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better nutrition education helps reduce malnutrition

better nutrition education helps reduce malnutrition

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Definition Malnutrition Malnutrition is a broad term commonly used as an alternative to undernutrition but technically it also refers to overnutrition.

People are malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat due to illness (undernutrition). They are also malnourished if they consume too many calories (overnutrition). By UNICEF

1. The Causes of Hunger and Malnutrition: Macro and Micro Determinants Macro and micro causes of malnutrition Diagnosing the causes of hunger and malnutrition Proposing solutions The role of ideology (4)(5) A critical look at nutrition planning Working with the community References Hunger and Society, Vol.1, Chapter 3, Cornell Intl. Monograph Series No.17, 1988. CLAUDIO aviva@netman.org.vn Macro and micro causes of malnutrition This chapter attempts to look at how we can identify the major causes of hunger and malnutrition, reviews the principal characteristics of these determinants, and explores how we can convince others (peers, beneficiaries, and decision makers) of the implications for action that the profound understanding of these causes has, especially in terms of our attitude towards them as committed professionals active in different disciplines and contexts. This examination of malnutrition (undernutrition) as the biological translation of a social disease with historical roots, all determinants of the social and economic conditions that lead to the malnutrition of a sector of the population will be considered macro determinants. The more immediate causes responsible for malnutrition will here be called micro determinants. Most macro determinants of hunger and malnutrition are conditioned by the overall policies that govern national economics (both Internally and in their SCHUFTAN

foreign relations and trade). Macro determinants are more indirectly related to malnutrition. They are always related to international, national, and village level constraints. Macro causes explain most malnutrition in societies with capitalist or pro-capitalist modes of production. Malnutrition or nutritional vulnerability is a manifestation of a society's inability to produce its livelihood adequately - not because modern medicine has rendered it overpopulated or because agricultural productivity is not sufficiently high, but because the underdeveloped societies struggle for their own livelihood by producing the livelihood of other societies. (1) Macro causes usually relate to the major dialectical contradictions in a given society, especially in the agricultural sector. Macro causes imply objective constraints to meaningful changes. If one were to characterize macro determinants negatively, one would say that they correspond to those causes of malnutrition that are not removed or even touched by traditional nutrition intervention programs. In the long run, the fight against hunger and malnutrition becomes, therefore, an eminently political struggle and not a technical one. Technology cannot achieve the fundamental structural changes needed to end hunger and malnutrition. Removal of a few (or even one) of the main macro causes is more likely to alleviate malnutrition than acting on many micro determinants simultaneously. Nowadays macro determinants are very frequently mentioned and identified by planners analyzing specific situations, but the plans they devise seldom attack these determinants frontally. Micro determinants are more directly related to the physiological condition of malnutrition. They include health, environment, and educational determinants, which are those most frequently identified and selected for direct intervention by western planning approaches. Emphasis on this technical approach to nutrition planning has also in the past justified the need for western-trained experts who often come with ready-made analysis. Every expert brings his own view of development, and the suggestion for development programs will reflect that ideology. (Hunger + Society, Vol. 1, Chapter 3, Cornell Intl. Nutr. Monograph Series #17, 1988) Taken together, any attack on micro determinants only leads to a package of solutions or interventions that pretend to be apolitical and free of ideological connotations or influence. However, despite the fact that the spectrum of choices is a continuum, in the final analysis, one either bows to the system or objects to it, totally or partially. Any of these are political stances. Nutrition planners keep inventing new "more comprehensive" or "multisectoral" approaches to old problems as if these would change the major contradictions and the distribution of power within the system that is causing the problems to begin with.

Diagnosing the causes of hunger and malnutrition It should be clear that we cannot agree on the content of nutrition planning if we do not share the same understanding of why people are poor and mainourished. Different socioeconomic contexts call for different nutrition planning approaches. This does not imply that only macro causes should be identified and acted upon. An appropriate understanding of hunger and malnutrition will include consideration of a mix of macro and micro determinants. The challenge to the planner is to determine, in each national (or regional) context, how much and what kind of macro changes are necessary for the micro changes to have some prospect for success. The connections between macro and micro causes must be made explicit so as to justify the needed macro changes. This unequivocally means that any plan or program geared to ameliorating malnutrition as a public health and social problem will have to include a mix of interventions designed to affect change in both macro and micro determinants. For example, technical measures in themselves are not tools for income redistribution, but they may have a partial redistribution impact as a side-effect, assuming that they reach the lowest income group. In this context, the role of the nutrition planner is beyond doubt a delicate one. Sensitization and advocacy skills are perhaps more important than technical know-how. The type of strategy or plan that should follow a comprehensive diagnosis should be geared, first, to defining a set of specific activities directed to address and remove or minimize the effect of micro determinants, a classical approach, followed by an estimation of the potential of such a package of interventions to solve or address the major problems of hunger and malnutrition. A list of the macro causes should be identified and a brief analysis made of why and how each one of them contributes to the persistence of malnutrition, so that anybody can understand these links. A list of possible interventions should be prepared that aim at removing some of the structural bottlenecks or constraints that are ultimately determining a state of chronic hunger in defined sectors of the population. The similarities between Third World countries, being many, the following are some examples of nation-level manifestations of macro causes: low percentage of national income received by lowest 20 percent of the population (income maldistribution); land maldistribution; high percentage of landless agricultural laborers; rural unemployment; urban migration and urban unemployment; low minimum wage policies in all sectors of the economy, not in tune with the cost of a minimum diet and not following food price inflation; low farm-gate prices for food crops as opposed to their urban retail prices: produce marketing boards' exploitative practices towards small farmers, imbalance between cash and food crops (land allocation and incentives); low percentage of foreign export earnings reinvested in agriculture; food import policies contradicting national efforts to increase local food production; neglect of the primary sector with the share of agriculture In the national GDP slipping

in favor of the secondary and tertiary sectors of the economy; credit bias towards the modern agricultural sector as opposed to the traditional agricultural sector; lack of agricultural input subsidization for small farmers, especially for food crops; foreign aid not reaching the neediest; women left outside development programs with little incentive to incorporate them in the money economy; little emphasis on the scanty budgets for genuine community development and rural cooperatives; low primary school enrolment rates; feeble efforts to increase adult literacy, especially for women; and scanty budgets for preventive health services. Proposing solutions Malnutrition as a social disease cannot be cured through medical interventions (not even in a wide comprehensive package) nor can it be cured through the latter plus a package of agricultural interventions. Redistribution of resources and the consequent increase in purchasing power of the needy masses is a necessary, though not sufficient, solution to the problem of hunger. Moreover, poverty wears many other masks (e.g., cultural and educational deprivation, poor health, inadequate sanitation), and each mask has its own features. We should not be tempted, through lack of perspective, to try to improve only the features of the masks, without doing anything about the real face of poverty, which is socioeconomic deprivation. Many planners have divided the remedial actions they finally propose into two groups: recommendations and interventions. The former, which often concern macro determinants and the need to change or remove them, are worded in very vague, general terms and have no specific implementation budget set aside; the latter, which often concern micro determinants, are prepared in more detail, have a fixed implementation deadline, and are usually budgeted for. The frankness with which planners state the need for corrective measures directed to the macro determinants will depend on the political environment in which they are working. Political and professional risks are usually high,(2) and many planners feel that their positions in academe, government, or international or private organizations might be jeopardized if they demand radical solutions. They take a "survivor's" attitude, and this is disturbing. We actually need to stop thinking that we cannot contribute much to the selection and implementation of non-nutritional interventions that are outside our immediate field of expertise. Macro determinants can be exposed in a number of ways, not all of which are dramatic or sensational. For example, the possible interventions that flow from the analysis of the macro determinants could be listed under a title that could read something like. "Conditions under which Interventions Addressing the More Immediate Causes of Malnutrition Will Have a Better Chance of Having an Impact."(3) This should be followed by a subjective estimate of the potential of each macro intervention to ameliorate malnutrition. The idea is to compare and contrast the potentials of the latter with the potentialities of the

package of micro interventions to achieve the same or similar goals. In other words, what this kind of a presentation tries to emphasize is that if macro determinants are removed (or minimized) interventions that follow such removal and that are geared towards removing micro determinants stand a much better chance of having a real and lasting impact. The above is the gentlest way of making this point clear; there are many other, more direct ways of highlighting the need for structural changes to eliminate hunger and malnutrition. Political and ideological constraints as well as the attitude and commitment of decision makers towards eradicating hunger will determine how far the planning team can go in this recommendation. The major problem with this approach is that it might look too politically radical to some governments. If this is the case, then the particular governments are most probably not genuinely interested in solving the problems at hand. But this may be difficult to determine, given the frequency with which governments pay lip service to their commitments. At the very least, a presentation such as the one proposed here has an educational value, especially if it is documented with some hard evidence, things that politicians and decision makers have probably known all along. (We sometimes wrongly assume that decisions makers are rational, righteous, and pious and will accept hard scientific evidence or react to outrageous injustice). Technicians who have participated in the planning process may gain a new consciousness as a consequence of using this approach, a fact that is of value per se and that makes the effort worthwhile. The role of ideology (4)(5) Nutrition seems to be as good an entry point as any other (employment, education, energy, natural resources, ecology, etc.) for getting involved in questions of equity in our societies. Nutrition can lead to global consideration if it is not seen as an isolated issue. Malnutrition should not be attacked on grounds of utility, but because such an attack is morally necessary. What we need to fight for is equity not utility. Poverty should not be seen as an inevitable evil, but as a basic injustice to be corrected. In that sense, poverty is to be considered more as a relative rather than an absolute condition. The ideology and outlook on world affairs (largely determined by social class extraction) of the individual searching for the determinants of hunger and malnutrition play a vital role in the selection of the contents of the final indepth analysis (one seems to see only what one wants to see). Once a certain level of consciousness is attained an action-oriented attitude usually follows. At this point there is a convergence of ideology and action that makes the difference between taking an observer's as opposed to a protagonist's

role. Knowing about injustice does not move many of us: becoming conscious about it generates a creative anger that calls for involvement in corrective actions. The latter can only happen within the framework of an ideology consciously acquired. In the context of development, then, ideology carries the additional connotation of commitment, both emotional and intellectual, and action-oriented. Ideology is not simply a body of ideas determining goals; it also includes the instruments, strategies, and tactics to be used in planning for economic and social change.(6) Objectivity in the analytical stages of the planning process is nothing but a myth, and since the solutions proposed will heavily depend on the final diagnosis of the causes identified, there is no assurance that by following the procedures described above for the identification of macro and micro determinants one will end up with a better, more comprehensive plan to ameliorate hunger and malnutrition in any specific situation. The implications of this center on at least two issues. 1. Will the outlook for eliminating hunger and malnutrition in the world be any better without a concomitant process of political maturation of the people involved in nutrition planning? 2. Would more efforts towards demonstrating the futility of ongoing food and nutrition programs initiate a new, more aggressive approach? The possible answers to these two questions are again ideologically charged. In trying to solve the problem of malnutrition, intraprofessional responsibility should not be neglected. This responsibility has to be taken up starting with a process that critically analyzes our professional affairs and goals with their inherent contradictions. Basically, nutritionists should be searching for a new ethos, a professional, political ethos. The sense of responsibility found in many scientists does' not seem to be sufficient to see necessary changes occur; it leads nowhere. It may solve the conscience problems of the person who devotes time and effort to doing "something" to solve, malnutrition; however, it seems to have little effect on the real problems of the poor and the malnourished. An isolated emotional commitment is loose and romantic; ideological commitment is militant. The concept of being socially responsible is nothing but a euphemism for what really should be called political responsibility. Political commitment is important precisely because governments function as political entities.(7) Political forces are fought with political actions, not with morals, or with technological fixes.

A critical look at nutrition planning Nutrition planning as a technique, widely accepted for over 10 years has the exciting attractiveness and potential of broadening the horizon of nutritionists in the analysis of what is responsible for generating and perpetuating malnutrition. It seems to offer the possibility of understanding the deeper nature of the problems of the poor, especially the rural poor, and it opens avenues for sensitizing planners to the importance of macro determinants in the process of leading to malnutrition. Nutrition planning was thus a more comprehensive and multisectoral approach to solving malnutrition than any strategy used before. Because of its broad-based approach it was much closer to a political approach (in the classical sense of the term) than were the technical interventions. Therefore, nutrition planning had greater potential for effecting change than any of the other approaches used before. Nutrition planning, both as it has been developed in the West and implemented in the Third World, suffers from the basic flaw that, while it sometimes challenges the existing structure and demand change, it offers no concrete model of an alternative future. Through nutrition planning the planner was confronted with evidence that suggested the need for more radical interventions (meaning going to the roots of the problem and not necessarily in the pejorative sense of the word radical used in everyday politics). If planners chose not to go that route they were deliberately avoiding the issue, not at a subconscious, but at a conscious level. This has tended to make their contradictions more visible, less sustainable and less bearable. This is the major new dimension that nutrition planning offered and that has seldom really been exploited, either because the planners have not been able to find or point out the macro causes or because they did not know what to propose to attack them. This may explain some of the disillusionment people have felt with nutrition planning. It is precisely a misunderstanding of reality (or a partial understanding) that often reinforces the amoral position of some nutritionists. Or some of them may not really want to understand; they have, all too often and for all the wrong reasons, already made up their minds about one reality, thus often searching for the statistical "whats" instead of analyzing the "whys."(8) Used as a technical tool nutrition planning offers no real solution, no matter how much new coordination between different sectors (e.g., health, agriculture, education) it succeeds in setting up at any or all levels. To continue pushing suprastructural measures is to perpetuate the problems. It will mean a waste of scarce resources and precious time in the vast majority of cases. Critically speaking, nutrition planning will continue to offer us no more than a good diagnostic tool, a good framework to consider alternative intervention strategies, and a basis to validate ideologically stained policy decisions.

Working with the community If little can be expected from nutrition planning at the central level then community-level (grassroot) organization around food and nutrition issues may be the only viable answer in the long run. Popular participation is absolutely fundamental to success in nutrition planning, but planners have disregarded this central issue persistently. What is needed is more dedication to working directly with the poor so they can tackle the causes of their poverty and malnutrition themselves. This calls for nutritionists to go, as much as possible, back to fieldwork and out of their offices or laboratories. Only there can the strengths needed for a change in direction and perspective be found. Nutritionists need to learn from the people and from their perceptions of the problems, establish links with local mass movements and participate in their consciousness raising. The participation of the affected population begins with creating awareness that they have a problem, to be followed by ample discussion about what can be done about it. Here, the outsider's role is to ask the right questions and not to point at what he thinks is wrong. It is only through praxis that political consciousness can be strengthened, and it is only when people are convinced that change is in fact taking place that they will listen and learn the abstract concepts dial must be actualized in experience.(9) In our work with the community we have to pass from a mutually shared analysis and understanding of the local micro determinants of malnutrition, which should be more easily identifiable and perceived by the community at the beginning, to the analysis and understanding of the local and then general macro determinants of that condition. For the latter to be possible, the community will probably have to go through a slow process of political maturation before effectively gaining consciousness of the role of the social and economic constraints that determine malnutrition in their milieu but are more difficult to understand. People have to he made aware of their problems in a specific context first and then in an ideological one. The exposure of macro constraints should, in the first instance, lead to generating social commitment to effecting the needed structural changes. It is important to demonstrate to the masses that it is in their power to change not only the physical reality that surrounds them but the social reality as well.(10) There are three levels of possible involvement in fieldwork.(11) At the first level, one solicits the participation of the community in a given project. Participation has turned out be harmless for the vested interests and is, therefore, a regular appendage of every government project. A second level calls for outright consciousness raising among the population. At the third level, an effort is made towards the mobilization of the masses and the effective empowering of the poor. Because village problems are often not the governments' problems, local felt needs have to be converted into concrete issues so that a course of action to

address them can be mapped out. This may involve developing functional knowledge about people's rights, or challenging public agencies landlords or other powerful people or institutions by filing specific demands or claims. A new type of community-oriented nutrition planner is needed for this Herculean task: one that plans with people to get organized to work together in solving the problems. We need to move in the direction of training nutrition planners as trainers of others so that their own experiences can be reproduced at many levels in each country, given the limited geographical coverage per planner that this approach from the bottom inherently has. The shortcomings of this approach are many, not the least of which is the fact that it is a very slow process, based on mutual trust in each community and that its replicability is, therefore, also very slow even in the best cases. The dangers, of course, are also significant, especially when the political government is hostile. The question that still remains at the end of our discussion is whether this approach is realistic or not. If it is not, let us keep in mind that not being realistic is a judgment that history can change: what might sound unrealistic today can very well become true tomorrow, if we work for it with decision. References 1. N. Makhoul, "Agricultural Research and Human Nutrition: A Comparative Analysis of Brazil. Cuba, Israel and the US". Intl. J. of Health Services. 13, 1:15-24 (1983). 2. W. Chossudowsky. "The Neoliberal Model and the Mechanisms of Economic Repression", Coexistence. 12, 1 (1975). 3. C. Schuftan, et at., Recommended national food and nutrition plan for Liberia, mimeo (Interministerial technical committee on food and nutrition planning, Monrovia, 1982) 4. C. Schuftan, "Nutrition Planning - What Relevance to Hunger?", Food Policy. 3, 1:59-55 (1978) 5. C. Schuftan, "Ethics, Ideology and Nutrition", Food Policy. 7, 2:159-164 (1982). 6. W. David, Management. Administration and Politics in the Development Process: With Special Reference to Nutrition, mimeo, (Meharry Medical College, Nashville. Tenn., November 1985). 7. B. Winikoff, "Political Commitment and Nutrition Policy", in B. Winikoff, ed., Nutrition and National Policy. MIT Press. Cambridge, MA, 1978. 8. R. Critchfield, "The Village: The World as It Really Is...It's Changing", USAID Agenda. 2, 8, (1979).

