r i a of p e r c e n t a g e saturation of transferrin and absorption of ferrous iron; those individuals w h o had a saturation of t r a n s f e r r i n o f less t h a n 18 p e r c e n t , w e r e c o n s i d e r e d i r o n d e p l e t e d , as w e r e those w i t h an a b s o r p t i o n g r e a t e r than 2 5 per c e n t , from a d o s e o f 5 m g of iron as f e r r o u s s a l t . The studies c o n f i r m e d e a r l i e r findings that iron derived from plant sources was less w e l l absorbed than that from animal foods, even in iron-depleted s u b j e c t s . In n o r m a l s u b j e c t s , a b s o r p t i o n f r o m v e g e t a b l e f o o d s s u c h as c o r n and w h e a t w a s l e s s t h a n f i v e p e r cent.； on the o t h e r h a n d , a b s o r p t i o n from m e a t and fish p r o d u c t s w a s b e t w e e n 10 per c e n t , and 20 p e r c e n t . L a t e r studies h a v e also indicated that an e x t r i n s i c iron tag w i l l p r o v i d e , at a great s a v i n g of labour and c o s t , as a c c u r a t e results as the biological (intrinsic) tag p r e v i o u s l y used. T h i s is an i n v a l u a b l e tool in the s t u d y o f the a b s o r p t i o n of i r o n from w h o l e m e a l s . I n t e r a c t i o n b e t w e e n d i f f e r e n t d i e t a r y c o n s t i t u e n t s a f f e c t s iron a b s o r p t i o n as m e a s u r e d for each constituent of the d i e t . Meat increases the absorption of iron from a n u m b e r of sources (maize, blackbeans)； the a d m i n i s t r a t i o n of ascorbic acid increases absorption from n o n - h a e m food, w h i l e phytates and eggs cause a marked reduction. 1
Nutritional
1968, N o .
405.
a n a e m i a s , r e p o r t o f a W H O s c i e n t i f i c g r o u p , W l d H l t h O r g , t e c h n . R e p , Ser,，
Preventive
and t h e r a p e u t i c
trials
Pregnancy, lactation. T h e o b j e c t i v e of n u t r i e n t s u p p l e m e n t a t i o n d u r i n g t h i s p e r i o d is to e n s u r e the o p t i m a l h e a l t h of m o t h e r and c h i l d . This implies the m e e t i n g of the additional n u t r i t i o n a l r e q u i r e m e n t s i m p o s e d by p r e g n a n c y and l a c t a t i o n and the c o r r e c t i o n of any p r e existing deficiencies. T w o W H O - s u p p o r t e d studies h a v e been conducted in India, in N e w Delhi and in V e l l o r e , f o r the p u r p o s e of d e t e r m i n i n g the o p t i m a l d o s e s of h a e m a t i n i c s to b e g i v e n to mothers during those periods. On the b a s i s of p r e l i m i n a r y r e s u l t s and of s o m e o t h e r s t u d i e s c o n d u c t e d in M e x i c o and Israel, it w a s stated by the 1971 m e e t i n g of i n v e s t i g a t o r s on n u t r i t i o n a l a n a e m i a s that " T h e v a r i a t i o n s in the d i e t a r y i n t a k e of iron and in iron s t o r e s , in d i f f e r e n t p o p u l a t i o n g r o u p s , m a k e i t n e c e s s a r y to r e c o m m e n d i r o n s u p p l e m e n t a t i o n a t d i f f e r e n t çiosage levels. In w o m e n i n w h o m m o r e t h a n 2 5 p e r c e n t , o f t h e c a l o r i c i n t a k e c o m e s f r o m a n i m a l sources and w h o h a v e iron stores at the b e g i n n i n g of p r e g n a n c y , a daily s u p p l e m e n t of 30 m g of i r o n is s u f f i c i e n t to m a i n t a i n o p t i m a l h a e m o g l o b i n c o n c e n t r a t i o n s . H o w e v e r , there is evidence that those c o n d i t i o n s s e l d o m e x i s t , even in d e v e l o p e d c o u n t r i e s , and i t is p r o b a b l e that a d a i l y s u p p l e m e n t of 60 m g iron is d e s i r a b l e . In c o u n t r i e s w h e r e l e s s t h a n 1 0 p e r c e n t , o f calories come from foods of animal origin, iron deficiency is prevalent and many w o m e n are a n a e m i c at the c o m m e n c e m e n t of p r e g n a n c y . S u p p l e m e n t a t i o n w i t h h i g h e r amounts of iron is t h e r e f o r e r e q u i r e d and it is r e c o m m e n d e d that the d o s a g e of iron in s u c h c i r c u m s t a n c e s s h o u l d be f r o m 1 2 0 to 2 4 0 m g p e r d a y . In a d d i t i o n t o i r o n , a l l g r o u p s o f p r e g n a n t w o m e n s h o u l d r e c e i v e s u p p l e m e n t s o f f o l i c a c i d o f a b o u t 5 0 0 jig d a i l y . M o r e f o l a t e m a y be n e c e s s a r y in s e v e r e folate deficiency or in m u l t i p l e p r e g n a n c i e s . Supplementation with both iron and folic acid s h o u l d s t a r t as e a r l y as p o s s i b l e d u r i n g p r e g n a n c y and s h o u l d c o n t i n u e till the end of 1 lactation.' General population, A study on fortification of fish sauce w i t h iron EDTA (ethylene-diaminot e t r a a c e t a t e ) is b e i n g c a r r i e d o u t at p r e s e n t in T h a i l a n d . Fish sauce is w i