Nutritional surveillance

The concept of nutritional surveillance is derived from disease surveillance, and means “to watch over nutrition, in order to make decisions that lead to improvements in nutrition in populations”. Three distinct objectives have been defined for surveillance systems, primarily in relation to problems of malnutrition in developing countries: to aid long-term planning in health and development; to provide input for programme management and evaluation; and to give timely warning of the need for intervention to prevent critical deteriorations in food consumption. Decisions affecting nutrition are made at various administrative levels, and the uses of different types of nutritional surveillance information can be related to national policies, development programmes, public health and nutrition programmes, and timely warning and intervention programmes. The information should answer specific questions, for example concerning the nutritional status and trends of particular population groups.     

Globalization, food and health in Pacific Island countries

Pacific Island countries (PICs) are experiencing an epidemic of obesity and consequent chronic diseases. Despite investment in the development of National Plans of Action for Nutrition (NPANs) and interventions to promote healthy eating and physical activity, nutritional status appears to show little improvement. This paper presents a synthesis of the findings from two research papers that were prepared for a 2003 food safety and quality meeting in Nadi, Fiji. The findings indicate that although lifestyle behaviours might be the immediate cause of dietary imbalances, greater attention should focus on omnipresent influences of globalization as a critical element of the nutrition transition in the Pacific. In particular, those aspects of globalization mediated through the World Trade Organization (WTO) Agreements that are placing pressures on food security and fostering increased dependence on imported food of poor nutritional quality. Rapid, significant and sustainable improvements in public health in PICs require interventions that can tackle these underlying contributors to ill health. There are opportunities to explore the use of food regulatory approaches to influence the composition, availability and accessibility of food products. Within the context of the WTO Agreements the legitimacy of food regulatory approaches will depend upon the case to demonstrate the relationship between the intervention and the protection of food security and public health nutrition. The challenges in realising these opportunities are: 1) to have the capacity to construct a case, 2) meet the technical and financial demands to administer and enforce regulatory approaches, and 3) to take advantage of opportunities available and to be able to fully participate in the international policy-making process.     

Nutritional interventions through primary health care: impact of the ICDS projects in India

In 1975 the Government of India initiated an integrated approach for the delivery of health care as well as nutrition and education services for deprived populations at the village level and in urban slums through centres, each of which was run by a local part-time female worker (anganwadi) who was paid an honorarium and had a helper. This national programme, known as the Integrated Child Development Services (ICDS), began with 33 projects but, by March 1986, had expanded to 1611 projects covering 23% of the country's population and representing about 50% of the population in the socioeconomically backward areas. The ICDS can therefore be considered to function as a primary health care programme for preschool children (under 6 years old), pregnant women, and lactating mothers. The present study investigated the impact on the nutritional status of the target population after 3-5 years and after 8 years of ICDS interventions, compared with the nutritional status of non-ICDS (control) groups. The results showed that the ICDS nutrition intervention programmes achieved better coverage of the target population and led to a significant decline in malnutrition among preschool children in the ICDS population, compared with the non-ICDS groups that received nutrition, health care and education through separate programmes. This example may lead other developing countries to introduce integrated programmes with certain modifications to suit local conditions. International agencies and national governments should strive to bring about the integration of nutritional services with primary health care and development programmes for children because of the good results in terms of child survival and child development.     

Policy-making in Pakistan's population programme

Pakistan launched one of the first population control programmesin the 1950s, yet has lagged far behind other countries in effectivelyimplementing or developing its understanding of population programmes.This paper explores the policy-making process which shaped theprogramme in Pakistan in terms of the political considerationsof the various military and civilian regimes, the role of religionin politics, the influences of Western donors (particularlyUSAID), and the effect of international development ideology.The resulting instability of the population programmes is analyzedin terms of: a) the rivalry between the separate populationand health programmes within government; b) the politicallycharged problem of over-centralized federal control over population;c) the unresolved and uneasy working relationship between governmentand non-government organizations. The paper concludes that theconflicts in these areas are directly related to the largerpolicy context in which they have evolved, and without addressingthe latter, the population programme will remain victim to deep-rootedstructural problems     