9. K. Constantino-David. "Issues in Community Organization", IFDA Dossier. 23:5 (1981). 10. A. Rahman. "Science for Social Revolution", IFDA Dossier, 4 (1979). 11. H. Bantje, Constraint Mechanisms and Social Theory in Nutrition Education, mimeo, presented at the XI Intl. Congress of the IUNS, Rio de Janeiro, August 1978 (BRALUP, Dar es Salaam, 1978).

2020 Vision for Food, Agriculture, and the Environment in South Asia: A Synthesis
edited by Mark W. Rosegrant and Sohail Malik As part of its 2020 Vision for Food, Agriculture, and the Environment initiative, IFPRI held workshops in three developing regions of the world. The workshop on South Asia, jointly sponsored by the Institute for Integrated Development Studies of Nepal and IFPRI, was held in Kathmandu, Nepal, 26-29 March 1995. This synthesis is based on discussions among some 19 South Asian researchers, technical experts, and policymakers and 9 IFPRI staff who participated in the workshop, and the objectives and strategies noted below are those agreed upon by the workshop participants. The 2020 Vision The 2020 vision for South Asia aims to • ensure the minimum food and nutrition needs of the population through entitlement programs and income-augmenting agricultural technologies that are environmentally friendly; • eliminate severe malnutrition and extreme poverty; • ensure comprehensive food and nutritional security at the family level, including an adequate supply of food to meet quantitative and nutritional requirements, acknowledging that policies may vary from country to country, depending on the resources available to the country; • arrest environmental degradation and improve the conservation of natural resources for enhanced sustainability and productivity of agriculture; and • strengthen or establish linkages among related sectors to promote agricultural diversification and to improve the quality of life. Existing Conditions and Trends Looking at the past 30 years, conditions relating to food, agriculture, and the environment in South Asia appear to be improving. In the region as a whole, the population growth rate has shown a declining trend. Each country is in a different stage of demographic transition, however. For example, Sri Lanka's birth rate has almost declined to a point where it is just replacing the present population, and India and Bangladesh are at the point where both the fertility and mortality rates are beginning to decline. Nepal and Pakistan, on the other hand, still have high population growth rates. The per capita availability of food in the region is rising. As a result of the yield increases associated with the Green Revolution, food production in South Asia as a whole is growing faster than the population growth rate. This is also true at the national level for India, Pakistan, and Bangladesh. In general, there has also been an increase in income per capita, which has affected food demand. As incomes rise, consumers' tastes and preferences for certain foods change. They

want higher quality and more nutritional food as well as larger amounts of food than in the past. This has led to changes in the composition of the food basket, with consumers moving from coarse grains to superior grains, and from grains to animal and horticultural products. As the consumption of meats and fruits and vegetables increases, the demand for foodgrains decreases. Such changes are more pronounced in the urban areas than in rural areas. Overall, the share of food in total consumer expenditure has tended to fall. Despite these favorable income and food security trends, poverty and malnutrition remain serious problems. The average figures hide severe inequalities that prevent the poor from taking advantage of the increased supplies of food. These include a lack of productive employment for the poor and, particularly in rural areas, lack of access to both food and nonfood goods and services due to poor infrastructure development. Within South Asia, 58 percent of the children are currently malnourished (Figure 1). Even with the projected increase in food availability and better sanitation and health conditions, 46 percent of children are still projected to be malnourished in the year 2020. Although birth rates in South Asia are declining somewhat, the population still stood at close to 1.7 billion in 1990 and is expected to reach 2 billion by 2020 (Figure 2). Because the region's population is so huge, global trends and levels of malnutrition in the year 2020 will be largely colored by what happens in South Asia. For example, more than 50 percent of the malnourished children in all developing countries are found in South Asia today. By 2020, South Asia's share of the world's malnourished children will still stand at 48 percent. Maternal and child health and nutrition are crucially linked to the overall health and nutritional security of the population. Anemia and iodine-deficiency disorders afflict more women than men in the region. When health care is generally poor, and women are ill or malnourished, it affects their capacity to care for their children, which in turn affects the nutritional status of the children. Access to clean water and proper sanitation are two of the most important determinants of good nutrition. Education levels are generally low in the region, especially for women. Unfortunately, most existing food security programs in the region ignore the intrahousehold distribution aspects, whereas others include whole communities while trying to target a few with special needs. In agriculture, no significant scope exists for increasing the amount of cultivated land in South Asia. Therefore, future production increases must come from yield increases. However, the momentum of the Green Revolution has generally waned. Considering the large projected demand for food in the region, the decline in agricultural productivity is a matter of serious concern. Given the complexity of enhancing food production in a sustainable manner in the years to come, future gains will essentially be realized through the generation and adoption of new, appropriate agricultural technologies. This is not easy to achieve because of widespread environmental degradation, continued deforestation, loss of soil and soil fertility, increase in soil salinity and waterlogging, and loss of biodiversity. These trends are likely to continue as a result of existing high levels of poverty, but also as a result of policies that have encouraged activities that lead to environmental degradation, such as expansion of major irrigation projects without adequate thought given to drainage and distributory channels and distorted and subsidized irrigation water and fertilizer prices. These practices have contributed greatly to land and soil degradation, which has, in turn, contributed to the unsustainability of agriculture in the region. There is no doubt that agriculture provides the strongest basis for economic development and poverty alleviation in South Asia. Because the large rural population is mostly dependent on agriculture, technologies that bring about agricultural growth are also likely to generate employment through linkages with the nonagriculture sector. So policies that discriminate against agriculture have also harmed the prospects for economic development and poverty alleviation. For the countries of the region to harness the gains from the proposed increase in investment in agriculture and to realize the full potential of new agricultural technologies, removal of these antiagricultural policies is essential. Additionally, land tenure policies prevent some countries of the region from reaping the full benefits of growth in the agricultural sector.

A skewed distribution of landownership in some countries has also led to worsening income inequalities. Where the potential of agriculture is not fully realized, the deceleration in investment in agriculture should not only be arrested, but both domestic and international investment should be accelerated. Resources should be judiciously deployed according to priorities. Therefore, the countries of the region must develop capabilities for setting priorities for agricultural development and allocating resources to agriculture. Currently, governments have actually decreased investment in agriculture by cutting spending on infrastructure, on agricultural research, and in rural areas. This lack of investment, especially in rural infrastructure and in the development of new agricultural technologies, hinders the ability of producers to respond to the market and, therefore, decreases the prospects of overall agricultural growth. If development and growth in agriculture is hampered by these factors, lack of intraregional trade only exacerbates the situation. Despite increasing economic liberalization, agricultural trade still suffers from tariff and nontariff barriers to the disadvantage of the countries in this region. Welfare would be increased greatly by expanding intraregional trade in food and nonfood goods. The composition of agricultural exports has recently been diversified toward rice, wheat, fruits, vegetables, and processed foods. Even with the benefits to be gained from economic liberalization, one must be aware that the increasing emphasis on structural adjustment is, in the short run, likely to increase the number of vulnerable and at-risk people in the region. Underlying all of this is the fact that good governance is a necessary condition for addressing most of the problems associated with poverty and underdevelopment in the rural areas of the region. The ability to involve local government and nongovernment agencies in addressing these problems will largely define the future scenario in the region. To make good decisions, policymakers need good information. Any accurate assessment of the problems of agricultural development in South Asia is also constrained by a lack of dependable databases on the demographic, agricultural, income, environmental degradation, and poverty characteristics of the region. The existing databases are extremely inadequate for effective policy research, policy planning, and policy reform. Implications for the Year 2020 If existing trends in high population growth, low agricultural development, large disparities in income, high environmental degradation, and high incidence of poverty continue, South Asia's food, agriculture, environment, and quality of human life will be seriously threatened in the coming years. Poverty and malnutrition will remain the major problems. Pressures to produce more food and to use more natural resources, brought about by the changing composition and growth of the population and the unequal distribution of income, will harm the environment. While the total eradication of poverty, malnutrition, and environmental degradation are desirable goals, policies should be framed in the context of what can be achieved with given resources--natural and human--and in given time horizons. Therefore, the 2020 vision for South Asia aims to significantly reduce the proportion of the population that is below a specified level of poverty, to reduce the number of malnourished children, and to decrease maternal, infant, and child mortality by the year 2020. To achieve this vision, bold strategies are called for to meet the challenges by the year 2020. Participants in the South Asia workshop identified the following actions that need to be undertaken in order to meet these challenges. Strategies to Meet the Challenges

Increase Investment in the Agricultural Sector • Facilitate irrigation expansion* and improve water management. • Undertake research and technology development and transfer. • Emphasize development of rural infrastructure. • Emphasize development of human resources. • Undertake sustainable management of land, water, forest, and other natural resources. Enhance Access to Improved Agricultural Technologies • Close the realizable yield gap by strengthening linkages among research, extension, and farmers through a participatory (bottom-up) approach. • Increase information sharing and communication. • Strengthen national capabilities in biotechnology and in other nonconventional technologies to achieve higher yield levels in consort with conventional technologies. • Develop regional networks, such as the South Asian Association for Regional Cooperation, to strengthen the capability of the region in emerging areas of agricultural development. Develop Productive, Sustainable, Environmentally Friendly Technologies • Render the region's agriculture more efficient by focusing on new technologies that enhance employment, incomes, and access to basic needs and also pay close attention to the conservation and rational exploitation of natural resources as well as other inputs such as irrigation, fertilizer, and other agrochemicals. • Give high priority to development of a systems approach to agricultural development, such as integrated plant nutrient systems, integrated pest management systems, and integrated farming systems. Strengthen Efforts to Protect the Environment • Gradually discontinue policies that lead to environmental degradation. • Promote approaches, such as drip irrigation, to increase water use efficiency; increase unskilled labor productivity and sustainability; and foster community forestry and agroforestry, watershed management, and farmer-managed irrigation systems, in order to achieve both increased agricultural productivity and sustainability. Improve Commercialization of Agriculture • Improve commercialization through better production and marketing by increasing the role of the private sector and making available strategic inputs in the right quantities and at the right time. • Develop rural infrastructure to increase the efficiency of local and regional trade flows. • Increase research and development to improve the quality of exports, develop new varieties, and prevent losses. • Step up efforts to enable products to meet standards and improve market intelligence and information. Increase Investment in Human Resources

• Introduce new programs and strengthen existing ones to target the poor and disadvantaged at household and intrahousehold levels based on effective policy research. • Emphasize maternal and child health and nutrition programs. • Improve access to clean water and sanitation. • Provide safety nets for the poor and landless rural households affected by the new economic policy reforms. • Invest more in schooling, especially for girls. Improve Trade Linkages • Increase trade linkages with the global economy and with the fast-growing Asia-Pacific region, in addition to regional arrangements such as the South Asian Free Trade Agreement. • Liberalize trade in feedgrains immediately. • Continue to liberalize trade and exchange rates through relaxation of trade controls, including quotas and taxes, to ensure favorable treatment of exports from the agriculture sector. Improve Government Policies • Adopt macroeconomic policies that are neutral, if not favorable, to agriculture. • Implement agrarian reforms to address the problems of inequality and poverty caused by landlessness. • Improve the quality of governance at both the national and local levels. • Devolve effective democratic and economic power to the grassroots level and ensure local participation in decisionmaking. • Conduct surveys and studies to build up the policy-relevant databases, especially for the analysis of poverty, malnutrition, health, and the environment. Conclusion The challenge for South Asia over the next 25 years will be to create conditions that will allow continued and sustainable growth in agricultural output and improve the livelihoods of those currently malnourished and living in poverty. The sheer numbers of people, high population densities, and current low nutrition status in the region suggest that global projections of hunger and poverty depend to a large extent on improving conditions in South Asia. The 2020 Vision for South Asia outlines necessary steps that will help South Asian countries meet the challenges they will face in the year 2020. *Continued investment in irrigation expansion remains a priority for most of South Asia, though in some parts of the region, such as Sri Lanka, the limits of expansion of major irrigation appear to have been reached.

Lack of nutritional knowledge a cause for malnutrition First Lady Lucy Kibaki has called on Kenyans to create a culture of health that encourages self individual diet and exercise plans which will help prevent disease and malnutrition. Speaking at a Nairobi Hotel last evening when she presided over the ceremony to launch the Kenya Coalition for Action in Nutrition

(KCAN) Nutritionist of the Year Award the First Lady First Lady noted that lack of nutritional knowledge among people is a major cause of malnutrition in the country. Citing statistics of the world health organization WHO, the First Lady said poor nutrition causes nearly one in three people to die pre maturely or suffer disabilities. She noted that every year more than 20 million low-birth weight babies are born in developing countries due to the nutritional deficiencies of their mothers noting that such babies risk dying in infancy while those who survive often suffer lifelong physical and cognitive disabilities. Said the First Lady, "These grim statistics suggest a nutritional crisis and underlines that need for concerted efforts to address the problem of malnutrition." She therefore called for increased measures to educate people on the need to embrace healthy dietary practices noting that a regular intake of proper mix of nutrients enables human bodies to resist infection and illness. In this connection the First Lady urged Kenyans, particularly those living with the HIV/AIDS to ensure they have a well balanced diet that contains all the nutrients the body needs. Said the First Lady, "A well balanced diet will increase their resistance to infection, boost their immune system, improve the response to treatment for opportunistic infections and delay the rate of progression of HIV/AIDS." She noted that in spite of the knowledge that lack of proper diet makes an individual be vulnerable to diseases, unhealthy diet, particularly insufficient nutrient intake has continued to be a major source of poor health in Kenya and the world in general. The First lady therefore called on all Kenyans in general to observe good nutrition, which includes regular exercise, avoidance of smoking and excessive alcohol as well as avoidance of fast foods that are deficient in nutrients. Besides ignorance, the First lady noted that poverty is another major cause of malnutrition which has made it impossible for most people to access basic necessities such as a balanced diet, health care, safe drinking water and sanitation.