d e l y c o n s u m e d in t h a t c o u n t r y a n d o f t e n r e p l a c e s s a l t in t h e d i e t . Preliminary trials have indicated that the a b s o r b a b i l i t y o f the i r o n a d d e d to the f i s h s a u c e w h e n c o n s u m e d t o g e t h e r w i t h a m e a l is approximately five per cent. T h e e f f e c t s of this f o r t i f i c a t i o n are b e i n g s t u d i e d at p r e s e n t in two villages of T h a i l a n d o v e r a period of one y e a r . In v i e w o f t h e h i g h p r e v a l e n c e o f i r o n d e f i c i e n c y i n t h e w o r l d , i t i s p r o p o s e d t o c o n c e n trate efforts on this aspect of research, which deals more specifically with prevention and therapy. E f f o r t s w i l l t h e r e f o r e b e m a d e to s t i m u l a t e m o r e r e s e a r c h a c t i v i t i e s in this f i e l d and to test any a p p r o a c h u n d e r v a r i o u s e n v i r o n m e n t a l c o n d i t i o n s • 5.6
Tropical
sprue
T r o p i c a l s p r u e is fairly p r e v a l e n t in s o m e areas of S o u t h « E a s t A s i a and of L a t i n A m e r i c a . A s t u d y c o n d u c t e d in South India ( V e l l o r e ) i n d i c a t e s that in this area t r o p i c a l s p r u e o c c u r s in both endemic and epidemic forms. One hundred endemic cases have been studied in d e t a i l , three village e p i d e m i c s have been investigated and valuable clinical and e p i d e m i o l o g i c a l data have been obtained. A t t e m p t s to i s o l a t e b a c t e r i a l o r v i r a l a g e n t s f r o m e p i d e m i c c a s e s h a v e so far been u n s u c c e s s f u l , isolation rates being the same in patients and in a c o n t r o l population. 5.7
Endemic
goitre
A r e s e a r c h p r o j e c t is b e i n g s p o n s o r e d by the W H O R e g i o n a l O f f i c e f o r the A m e r i c a s in E c u a d o r and P e r u to i n v e s t i g a t e the s a f e t y and e f f i c a c y of i n j e c t i o n s of i o d i z e d o i l in the c o n t r o l of e n d e m i c g o i t r e . This method has already been used by independent investigators in s o m e o t h e r c o u n t r i e s b u t m u c h i n f o r m a t i o n is s t i l l n e e d e d o n the l e v e l s of i o d i n e to be u s e d and the p e r i o d i c i t y of a d m i n i s t r a t i o n .
5.8
Rickets
T h i s d e f i c i e n c y is s t i l l f a i r l y p r e v a l e n t in m a n y d e v e l o p i n g c o u n t r i e s w h e r e , a l t h o u g h t h e r e is n o l a c k of s u n s h i n e , c h i l d r e n a r e n o t e x p o s e d to the sun b e c a u s e of s o c i a l c u s t o m s . A team o f c o n s u l t a n t s h a s s t u d i e d in A l g e r i a and T u n i s i a the f e a s i b i l i t y , s a f e t y and e f f i c a c y of m e t h o d s of m a s s c o n t r o l of r i c k e t s in c o u n t r i e s w h e r e food f o r t i f i c a t i o n w i t h v i t a m i n D is not p r a c t i c a b l e at p r e s e n t . 5.9
Budget of research Funds
available
programme
for the implementation Assistance 1965 1966 1967 1968 1969 1970 1971
of this research programme have
to m e d i c a l
research
$
122
000
- $ ，$ $
53
500
144
000
184
000
一
一
麵$ 一
$
$
Special account for medical 1965 1966 1967 1968 1969 1970 1971
6.
POSSIBLE LINES OF FUTURE
$ $ $ $ $ $ $
29 5 22 21 24 31 29
been as follows :
research
519 200 320 580 825 240 529
ACTION
F r o m w h a t has b e e n said in this r e p o r t , it is clear that the s c o p e of W H O a c t i v i t i e s is i n c r e a s i n g at great s p e e d .
nutrition
From the period when nutrition was considered to be just a welfare activity, we are now p a s s i n g i n t o one w h e n n u t r i t i o n w i l l form part of the socio-economic d e v e l o p m e n t p l a n s of countries. C o m p l e m e n t a r y a p p r o a c h e s will p r o b a b l y be n e c e s s a r y in the f u t u r e . Nutrition programmes are becoming more complex and co-ordination more difficult but essential. More use will be m a d e in t h e future of m a t h e m a t i c a l m o d e l s , systems a n a l y s i s , operational research and other m a t h e m a t i c a l instruments than in the p a s t . However, difficulties may be anticipated because of t h e g r e a t n u m b e r of v a r i a b l e s i n v o l v e d in n u t r i t i o n a l p r o b l e m s . W h a t is i m p o r t a n t for W H O in t h i s c o n n e x i o n is to d e f i n e its r e s p o n s i b i l i t i e s in t h e field of n u t r i t i o n . Mention h a s a l r e a d y b e e n m a d e in t h i s p a p e r of t h e p o s s i b i l i t i e s and l i m i t a t i o n s • It s h o u l d a l s o b e p o s s i b l e in the future to identify w i t h m o r e p r e c i s i o n most of the areas in w h i c h W H O has a primary responsibility. F u t u r e a c t i o n m a y t a k e s o m e of t h e f o l l o w i n g
forms.