Equity,democracy and globalization

Pragmatic moves have been proposed to democratize deliberation about health care within states while putting aside questions of equity. Wealthy countries are being advised that they must, in the context of globalization, adopt stringent market-led disciplines, long familiar to less developed countries subject to structural adjustment programmes. Decisions affecting inequalities in health are being made by undemocratic trans-national regulatory organizations pursuing a market based project, including the World Trade Organisation (WTO). Inequalities in income and health are pronounced in the United States, where market liberalism is entrenched. Accounts of globalization differ regarding the scope attributable to individual states to carry out sustainable redistributive policy. Critics of free-market globalization argue that states can co-operate to challenge democratic deficits in trans-national regulatory bodies to counter the growth in inequality.     

The FINUT Healthy Lifestyles Guide: Beyond the Food Pyramid

The WHO has proposed that health be promoted and protected through the development of an environment that enables sustainable actions at individual, community, national, and global levels. Indeed, food-based dietary guidelines, i.e., food pyramids, have been developed in numerous countries to disseminate nutritional information to the general population. However, wider recommendations are needed, with information on an active healthy lifestyle, not just healthy eating. The objective of the present work is to propose a three-dimensional pyramid as a new strategy for promoting adequate nutrition and active healthy lifestyles in a sustainable way. Indeed, the Iberoamerican Nutrition Foundation (FINUT) pyramid of healthy lifestyles has been designed as a tetrahedron, with its 3 lateral faces corresponding to the facets of food and nutrition, physical activity and rest, and education and hygiene. Each lateral face is divided into 2 triangles. These faces show the following: 1) food-based guidelines and healthy eating habits as related to a sustainable environment; 2) recommendations for rest and physical activity and educational, social, and cultural issues; and 3) selected hygiene and educational guidelines that, in conjunction with the other 2 faces, would contribute to better health for people in a sustainable planet. The new FINUT pyramid is addressed to the general population of all ages and should serve as a guide for living a healthy lifestyle within a defined social and cultural context. It includes an environmental and sustainability dimension providing measures that should contribute to the prevention of noncommunicable chronic diseases.     

Nutrition advocacy and national development: the PROFILES programme and its application.

Investment in nutritional programmes can contribute to economic growth and is cost-effective in improving child survival and development. In order to communicate this to decision-makers, the PROFILES nutrition advocacy and policy development programme was applied in certain developing countries. Effective advocacy is necessary to generate financial and political support for scaling up from small pilot projects and maintaining successful national programmes. The programme uses scientific knowledge to estimate development indicators such as mortality, morbidity, fertility, school performance and labour productivity from the size and nutritional condition of populations. Changes in nutritional condition are estimated from the costs, coverage and effectiveness of proposed programmes. In Bangladesh this approach helped to gain approval and funding for a major nutrition programme. PROFILES helped to promote the nutrition component of an early childhood development programme in the Philippines, and to make nutrition a top priority in Ghana's new national child survival strategy. The application of PROFILES in these and other countries has been supported by the United States Agency for International Development, the United Nations Children's Fund, the World Bank, the Asian Development Bank, the Micronutrient Initiative and other bodies.     

Potential impacts of iron biofortification in India

Iron deficiency is a widespread nutrition and health problem in developing countries, causing impairments in physical activity and cognitive development, as well as maternal mortality. Although food fortification and supplementation programmes have been effective in some countries, their overall success remains limited. Biofortification, that is, breeding food crops for higher micronutrient content, is a relatively new approach, which has been gaining international attention recently. We propose a methodology for ex ante impact assessment of iron biofortification, building on a disability-adjusted life years (DALYs) framework. This methodology is applied in an Indian context. Using a large and representative data set of household food consumption, the likely effects of iron-rich rice and wheat varieties are simulated for different target groups and regions. These varieties, which are being developed by an international public research consortium, based on conventional breeding techniques, might be ready for local distribution within the next couple of years. The results indicate sizeable potential health benefits. Depending on the underlying assumptions, the disease burden associated with iron deficiency could be reduced by 19-58%. Due to the relatively low institutional cost to reach the target population, the expected cost-effectiveness of iron biofortification compares favourably with other micronutrient interventions. Nonetheless, biofortification should not be seen as a substitute for other interventions. Each approach has its particular strengths, so they complement one another.     