Said the First Lady "Worldwide, it is today estimated that more than 1 billion people live below the poverty line and are therefore unable to afford nutritious food for themselves and their families." In this regard, the First Lady expressed her appreciation that the Government is fully aware of the challenge and has stepped up measures to improve the living standards of all Kenyans citing the consistently increased budgetary allocation to agriculture from which the majority of Kenyans draw their livelihood. She added that it was encouraging to note that living standards in the country are improving along with the improving performance of the economy. However the First Lady Lucy Kibaki who is also the patron of the Kenya Coalition For Action in Nutrition (KCAN) called on the international community to support poverty eradication Programmes in developing countries, since these countries do not have adequate resources to fully eradicate poverty. Said the First Lady, "It is sad to note that approximately 16,000 children are estimated to die from hunger-related causes every day." The First Lady further said the subject of nutrition needs to be addressed through broad based partnerships involving communities, Non-Governmental Organizations, Governments and developments partners. She said such partnerships are required in order to realize the material and intellectual resources needed to fight poverty and build widespread awareness of roots and consequences of malnutrition. In this connection the First Lady Lucy Kibaki congratulated pioneer recipients of the Kenya Coalition for Action in Nutrition for their outstanding role they have played in the field of nutrition saying Kenyans are proud of their contribution and that the awards will encourage them to put more efforts in that filed. The First Lady at the same time called upon the food industry to fully shoulder its primary responsibility for producing safe and healthful foods and for making sure that all products are handled properly until they reach the consumer. She noted that it is essential that consumers understand their role in ensuring food safety saying consumers must know how to handle and prepare foods to ensure they are safe adding that this is the

only sure way to overcome many health challenges including the Rift Valley Fever. The pioneer recipients of the award were Professor Julia Ojiambo, Professor Ruth Oniang'o and Professor Julia Gitobu. Among those present were the Nairobi Provincial Commissioner James Waweru. Better nutrition education helps reduce malnutrition FAO nutrition materials educate people to make healthy food choices

GIẢM TỶ LỆ SUY DINH DƯỠNG TRẺ EM CON SỐ THÁCH THỨC VÀ NHỮNG GIẢI PHÁP BS. ĐÂNG QUỐC VIỆT Theo số liệu báo cáo của Bộ Y tế, đến cuối năm 1998, tỷ lệ suy dinh dưỡng trẻ em dưới 5 tuổi của cả nước là 39,8%. Vấn đề đặt ra là trong 2 năm 1999 và 2000 cả nước phấn đấu đạt chỉ tiêu tỷ lệ trẻ dưới 5 tuổi suy dinh dưỡng chỉ còn 30% như theo Nghị quyết 37 C/P của Chính phủ. Giải pháp nào để đạt được chỉ tiêu đó? 30% - CON SỐ THÁCH THỨC Rất nhiều nguyên nhân để chỉ tiêu chỉ còn 30% trẻ dưới 5 tuổi suy dinh dưỡng (SDD) vào năm 2000 trở nên một con số thách thức. Trước hết, năm 1998, nước ta chịu ảnh hưởng của cuộc khủng hoảng tài chính tiền tệ trên thế giới và trong khu vực, thu nhập quốc dân giảm (chỉ tăng 5,83% so với dự kiến là 9%). Những tác động này sẽ còn tiếp tục ảnh hưởng kéo dài trong cả năm 1999 và năm 2000. Thứ đến, ngân sách Nhà nước đầu tư cho y tế không tăng trong khi dân số tăng hơn 1 triệu người, nhiệm vụ của ngành Y tế tăng (triển khai công tác quản lý chất lượng và an toàn thực phẩm). Ngược lại các nguồn viện trợ, vốn vay có chiều hướng giảm do các nhà tài trợ quốc tế chuyển đầu tư từ châu Á sang châu Phi. Thời tiết, khí hậu diễn biến phức tạp ở nước ta cũng là một thách thức. Nhiều nơi bị hạn hán, thiếu nước trồng trọt nên năng suất cây trồng giảm, kinh tế phát triển chậm dẫn đến số hộ đói nghèo nguy cơ tăng. Đồng thời thiếu nước sinh hoạt không bảo đảm vệ sinh ăn uống cũng dễ làm bệnh dịch phát sinh, phát triển. Mặt khác theo dự báo, năm nay có khả năng xuất hiện bão to, lũ lớn vừa là nguyên nhân gây thiệt hại kinh tế vừa là điều kiện thuận lợi cho dịch bệnh bùng phát. Các yếu tố này đều dẫn đến nguy cơ làm tăng số trẻ SDD.

Môi trường sống đang bị tàn phá nặng nề do tốc độ công nghiệp hóa và đô thị hóa tăng nhanh, đồng thời tình trạng di dân tự do đã làm cho nhiều dịch bệnh trước đây đã bị khống chế nay có cơ hội bùng phát thành dịch như sốt rét, sốt xuất huyết, dịch hạch. Cuối cùng, phải nói là nước ta đang còn gần 20% dân số là người nghèo sống ở nông thôn, miền núi (trong đó 1.715 xã đặc biệt khó khăn) là vùng kinh tế phát triển chậm. Tỷ lệ trẻ em SDD ở những gia đình nghèo, vùng nghèo cao hơn các vùng khác, nhiều nơi tỷ lệ trẻ em SDD còn trên 50%. Đó là những nguyên nhân chủ yếu để con số tỷ lệ 30% trẻ em dưới 5 tuổi SDD vào năm 2000 trở nên một con số thách thức chúng ta. CÁC GIẢI PHÁP Trên thực tế, khi đi công tác ở cơ sở, chúng tôi thấy có khá nhiều địa phương triển khai phòng chống SDD trẻ em đạt kết quả tốt. Huyện Thanh Miện (Hải Dương) tỷ lệ SDD trẻ em còn 33,7%, Thị trấn Chợ Gạo (Tiền Giang) còn 21%, phường Phú Thọ (thị xã Thủ Dầu Một, tỉnh Bình Dương) còn 21%. Qua tình hình thực tế, kinh nghiệm của các địa phương, chúng tôi đề xuất một số giải pháp để đạt được chỉ tiêu nói trên. Trước hết, phải nói đến là nâng cao đời sống kinh tế cũng như xã hội cho người dân. Đói nghèo vừa là nguyên nhân vừa là bạn đồng hành của SDD, nên vấn đề cơ bản số 1 là phải giải quyết lương thực cho dân đủ ăn. Mục tiêu xóa đói, giảm nghèo của Đảng và Nhà nước ta được cụ thể bằng 2 chương trình: chương trình mục tiêu Quốc gia xóa đói giảm nghèo (chương trình 133) và chương trình phát triển kinh tế, xã hội các xã đặc biệt khó khăn miền núi và vùng sâu, vùng xa (chương trình 135). Đây là hai chính sách đòn bẩy đẩy mạnh phát triển kinh tế, thực hiện công bằng xã hội, đồng thời là cơ sở chính trị, xã hội vững chắc góp phần giải quyết vấn đề phát triển kinh tế cho vùng nghèo, người nghèo. Chúng ta cũng nhận thấy rằng, hiện nay tỷ lệ trẻ SDD ở những gia đình không nghèo còn chiếm tỷ lệ đáng kể. Nguyên nhân là do các bà mẹ, nhất là bà mẹ trẻ đang thiếu kinh nghiệm nuôi con. Để giải quyết vấn đề này cần triển khai mạnh mẽ công tác truyền thông, tư vấn và hướng dẫn cách nuôi con khoa học cho các bà mẹ. Kinh nghiệm phát triển kinh tế nông thôn trong thời gian vừa qua với mô hình vườn - ao - chuồng (VAC), ở miền núi là VACR đã có nơi làm tốt. Huyện Thanh Miện (Hải Dương) xuất hiện mô hình "màu xanh rau ngót, màu vàng đu đủ, màu đỏ trứng gà". Ơû đây mỗi gia đình đã hưởng ứng phong trào trồng thêm một mét vuông rau ngót, trồng thêm một cây đu đủ và thêm một con gà. Kết quả sau ba năm thực hiện đã giảm tỷ lệ trẻ SDD. Nhưng không phải địa phương nào cũng thực hiện được như Thanh Miện, nhiều nơi đang lúng túng.

Nguyên nhân sinh nhiều ở các gia đình nghèo là do thiếu điều kiện giải trí, nâng cao hiểu biết. Họ không có radio và tivi. và đó cũng là nguyên nhân sinh con nhiều ở các gia đình này. Giải quyết vấn đề này, chương trình 135 đầu tư xây dựng đồng bộ cơ sở hạ tầng điện, đường, trường, trạm. cho các xã nghèo, nhằm cung ứng các dịch vụ cần thiết để nhân dân trong đó có người nghèo có thể tiếp cận và sử dụng được. Bên cạnh đó, tập tục lạc hậu còn có ở đồng bào dân tộc thiểu số vùng cao như sinh nhiều, sinh dày, sinh tại nhà, cúng bái khi ốm đau. là những nguyên nhân gây tai biến sản khoa, nhiễm khuẩn. và cũng làm tăng tỷ lệ SDD trẻ em. Giải bài toán này cần tăng cường tuyên truyền giáo dục nâng cao nhận thức của nhân dân để họ từng bước thay đổi hành vi và tự nguyện loại bỏ các tập tục lạc hậu. Các giải pháp về kinh tế xã hội cần được thực hiện đồng bộ với các giải pháp tác động đến trẻ dưới 5 tuổi và bà mẹ đang độ tuổi sinh con. Đối với trẻ dưới 5 tuổi cần được tiêm chủng 6 loại vắc-xin 6 bệnh truyền nhiễm; trẻ cần được giảm tỷ lệ mắc bệnh và tử vong do bệnh viêm phổi, bệnh tiêu chảy. Cần cân và theo dõi biểu đồ tăng trưởng trẻ em và cho trẻ em uống viên sắt, vitamin A. Chú ý nhất là trẻ dễ mắc, tử vong do viêm phổi, tiêu chảy. Đây là hai nhóm bệnh trẻ dễ mắc nhất, mắc nhiều nhất và diễn biến phức tạp nhất, nguy cơ dẫn đến SDD cao nhất và gây tử vong nhiều nhất. Với các bà mẹ trong độ tuổi sinh con phải chú ý: phụ nữ có thai được khám đủ ba lần, được theo dõi biểu đồ tăng trưởng đề phòng SDD bào thai. Họ cần được uống viên sắt đề phòng thiếu máu. Phụ nữ nuôi con ba tháng đầu được uống vitamin A đề phòng thiếu vitamin A và phòng bệnh khô mắt cho trẻ. Phụ nữ có thai được tiêm chủng uốn ván 2 lần. Cần giảm tỷ lệ SDD và giảm tình trạng thiếu vi chất dinh dưỡng ở phụ nữ trong độ tuổi sinh đẻ. Đầu tư cho công tác phòng chống SDD chính là đầu tư cho sự phát triển kinh tế, xã hội, bởi đó là sự đầu tư xây dựng nguồn lực quan trọng nhất - nguồn lực con người - nguồn lực có vai trò quyết định sự phát triển của đất nước. Trong đó đầu tư cho công tác phòng chống SDD trẻ em còn mang ý nghĩa nhân văn sâu sắc, bởi đó chính là sự đầu tư cho những chủ nhân tương lai của đất nước, góp phần phát triển giống nòi. Để thực hiện mục tiêu cao đẹp trên, trong điều kiện đất nước còn nghèo, nguồn lực có hạn, thì việc triển khai đồng bộ các giải pháp là phương thức hiệu quả nhất góp phần giảm tỷ lệ SDD nói chung và SDD trẻ em nói riêng. Dinh dưỡng trẻ em, không thể xem thường - Trẻ bị suy dinh dưỡng chủ yếu là do người nuôi trẻ thiếu hiểu biết cơ bản về thực phẩm, về dinh dưỡng cho trẻ. Ngay cả trong điều kiện chăm sóc tốt nhất, trẻ vẫn mắc phải tình trạng suy dinh dưỡng hoặc béo phì rất đáng lo ngại. Khi sinh, trung bình một đứa trẻ nặng 3 kg và dài 50 cm. Lúc bốn tháng, bé nặng gấp hai lần; khi một tuổi, nặng gấp ba lần; hai tuổi bé đã nặng gấp bốn lần. Chiều cao của trẻ cũng tăng nhanh ở những năm đầu. Sự phát triển của bộ não trong những năm đầu cũng đáng chú ý: lúc mới sinh não nặng khoảng 300g; đến sáu tháng nặng gấp hai lần, khi một tuổi não nặng gấp ba lần; hai tuổi não trẻ đạt 80% so với não người lớn.

Chuyện cung cấp dinh dưỡng cho trẻ tưởng đơn giản, nhưng thực tế lại không đơn giản chút nào bởi nhiều phụ huynh đã và đang phải đối mặt một thực trạng đáng lo ngại về dinh dưỡng cho trẻ em. Ở người lớn, năng lượng ăn vào bằng với năng lượng cần tiêu hao; còn ở trẻ em, năng lượng ăn vào phải lớn hơn năng lượng tiêu hao vì trẻ em cần dự trữ năng lượng để phát triển. Suy dinh dưỡng là do năng lượng ăn vào giảm và năng lượng tiêu hao tăng. Khi bị suy dinh dưỡng, trẻ không tăng cân, giảm sức đề kháng, dễ mắc bệnh nhiễm trùng gấp hai, ba lần. Từ thực tế của một trong các trung tâm dinh dưỡng lớn của TP Hồ Chí Minh cho thấy, mỗi ngày có 700-800 ca khám và tư vấn dinh dưỡng thì có đến 40% ca gặp khó khăn về ăn uống, có nghĩa là tình trạng trẻ biếng ăn hiện trở thành rất phổ biến. Nếu như cách đây vài chục năm, nguyên nhân chủ yếu là thiếu ăn, thì hiện nay, chính sự thiếu hiểu biết về dinh dưỡng và sự phát triển của trẻ lại là nguyên nhân chính. Có nhiều nguyên nhân gây biếng ăn ở trẻ: nguyên nhân bệnh lý và nguyên nhân tâm lý. Trong đó, nguyên nhân tâm lý thường xảy ra do những sai lầm trong việc nuôi con. Nhiều phụ huynh không cho trẻ được tự xúc, tự ăn vì sợ trẻ ăn lâu mất thời gian hoặc làm đổ thức ăn. Thực đơn cho bé cũng thường bị áp đặt theo khẩu vị và theo chủ quan của người lớn. Trong môi trường ăn uống căng thẳng như thế, trẻ sẽ sợ ăn, dẫn đến rối loạn cơ chế no - đói, lâu ngày thành suy dinh dưỡng. Không ít phụ huynh tuy thấy con biếng ăn, chậm lớn, thay vì phải đưa con đến bác sĩ khám và tư vấn thì lại tự làm bác sĩ, cho uống bừa bãi các loại thuốc trị biếng ăn trên thị trường. Nguyên nhân thường gặp là do người nuôi trẻ thiếu hiểu biết cơ bản về thực phẩm, về dinh dưỡng cho trẻ. Cũng có những sai lầm thường gặp do cho trẻ ăn dặm quá sớm, làm trẻ bị rối loạn hấp thụ, tiêu chảy. Ngược lại, ăn dặm quá trễ sẽ làm bé bị suy dinh dưỡng, sẽ không chịu ăn gì khác ngoài sữa mẹ trong khi sữa mẹ không còn đáp ứng đủ nhu cầu dinh dưỡng. Khi trẻ bị bệnh, cần bổ sung nguồn dinh dưỡng tốt hơn để chống đỡ bệnh và phục hồi thì nhiều người lại bắt bé kiêng cữ, sẽ dẫn đến tình trạng suy dinh dưỡng. Cũng có người quan niệm ăn cơm sớm bé sẽ mau cứng cáp mà không hiểu rằng, ăn cơm khi chưa có răng hàm để nhai, dễ dẫn đến rối loạn tiêu hóa, đi phân sống và...cũng sẽ bị suy dinh dưỡng. Trẻ bị thiếu nhiều chất, suy dinh dưỡng lâu ngày mà không biết hoặc bị ép ăn quá nhiều, sợ hoặc biếng ăn thường xuyên sẽ bị rối loạn hành vi tiêu hóa. Hiện tỷ lệ trẻ bị suy dinh dưỡng rất cao. Ðể hạn chế tình trạng suy dinh dưỡng ở trẻ, cần phải có chế độ ăn dặm đúng cách cho bé với bốn nhóm thức ăn bột - đạm - dầu - rau, phát hiện sớm tình trạng thiếu các chất đặc biệt quan trọng cho sự phát triển của trẻ như: vitamin A, sắt, calci... Nếu thiếu các chất này, trẻ sẽ bị thiếu máu, còi xương, tầm vóc lúc trưởng thành bị hạn chế, bị các bệnh về mắt (khô giác mạc, quáng gà, thậm chí mù mắt)...