1•
Evaluation
of p a s t and p r e s e n t
activities
Until now two specific activities have already been evaluated： the training programmes 2 (10 years ago) and the applied n u t r i t i o n p r o g r a m m e s (five years a g o ) , both in co-operation with FAO and U N I C E F . ‘
1
A d e t a i l e d e x a m i n a t i o n of the r e s u l t s of W H O w o r k in o t h e r a r e a s is n e c e s s a r y . Among others m e n t i o n m u s t be m a d e of the o r i e n t a t i o n of research a c t i v i t i e s . W H O e x p e c t s in 1972 to convene two or three consultants to evaluate the present orientation and to suggest new a r e a s of r e s e a r c h . The subject will be discussed later in the A d v i s o r y Committee on Medical Research. O t h e r a r e a s o f W H O a c t i o n w h i c h r e q u i r e m o r e d e t a i l e d e v a l u a t i o n are： (a) the assistance g i v e n t o g o v e r n m e n t s , p a r t i c u l a r l y in t h e f i e l d s of e p i d e m i o l o g i c a l s t u d i e s , (b) n u t r i t i o n a l a c t i v i t i e s in h e a l t h s e r v i c e s , a n d (c) n e w e v a l u a t i o n of t r a i n i n g p r o g r a m m e s . 2.
Standardization
of f o r m s
for period
surveillance
of the n u t r i t i o n a l
status
of
populations
W H O assistance in epidemiological nutritional studies has to be to some d e g r e e uniform in o r d e r to f a c i l i t a t e the t a s k of W H O c o n s u l t a n t s and m a k e it p o s s i b l e to a t t a i n a c o m p a r a b l e presentation. T h e i n i t i a t i v e t a k e n by W H O in a n t h r o p o m e t r i c a l s t u d i e s s h o u l d be e x p a n d e d to include o t h e r p a r a m e t e r s , such as c l i n i c a l and b i o c h e m i c a l . 3.
Cost-benefit
studies
T h e n u m b e r of a l t e r n a t i v e w a y s of s o l v i n g or a l l e v i a t i n g m a l n u t r i t i o n a r e so g r e a t that it is i n d i s p e n s a b l e to m a k e the c o s t - b e n e f i t a s s e s s m e n t of each of t h e m , or p e r h a p s of a g r o u p of t h e m , e v e n t h o u g h such s t u d i e s are c o m p l e x and c o s t l y . 4•
Intensification
of studies on the effect of malnutrition
on human
development
T h e s a t i s f a c t o r y p h y s i c a l , f u n c t i o n a l a n d s o c i a l d e v e l o p m e n t o f h u m a n b e i n g s is the f o u n d a t i o n of W H O h e a l t h p o l i c y . M a l n u t r i t i o n a f f e c t s all t h r e e l e v e l s of d e v e l o p m e n t and i n t e n s i f i c a t i o n of the s t u d y of the r e l a t i o n s h i p b e t w e e n them is u r g e n t l y r e q u i r e d . This i n c l u d e s the i m p a c t of m a l n u t r i t i o n on p r o d u c t i v i t y . 5.
Development
of conventional
and non-conventional
protein
foods
This programme which has already been in operation for several y e a r s , will require to be i n t e n s i f i e d in c o l l a b o r a t i o n w i t h o t h e r i n t e r n a t i o n a l a g e n c i e s , and b a s e d on the r e c o m m e n d a tions m a d e by P A G . 6•
Food
and nutrition
policy
It is c l e a r f r o m t h e r e p o r t t h a t it is n o t e a s y t o d e f i n e t h e c o n t e n t a n d o p e r a t i o n of W H O should intensify its efforts to d e f i n e the resa national food and nutrition p o l i c y , p o n s i b i l i t i e s of t h e h e a l t h s e c t o r in t h e d e t e r m i n a t i o n of s u c h p o l i c i e s •
1
R e p o r t of A J o i n t W H 0 / F A 0 / U N I C E F
s u r v e y of
education.
о Assessment Economic
of a p p l i e d n u t r i t i o n p r o j e c t s , R e p o r t by J . M . H u n d l e y , U n i t e d
and Social
Council, 1966, document
e/icEf/l.1266*
Nations,
7•
Manpower
studies and intensification
of t r a i n i n g
programme 1
T h e recent report on the d e v e l o p m e n t of studies in h e a l t h m a n p o w e r w i l l f a c i l i t a t e the t a s k of s p e c i f i c s t u d i e s in m a n p o w e r in t h e f i e l d of n u t r i t i o n and w i l l p r o v i d e a good b a s i s for a n y r e o r g a n i z a t i o n of the t r a i n i n g p r o g r a m m e s for the f u t u r e . 8.
Studies on nutrition and family
planning
T h i s t o p i c is of i n c r e a s i n g i m p o r t a n c e in m a n y n a t i o n a l p r o g r a m m e s • There are indicat i o n s of a s t a t i s t i c a l c o r r e l a t i o n between, t h e n u m b e r of p r e g n a n c i e s a n d m a t e r n a l a n d i n f a n t malnutrition which requires further study. T h e i n f l u e n c e of c o n t r a c e p t i v e m e t h o d s on lactation performance should also be studied. 9•
Relationship between nutrition and non-infectious
disease
W h i l e it is e s s e n t i a l to i n t e n s i f y w o r k on the c l a s s i c a l n u t r i t i o n a l d i s e a s e s and on the i n t e r a c t i o n b e t w e e n m a l n u t r i t i o n and i n f e c t i o u s d i s e a s e s , t h e r e is a c l e a r n e e d to v i e w the p r o b l e m o f n u t r i t i o n f r o m t h e w i d e r p e r s p e c t i v e of i t s f u t u r e r o l e i n m e d i c i n e a n d p u b l i c health. There are many clinical conditions whose etiology and pathogenesis are obscure, w h o s e t r e a t m e n t is e m p i r i c a l a n d w h o s e p r e v e n t i o n is n o t y e t p r a c t i c a b l e . Among the condit i o n s t o w h i c h m o r e a t t e n t i o n s h o u l d b e g i v e n a r e d i a b e t e s , o s t e o p o r o s i s , b l a d d e r s t o n e s in c h i l d r e n , the a g i n g p r o c e s s , a n d t h e i n f l u e n c e of d i e t a r y h a b i t s on a t h e r o s c l e r o s i s from e a r l y infancy on. 10.