The demographic factor in the provision of health facilities in developing countries: The case of Nigeria

Current emphasis on preventive health measures in developing countries such as Nigeria is not often reflected in actual performance of health programmes. It is still common to find that a major proportion of the health budget is expended on the construction of modern hospitals in a few privileged areas such as the major towns and urban centres. This strategy of medical care delivery continues in spite of the demographic situation which makes it virtually impossible for any developing nation to aim at providing adequate hospital-based care for its growing and basically rural population. Therefore, it is being suggested that the existing practice of medical care planning which places an undue emphasis on hospital based care is too expensive and will have to give way to less expensive and comprehensive strategies involving community participation such as health education, nutritional improvement programmes and more reliance on local medical resources.     

Food and nutrition policies of Nordic countries: how have they been developed and what evidence substantiates the development of these policies?

The present paper addresses the emergence and development of Nordic food and nutrition policies, with some reference to the types of nutrition policies characteristic of other North European countries. Nutrition programmes aimed at dietary change have a long history of public responsibility in several Nordic and North European countries. The extent of involvement, the orientation and (indication of) success have, however, varied considerably between countries. First, different types of policies are characterised by their choice of programmes and measures, e.g. information campaigns v. market regulation or catering and public services. Second, the distinctions are associated not only with programmes, but also with the status and validity of nutritional advice and dietary guidelines in public policy making. Third, when focusing on how and on what grounds the governments have developed nutrition policies, it is evident that while more or less the same participants and issues are involved, their roles and relationships may be different. In this case the role and involvement of nutritional expertise and scientific arguments in various countries will be discussed. Finally, nutrition policies may entail conflicts of interest, particularly when health concerns are confronted with food industry and agricultural interests. This situation is quite evident in the question of animal fat. The present paper addresses how these issues have been dealt with quite differently in various countries.     

Communication strategy for implementing community IMCI

In resource-poor developing countries, significant improvements in child survival, growth, and development can be made by: (a) shifting from sectoral programmes (for example, in nutrition or immunization) to holistic strategies such as the Integrated Management of Childhood Illnesses (IMCI) and (b) improving household and community care and health-seeking practices as a priority, while concurrently strengthening health systems and the skills of health professionals. This article focuses on household and community learning, and proposes a communication strategy for implementing community IMCI (c-IMCI) that is based on human rights principles such as inclusion, participation, and self-determination. Rather than attempt to change the care practices and health-seeking behaviour of individuals through the design and delivery of messages alone, it proposes an approach that is based on community engagement and discussion to create the social conditions in which individual change is possible. The strategy advocates for the integration of sectoral programmes rather than the development of new holistic programmes, so that integrated programmes are created from "multiple entry points". As integration occurs, the participatory communication processes that are used in sectoral programmes can be enriched and combined, improving the capacity of governments and agencies to engage community members effectively in a process of learning and action related to child health and development.     

The role of the World Bank in international health: renewed commitment and partnership

During the course of the past ten years, the World Bank has become the single largest external financier of health activities in low and middle income countries and an important voice in national and international debates on health policy. This article highlights the Bank's new strategic direction in the health sector aimed at: improving health, nutrition, and population outcomes of the poor; enhancing the performance of health care systems; and securing sustainable health care financing. Millions of preventable deaths and treatable illnesses, together with health systems that are inefficient, inequitable and ineffective, have motivated expanded Bank support for the health sector in many of its client countries. The new policy directions and system-wide reforms observed in these countries are the result of both demand and supply factors. It is part of a general shift in the Bank's approach to development assistance, which sees systemic reform as a way to improve the impact and sustainability of investments in health. On the demand side, the Bank is trying to adapt to ongoing political, technological, economic, demographic, epidemiological and social pressures. On the supply side, the Bank's growing international experience and substantial financial resources are used to complement the development assistance provided by other organizations and the global effort to improve health and health systems in low and middle income countries.     