Bên cạnh tình trạng suy dinh dưỡng của trẻ em, giờ đây còn có thêm một vấn đề làm nhiều người phải quan tâm, đó là việc có quá nhiều trẻ dư cân và béo phì ở các thành phố lớn. Năm 1996 tỷ lệ trẻ dư cân và béo phì là 2%, đến năm 2000 đã tăng đến 3,1% và cho đến nay thì mức gia tăng đang ở mức báo động. Béo phì được coi là một bệnh, và nguy hiểm ở chỗ là bệnh mãn tính, vì là bệnh mãn tính nên tích tụ theo thời gian. Rất nhiều trường học hiện đang phải áp dụng các biện pháp làm giảm cân, chống béo phì cho trẻ, thậm chí tại các bệnh viện có không ít trẻ phải điều trị bệnh béo phì. Trẻ dưới 1 tuổi thường mập (đôi khi rất mập), nhất là từ tháng thứ 4-6. Ðây là giai đoạn bé tích mỡ nhanh nhất, nhưng lại chưa vận động nhiều để tiêu hao năng lượng. Hai giai đoạn dễ xuất hiện béo phì dai dẳng ở trẻ em là trong hai năm đầu và vào khoảng 4-11 tuổi. Các bậc cha mẹ ngày nay thường thích con mình mập mạp và đánh đồng sự tròn trĩnh với tình trạng sức khỏe tốt nên có khuynh hướng cho trẻ ăn quá nhiều mà không quan tâm đến nhu cầu thật của cơ thể trẻ. Phần lớn trẻ đều thích ăn quà vặt và rất dễ bị lôi cuốn bởi vô vàn thứ thức ăn bắt mắt. Khi đã béo phì rồi thì hậu quả cũng không xảy ra ngay mà phải một thời gian sau. 80% trẻ bị béo phì sẽ trở thành người lớn béo phì, sẽ bị một số bệnh mãn tính như: tim mạch, cao huyết áp, tai biến mạch máu não, tiểu đường, sỏi mật, gan nhiễm mỡ, khớp, rối loạn chuyển hóa lipit trong máu. Trẻ béo phì lại thường nặng nề, chậm chạp, vụng về, dễ mặc cảm, tự ti và khó hòa nhập bạn bè cùng trang lứa.22 November 2005, Rome -- Eating well is vital for a healthy and active life, but many people in virtually all countries do not eat well because of poverty and a lack of nutrition education, according to FAO. “To be food secure, families need sufficient resources to produce or purchase adequate food,” said FAO Nutrition Officer Peter Glasauer. “However, this does not guarantee good nutrition and health as we can see from the diet-related health problems among even more affluent population groups. People also need an understanding of what constitutes an appropriate diet for good health, and they must have the skills and motivation to make the best food choice available to them.” THỰC TRẠNG TÌNH HÌNH DINH DƯỠNG 1. Tình hình an ninh lương thực và bữa ǎn của nhân dân Thành tựu quan trọng trong thời gian vừa qua là tình trạng đói ǎn đã giảm đi trên diện rộng. Hiện nay, cả nước còn khoảng 1,4 triệu hộ còn đói ǎn so với 3,8 triệu hộ nǎm 1992. Nǎm 1999, tổng sản lượng lương thực quy thóc đạt 32,8 triệu tấn, đạt được chỉ tiêu đề ra, các loại thực phẩm sản xuất đa dạng hơn. So sánh mức ǎn của đầu thập kỷ và cuối thập kỷ 90 cho thấy nạn đói giáp vụ cần trợ cấp hoặc bị đứt bữa ở các địa phương đã giảm đi rõ rệt. ở khu vực đồng bằng nông thôn, mức ǎn là 2062 Kcal đầu người/ngày (điều

tra điểm) so với mức ǎn trung bình cả nước nǎm 1990 là 1940 Kcal. So với 10 nǎm trước đây, bữa ǎn của người Việt nam có tǎng hơn về lượng thịt, mỡ, đậu phụ, đường và quả chín. Tỷ lệ hộ gia đình có mức bình quân nǎng lượng thấp đã giảm hẳn ở hầu hết các tỉnh đồng bằng và khu vực thành phố. Tuy nhiên, tình trạng an ninh lương thực ở nhiều vùng còn bấp bênh do chịu ảnh hưởng của thiên tai, lũ lụt bất thường. Đó là các tỉnh miền Trung, Tây nguyên và miền Núi phiá Bắc với địa bàn rộng lớn và đông dân. Trong khi đó, ở khu vực đồng bằng sông Hồng và sông Cửu long, tổng diện tích gieo trồng cây lương thực tǎng không nhiều, diện tích đất canh tác nông nghiệp bị thu hẹp. Điều này sẽ là thách thức đối với mục tiêu mở rộng phát triển nông nghiệp thời gian tới. Mặc dù có sự phát triển đa dạng hơn trong nông nghiệp, song cơ cấu sản xuất nông nghiệp trong những nǎm qua chưa thay đổi nhiều, lĩnh vực chế biến bảo quản nông sản, giá cả, thị trường còn gặp nhiều khó khǎn. Các yếu tố của sản xuất thực phẩm của hộ gia đình và tập thể... không đồng đều và chưa bền vững. Bên cạnh đó, do đòi hỏi của quá trình đẩy mạnh công nghiệp hóa, hiện đại hóa và do ảnh hưởng của xu hướng đô thị hóa, thị hiếu, quảng cáo...thói quen ǎn uống của một bộ phận dân cư đã dần thay đổi. Nhìn chung, tình trạng an ninh lương thực và bữa ǎn của nhân dân đã có cải thiện rõ song vẫn tiềm ẩn nhiều yếu tố rủi ro ở nhiều địa phương. Tỷ lệ hộ đói nghèo trên tổng số hộ trong cả nước theo tiêu chuẩn hiện nay tuy đã giảm từ 20% (1995) xuống 11% (nǎm 2000) nhưng vẫn còn cao. 2. Suy dinh dưỡng trẻ em (SDD) và bà mẹ Tỷ lệ trẻ SDD đã giảm nhiều nếu tính từ 1985 (51,5%) đến 1995 (44,9%) mỗi nǎm giảm trung bình 0,66%. Từ nǎm bắt đầu KHQGDD (1995), chỉ sau 4 nǎm tỷ lệ SDD đã giảm xuống còn 36,7% (1999), trung bình mỗi nǎm giảm 2%, là tốc độ được quốc tế công nhận là giảm nhanh. Như vậy, mỗi nǎm đã đưa khoảng gần 200 ngàn trẻ dưới 5 tuổi thoát khỏi suy dinh

dưỡng. Nǎm 2000, theo số liệu điều tra MICS của Tổng cục thống kê, tỷ lệ trên còn 33,1%. Có thể nói thành tựu giảm nhanh tỷ lệ suy dinh dưỡng trẻ em trong 5 nǎm qua rất đáng ghi nhận. Suy dinh dưỡng nặng đã giảm hẳn (0,8%) và SDD ở nước ta hiện nay chủ yếu là thể nhẹ và thể vừa. Tuy nhiên, tỷ lệ suy dinh dưỡng ở nước ta vẫn ở mức rất cao so với quy định của Tổ chức Y tế thế giới. Mặt khác, mặc dù tỷ lệ trẻ em bị thấp còi đã giảm nhanh trong những nǎm qua song vẫn còn ở mức khá cao (38,6%), những vùng có tỷ lệ trẻ nhẹ cân cao cũng là những vùng có tỷ lệ thấp còi cao. Tỷ lệ SDD có sự khác biệt giữa các vùng sinh thái, giữa các tỉnh. Tỷ lệ SDD cân nặng theo tuổi thấp nhất là ở thành phố Hồ Chí Minh (18,1%) và Hà nội (21%), trong khi đó có tỉnh, tỷ lệ SDD còn trên 50%. Cụ thể, vùng có tỷ lệ SDD thấp nhất là vùng Đông Nam bộ - trong đó có TP HCM - (29,6%); sau đó là vùng Đồng bằng Sông Cửu long (32,3%); vùng Đồng bằng Sông Hồng (33,8%); vùng Duyên Hải Nam Trung bộ (39,2%); vùng Đông bắc (40,9%); vùng Tây bắc (41,6%); vùng Bắc Trung bộ (39,2%) và cao nhất là vùng Tây nguyên (49,1%). ở Việt nam không có sự khác biệt rõ ràng về giới đối với mức độ SDD. Nhóm tuổi bị ảnh hưởng nhiều nhất là 6-24 tháng tuổi, đây là nhóm tuổi bắt đầu chuyển từ chế độ bú sữa mẹ sang chế độ ǎn sam, nếu chế độ ǎn sam không đúng sẽ tác động rất lớn đến tình trạng dinh dưỡng ở nhóm tuổi này. Các nguyên nhân của SDD là phức hợp từ nguyên nhân trực tiếp là ǎn uống, bệnh tật đến các yếu tố về chǎm sóc và nguyên nhân gốc rễ là sự nghèo đói. Tuy vậy, mức độ tác động của các yếu tố khác nhau theo vùng: Vùng Trung bộ, Tây nguyên và miền núi phía Bắc: vấn đề an ninh lương thực nổi lên hàng đầu; Vùng đồng bằng nông thôn khác: vấn đề chǎm sóc (trong đó có cách nuôi dưỡng trẻ) nổi lên hàng đầu; Vùng đô thị lớn: vấn đề bệnh tật từ nhỏ dẫn tới SDD nổi lên hàng đầu. Sở dĩ như vậy là vì ở thành thị vấn đề thiếu ǎn không còn phổ biến và chất lượng chǎm sóc trẻ tốt hơn, trong khi nhiều địa phương ở khu vực nông thôn thì vấn đề chǎm sóc, nuôi dưỡng trẻ còn nhiều hạn chế. Điều này đòi hỏi các chiến lược tác động khác nhau theo từng khu vực và từng giai đoạn. Gần đây, tổng kết của Viện

Nghiên cứu Chiến lược và Chính sách Dinh dưỡng quốc tế (IFPRI) cho thấy học vấn của người phụ nữ đóng góp 43% đối với SDD, trong khi an ninh thực phẩm đóng góp 26,1% đối với SDD. Điều này cho thấy yếu tố về cách nuôi dưỡng, cách chǎm sóc (thể hiện qua trình độ học vấn của người phụ nữ) có vai trò quan trọng đối với SDD. Thiếu nǎng lượng trường diễn ở phụ nữ, thể hiện bằng chỉ số khối cơ thể (BMI) thấp (<18,5), nǎm 1977 là 38% và gần đây là 32%. Tình trạng thiếu nǎng lượng trường diễn ở phụ nữ phản ánh những vấn đề tồn tại trong chǎm sóc phụ nữ, đồng thời có liên quan tới tỷ lệ suy dinh dưỡng bào thai. 3. Tình hình thiếu vi chất dinh dưỡng 3.1. Thiếu Vitamin A: Thành tựu nổi bật trong 5 nǎm qua là việc triển khai có hiệu quả chương trình Vitamin A, đẩy lùi được bệnh mù dinh dưỡng mà trước đây hàng nǎm có khoảng 5 đến 7 ngàn trẻ bị đe dọa mù vĩnh viễn do thiếu vitamin A. Tỷ lệ khô loét giác mạc hoạt tính dẫn tới mù loà từ chỗ 7 lần cao hơn so với ngưỡng quy định của Tổ chức Y tế thế giới, nay giảm xuống thấp hơn mức có ý nghĩa sức khoẻ cộng đồng. Hàng nǎm có khoảng 94-97% trẻ em trong độ tuổi từ 6-36 tháng được uống viên nang Vitamin A liều cao định kỳ 6 tháng một lần. Hiện nay, thiếu vitamin A thể tiền lâm sàng vẫn còn cao (10,8% ở trẻ em và trên 50% ở bà mẹ nuôi con bú). Thiếu vitamin A thể tiền lâm sàng có liên quan tới bệnh tật và tử vong. Nguyên nhân chính dẫn đến thiếu Vitamin A là do khẩu phần ǎn còn ít các loại thực phẩm giàu Vitamin A, lượng dầu ǎn và chất béo còn thấp. 3.2. Thiếu máu do thiếu Sắt: Là vấn đề thiếu vi chất dinh dưỡng quan trọng hàng đầu hiện nay. Nhóm đối tượng có nguy cơ cao là phụ nữ tuổi sinh đẻ và trẻ em (53% phụ nữ có thai, 40% phụ nữ không có thai và 60% trẻ em dưới 2 tuổi bị thiếu máu do thiếu sắt). Nguyên nhân chính của thiếu máu do thiếu sắt là khẩu phần ǎn còn thiếu các thực phẩm giàu chất sắt, đặc biệt là các thức ǎn nguồn gốc động

vật. Mặt khác, tỷ lệ nhiễm giun móc khá cao đóng góp vào nguyên nhân thiếu máu do thiếu sắt. Chương trình phòng chống thiếu máu do thiếu sắt được triển khai với 2 hoạt động là bổ sung viên sắt-acid folic; giáo dục truyền thông kết hợp với phòng chống nhiễm giun. ở nơi có chương trình, tỷ lệ thiếu máu ở phụ nữ tuổi sinh đẻ hạ xuống còn 25%. Tuy nhiên, chương trình mới triển khai giới hạn ở 1282 xã trong toàn quốc. 3.3. Thiếu Iốt: Các bệnh rối loạn do thiếu Iốt khá phổ biến ở nước ta. Chương trình quốc gia phòng chống thiếu Iốt đã đạt được mục tiêu đề ra đến nǎm 2000 (dựa trên chỉ số Iốt niệu). Mặc dù vậy, còn hơn 1/4 trẻ em tuổi học đường bị bướu cổ ở các mức độ (số liệu 1999). Tỷ lệ bướu cổ phụ thuộc vào điều kiện địa lý, vùng sinh thái. Khoảng 30% số hộ gia đình ở vùng đồng bằng sông Cửu long có chỉ số Iốt niệu thấp (<10mcg/dl). Việc phòng chống thiếu Iốt và bệnh bướu cổ cũng đã được triển khai rộng. Việc toàn dân sử dụng muối Iốt đã được đưa vào Nghị định của Chính phủ, hiện có khoảng 61% dân số trong toàn quốc sử dụng muối Iốt. Như vậy, chương trình phòng chống thiếu vitamin A và phòng chống các rối loạn do thiếu Iốt đã thu được kết quả đáng khích lệ, cần tiếp tục duy trì củng cố trong những nǎm tới. Hiệu quả của 2 chương trình trên đã được quốc tế công nhận và đánh giá cao. Trong khi đó, chương trình phòng chống thiếu máu do thiếu sắt còn đi sau, cần được quan tâm triển khai mạnh mẽ trong thời gian tới. 4. Tình hình chǎm sóc sức khỏe bà mẹ và trẻ em Số liệu mới đây cho thấy mức tǎng cân trong thời kỳ có thai ở phụ nữ nông thôn còn thấp phản ánh chất lượng chǎm sóc thai nghén còn hạn chế, trung bình tǎng 8 kg trong thời kỳ mang thai (nǎm 1985 là 6 kg), trong khi đó phụ nữ có thai ở Hà nội tǎng trung bình được 10,6 kg (nǎm 1985 là 8,5kg). Có khoảng 40% bà mẹ không được chǎm sóc thai sản và không được theo dõi cân nặng trong quá trình mang thai. Thực hành nuôi con bằng sữa mẹ đã có nhiều tiến bộ. Tuy nhiên mới có 31,1% bà mẹ cho con bú hoàn toàn