Fortification
of
foods
The last Joint FAO/WHO Expert Committee on Nutrition^ made recommendations i n t o t h e p r a c t i c a ] a p p l i c a t i o n of food f o r t i f i c a t i o n p r o g r a m m e s .
on
research
In v i e w of the g r e a t p u b l i c h e a l t h s i g n i f i c a n c e of a n a e m i a s and x e r o p h t h a l m i a , i n t e n s i f i e d e f f o r t s s h o u l d b e m a d e on t h e f e a s i b i l i t y of f o r t i f i c a t i o n of foods w i t h i r o n a n d vitamin A .
T h e i m p l e m e n t a t i o n of the a b o v e suggestions w i l l depend on the interest of the g o v e r n m e n t s and W H O g o v e r n i n g b o d i e s , and also on the new d e v e l o p m e n t s which m a y occur in the near f u t u r e in the field of a g r i c u l t u r e , food t e c h n o l o g y , public h e a l t h , e t c . Such developments m a y c h a n g e the n u t r i t i o n a l s i t u a t i o n , and the a p p r o a c h e s m a y then be d i f f e r e n t •
i
Wld Hlth Org, techn. Rep, Ser., 1971, N o .
481.
•
Joint F A O / W H O E x p e r t C o m m i t t e e on N u t r i t i o n , eighth report Rep. Ser., No.
477.
(1971) Wld Hlth O r g ,
techn,
TRAINING COURSES SPONSORED BY INTERNATIONAL
AGENCIES
In t h i s t a b l e , t h e s u c c e s s i v e c o l u m n s indicate： (1) the p l a c e w h e r e t h e c o u r s e is h e l d and t h e i n s t i t u t i o n ( s ) o r g a n i z i n g it; (2) the s p o n s o r i n g agencies; (3) the d u r a t i o n of the c o u r s e ; (4) its t e c h n i c a l o r i e n t a t i o n ; (5) the r e q u i r e m e n t s for admission; ( 6 ) t h e l a n g u a g e i n w h i c h t h e l e c t u r e s a r e d e l i v e r e d (E： E n g l i s h ; F: F r e n c h ； P： P o r t u g u e s e ; S： Spanish).
CERTIFICATE
COURSE
IN F O O D S C I E N C E A N D A P P L I E D
8 months (January-August)
UNICEF/WHO/FAO
Ibadan
NUTRITION
University
Multi-disciplinary training with emphasis on dietary s u r v e y s , p r e p a r a t i o n of applied nutrition programmes, nutrition education, p l a n n i n g of national food policies
Degree in m e d i c i n e , science, agriculture, veterinary medicine and home economics• Workers who, while not graduates, have suitable general and technical education and practical experience
AMRO CENTRO REGIONAL DE CAPACITACION EN ECONOMIA Y NUTRICION APLICADA： Bogotá Universidad Nacional de Colombia Instituto Nacional de Nutrición
SUMMER
COURSE
(Certificate)
WHO-PAHO/UNICEF
8 weeks
Physicians with a degree in public h e a l t h , or at l e a s t t w o y e a r s of experience and responsibility in a public health programme or one year academic training in n u t r i t i o n .
E
35
Intensive theoretical and practical training in n u t r i t i o n as applied to public health. Emphasis on nutritional problems prevalent in underdeveloped countries.
Ею办9/З0
IN P U B L I C H E A L T H N U T R I T I O N
T r a i n i n g of： h i g h l e v e l Course intended mainly executive personnel, for economists and u n i v e r s i t y teachers to agronomists d e v e l o p p r o g r a m m e s of applied nutrition and teaching of human n u t r i t i o n in f a c u l t i e s of a g r i c u l t u r e , veterinary science, agricultural economics, etc•
рртое
City
5 months
ANNEX 1
Guatemala INCAP
UNICEF/WHO-PAHO/FA0
CRECENA
BACHELOR DEGREE Guatemala INCAP
IN
NUTRITION
Escuela de nutrición Universidad de San Carlos
MASTER
y
IN N U T R I T I O N A N D P U B L I C
Guatemala INCAP
COMMUNITY NUTRITION
Kingston
FAO/WHOHPAHO
1
variable
WHOPAHO
EN
12 m o n t h s , of w h i c h 2 w i l l be spent in
INTERNACIONAL DE NUTRI CAO EM SAUDE PUBLICA
University
education
pedagogy, economics, tion, public
health,
mathematics,
English
Degree
medicine
nutri^
WHO-PAHO
in
in
2
T h e o b j e c t i v e of the c o u r s e s is to w i d e n the p e r s p e c t i v e s of t h o s e already working in some nutrition related activity so that they m a y be able to e m p h a s i z e the interd i s c i p l i n a r y a s p e c t s of n u t r i t i o n in t h e i r w o r k a n d their teaching.