Working towards compliance with international standards

Developing countries are increasingly coming under pressure to improve their delivery of veterinary services as a prerequisite for entering the competitive arena of international trade in animals and animal products. The demands placed on developing countries by predominantly developed countries to comply with international disease prevention standards have also resulted in increasing demands on the financial, human and technological resources of these developing countries. The minimum requirements of the Agreement on the Application of Sanitary and Phytosanitary Measures and the standards, guidelines and recommendations of international standard-setting organisations, such as the OIE (World organisation for animal health), are evaluated in terms of the opportunities embedded within these guidelines for developing countries. Such an evaluation indicates that the rights and obligations contained in these standards, guidelines and recommendations do not necessarily protect only the interests of developed countries but also encourage developing countries to work towards the levels of compliance and disease prevention required by their potential trade partners. The costs of this compliance can be reduced by exploiting more cost-effective alternatives for delivering services, when dictated by budgetary constraints. International organisations have illustrated on many occasions, and through a variety of development programmes, that they do indeed realise their responsibility towards developing countries in the areas of increased capacity building and technical assistance. If international organisations can refocus their interventions on the actual and specific needs of developing countries, then they can help to expedite the process of compliance with international standards.     

The Challenges of Home Enteral Tube Feeding: A Global Perspective

The aim of this review is to provide a global perspective of Home Enteral Tube Feeding (HETF) and to outline some of the challenges of home enteral nutrition (HEN) provisions. It is well established that the number of patients on HETF is on the increase worldwide due to advances in technology, development of percutaneous endoscopic gastrostomy techniques, and the shift in care provisions from acute to community settings. While the significance of home enteral nutrition in meeting the nutritional requirements of patients with poor swallowing reflexes and those with poor nutritional status is not in doubt, differences exist in terms of funding, standards, management approaches and the level of infrastructural development across the world. Strategies for alleviating some of the challenges militating against the effective delivery of HETF including the development of national and international standards, guidelines and policies for HETF, increased awareness and funding by government at all levels were discussed. Others, including development of HEN services, which should create the enabling environment for multidisciplinary team work, clinical audit and research, recruitment and retention of specialist staff, and improvement in patient outcomes have been outlined. However, more research is required to fully establish the cost effectiveness of the HEN service especially in developing countries and to compare the organization of HEN service between developing and developed countries.     

Quality of water--quality of life

Especially in developing countries, the problem of adequate drinking water supply is an ever growing one. Public health programmes have been established to improve the population's health conditions, but these programmes require big financial means for guaranteeing adequate supply of potable water and medical therapy for sick people. Too little emphasis is still put on regular testing of drinking water for microorganisms such as Aeromonas sp. and Vibrio sp. In a spot check analysis in various countries, the importance of Aeromonas sp. is shown--not a single sample complied with international norms and guidelines for drinking water.     

Improving health outcomes through community empowerment: a review of the literature

This paper reviews the literature on how empowerment can lead to an improvement in the health status of an individual, group, or community. There is a broad body of literature on empowerment, and this review has been designed to identify material, particularly case studies, that can be included within the following 'empowerment domains': Participation; Community-based organizations; Local leadership; Resource mobilization; Asking 'why'; Assessment of problems; Links with other people and organizations; Role of outside agents; and Programme management. The paper discusses the results of the literature review and provides examples, from both developed and developing countries, of how each of the 'empowerment domains' has led to an improvement in health outcomes. The results of the review should be of interest to the planners and practitioners of health, population and nutrition programmes that have a particular focus on empowerment.     

Is globalization good for your health?