trong 4 tháng đầu và 20,2% bà mẹ đã có kiến thức thực hành nuôi dưỡng hợp lý khi trẻ bị bệnh (số liệu nǎm 2000). Mặc dù đã có sự cải thiện về đời sống nói chung, song trên thực tế, phụ nữ, nhất là ở nông thôn, thường phải lao động rất vất vả, ngay cả khi có thai hoặc cho con bú. Hầu hết phụ nữ không được chia sẻ gánh nặng nội trợ gia đình, chǎm sóc con cái. Thời gian nghỉ trước và sau đẻ ngắn là một cản trở quan trọng đối với việc thực hiện nuôi con bằng sữa mẹ, ǎn bổ sung của trẻ, và quỹ thời gian chǎm sóc trẻ. Hoạt động chǎm sóc sức khoẻ trẻ em qua các chương trình chǎm sóc sức khoẻ ban đầu đã có những tiến bộ đáng kể. Tuy nhiên, những điều kiện thiết yếu của chǎm sóc như nước sạch, công trình vệ sinh, hệ thống nhà trẻ còn nhiều bất cập. Đến nay mới khoảng 30% dân số nông thôn được dùng nước sạch, tỷ lệ nhà tiêu hợp vệ sinh còn thấp (khoảng 20%), và hệ thống nhà trẻ mới đảm bảo 8,68% trẻ trong độ tuổi đi nhà trẻ. Điều kiện vệ sinh ảnh hưởng tới bệnh tật của trẻ, tỷ lệ nhiễm giun cao (70-90% bị nhiễm giun đũa, giun tóc), ước tính một trẻ dưới 5 tuổi bị tiêu chảy trung bình 2 lần trong nǎm. Điều này còn liên quan đến thực hành chǎm sóc vệ sinh tại gia đình. 5. Tình hình vệ sinh an toàn thực phẩm Tháng 2/1999 Thủ tướng chính phủ ký quyết định thành lập Cục quản lý Chất lượng Vệ sinh an toàn thực phẩm (CLVSATTP). Sự ra đời của một cơ quan quản lý nhà nước chịu trách nhiệm quản lý CLVSATTP có ý nghĩa quan trọng trong việc điều phối liên ngành để triển khai có hiệu quả chương trình VSATTP ở Việt nam. Vào tháng 4 hàng nǎm tổ chức "Tháng hành động Vì CLVSATTP" trong toàn quốc (từ 15 tháng 4 đến 15 tháng 5 hàng nǎm). Tuy nhiên công tác này còn gặp nhiều khó khǎn. Hệ thống quản lý Chất lượng An toàn thực phẩm theo HACCP (Phân tích mối nguy hại và các điểm kiểm soát trọng yếu) , GMP (Thực hành sản xuất tốt) ở các cơ sở sản xuất, chế biến, bảo quản cung ứng thực phẩm mới chỉ triển khai ở quy mô hạn chế. Các cơ sở chế biến thực phẩm thiếu các điều kiện và kiến thức về vệ sinh an toàn thực phẩm. Các sản phẩm, nhất là thực phẩm chế biến sẵn, có thể

là nguồn gây bệnh. Các vụ ngộ độc thức ǎn ở nhiều địa phương còn xảy ra. Theo số liệu của Bộ Y tế, trong nǎm 1999 có 327 vụ ngộ độc thức ǎn với 7576 người mắc, trong đó có 72 trường hợp bị tử vong. Nguyên nhân của các vụ ngộ độc thức ǎn: 50% do ô nhiễm vi sinh vật, 11% do nhiễm hóa chất, 6% do độc tố tự nhiên, 34% không rõ nguyên nhân. Có tới 60% thức ǎn đường phố được phát hiện có ô nhiễm vi sinh vật. Thêm vào đó, các quy định còn chưa hoàn chỉnh và ý thức của người sản xuất cũng như kiến thức của người tiêu dùng về mức nguy hại đối với sức khỏe con người khi vi phạm các quy định về vệ sinh an toàn thực phẩm còn hạn chế. Việc thực hiện các vǎn bản pháp lệnh của nhà nước về vệ sinh an toàn thực phẩm còn chưa triệt để, sự phối hợp đồng bộ của các ngành liên quan còn chưa chặt chẽ. 6. Một số bệnh mãn tính có liên quan tới dinh dưỡng Có bằng chứng cho thấy những nǎm gần đây các bệnh mãn tính liên quan đến dinh dưỡng có xu hướng gia tǎng như Béo phì, Tim mạch, Tiểu đường và Ung thư. Vai trò của chế độ ǎn đã được chứng minh là đặc biệt quan trọng trong các bệnh trên. Béo phì: Béo phì có nguy cơ gia tǎng ở khu vực các thành phố lớn như Hà nội, thành phố Hồ Chí Minh. Tỷ lệ thừa cân và béo phì của nhóm 4-5 tuổi ở thành phố Hồ chí minh là 2.5%, ở Hà nội trên 1%. Tỷ lệ thừa cân và béo phì của nhóm tuổi 6-11 tuổi ở nội thành thành phố Hồ Chí Minh là 12%, ở nội thành Hà nội là 4%. Tỷ lệ này của người trưởng thành ở Hà nội: nam là 15%, nữ là 19%. Tiểu đường: Tỷ lệ mắc hiện nay ở Hà nội là 1%, ở thành phố Hồ chí minh là 2.5%, ở Huế là 1%. Bằng chứng cho thấy có sự liên quan giữa tỷ lệ mắc tiểu đường với lối sống và cách ǎn uống ở các đô thị lớn. Số liệu theo dõi trong bệnh viện cho thấy số bệnh nhân tiểu đường, kể cả thể không phụ thuộc Insulin (type II) tǎng lên rõ rệt. Tim mạch: Có sự liên quan chặt chẽ giữa thừa cân và bệnh tǎng huyết áp ở người trên 60 tuổi. Gần đây số trường hợp đột quỵ tǎng gấp 3 lần so với 10

nǎm trước. Tỷ lệ bị nhồi máu cơ tim hiện nay tǎng gấp 6 lần so với thập kỷ 60. Ung thư: Trên 35% các trường hợp ung thư được phát hiện là có liên quan đến chế độ ǎn, đặc biệt là chế độ ǎn nhiều chất béo, đạm động vật, và nhiễm hóa chất bảo vệ thực vật, các loại hạt có nhiễm độc tố Aflatoxin. II. Tình hình thực hiện Kế hoạch Hành động Quốc gia về Dinh dưỡng (KHQGDD) 1996-2000 Kế hoạch hành động quốc gia về dinh dưỡng là bản kế hoạch liên ngành, trong đó Viện Dinh dưỡng được giao là đầu mối theo dõi dưới sự chỉ đạo của Bộ Kế hoạch-Đầu tư và Bộ Y tế. Bảy tiểu ban giúp việc có trách nhiệm theo dõi từng nội dung ưu tiên mà kế hoạch đề ra, đồng thời trực tiếp tổ chức các hoạt động thí điểm nhằm đúc rút kinh nghiệm chỉ đạo. Từng giải pháp đã có sự đầu tư ưu tiên của nhà nước để thực hiện mục tiêu cụ thể như Phòng chống SDD trẻ em; Phòng chống các rối loạn do thiếu Iốt; An ninh thực phẩm... Trong khi đó, các hoạt động khác chủ yếu dựa vào nguồn huy động của cộng đồng và hỗ trợ quốc tế. Công tác giáo dục truyền thông và huấn luyện liên ngành cho các cấp được tổ chức có hiệu quả, do đó đã thúc đẩy các mặt hoạt động của Kế hoạch. Đánh giá kết quả tổng hợp về việc thực hiện các mục tiêu cho thấy:

Vấn đề dinh dưỡng được xã hội quan tâm và được nhìn nhận

đầy đủ hơn. Nhận thức và thực hành của người dân về dinh dưỡng đã nâng cao đáng kể.

Tỷ lệ SDD trẻ em: 33,1% vào nǎm 2000. Mặc dù chưa đạt so

với mục tiêu đề ra là xuống dưới 30%, song mức giảm SDD trong thời gian qua là khá nhanh (2%/nǎm).

Giảm có ý nghĩa tình trạng thiếu vi chất dinh dưỡng: đạt được

mục tiêu phòng chống thiếu vitamin A và Iốt đến nǎm 2000; chương trình phòng chống thiếu máu dinh dưỡng đạt mục tiêu trong phạm vi 1282 xã có triển khai chương trình.

Giảm đáng kể số hộ có mức nǎng lượng khẩu phần ǎn vào

bình quân đầu người dưới 1800 Kcal: từ 22,5% xuống 15%. Chưa đạt so với mục tiêu đề ra là dưới 10% vào nǎm 2000. Bản KHQGDD 1996-2000 thực chất là vǎn bản đường lối với các chiến lược chủ đạo về dinh dưỡng ở nước ta. Chính vì vậy, chúng ta đã nhận được sự hỗ trợ quốc tế để triển khai nhiều hoạt động có kết quả. Các vấn đề mà 7 tiểu ban của Kế hoạch này theo dõi đã quan tâm một cách toàn diện từ nguyên nhân gốc rễ đến nguyên nhân tiềm tàng và nguyên nhân trực tiếp của SDD. Nhờ có KHQGDD 96-2000, các chỉ tiêu dinh dưỡng được theo dõi có hệ thống, nhiều chỉ tiêu đã được ghi trong mục tiêu phát triển kinh tếxã hội của các địa phương. III. Những tồn tại

Tỷ lệ SDD xuất phát điểm ở mức cao; An ninh lương thực hộ

gia đình ở những vùng khó khǎn chưa đảm bảo; Kiến thức, thực hành chǎm sóc dinh dưỡng còn hạn chế, trong khi công tác giáo dục truyền thông dinh dưỡng chưa đến tận hộ gia đình, chưa tác động đến toàn xã hội. Mặt khác việc giáo dục dinh dưỡng làm thay đổi tập quán ǎn uống không hợp lý cũng không phải là dễ dàng.

Nhận thức của nhiều ngành, nhiều cấp về tầm quan trọng của

vấn đề dinh dưỡng cũng như trách nhiệm của các lực lượng xã hội đối với vấn đề cải thiện tình trạng dinh dưỡng còn chưa đầy đủ.

Các giải pháp can thiệp và tổ chức triển khai, cơ chế điều hành

chưa đồng bộ và chưa thích hợp với từng vùng khác nhau. Thiếu cán bộ để triển khai các hoạt động dinh dưỡng ở cơ sở.

Nguồn ngân sách của nhà nước đầu tư cho dinh dưỡng còn

hạn hẹp, trong khi đó chưa phát huy hết tiềm nǎng và sự tham gia của cộng đồng cho công tác này.

Phối hợp liên ngành còn chưa chặt chẽ, chưa đồng bộ, thiếu

các chính sách hỗ trợ cần thiết. Nhiều nội dung vẫn triển khai theo trục dọc và chưa được quán triệt xuống các địa phương để các cấp chính quyền coi đây là trách nhiệm thực hiện và điều phối chung.

Chưa quan tâm nhiều đến công tác dinh dưỡng cho các đối

tượng, lứa tuổi, ngành nghề khác nhau cũng như vấn đề ǎn-điều trị trong hệ thống bệnh viện. IV. Những thách thức

Tǎng trưởng kinh tế: Nǎm 1999, mức tǎng GDP đạt 4,5%. Tuy

rằng hiện nay mức tǎng GDP đã có xu hướng đi lên, nhưng không đồng đều. Tình trạng thiếu việc làm có thể tǎng cao và số người ở giới hạn ngưỡng nghèo còn nhiều.

Tình trạng mất an ninh lương thực vẫn có thể tiếp tục đe dọa ở

nhiều vùng do ảnh hưởng của thiên tai bất thường tác động xấu tới sản xuất và môi trường.

Sức ép tǎng dân số còn tiếp tục: Dự báo nǎm 2005 khoảng 85 Các điều kiện hạ tầng đảm bảo cho chất lượng của công tác

triệu người, đến nǎm 2010 khoảng 93 triệu người.

chǎm sóc sức khoẻ và dinh dưỡng như nước sạch, hệ thống nhà trẻ, công trình vệ sinh gia đình, vệ sinh môi trường, vệ sinh an toàn thực phẩm, tập quán canh tác, mạng lưới y tế...còn chưa đáp ứng kịp yêu cầu. Hiểu biết, quan niệm về chǎm sóc trong cộng đồng còn hạn chế.

Một số tập quán lạc hậu ảnh hưởng trực tiếp tới thực hành dinh

dưỡng của bà mẹ và trẻ em nhỏ còn tồn tại ở nhiều vùng. Trong khi đó, sự thiếu hiểu biết và thực hành về dinh dưỡng hợp lý của một bộ phận cư dân đô thị làm tǎng tình trạng thừa dinh dưỡng cùng với các bệnh mãn tính có liên quan tới ǎn uống.
• •

Mạng lưới triển khai: còn thiếu cán bộ dinh dưỡng. Nguồn kinh phí đầu tư còn hạn hẹp, trong khi mỗi nǎm cả nước

có thêm gần một triệu trẻ ra đời, đòi hỏi tǎng đầu tư cho công tác chǎm sóc dinh dưỡng. V. Hiệu quả kinh tế xã hội Theo tính toán của Ngân hàng Thế giới, đối với nước ta, các bệnh suy dinh dưỡng đã làm giảm khoảng 2,4% mức gia tǎng GDP hằng nǎm nếu chỉ đơn thuần tính đến lý do làm giảm nǎng xuất lao động. Sự thiệt hại này còn

chưa kể đến giảm sút về tri thức do thiếu dinh dưỡng trong thời kỳ thơ ấu hoặc do chi phí cho chǎm sóc nuôi nấng. Những thiệt hại về kinh tế do SDD chủ yếu là vì nǎng xuất lao động kém ở người trưởng thành do đã bị SDD. Trong đó, thiệt hại về kinh tế do SDD Protein-nǎng lượng (PEM) chiếm 0,3%, do thiếu i-ốt (IDD) là 1,0% và do thiếu máu thiếu sắt là 1,1% của GDP. Phân tích Chi phí - Lợi ích: Xét về mặt kinh tế, đầu tư cho dinh dưỡng có tỷ xuất lợi ích kinh tế cao. Theo tính toán, nếu chi phí 1 tỷ đồng cho phòng chống SDD, sẽ mang lại lợi ích là 8,56 tỷ đồng. Nếu chi phí 1 tỷ đồng cho phòng chống thiếu máu do thiếu sắt sẽ mang lại lợi ích là 5,38 tỷ đồng (tính toán của Ngân hàng Thế giới cho nước ta). Bên cạnh đó, đầu tư cho dinh dưỡng không chỉ là một can thiệp mang tính lợi ích lớn về kinh tế, mà đây còn là đầu tư có hiệu qủa do giảm chi phí cho tử vong do SDD. Giảm đói nghèo sẽ dẫn tới giảm SDD, ngược lại giảm SDD sẽ chủ động góp phần giảm đói nghèo. Meeting the Millennium Development Goals FAO stresses that nutrition education is a key for developing the skills and motivation needed to eat well, and is especially important in situations where families have limited resources. It is also in those same low-income situations that the challenge of providing nutrition education is often the greatest. A lack of trained personnel, coupled with a shortage of libraries, books, guidelines, other sources of information, and non-existent or slow internet connections, make educating people about nutrition a formidable challenge. But meeting this challenge is essential if progress is to be made on the global commitment to reach the Millennium Development Goals (MDGs). Fundamentally, the MDGs are about improving the health and welfare of the poor, and in most instances this cannot occur without improvements in nutrition. While the links among poverty, hunger and malnutrition, which is the focus of MDG1, are obvious, nutrition also has an important role to play in the other MDGs as well. Nutrition is central to efforts to improve maternal and child health (MDGs 4 & 5) and to combat HIV/AIDS and other diseases (MDG 6). Better nutrition among schoolchildren also contributes to achieving MDG2, universal primary education, by reducing absences and enabling students to better concentrate and learn more. Bridging the gap between knowledge and action As part of its global efforts to strengthen nutrition education activities FAO produces a number of information, communication and educational materials. Some of the more recent publications are described below.