Courses intended for university graduates or persons with appropriate professional qualifications and cons i d e r a b l e e x p e r i e n c e in their field
T r a i n i n g of personnel p a r t i c i p a t i n g in p l a n n i n g , e x e c u t i o n of n u t r i t i o n p r o g r a m m e s in p u b l i c h e a l t h and in t e a c h i n g and research activities related to such programmes
U n i v e r s i t y d e g r e e (of at least four years duration) and at least two y e a r s of a c t i v i t y in the f i e l d s of applied nutrition, MCH, public health
Intensive course in theoretical and practical aspects of nutrition as related to public h e a l t h
Degree in m e d i c i n e (medical officers from public health services, teachers in m e d i c a l colleges)
NUTRICION
field work. (Begins in A u g u s t . )
Sao Paulo
Secondary
sciences,
COURSES
M A E S T R I A E N C I E N C I A S D E L A S A L U D СШ C O N C E N T R A C I O N
CORSO
biology,
chemistry, social
Emphasis on practical p r o b l e m s of n u t r i t i o n public health
year
Caribbean Food and Nutrition Institute, U n i v e r s i t y of the West Indies
Puerto Rico Escuela de medicina
Curriculum：
HEALTH
WHO-PAHO
City
INTERDISCIPLINARY
4 years, the last b e i n g s p e n t in field work： 6 m o n t h s in applied nutrition, 6 months in institutional feeding
WHO-PAHO
City
(Certificate) months
(March-April)
EMRO R E G I O N A L T R A I N I N G C O U R S E ON F O O D A N D N U T R I T I O N Beirut American University
UNICEF/FAO/WHO
C O U R S E IN FOOD A N D A P P L I E D N U T R I T I O N Jerusalem Hebrew University Hadassah Medical School
I n s t r u c t i o n in the b a s i c p r i n c i p l e s of food and n u t r i t i o n w i t h e m p h a s i s on practical aspects. During the last two w e e k s the p a r t i c i p a n t s from each c o u n t r y w i l l s t u d y the p a r t i c u l a r s i t u a t i o n of their c o u n t r y
H o l d e r s of s e n i o r a p p o i n t m e n t s in m i n i s tries of a g r i c u l t u r e , education, planning, social affairs/ community development, h e a l t h , r e s p o n s i b l e for the e x e c u t i o n of g o v e r n m e n t a l a c t i o n s in the fields of food and nutrition
6 months plus 1 m o n t h of field w o r k in A f r i c a
T r a i n i n g in the field of food and applied n u t r i t i o n , m i d d l e level p e r s o n n e l
Candidates should have c o m p l e t e d 12 y e a r s of f o r m a l e d u c a t i o n and (alternatively) should have at least 2-3 years of e x p e r i e n c e in n u t r i tion, health education or c o m m u n i t y d e v e l o p m e n t
3 months (December to end February)
O v e r a l l view of n u t r i t i o n a l p r o b l e m s in r e l a t i o n to socio—cultural economic factors, particularly m e d i c i n e and p u b l i c h e a l t h
D e g r e e in m e d i c i n e , preferably with post" graduate qualifications, or d i p l o m a s such as M . S c ” D.P.H., Ph.D., etc.
9 months (June-February)
T r a i n i n g in theory and p r a c t i c e of n u t r i t i o n , E m p h a s i s on p r a c t i c a l aspects
D e g r e e in m e d i c i n e or in s c i e n c e , p r e f e r a b l y with post-graduate qualification
T h e s e c o u r s e s should g i v e a b a c k g r o u n d in applied n u t r i t i o n to p e r s o n n e l from the d e p a r t m e n t s of h e a l t h , e d u c a t i o n and a g r i c u l t u r e
T h e r e are two d i f f e r e n t t y p e s of c o u r s e s i n t e n d e d for m e d i u m level and for h i g h e r level personnel respectively
8 weeks (July-August 1 9 7 0 )
(Certificate)
W i t h the c o l l a b o r a tion of F A O / W H O
SEARO A N N U A L C E R T I F I C A T E C O U R S E IN N U T R I T I O N Hyderabad N a t i o n a l Institute of N u t r i t i o n
WHO/UNICEF
M A S T E R OF S C I E N C E (APPLIED N U T R I T I O N ) Hyderabad N a t i o n a l Institute of N u t r i t i o n
WHO/UNICEF
WPRO
short c o u r s e s
E&F
Его办9/wo
WHO/FAQ/UNICEF/SPC
fîage 37
South P a c i f i c
Annex M
A P P L I E D N U T R I T I C N E D U C A T I O N A N D T R A I N I N G PROJECT
EB49/30 page
38
ANNEX
2
P A G L I S T OF A D H O C W O R K I N G GROUPS A N D OF D O C U M E N T S
PAG ad hoc w o r k i n g
protein
Remarks
1.
Single
2.
Feeding
3.
Marketing
4.
F e a s i b i l i t y of fish一protein c o n c e n t r a t e s developing countries (Nov. 1970)
5.
Single
6.
Feeding the pre-school
7.
Milk intolerance: (Oct. 1971)
PAG
cell
groups (April
the pre-school
protein
1970)
child
of protein-rich
cell
ISSUED
(June
(Sept.
foods
1970)
(Nov.
1970)
for
1971)
child
statement was
A
technical report was
developed issued
A guideline and issued
two statements
A guideline and issued
a statement
Report
(Oct.
nutritional
A
in
were
were
preparation
1971)
implications
publications Lives
in peril :
protein and the child.
Marketing of protein-rich Bo Wickstrom.
in d e v e l o p i n g
prepared
by
countries.
FAO.