Four points are made about globalization and health. First, economic integration is a powerful force for raising the incomes of poor countries. In the past 20 years several large developing countries have opened up to trade and investment, and they are growing well--faster than the rich countries. Second, there is no tendency for income inequality to increase in countries that open up. The higher growth that accompanies globalization in developing countries generally benefits poor people. Since there is a large literature linking income of the poor to health status, we can be reasonably confident that globalization has indirect positive effects on nutrition, infant mortality and other health issues related to income. Third, economic integration can obviously have adverse health effects as well: the transmission of AIDS through migration and travel is a dramatic recent example. However, both relatively closed and relatively open developing countries have severe AIDS problems. The practical solution lies in health policies, not in policies on economic integration. Likewise, free trade in tobacco will lead to increased smoking unless health-motivated disincentives are put in place. Global integration requires supporting institutions and policies. Fourth, the international architecture can be improved so that it is more beneficial to poor countries. For example, with regard to intellectual property rights, it may be practical for pharmaceutical innovators to choose to have intellectual property rights in either rich country markets or poor country ones, but not both. In this way incentives could be strong for research on diseases in both rich and poor countries.     

Teaching nutrition in an International Master of Public Health program

The health of populations is related to the norms and characteristics of society and its socio-economic organization. The causes of food-related ill health are located at the national and international levels and the cure must be sought in good governance. Thus, it is obvious that a Master's Degree in International Public Health must include a thorough overview of the "food chain" from "plough to plate" within the political, economical, socio-economic changes, environmental, industrial, scientific, and health contexts. Nutritional deficiencies are addressed by a variety of measures, including food supply and utilization programs, specific supplementation for high-risk groups, and food fortification to reach a general population. All are part of a wide-based public health nutrition approach, applicable in developed, redeveloping, and newly developing countries. This article is based on experience in teaching Public Health Nutrition to a mixed group of foreign students from different countries. Our goal is to prepare students for a variety of public health careers related to nutrition and health. The aim of this course is to introduce current roles and aspects of food and nutrition policy, focusing on food and nutrition security, human rights for food and nutrition, and the complex interactions among local and global systems. Students are introduced to nutrition screening, assessment, and research skills, and nutrition in emergency situations and in disaster relief. During the course the students learn about the design and the evaluation of nutrition interventions at the individual, community, and national level. The course gives a broad-based examination of major themes related to development and underdevelopment, poverty and wealth, equality and inequality. It also introduces program planning from the perspective of international organisations such as the World Food Program and the Food and Agriculture Organisation and the World Health Organisation of the United Nations. More specific objectives include: 1. To define the nutritional problems at the level of the individual, family, the community, and the nation. Use of Causal Modelling. 2. To learn in what ways data may be gathered. 3. To suggest methods of intervention according to priorities. 4. To monitor the effects of such interventions. 5. To assess the scientific evidence underlying the connections between diet and disease.     

社区高血压及营养KAP健康教育效果分析

目的 评价高血压及营养健教对社区高血压人群的干预效果。方法 在上海某社区随机抽取370名年龄为35-75岁高血压病人作为高血压及营养知识。态度及行为（KAP）调查的基线人群,其中干预组176人,对照组194人。结果 经一年的社区干预后,对两组人群进行高血压及营养知识,态度及行为复查,干预组对营养知识的掌握优于对照组;干预组对中国居民膳食指南的知晓率在干预后也明显提高;在改善不良膳食行为方面,干预组行为改善率高于对照组,两组相比有显著性差异。结论 社区高血压及营养知识健康教育对高血压人群提高高血压及营养知识水平是有效的和可行的。     

An integrated sociocultural curriculum for community medicine in Bali, Indonesia

Since 1983, social scientists have collaborated with teaching staff at the Faculty of Medicine, Udayana University, Bali, Indonesia, to develop an integrated sociocultural curriculum for undergraduate students in community health. The Udayana curriculum is discussed in the context of an international commitment over the last two decades to appropriate education for primary health care and community health in developing countries. The authors describe their work as consultants with Udayana staff. Participants formulated a five-stage project of curriculum development and community health research that could be continued as part of an ongoing community medicine teaching program. Recommendations for integrating social science perspectives within medical domains are outlined, based on the project experience. The paper also discusses the undertaking as a 'development project' suggesting that many of the issues and problems that arose are common to bureaucratic institutions in Third World countries when development projects are initiated.