The Family Nutrition Guide helps governments and non-governmental organizations to inform and motivate people to adopt healthy diets and lifestyles throughout their lives. “The Guide is a basic nutrition education tool that can play a vital role in promoting good eating habits,” according to Ellen Muehlhoff of FAO’s Nutrition Education and Communication Group. “It was written primarily for health workers, nutritionists, agricultural extension workers, or other development workers, because these are the people most often working with poor rural and urban families. It also gives many suggestions on how to communicate and share this information when working with groups of people.” The Guide can also be helpful to individuals or community groups who want to know more about nutritious family feeding. With chapters like "Getting enough food", "Making good family meals" and "Keeping food safe and clean", the Guide can improve family nutrition in a number of areas. While the illustrations and food examples in the Guide reflect the situation in East African and Southern African countries, the basic information is relevant for all regions of the developing world and similar nutrition education material for other developing countries can be produced using this book as a model. Nutrition Education in Primary Schools – A Planning Guide for Curriculum Development This package will assist educators to establish effective nutrition education in schools. This practical hands-on material consists of a technical reader, a set of worksheets and a classroom curriculum chart and gives step-by-step guidance in planning or redesigning a nutrition education classroom curriculum and related school-based nutrition activities. But the Planning Guide goes further; it should “add value” to a standard curriculum development process because it adopts a “whole school” approach. This means that classroom learning is linked with practical action, backed up by improvements in the school environment and family and community participation. Growing international interest shown in nutrition publications Teaching Aids at Low Cost (TALC), based in the United Kingdom, and India-based Transformation Net, or Parivartan Net, which works to educate and empower farmers, women and other rural populations, have expressed interest in translating and distributing the FAO publications to teaching institutions in a number of developing countries. Improving access to adequate food and promoting better dietary intakes are central activities in FAO’s drive to reduce the number of hungry and malnourished people in the world, thus helping achieve the World Food Summit and Millennium Development Goals.

World Hunger Facts 2008 World Hunger Education Service Hunger is a term which has three meanings (Oxford English Dictionary 1971) the uneasy or painful sensation caused by want of food; craving appetite. Also the exhausted condition caused by want of food • the want or scarcity of food in a country • a strong desire or craving

World hunger refers to the second definition, aggregated to the world level. The related technical term (in this case operationalized in medicine) is malnutrition.1 Malnutrition is a general term that indicates a lack of some or all nutritional elements necessary for human health (Medline Plus Medical Encyclopedia). There are two basic types of malnutrition. The first and most important is proteinenergy malnutrition--the lack of enough protein (from meat and other sources) and food that provides energy (measured in calories) which all of the basic food groups provide. This is the type of malnutrition that is referred to when world hunger is discussed. The second type of malnutrition, also very important, is micronutrient (vitamin and mineral) deficiency. This is not the type of malnutrition that is referred to when world hunger is discussed, though it is certainly very important. [Recently there has also been a move to include obesity as a third form of malnutrition. Considering obesity as malnutrition expands the previous usual meaning of the term which referred to poor nutrition due to lack of food inputs.2 It is poor nutrition, but it is certainly not typically due to a lack of calories, but rather too many (although poor food choices, often due to poverty, are part of the problem). Obesity will not be considered here, although obesity is certainly a health problem and is increasingly considered as a type of malnutrition.] Protein-energy malnutrition (PEM) is the most lethal form of malnutrition/hunger. It is basically a lack of calories and protein. No one really knows how many people are malnourished. The statistic most frequently cited is that of the United Nations Food and Agriculture Organization, which measures 'undernutrition'. The most recent estimate (2006) of the FAO says that 854 million people worldwide are undernourished. This is 12.6 percent of the estimated world population of 6.6 billion. Most of the undernourished--820 million--are in developing countries. 'Undernourishment' is certainly related to malnutrition, but it is important to emphasize that it is an estimate (that is one reason why is referred to as undernutrition, as it is not exactly malnutrition) of malnutrition based on statistical aggregates, and not an estimate based on seeing to what extent actual people are malnourished and projecting from there (as would be done by survey sampling). It has been argued that the FAO approach is not sufficient to give accurate estimates of malnutrition (Poverty and Undernutrition p. 298 by Peter Svedberg).

Children are the most visible victims of undernutrition. Children who are poorly nourished suffer up to 160 days of illness each year. Poor nutrition plays a role in at least half of the 10.9 million child deaths each year--five million deaths. Undernutrition magnifies the effect of every disease, including measles and malaria. The estimated proportions of deaths in which undernutrition is an underlying cause are roughly similar for diarrhea (61%), malaria (57%), pneumonia (52%), and measles (45%) (Black 2003, Bryce 2005). Malnutrition can also be caused by diseases, such as the diseases that cause diarrhea, by reducing the body's ability to convert food into usable nutrients. According to the most recent estimate that Hunger Notes could find, malnutrition, as measured by stunting, affects 32.5 percent of children in developing countries--one of three (de Onis 2000). Geographically, more than 70 percent of malnourished children live in Asia, 26 percent in Africa and 4 percent in Latin America and the Caribbean. In many cases, their plight began even before birth with a malnourished mother. Under-nutrition among pregnant women in developing countries leads to 1 out of 6 infants born with low birth weight. This is not only a risk factor for neonatal deaths, but also causes learning disabilities, mental, retardation, poor health, blindness and premature death. The world produces enough food to feed everyone. World agriculture produces 17 percent more calories per person today than it did 30 years ago, despite a 70 percent population increase. This is enough to provide everyone in the world with at least 2,720 kilocalories (kcal) per person per day (FAO 2002, p.9). The principal problem is that many people in the world do not have sufficient land to grow, or income to purchase, enough food. Poverty is the principal cause of hunger. The causes of poverty include poor people's lack of resources, an extremely unequal income distribution in the world and within specific countries, conflict, and hunger itself. As of 2008 (2004 statistics), the World Bank has estimated that there were an estimated 982 million poor people in developing countries who live on $1 a day or less (World Bank, Understanding Poverty, Chen 2004). This compares to the FAO estimate of 850 million undernourished people. Extreme poverty remains an alarming problem in the world’s developing regions, despite the advances made in the 1990s till now, which reduced "dollar a day" poverty from (an estimated) 1.23 billion people to 982 million in 2004, a reduction of 20 percent over the period. Progress in poverty reduction has been concentrated in Asia, and especially, East Asia, with the major improvement occurring in China. In Sub-Saharan Africa, the number of people in extreme poverty has increased. Conflict as a cause of hunger and poverty. The United Nations High Commissioner for Refugees (UNHCR) reports that as of December 2006, there were at least 22.7 million displaced, including 9.9 million refugees and 12.8 million internally displaced persons (UNHCR 2007). (Refugees flee to another country while internally displaced people move to another area of their own country.) Most people become refugees or are internally displaced as a result of conflict, though there are also natural causes such as drought, earthquakes, and flooding. In the early stages of refugee emergencies, malnutrition runs rampant, exponentially increasing the risk of disease and

death (World Health Organization 2003). But, important and (relatively) visible though it is, conflict is less important as poverty as a cause of hunger. (Using the statistics above 798 million people suffer from chronic hunger while 22.7 million people are displaced.) Hunger is also a cause of poverty. By causing poor health, low levels of energy, and even mental impairment, hunger can lead to even greater poverty by reducing people's ability to work and learn. [Expand with citations] Progress in reducing the number of hungry people. The target set at the 1996 World Food Summit was to halve the number of undernourished people by 2015 from their number in 1990-92. (FAO uses three year averages in its calculation of undernourished people.) The (estimated) number of undernourished people in developing countries was 824 million in 1990-92. In 2000-02, the number had declined only slightly to 820 million (854 million worldwide including countries in transition--formerly part of the Soviet bloc-and developed countries [FAO 2006]) So, overall, the world is not making progress toward the world food summit goal, although there has been progress in Asia, and Latin America and the Caribbean. [Mention Millennium development goals.] Micronutrients Quite a few trace elements or micronutrients--vitamins and minerals--are important for health. 1 out of 3 people in developing countries are affected by vitamin and mineral deficiencies, according to the World Health Organization. Three--perhaps the most important in terms of current health consequences for poor people in developing countries--are: Vitamin A Vitamin A deficiency can cause night blindness and reduces the body's resistance to disease. In children Vitamin A deficiency can also cause growth retardation. Between 100 and 140 million children are vitamin A deficient. An estimated 250,000 to 500 000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight. (World Health Organization) Iron Iron deficiency is a principal cause of anemia. Two billion people—over 30 percent of the world’s population—are anemic, mainly due to iron deficiency, and, in developing countries, frequently exacerbated by malaria and worm infections. For children, health consequences include premature birth, low birth weight, infections, and elevated risk of death. Later, physical and cognitive development are impaired, resulting in lowered school performance. For pregnant women, anemia contributes to 20 percent of all maternal deaths (World Health Organization). Iodine Iodine deficiency disorders (IDD) jeopardize children’s mental health– often their very lives. Serious iodine deficiency during pregnancy may result in stillbirths, abortions and congenital abnormalities such as cretinism, a grave, irreversible form of mental retardation that affects people living in iodine-deficient areas of Africa and Asia. IDD also causes mental impairment that lowers intellectual prowess at home, at school, and at work. IDD affects over 740 million people, 13 percent of the world’s

population. Fifty million people have some degree of mental impairment caused by IDD (World Health Organization). (Updated February 2, 2008) Footnotes 1. The relation between hunger, malnutrition, and other terms such as undernutrition is not 'perfectly clear,' so we have attempted to spell them out briefly in "World Hunger Facts." 2. For example, the Oxford English Dictionary (1971 edition) has 'insufficient nutrition' as the only meaning for malnutrition. 3. The table used to calculate this number. % in $1 a day poverty East Asia and Pacific 9.07 Latin America and 8.63 the Caribbean South Asia 31.08 Sub-Saharan Africa 41.09 Total Developing countries Europe and Central 0.95 Asia Middle East and 1.47 North Africa Total Region Population (millions) 1,885.0 549.0 1,470.0 753.0 Pop. in $1 a day poverty (millions) 170.0 47.0 456.0 309.0 982.0 460.0 306.0 1.0 4.0 987

Sources: For columns 1 and 2, we have used World Bank (regional) poverty figures given at http://iresearch.worldbank.org/PovcalNet/jsp/index.jsp (accessed January 24, 2008). For population figures we have used World Bank figures for the same regions given at http://web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMD K:20394872~pagePK:64133150~piPK:64133175~theSitePK:239419,00.html (accessed January 24, 2008). Bibliography Oxford University Press. 1971. Oxford English Dictionary. Definition for malnutrition. Black RE, Morris SS, Bryce J. "Where and why are 10 million children dying every year?" Lancet. 2003 Jun 28;361(9376):2226-34.

Jennifer Bryce, Cynthia Boschi-Pinto, Kenji Shibuya, Robert E. Black, and the WHO Child Health Epidemiology Reference Group. 2005. "WHO estimates of the causes of death in children." Lancet ; 365: 1147–52. Shaohua Chen and Martin Ravallion. June 2004. "How have the world’s poorest fared since the early 1980s?" World Bank Policy Research Working Paper 3341 Washington: World Bank. http://wwwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2004/07/22/00011 2742_20040722172047/Rendered/PDF/wps3341.pdf de Onis, Mercedes, Edward A. Frongillo and Monika Blossner. 2000. "Is malnutrition declining? An analysis of changes in levels of child malnutrition since 1980." Bulletin of the World Health Organization 2000, 78: 1222–1233. Food and Agriculture Organization, International Fund for Agricultural Development, World Food Program. 2002 "Reducing Poverty and Hunger, the Critical Role of Financing for Food, Agriculture, and Rural Development." Food and Agriculture Organization. 2006. State of World Food Insecurity 2006 Svedberg, Peter. 2000. Poverty and Undernutrition p. 298 United Nations High Commissioner on Refugees. 2007. Statistical Yearbook 2006 "Main Findings" World Bank. Understanding Poverty website Accessed February 3, 2008 Learn About Hunger Page Hunger Notes Home Page

Asian workshop on nutrition education - Sharing expertise Atelier sur l'éducation nutritionnelle en Asie Taller sobre educación nutricional en Asia K. Tontisirin, G. Attig, P. Winichagoon and J. Yhoung-Aree Prof. Dr Kraisid Tontisirin is Director of the Institute of Nutrition, Mahidol University (INMU), Thailand. George A. Attig is an INMU consultant. Dr Pattanee Winichagoon is head of INMU's Division of Community Nutrition. Jintana Yhoung-Aree is an INMU researcher. Most South and East Asian countries still encounter problems of undernutrition, of which the most common and persistent are protein-energy malnutrition (PEM) and vitamin A, iron and iodine deficiencies, Infants and children under five and pregnant and lactating women are the most vulnerable people, especially those living in poor rural areas and urban slums. Compounding nutrition problems is the fact that several South and East Asian societies are entering a transitional stage in their development. This transition involves shifts in the population structure; changes in disease patterns (from infectious to chronic degenerative diseases); socio-economic transformation from fully subsistent to semi-subsistent, market-oriented economies; and an advance from struggling for child survival to aiming for development of full growth potential. Furthermore, contradictory problems such as under- and over-nutrition exist in the region and must often be dealt with in the same country. To highlight the importance of creating nutritional awareness among populations through nutrition education and communication, FAO sponsored the Inter-Country Workshop on Nutrition Education for South and East Asian Countries, organized by and held at the Institute of Nutrition at Mahidol University, Salaya, Thailand from 22 to 26 February 1993. Nutritionists. communicators. agriculturists and public health officials came from Bangladesh, China, Laos, Nepal, the Philippines, Sri Lanka, Thailand and Viet Nam to exchange information and discuss effective education and communication strategies in order to benefit from each other's experiences in implementing local and nationwide programmes. In planning the workshop, it was realized that in terms of programme development these South and East Asian countries can be divided broadly into two groups. China, the Philippines and Thailand have successfully developed and operated nutrition education programmes for the public to control and prevent malnutrition; Bangladesh, Laos, Népal, Sri Lanka and Viet Nam have not yet developed such programmes successfully at the national level. The workshop's concept rested on using the expertise available in the first group of countries to assist in the preparation of national project proposals for the second group, in the true spirit of FAO's concept of Technical Cooperation among Developing Countries (TCDC).

The workshop opened with presentations on the countries' efforts to combat nutrition problems through nutrition education strategies. The merits and limitations of current methods were assessed and ways of making the methods more effective were discussed. Case-studies of successful programmes in Thailand, China and the Philippines were presented. The teams from the second group of countries then prepared nutrition education project proposals and the group provided suggestions to improve them. In addition, the work and needs of the institutions that implement nutrition education programmes in each country were discussed, and specific forms of intercountry collaboration were developed so that resources can be shared between nations and specialists. COUNTRY SITUATIONS Bangladesh In 1991, Bangladesh had a population of 109 million people, with an annual population growth rate of 2.17 percent. In this densely populated country, approximately 83 percent of the people were living in rural areas. Life expectancy was 56,4 years for males and 54.4 years for females. The infant mortality rate (IMR) was 110 per 1000 live births and the under-five mortality rate was 180 per 1000, while the maternal mortality rate was 6 per 1000 births. The literacy rate was 29 percent and 19 percent for males and females, respectively. Bangladesh's major nutritional problems include chronic energy deficiency, PEM, maternal malnutrition, low birth weight, vitamin A deficiency, iron deficiency anaemia, iodine deficiency disorders (IDD) and deficiencies of other micronutrients such as riboflavin, vitamin C and zinc, The major causes of the nutritional disorders can be listed as inadequate supplies and/or intake of micronutrient-rich foods; lack of nutritional awareness; low production and purchasing power; inadequate household food security; inequitable food distribution within families; traditional food beliefs; and inappropriate infant feeding practices (e.g. bottle feeding, colostrum discarding). Despite obstacles and the lack of a nutrition education policy, important nutrition education work has been carried out. In agriculture, nutrition education has been a component in a marginal-farming and small-farm system, crop intensification and diversification programmes, horticultural development, strengthened nutrition research, sessions for training trainers and field demonstrations. The Ministry of Health and Family Welfare has programmes for nutrition education, feeding malnourished children, vitamin A capsule distribution, growth monitoring, iron and folic acid supplementation for pregnant women, extended programme of immunization (EPI) activities, treatment of minor illnesses, antenatal care and family planning. The Ministry of Women's Affairs and Social Welfare offers training for enhancing nutrition and socio-economic development, vitamin A capsule distribution, nutrition awareness-raising programmes and day care services for children of working women. Plans to conduct radio and television programmes on health, family planning and nutrition are under way in the Ministry of Information. In addition,