1971;
prepared
H o m e - m a d e w e a n i n g foods for infants and young children： a countries. Cameron & Hofvander； ready for publication.
manual for
Processed protein of p r e p a r a t i o n .
Miss E . Orr;
Protein problem List
foods
1970;
of most recent
Statement
foods for use in d e v e l o p i n g
in developing c o u n t r i e s . PAG statements
and
countries.
Professor Aylward；
by
developing
in draft
final
stages
stage.
guidelines
Title
Date
3
PAG Statement
on the n a t u r e
4
PAG Statement
on single cell
5
PAG Statement
on the m a r k e t i n g and distribution
PAG Recommendation malnutrition 8
PAG Statement
9
PAG Recommendation
and m a g n i t u d e of the p r o t e i n
1971
protein
on prevention
on p l a n t
problem
of food
improvement
on amino acid
1970 of p r o t e i n - r i c h
losses and
by genetic
protein-calorie
means
fortification
of
foods
1969
1970
PAG Statement needs
13a
R e v i e w of the s p e c i f i c p r o p o s a l s c o n t a i n e d in A C A S T r e p o r t "International Action to Avert the Impending Protein Crisis", United Nations, 1968
research
1971
1970
12
on t h e w o r l d p r o t e i n problem：
foods
and
development
1971
1971
Guideline No^
Title
Date
2
PAG Guideline
for preparing food-quality
4
PAG Guideline
for preparation
5
PAG Guideline
for edible, heat-processed
6
PAG Guideline
for pre-clinical
7
PAG Guideline
for human t e s t i n g of s u p p l e m e n t a r y
8
PAG Guideline on protein-rich mixtures
9
PAG Guideline on fish protein
10
cottonseed protein
of e d i b l e
soy
grits and
food
Title
1
Field
2
E v a l u a t i o n of a n u t r i t i o n action
3
Microbiological
4
F e a s i b i l i t y of F P C for d e v e l o p i n g
5
Milk
6
Textured vegetable
t r i a l of a n o v e l or u n t r i e d
1970 1971
foods
f o o d s iri d e v e l o p i n g
food programme
countries
1970
1971
standards for protein-rich dry
proteins
protein
concentrate
No.
1970 1969
mixtures
for use as w e a n i n g
preparation
substitutes
concentrate
flour
t e s t i n g of n o v e l sources of
P A G G u i d e l i n e o n :m a r k e t i n g o f p r o t e i n - r i c h
Other guidelines and statements in
1970
groundnut flour
foods
countries
1971
АШЕХ 3
ESSENTIAL ELEMENTS OF A C T I O N T O AVERT 1 T H E P R O T E I N C R I S I S IN D E V E L O P I N G C O U N T R I E S
Balance
the effects
Improve
thç nutritive
Expand
of t h e green
value of cereal
Prevention and home•
of animal
of u n n e c e s s a r y
through
production,
genetic engineering
pulse, legume and oilseed
foods in field
from marine and freshwater fishery
and promotion
science and technology
(breeding)«
crops.
proteins.
loss of p r o t e i n - c o n t a i n i n g
Increased protein production Development, distribution
on overall protein
proteins
research to develop high yielding
Increase the production
Apply
revolution
of f o r m u l a t e d p r o t e i n
to the d e v e l o p m e n t
of new protein
storage,
transport
resources.
foods. sources.
D e v e l o p and support regional and n a t i o n a l centres for research and training in tural technology, food science, food technology and n u t r i t i o n . Conduct
informational
and educational
Improv© protein utilization including parasitosis.
campaigns.
through the control and prevention
of infectious
Governments should review and improve policies and legislation and regulation all a s p e c t s of food and p r o t e i n p r o d u c t i o n , p r o c e s s i n g and m a r k e t i n g so as to unnecessary obstacles and encourage appropriate activities. Give special attention Intervention
1
to the protein needs of vulnerable
diseases
regarding remove
groups.
considerations.
Recognize the important protein problem. Recognize problem.
agricul-
relationships
between family size, population growth and
t h e r o l e of e c o n o m i c d e v e l o p m e n t and s o c i a l m o d e r n i z a t i o n
the
in s o l v i n g the
Source： S t r a t e g y statement on action to a v e r t the protein crisis in the countries, United Nations, New York, 1971, Publication E.71 II.A.17.
protein
developing
ANNEX
W H O A N D W H O - S P O N S O R E D P U B L I C A T I O N S IN THE OF NUTRITION FROM 1965 NUTRITION,
4
FIELD
GENERAL
Joint FAQ/WHO Expert Committee on
Nutrition:
Seventh R e p o r t , Wld Hlth O r g , t e c h n . R e p . Ser., 1967, N o . 377 Eighth Report, Wld Hlth Org# techn. R e p . S e r " 1971, N o . 477 WHO Activities in nutrition, 1948-1964, W H O , Geneva, 1965 1 9 , 3 8 7 - 3 9 6 , 4 2 9 - 4 4 3 and 4 6 7 - 4 7 6 ) Human n u t r i t i o n in tropical A f r i c a by M . C . L a t h a m . N u t r i c i ó n h u m a n a , b y В. T . B u r t o n Washington, 1966
(Reprint
FAO, Rome,
from WHO Chronicle, “
1965,
1965
( t r a n s l a t i o n o f H e i n z H a n d b o o k o f N u t r i t i o n ) РАНО,
The h e a l t h aspects of food and n u t r i t i o n . A m a n u a l for d e v e l o p i n g c o u n t r i e s in the P a c i f i c R e g i o n of the World H e a l t h O r g a n i z a t i o n . WPRO, Manila, 1969
Western
The m e d i c a l r e s e a r c h programme of the World H e a l t h O r g a n i z a t i o n , 1 9 6 4 - 1 9 6 8 , Report by Director-General. Nutritional Diseases, pp. 209-222л WHO, Geneva, 1969 Conquest of deficiency diseases, by W . R . Aykroyd. study N o . 24. WHO, Geneva, 1970
Freedom from Hunger Campaign,
Regional Food and Nutrition Seminar, Beirut, 26-29 January RNTP/RFNS/23/Rev.1, AUB, Beirut, 1970
1970, Report,
the
basic
Document
Periodicals B u l l e t i n of the P r o t e i n Advisory G r o u p , N e w Y o r k , United States of C a j a n u s , n e w s l e t t e r o f the C a r i b b e a n Food and N u t r i t i o n
America.
Institute, Kingston,
Jamaica
Food and N u t r i t i o n in A f r i c a , News B u l l e t i n of the Joint F A O / W H O / O A U - S T R C Regional Food N u t r i t i o n C o m m i s s i o n for A f r i c a , A c c r a , G h a n a
and
Others R e c o p i l a c i o n e s d e la p u b l i c a c i o n e s c i e n t í f i c a s del I n s t i t u t o de N u t r i c i ó n d e C e n t r o A m e r i c a y Panama. First edition in 1953, second in 1955, third in 1959, fourth in 1962 and fifth in 1966 FOOD AND NUTRITION
POLICY
E l e m e n t s o f a f o o d a n d n u t r i t i o n p o l i c y i n L a t i n A m e r i c a , R e p o r t o f а РАНО T e c h n i c a l m e e t i n g , РАНО, S c i e n t i f i c p u b l i c a t i o n N o . 1 9 4 , W a s h i n g t o n , 1 9 7 0 ASSESSMENT OF NUTRITIONAL
group
STATUS
T h e a s s e s s m e n t of the nutritional M o n o g r . S e r . , 53, 1966
s t a t u s o f t h e c o m m u n i t y , b y D . В. J e l l i f f e , W l d H l t h
Org.
N u t r i t i o n a l s t a t u s of populations： WH0/NUTR/70.129.
a manual on anthropometric
a p p r a i s a l of
trends；
REQUIREMENTS Protein requirements, Report of a joint FAO/WHO Expert G r o u p . 1965, N o . 301
Wld Hlth Org, techn. Rep,
Requirements of vitamin A , thiamine, riboflavine and niacin, Report of a Joint FAO/WHO Group. Wld Hlth O r g , t e c h n . R e p , Ser., 1967, N o . 362 R e q u i r e m e n t s of ascorbic a c i d , vitamin D , vitamin B ^ ^ , folate and iron, Report of a FAO/WHO Expert Group. Wld Hlth Org, techn. Rep, S e r ” 1970, N o . 452 PROTEIN-CALORIE
Ser.,
Expert
Joint
MALNUTRITION
N a r a i n , В. & S a i , F . T . document, June, 1967
(1967) Nutrition problems of peri-urban
FAO /WHO Inter-secretariat G e n e v a , 27-31 May 1968
areas, WHO/HQ
mimeographed
m e e t i n g on n u t r i t i o n problems of u r b a n and peri-urban a r e a s ,
Report,
B e n g o a , J . M . (1969) Recent trends in public health nutrition, protein-calorie malnutrition. Paper p r e s e n t e d at the E i g h t h International C o n g r e s s of N u t r i t i o n , P r a g u e , A u g u s t — September 1969. Excerpta Medica International Congress Series, N o . 213, 14, 1970 D e m a , I. S . & Den H a r t o g , A . P . (1969) Urbanization and dietary change in tropical A f r i c a , Special paper No. 5, Joint FAO/WHO/OAU-STRC Regional Food and Nutrition Commission for Africa WHO Activities in the field of protein D o c u m e n t Нити/то.1, 1 9 7 0
(-calorie) malnutrition, WHO report
to
ACAST.
Inter-regional Seminar on epidemiology, prevention and treatment of protein-calorie Nairobi, 10-22 November 1969, Report. WHO, Geneva, 1970. D o c u m e n t Мити/тол HYPOVITAMINOSIS
malnutrition,
A
M c L a r e n , D . S . , O o m e n , H , A . P . С. & E s c a p i n i , H . ( 1 9 6 6 ) O c u l a r m a n i f e s t a t i o n s deficiency in man, Bull, Wld Hlth O r g . , 34, 357
of
vitamin-A
H i p o v i t a m i n o s i s A en las A m e r i c a s , I n f o r m e d e la r e u n i o n d e u n G r u p o T é c n i c o d e la O P S , Washington, 28-30 de noviembre de 1968. РАНО, W a s h i n g t o n , 1 9 7 0 . (A s u m m a r y i n E n g l i s h w i l l b e f o u n d in: Amer. J. clin. Nutr., 1970, 23, 231) ENDEMIC
GOITRE
Seminario sobre yodizacion de la sal para prevención del bocio e n d e m i c o , Salta, 21-26 de junio de 1 9 6 5 , Informe f i n a l . OPS/OMS, Washington, 1965 Report of a seminar on goitre c o n t r o l , New D e l h i , 30 October
to 4 N o v e m b e r
1967.