117 non-governmental organizations (NGOs) are involved in community nutrition programmes, some of which deal with nutrition education. While people with knowledge of nutrition education are available for activities, there are constraints including lack of strong political and administrative commitment; inadequate integration of nutrition into the nation's overall development plan; poor intersectoral coordination, monitoring and evaluation; and insufficient budgetary resources. Capacity to produce audiovisual aids and training materials, access to media services and personnel development and exchange of scientists with other nations are limited. Technical assistance is required for provision of training inputs, equipment, transport and maintenance. Personnel development facilities are also needed, especially for advanced training and education. Increased facilities are needed for infrastructure development. Laos Laos has a small, sparsely settled population of 3.94 million people, of whom 43.7 percent are under 14 years of age. The nation's economy is dependent on agriculture and forestry, and 85 percent of the people live in rural areas. Life expectancy rates are 47.5 years for females and 44.6 years for males. The IMR was 104 per 1 000 live births in 1990, and the under-five mortality rate was 193 per 1 000 in 1985. Malaria, acute respiratory infections and diarrheal diseases are the top three causes of morbidity and mortality among infants and small children. The adult literacy rate is estimated to be 44 percent. Laotian households are largely dependent on rice and horticultural products, which provide a daily dietary intake of approximately 1745 to 1976 calories, or about 70 to 80 percent of the recommended requirement. Protein requirements cannot be met through farming alone; hence almost every rural household is involved in gardening and/or hunting. Markets are not common sources of food. Nutrition surveys in Laos are limited and confined to small-scale studies. They show, however, that the major problems are low birth weight, PEM in preschool children (0 to 60 months), IDD, vitamin A deficiency, vitamin B, and B2 deficiencies, nutritional anaemia and bladder stone disease. To combat these problems, nutrition activities such as anthropometry and nutrition education are being conducted in provincial hospitals and Vientiane Municipality. Led by the Lao Women's Union, the Ministries of Public Health, Agriculture and Forestry, and Education are working together to disseminate nutrition messages to the population. The government has set objectives for 1992 to 1996 to reduce low birth weight to less than 20 percent, lower moderate malnutrition to less than 20 percent and lower severe malnutrition to less than 1 percent. For micronutrients, the objectives are to reduce iron deficiency anaemia in women to less than 20 percent; to reduce IDD in terms of the goitre rate among schoolchildren to 15 percent; and to reduce xerophthalmia

to less than 1 percent or, in preschool children with less than 10 mg of serum retinol, to 10 percent. Another goal is for 50 percent of mothers to breast-feed exclusively for the first four to six months. Most women should be able to continue breast-feeding, with complementary food, well into the child's second year. Growth promotion will be institutionalized and monitored regularly in 50 percent of the villages, with 80 percent coverage of preschool children. Finally, nutrition messages will be disseminated to 50 percent of villages. The constraints to attaining these objectives include a limited number of trained workers. Furthermore, those who have nutrition training usually have other responsibilities. The quality of printed materials is poor, and access to newspapers, magazines and other technical handbooks is restricted to urban areas, generally because of low interest and poor communication. Budget constraints prevent regular health and education sessions, and programmes lack appropriate equipment, transportation facilities and financial support. Training of trainers in health and nutrition education is needed, including instruction in the use of audiovisual and other educational materials. Equipment for audiovisual aids and production of radio and television programmes needs upgrading. Financial support is required for production of printed materials and simplified handbooks and for community outreach programmes. Finally, short-term fellowships, study tours and fora for exchange of experiences would improve the capabilities of nutrition education personnel in Laos. Nepal In 1990, Nepal had a population of 19,1 million, of which 3.1 million were under age five. The IMR was 123 per 1000 live births in 1990, and life expectancy at birth was 52 years. Approximately 35 percent of the Nepalese people are literate, though a disparity exists, with men showing higher literacy rates than women. Present assessments of Nepal's nutrition situation are based on data from the 1975 National Nutritional Status Survey as well as recent and ad hoc studies. Over 50 percent of children are undernourished, and PEM and micronutrient deficiencies (vitamin A, iron, iodine) are prevalent at very high levels in parts of the country. The most significant cause of nutritional problems is poor dietary intake. Inadequate food supplies, health services, awareness, water supplies, sanitation facilities, food hygiene and child care, as well as population growth, improper feeding practices, traditional food beliefs and other social and economic constraints, contribute to nutritional problems. These problems stem from inequitable distribution of resources and poverty. The Nepalese government has created a large cadre of teachers and field workers and strong extension networks in agriculture, health, education and development which conduct many nutrition-related activities. Nutrition

education efforts employ both interpersonal and media (radio, television, print) programmes.1

Editor's note: See the article "Building Nepal's capacity to create nutritional awareness through multisectoral training" by D. Shrestha and M.A. Hussain in Food, Nutrition and Agriculture, 7:34-40, 1993. Many NGOs, international organizations and international development agencies are active in development communications; however, they work in an ad hoc manner. Most projects lack the experts or resources required to produce communication and training materials. With a few exceptions, current communication activities in communities depend on the extension systems of government and non-government agencies. Other areas needing strengthening include personnel qualifications, training, equipment availability, institutional arrangements, commitment, financial arrangements and interdisciplinary involvement and coordination. Perhaps the greatest challenge for nutrition education is in developing and delivering effective programmes (media and interpersonal) that can accommodate Nepal's geographic, racial, ethnic and cultural diversities. Sri Lanka Sri Lanka has a population of nearly 17.5 million people, of whom about 70 percent live in rural areas. Agriculture is the main source of income. Although Sri Lanka has an average annual per caput income of less than US$ 450, the health status of the people remains impressive with a crude birth rate of 21.3 per 1 000 people, crude death rate of 7 per 1000 people, IMR of 19 per 1000 live births, maternal mortality rate of 0.1 per 1 000 live births and life expectancy at birth of 74.8 years for females and 76.7 for males. The vast majority of people, 87 percent, are literate. These exceptional achievements are attributed to social welfare measures. Paradoxically, this favourable overall situation exists in parallel with high rates of morbidity and ill health. Malnutrition, including PEM, low birth weight and deficiencies in iron, iodine and vitamin A, is a major health problem in Sri Lanka. Among many causal factors, inadequate dietary intake, low awareness and improper food habits are prominent. Family planning, maternal and child health (MCH), nutrition and immunization services form an integral part of the Health Ministry's Family Health Programme. Comprehensive programmes vary and are mainly implemented by the Ministry of Policy Planning and Implementation, the Ministry of Education and the Mahaweli Authority. Nutrition is also a component of the training programmes conducted by institutions in other sectors. The only mass media campaign has been one that promotes consumption of iodized salt. Common hindrances are lack of expertise and trained personnel, limited resources and inadequate coordination. An urgent necessity is nutrition orientation for à core group of people, for example medical officers, who could train primary health care workers and others. Technical assistance is needed to develop an information, education and communication (IEC) programme on

nutrition. While the equipment and expertise exists within Sri Lanka for producing audiovisual materials, lack of finances obstructs development. Video is gaining popularity, and video recorders and televisions for medical officers would be an asset. Viet Nam Viet Nam is an agricultural country with a population of over 70 million people. In 1991, the average annual per caput income was still low at US$ 200. Foodconsumption and nutrition-survey data indicate that chronic energy deficiency exists among a large proportion of the population. PEM afflicts about 42 percent of children under five, with severe PEM affecting approximately 14 percent of young children. Prevalence of nutritional anaemia in pregnant women in urban areas is 41 percent, while among rural women the rate is 49 percent. Vitamin A deficiency and xerophthalmia affect many people, and iodine deficiency is found in certain regions. Low levels of education and literacy among vulnerable groups, lack of awareness and improper child feeding practices are the main causes of these problems. A project is being implemented to educate people about the biological values of vitamin A and to raise their awareness of the benefits of breast-feeding, consumption of various food sources and proper child care. Home garden production of vitamin A-rich fruits and vegetables is promoted. Health education materials (manuals, flip charts, slide programmes, leaflets and videos) have been developed. The main interpersonal programme involves the strengthening of commune and village communication networks. THEORIES IN NUTRITION COMMUNICATION A paper was presented reviewing theories of nutrition education as background to assist participants in developing nutrition communication proposals. Over the last 50 years, three streams of thought have influenced nutrition communication. The first is concerned with education, psychology and behaviour change, the second with communication and the third with social marketing. Today's integrated model suggests that experts interact with audiences to plan original messages that are delivered through channels or media that are accessible to the audiences. This interaction improves the way a message is perceived, as the audience is moved from attention, through awareness and concern, to comprehension, then through decision-making or action, and finally to behaviour adoption. Consideration is given to local, socio-cultural and historical contexts. Programme planners need to consider each stage in the above sequence and to determine how they will address key issues over time with the audiences of interest. CASE-STUDIES Thailand To improve the nutritional status as well as knowledge, attitudes and practices of pregnant and lactating women and preschool children in seven regions,

Thailand undertook a project from 1985 to 1989 to assess and analyse food habit problems and explore flexible community-based approaches for behavioural modification, The objective was to change undesirable food habits while strengthening desirable ones. A fourfold strategy of participatory action research (PAR), nutrition communication, supportive activities and evaluation was used to attain the objectives. Modifying inappropriate food habits requires an integrated concept of nutrition that includes biomédical and behavioural-science perspectives. A clear understanding of the target groups and audiences, as individuals and as family members, and of their behaviour, attitudes and environmental constraints was necessary to set realistic objectives, and flexibility was required to achieve them. To begin, an accurate, early analysis was needed of the ways in which aspects of the socio-cultural, economic, political, psychological and physical environment shape existing food practices in a community. Formative research indicated that the major causal and contributing factors affecting food habits were learning experiences, culture, food availability, health services and mass-media advertisements. A participatory atmosphere and a "bottom-up/top-down" team approach was created for implementing the project. Local development agents from the health, agriculture, education and rural development sectors were encouraged to work with community leaders in developing and implementing communication and support activities. Using the PAR approach, villagers identified their major problems (e.g. illiteracy, insufficient household food security, poor access to health services and ineffective school lunch programmes) and then worked with local development agents to develop community-based intervention programmes such as food production and preservation activities, school lunch programme improvements, literacy campaigns and environmental sanitation campaigns. Coordination was critical for the project's long-term success and sustainability. Activities and responsibilities were shared by communities, local development organizers and project personnel. Accordingly a positive, empathetic relationship needed to be developed among all collaborators based on a common purpose and a meaningful set of attainable objectives. Combining nutrition messages with concrete support activities and emphasizing careful, effective management and evaluation were crucial. Last, a style was adopted that included a variety of supportive nutrition communication media and activities that fit practically with village life and the people's interests. This adaptation was crucial because, ultimately, community members are the ones who make the real difference. They are the ones who must change themselves. China

An intervention to change nutrition and food hygiene behaviour took place in rural China in 1991. In Shanxi Province 212 villages participated in a pilot project to increase the intake of high-quality protein by adding animal and soybean foods, to increase intake of vitamins A and B2 by eating more darkgreen vegetables, to decrease salt intake and to control diarrhoea. After one year, the intervention district showed great change, while the control district showed no significant changes. In the intervention district the proportion of residents aged 15 to 60 years with basic health knowledge increased from 11 percent to 81 percent. In the same age group, the proportion that ate at least one egg and 100 g of soybean food per day increased from 39 to 71 percent. Furthermore, the percentage of persons consuming less than 10 g of salt per day rose from 21 to 42 percent. Three lessons were drawn from the programme: first, support from community leaders, who are not only decision-makers but also influential persons in rural communities, is essential. Second, the focus should be on the most important target group, such as women who have control over family food selection and preparation; activities should be tailored to fit this group. Third, a comprehensive communication strategy is essential, and it should use media programmes that target a wide audience. Interpersonal communication is also needed, including training and counselling aimed at community leaders, families, local health workers and other important change agents. The Philippines The Barangay Integrated Development Approach for Nutrition Improvement of the Rural Poor (BIDANI), initiated in 1978, was conceived to improve family welfare, generate income and enhance food security. The intention was to coordinate efforts of the barangay or village people, the local government, NGOs and state colleges and universities in an agriculture-based actionresearch project. The five objectives were: to establish participatory models of improving the nutritional status of the rural poor; to develop practical nutrition education approaches, e.g. training courses for barangay leaders and trainers; to develop packages of participatory communication approaches and services at the village level; to institutionalize the models at the provincial and municipal levels for speedy, sustained and wider implementation and impact; and to sustain BIDANI with the technical assistance of state colleges and universities, as a complement to a programme of the National Nutrition Council of the Philippines entitled Toward A Stronger Body with Adequate Nutrition. During Phase 1, Barangay Nutrition Scholar-Development Workers were selected and given technical and practical training. A programme planning and implementing committee was organized at each barangay, a situational analysis was conducted and a barangay integrated development plan was formulated. Linkages with government and private agencies were established and indigenous extension and communication approaches were used. The barangay projects were implemented, monitored and evaluated.

Phase 2 focused on institutionalizing the programme by turning it over to existing government structures, personnel and resources. Phase 3 involved regionalization and expansion of the BIDANI model, which now covers seven regions in the Philippines. All stages of the development support communication (DSC) process were embodied in the components and phases of the BIDANI programme. These DSC stages are communication training; communication research; communication strategy planning; message design; materials and media development; the use of interpersonal, group and mass media; and communication evaluation. From the outset, the BIDANI programme planners recognized the pivotal role of communication in building sustainability and institutionalization into the programme. The BIDANI experience illustrates how nutrition, information, education and communication can be built into an overall nutrition programme. DSC should be an integral component of development programme or project planning, implementation and evaluation. While the initial investment in DSC may be high, it has been proven cost-effective in terms of multiplier effect, project survival, sustainability and, more important, socio-economic impact. PROPOSALS AND RECOMMENDATIONS Bangladesh, Sri Lanka, Viet Nam, Laos and Nepal formulated proposals for controlling nutrition problems in their respective countries. These projects will require coordination at the country level and collaboration within and among countries. • The Bangladesh Ministry of Agriculture proposed that communication facilities, equipment and personnel be upgraded so that communication can be used to solve problems of food production and nutritional practices among landless and marginal farm families. • Sri Lanka planned an effort to improve haemoglobin levels using a multisectoral multimedia approach involving interpersonal and small group discussion methods and community organization techniques as well as radio spots and video. • The Ministries of Health and Agriculture in Viet Nam aim to improve the energy and micronutrient status of farm families and raise their levels of nutrition knowledge, attitudes and practices. • To alleviate PEM among children, Laos seeks to employ nutrition communication and technical skills to improve attitudes and feeding practices of mothers as well as food handling behaviours. Breast-feeding and the timely introduction of supplementary foods are to be promoted and household food production improved.

• In Nepal, a multimedia communication approach was proposed to coordinate health, agriculture, education and local development activities to improve household food security and promote better nutritional practices. The workshop participants recommended that governments and international development agencies provide both technical and financial assistance to promote nutrition education and communication. The need for a network to exchange technical information and experiences in nutrition education and communication was recognized. This network should incorporate the concept of intersectoral approaches and integrating nutrition in development. Meetings, seminars and training workshops were also suggested for further development of technical skills in nutrition communication, communication project planning, strategy formulation and implementation, management and evaluation. Finally, interinstitutional and person-to-person information exchange was encouraged. Because of the importance of nutrition education and communication for improving food habits and nutrition status and sustaining the improvements, Asian governments, FAO and other United Nations organizations were urged to make it a priority in planning and to promote it through establishment of national policies and continuous international efforts.