Argentina,
SEARO,
1967
Buttfield, I. H . & Hetzel, B . S . (1967) Endemic goitre in Eastern New Guinea, with special r e f e r e n c e to the u s e of i o d i z e d o i l i n p r o p h y l a x i s and t r e a t m e n t , B u l l . W l d H l t h O r g , , 3 6 ,
243
C l e m e n t s , F . W . , G i b s o n , H . В. & H o w e 1 e r - C o y , J . F . ( 1 9 6 8 ) G o i t r e s t u d i e s i n T a s m a n i a , 1 6 prophylaxis with iodide, Bull. Wld Hlth Org,, 38, 297 E n d e m i c g o i t r e , R e p o r t o f t h e m e e t i n g o f t h e РАНО S c i e n t i f i c G r o u p o n R e s e a r c h i n Goitre held in Puebla, Mexico, 27-29 June 1968. РАНО, W a s h i n g t o n , 1 9 6 9 NUTRITIONAL
ANAEMIAS
Nutritional No. 405
anaemias, Report of a WHO Scientific G r o u p .
NUTRITION AND
Wld Hlth Org, techn. Rep. S e r ” 1968,
Wld Hlth Org, techn• Rep,
Lowenstein, F . (1967) Nutrition and infection in Africa, Joint FAO/WHO/OAU-STRC Food and Nutrition Commission for Africa, Technical paper N o . 2 v Interactions of nutrition and i n f e c t i o n , by Wld Hlth Org. Monogr. Ser., N o . 57, 1968
PROTEIN-RICH
Endemic
INFECTION
Nutrition and infection, Report of a WHO Expert Committee. 1 9 6 5 , N o . 314
Bengoa, J. M. and Bioeng.
years
Ser”
Regional
S c r i m s h a w , N . S . , T a y l o r , С. E . & G o r d o n , J .
(1969) Malnutrition and infectious diseases Symposium,丄，253
M
- the "surviving chilçi .
E.,
Biotech,
FOODS
De Maeyer, E . M . , FAO/WHO/UNICEF Guidelines for safety evaluation and human testing of supplementary food mixtures in: Protein-enriched cereal foods for world n e e d s , M . Milner editor. The American Association of cereal c h e m i s t s , St Paul, United States of A m e r i c a , 1969 Report of a consultation on human testing of protein-rich NUTRITION OF SPECIAL
foods.
Geneva, 9-11 March
GROUPS
Nutrition in pregnancy and lactation, Report of a WHO Expert Committee. R e p . Ser., 1965, N o . 302 Nutrition in maternal and child health. Infant n u t r i t i o n in the subtropics and N o . 29, second edition, 1968 Nutritional problems Alexandria, 1969
D o c u m e n t WPRy4ïUTR/26 R e v . 2 . tropics, by
Wld Hlth Org,
WPRO, Manila,
techn.
1967
J e l l i f f e , D . В., W l d H l t h O r g . M o n o g r .
in the weaning period, Seminar, Addis A b a b a , 3-15 March 1969.
M a t e r n a l n u t r i t i o n a n d f a m i l y p l a n n i n g i n t h e A m e r i c a s , R e p o r t o f а РАНО T e c h n i c a l M e e t i n g , РАНО S c i e n t i f i c p u b l i c a t i o n , N o . 2 0 4 , W a s h i n g t o n , 1 9 7 0 APPLIED NUTRITION
1970
Ser.,
EMRO,
Group
PROGRAMMES
Joint FAO/WHO seminar on the p l a n n i n g and e v a l u a t i o n of applied n u t r i t i o n programmes N a i r o b i , K e n y a , 25 October - 3 N o v e m b e r 1 9 6 5 . Report. FAO, Rome 1966
in
Airica,
Joint FAO /WHO seminar on the planning and evaluation of applied nutrition programmes in Asia and the Far E a s t , N e w D e l h i , India, 30 November - 10 December 1 9 6 6 , Report• FAO, Rome, 1967 L a t i n A m e r i c a n s e m i n a r o n t h e p l a n n i n g a n d e v a l u a t i o n of. a p p l i e d n u t r i t i o n p r o g r a m s , Colombia, 10-17 November 1966. РАНО, W a s h i n g t o n , 1 9 6 7 J o i n t F A O / W H O technical m e e t i n g on m e t h o d s of p l a n n i n g and e v a l u a t i o n in applied programs, Report. Wld Hlth O r g , techn. R e p . Ser., 1966, N o . 340 A s s e s s m e n t of applied nutrition p r o j e c t s , by J . M . H u n d l e y . Social C o u n c i l , e / i C E f / l . 1 2 6 6 , 1966
TRAINING
nutrition
United Nations Economic
E v a l u a t i o n o f a p p l i e d n u t r i t i o n p r o g r a m s i n L a t i n A m e r i c a , b y В. B o s l e y . 1969
Popayan,
and
РАНО, W a s h i n g t o n ,
IN N U T R I T I O N
C o n f e r e n c e on n u t r i t i o n e d u c a t i o n in schools of m e d i c i n e and schools of public h e a l t h in Latin America, Washington, 19-22 September 1966, Report. United States Government Printing Office, Washington, 1967. Publication 0268.874 C o n f e r e n c e o n the t r a i n i n g of p u b l i c h e a l t h n u t r i t i o n i s t s - d i e t i t i a n s , C a r a c a s , 2 4 - 3 0 July 1 9 6 6 , Final report, E n g l i s h edition of B o l e t í n de la Oficina Sanitaria P a n a m e r i c a n a , Selections from 1967 Joint U N I C E F / W H 0 seminar on the teaching of n u t r i t i o n in M e d i t e r r a n e a n c o u n t r i e s . Haceteppe, 10-18 December 1970, Summary report. WHO R e g i o n a l O f f i c e for E u r o p e , C o p e n h a g e n , 1971
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