Food Security http://www.bread.org/learn/policy-statements/international/foodsecurity-and-insecurity.html Development specialists agree that nutrition must be placed at the heart of national poverty reduction efforts. A myriad of planning tools exist to help countries address poverty and food security. One of the most comprehensive is the Poverty Reduction Strategy Paper (PRSP), jointly administered by the World Bank and the International Monetary Fund….As the process of implementing and revising these plans proceeds, national leaders should work to raise the profile of nutrition and its importance to the success of poverty-reduction efforts….Finding solutions will mean mainstreaming nutrition concerns into the development agenda. (Hunger Report 2006, Page 107) Cross Reference: Development Assistance and Nutrition Safety Net

National governments have the ultimate responsibility for ensuring that families are able to improve their nutritional status and achieve long-term food security (Hunger Report 2006, Page 98)

National efforts to address food security should integrate nutrition interventions into their broader development initiatives. Incorporating nutrition concerns into agricultural production and processing, for example, is one way of improving knowledge of nutrition among the wider public. In the long term, these interventions are critical to ensuring that addressing hunger and health also means addressing nutrition (Hunger Report 2006, Page 91) Cross Reference: African Agriculture, Development Aid

Ending chronic malnutrition will mean overcoming the numerous barriers to food security: where and how much food is available, how much it costs, and how it is prepared and distributed. Responding to the multitude of factors that determine whether an individual will experience chronic hunger requires a two-track strategy. The root causes of hunger must be addressed through long-term commitments to improve infrastructure, increase agricultural production and reduce poverty. These strategies must be supported by direct nutrition interventions that aim to meet people's immediate food needs (Hunger Report 2006, Page 89) Cross Reference: Malnutrition

Most farmers in poor rural areas are women. Thus, women must be integral to any development discussion. Generally, women must gain legally recognized access to resources and decision making both in their homes and communities. Such gains would give them claim to social and legal rights that would increase their personal and households' productivity and contribute directly to food security (Hunger Report 2003, Page 109). Cross Reference: Empowerment of Women

Any effort to development agriculture and improve household food security must include a focus on women. Most African farmers are women, and female-headed households are prone to hunger and poverty. African women generate two-thirds of Africa's agricultural production, and participate in trade and processing (Hunger Report 2003, Page 77). Cross Reference: African Agriculture, Gender Equality, and Trade

Calls for a Development Box—a series of exemptions from WTO rules—Specifically, these exemptions would allow developing country governments to protect their poorest farmers in an effort to increase food security. Developing countries must avoid pushing for permission to enact policies that they cannot afford or cannot implement because of other factors. As a rule and not an exemption, the WTO should incorporate measures that represent and advance developing countries interests (Hunger Report 2003, Side Bar: Page 68).

The ultimate goal of U. S. farm programs must be to promote sustainable agriculture, reduce rural poverty and eliminate food insecurity, both in the United States and throughout the world. Toward this end, the United States should: gradually eliminate tariffs on developing country agriculture exports, export subsidies and production-linked domestic support payments; support U.S. farmers who leave agriculture with adjustment assistance that would include counseling, job training, education reimbursement and transportation aid; support small and mid-size farmers with comprehensive rural development programs and technical assistance in adopting new technologies and developing greater economies of scale; establish provisions for farmers to help them sustain losses resulting from catastrophic weather events; strengthen assistance for farmers in meeting conservation goals and environmental mandates, including increased technical assistance, cost-share programs and incentive payments for use of environmentally friendly practices; increase research and regulation in areas, such as biotechnology, food safety, disease prevention and environmental quality; invest in rural communities by supporting economic development initiatives, job training, business promotion and infrastructure development, and reduce hunger in the United States (through nutrition and poverty reduction programs) and worldwide (through development assistance and trade opportunities), with this adding to the ongoing demand for food production (Hunger Report 2003, Page 55). Cross Reference: Agriculture Domestic, Food Security Domestic Rural Development International, Environment, Biotechnology, Nutrition Programs, Trade, and Development Assistance.

Food Insecurity In 1996, at the World Food Summit in Rome, the United States joined 185 other nations in a pledge to halve food insecurity and

hunger by 2015….To meet the goal set in Rome, food insecurity must be reduced to 6 percent….The commitment to cut food insecurity and hunger in half needs to be matched by appropriate plans, investments and action. (Hunger Report, 2006, Page 41) Cross Reference: Food Insecurity—Domestic The goal of U.S. farm policy must be to promote sustainable agriculture, reduce rural hunger and poverty, and eliminate food insecurity here in our own country and around the world (Hunger Report 2005, Page 110) Cross Reference: Food Insecurity Domestic and Agriculture Domestic and International

Bread for the World and its coalition partners are asking Congress and the president to commit to cutting hunger and food insecurity in half by 2010 (Hunger Report 2005, Page 11). Cross Reference: Food Insecurity--Domestic

Malnutrition National governments can show their commitment not only through speeches and public information campaigns to educate people on the causes and consequences of malnutrition, but by developing and implementing national policies and devoting sufficient resources to carry out their commitments to the Millennium Development Goals (MDGs) (Hunger Report 2006, Page 106-107)

Since the greatest concentrations of undernourished people are in rural areas, this is where interventions should be focused.…One place to start is by helping farmers used technologies that improve the nutritional content of staple crops….Ending chronic malnutrition among the rural poor will require more than just providing smallholder farmers with better seeds….Helping smallholder farmers increase production of a varied selection of fruits and vegetables can help improve rural livelihoods and support greater dietary diversification (Hunger Report 2006, Page 102 and 104) Cross Reference: Agriculture and Biotechnology

Ending chronic malnutrition will mean overcoming the numerous barriers to food security: where and how much food is available, how much it costs, and how it is prepared and distributed. Responding to the multitude of factors that determine whether an individual will experience chronic hunger requires a two-track strategy. The root causes of hunger must be addressed through long-term commitments to improve infrastructure, increase agricultural production and reduce poverty. These strategies must be supported by direct nutrition interventions that aim to meet people's immediate food needs (Hunger Report 2006, Page 89) Cross Reference: Food Security

Devising and implementing a plan to solve a longstanding and acute problem like hunger is complex. One key strategy for identifying and serving people vulnerable to hunger is to focus on hunger

“hotspots” within countries. These are subnational units with (1) more than 20 percent of their children underweight; (2) more than 100,000 underweight children under five; (3) a high number of underweight children per square kilometer (Hunger Report 2006, Page 84) Nutrition interventions should function as an essential part of international development programming (Hunger Report 2006, Page 15)

Most people suffer micronutrient malnutrition because they do not have enough vitamin- and mineral-rich foods in their diets, a situation often aggravated by the body's impaired absorption or use of food nutrients because of an infection and/or parasitic infestation…the ultimate long-term solution to hunger and malnutrition is dietary diversification. Because poor diets most often stem from poverty itself —inability to purchase enough of the most nutritious foods—poverty reduction efforts must be tied to any nutrition intervention in poor countries (Hunger Report 2004: Side Bar: Page 47).

Effective targeting of micronutrient malnutrition in South Asia should begin with improving people's access to vitamin rich foods (Hunger Report 2000, Page 84).

Send suggestions or comments to Institute@bread.org

Special Food Security and Nutrition Brief http://www.fsausomali.org/ Issued February 8, 2008 FSAU together with FEWS NET Somalia, and forty-five partner agencies have completed the Post Deyr 2007/08 Seasonal Assessment of the Food, Nutrition, and Livelihood Security Situation throughout Somalia. The Special Food Security and Nutrition Brief highlighting the key findings of this assessment has been released. Click this link to download the full report (.pdf 3 MB) FSAU Press Release Isuued January 31, 2007 More than a Quarter of the Population of Somalia are in Humanitarian Crisis The Food Security Analysis Unit for Somalia (FAO/FSAU) and FEWS NET Somalia confirm that the overall humanitarian situation in Somalia has deteriorated over the last six months. Between 1.8 and 2 million people, including roughly 1 million IDPs, are estimated to be in need of humanitarian assistance and livelihood support for at least the next six months. The food security and nutrition situation has improved for the rural populations of southern regions of Juba and Gedo, regions previously devastated by the regional drought in 2005/6. However, the humanitarian situation has deteriorated over the last six months in the Shabelle, Hiran and Central regions due to a significant increase in the number of Internally Displaced Persons (IDPs) fleeing Mogadishu and a deepening drought in Hiran and Central regions. In addition, hyper-inflation in basic food and non-food items throughout the country is creating problems of food access for urban populations, especially the urban poor. These results are based on a country-wide comprehensive Post Deyr 2007/08 Seasonal Assessment, which was conducted by the Food Security Analysis Unit for Somalia (FSAU), together with FEWS NET Somalia, and 45 other UN, International and local NGOs, and local authorities. This assessment found that of the total number of people in need of humanitarian and livelihood support, an estimated 850,000 live in rural areas and face conditions of Humanitarian Emergency or Acute Food and Livelihood Crisis, while an estimated 700,000 are newly displaced people from Mogadishu (since March 2007), and an estimated 275,000 are long-term or protracted Internally Displaced Persons (IDPs). In the last six months, the number of people fleeing Mogadishu has more than doubled from 325,000 in August 2007, to more than 700,000. Most, or 82%, of these newly displaced people have concentrated in the regions that already face the worst problems in the country in terms food access, collapsing livelihoods, and emergency nutrition levels (Lower and Middle Shabelle, Hiran and Central regions). In addition to limited social support from host communities, displaced populations have limited options to earn income and face record high food and non-food prices. Nutrition surveys, also confirm that the protracted Internally Displaced Persons (IDPs), who

have been displaced for years, require urgent assistance as their nutrition situation is at or greater than internationally acceptable emergency thresholds. An estimated 155,000 pastoralists in the Central regions and another 70,000 agriculturalists and agro-pastoralists in Hiran region face a rapidly deteriorating situation and are in need of urgent humanitarian assistance or livelihood support. The current crisis confirms FSAU/FEWSNET early warnings issued in December (FSAU FSNB, Dec. 21, 2007) of a deteriorating food security and nutrition situation following two consecutive seasons of poor rainfall that has lead to crop failures, poor pasture and browse conditions, and water shortages. Pastoralists in Galgadud and south Mudug have limited options for moving their livestock due to insecurity and are forced to continue to purchase expensive trucked water for their livestock during the long dry season (January to mid-April). Furthermore, cereal and other essential commodity prices are at record high levels and are continuing to increase, while disruptions in trade are creating shortages in supplies. In addition, communities are overstretched as these areas are also hosting the second highest concentrations of new IDPs from Mogadishu (32% of the total or 224,000 people). “The Shabelle regions remain the worst affected regions in the current humanitarian crisis”, says Cindy Holleman, UN FAO Chief Technical Advisor to the FSAU, “with more than 325,000 agriculturalists and agro-pastoralists in states of Humanitarian Emergency or Acute Food and Livelihood Crisis. These regions are also hosting the largest concentration of new IDPs from Mogadishu totaling more than 367,000 people”. Although there will be limited and temporary relief for some communities due to good rainfed cereal crop production in some areas, overall the total Deyr ‘07/08 season cereal production of the two regions is significantly below normal (51% and 66% of Post War Average for Lower and Middle Shabelle), the third consecutive season of below average maize production (39% of Post War Average), and the second lowest annual cereal production in a decade. The nutrition situation is also still critical with rates of global acute malnutrition above emergency thresholds. Continuing insecurity and inflation over the next few months can only lead to further deteriorations in the crisis.

Malnutrition Caused by Fundamental Failure in Food Security Policy http://www.nyeleni2007.org/spip.php?article70 The child malnutrition outbreak has now spread from West Nusa Tenggara, to West Sumatra, Lampung and now South East Sulawesi Provinces. It is ironic, as these provinces have long been known as rice self-sufficient areas. How is it possible that malnutrition can occur in a place like Indonesia where, as an agricultural country, vast fertile land is available for producing a diverse range of foodstuffs. There must be a fundamental failure in food system policy as most malnutrition cases have occurred among farmer families; those who produce food. Yet more absurd is that the dry season has not even come yet, meaning that rice fields and farmlands still have enough water. In the words of an Indonesian proverb, this phenomenon is referred to as "the chicken dying of starvation inside a rice barn". The only policy effective in addressing this malnutrition is food security. There are various ways of defining the term food security. The FAO committee on World Food Security defines it as meaning that "all people at all times have both physical and economic access to the basic food they need". While the World Bank defines it as, "access by all people at all times to enough food for an active, healthy life". Such definitions never address where the food comes from and where it is produced. West Nusa Tenggara, for instance, where 21 children have died of chronic hunger, has actually been quite successful in implementing ’’green revolution’’ programs. Last year the province was awarded for being a rice self-sufficient province, and in fact the province exported rice to other regions. But the green revolution has only benefited farmers who have enough land. Agricultural workers who are landless do not have rice even during harvest seasons. They have to work hard every day to increase the productivity of rice fields, but their own income decreases even along with this increase in production. Modernization of farming under the green revolution changed the way farmers grow food, which now depends on inputs from the big agribusiness and transnational companies. Farmers have to spend more money to buy chemical pesticides and petrochemical fertilizers. Even in West Nusa Tenggara, farmers have to buy hybrid varieties from seed companies such as Monsanto as the biggest seed producers, even though the province has an abundance of diverse local varieties. Because farmers have to pay more for inputs even while prices for their produce remains fixed, they lose money, making them poorer. West Sumatra with 54,000 children suffering from malnutrition, seems to be an even more insane case. Padang people are famous not only in Indonesia but also worldwide for their cuisine stalls and restaurants. Their delicious

dishes reflect their high culture and high skill in agriculture and food matters. But because food security does not define where food comes from, and the agribusiness approach delivered by the government forcing farmers to be more market oriented, farmers produce rice more for export orientation rather than to fulfill local needs. Now, people of the city Medan, Batam and also Malaysia eat the flavorsome Solok and Nundam rice, but people in West Sumatra eat low-quality broken rice imported from Vietnam. And now in the regency of Solok, Pesisir Selatan and Pasaman, children are suffering from malnutrition. Market orientation has also encouraged farmers in Tanggamus in Lampung province to grow cash crops, namely coffee, instead of food plants. The local government encourages farmers to grow cash crops because it provides a high income for the province. Moreover, they invite foreign investors to open export businesses and plantations in order to boost economic growth and provide employment. The cash crops and export orientation of commodities are very depending on market prices, which are very difficult to control because of competition of a few big business that determine the price. But good prices at the international level never benefits small producers. The price of coffee beans is very low, around three to four thousand Rupiah at the farm gate, while the middle men get Rp 9,800 and the exporters sell for Rp 10,000. Children of coffee workers in Tanggamus now suffer from malnutrition because the price of coffee has collapsed and they cannot afford to buy rice, and of course they cannot eat their stockpiles of coffee beans as a substitute for rice or maize. Many of the decision makers in the central government at the local level are still market and export orientated. In many seminars and discussions they refer to Thailand as the model for developing agriculture and agro industries. They do not know that the profits taken from exporting agricultural commodities only benefits big agribusiness companies, such as Charoen Pokphand Co., and not the farmers. The peasant and small farmers in Thailand are now in debt and cannot repay the loans given to them by big agribusiness companies. President Susilo Bambang Yudhoyono promised to revitalize agriculture, fisheries and the forestry sector last Saturday (11/6), using a ’’triple track’’ strategy and thereby decreasing the percentage of people in poverty to 8.2 percent. The government should listen to the voices of peasants and farmers and change their food policies. A concept of food sovereignty has been formulated by La Via Campesina, the international movement of peasants formed during the World Food Summit in Rome in 1996. This concept is an alternative in solving the food problem that the food security concept has failed to do so. The fundamental change through

application of the food sovereignty concept is that communities have the right to define their own agricultural and food policies, to protect and to regulate their national agricultural and livestock production, and to shield their domestic market from dumping of agricultural surpluses and low priced imports from other countries. Food sovereignty demands prioritizing local agricultural production in order to feed the people, as well as access for peasants and landless people to land, water, seeds, and credit. It also demands land reform. Written by Tejo Pramono Via campesina

http://www.unaids.org/en/PolicyAndPractice/CareAndSupport/NutrAndFoodSu pport/ Good nutrition plays an important role in maintaining the health of people living with HIV. Adequate nutrition is essential to maintain a person’s immune system, to sustain healthy levels of physical activity, and for quality of life. Adequate nutrition is also necessary for optimal benefits from antiretroviral therapy. In many of the countries most heavily affected by HIV, food scarcity and poverty make adequate nutrition nearly impossible. Food is part of a comprehensive antiretroviral therapy package and food and nutrition support needed into programmes for the prevention of mother-to-child transmission. Such assistance not only contributes to the health of HIV-infected mothers and their newborns, but also helps reduce economic burdens associated with childbirth and HIV infection. Nutrition should become an integral part of the countries response to HIV. In particular, UNAIDS Programme recommend strengthening political commitment to nutrition and HIV within the national health agenda, reinforcing nutrition components in HIV policies and programmes, and incorporating HIV issues into national nutrition policies and programmes. One of the populations most vulnerable to malnutrition due to food scarcity and poverty is children, especially infants. Lack of breastfeeding exposes children to increased risk of malnutrition and life-threatening infectious diseases other than HIV, especially in the first year of life. The United Nations recommends that infants be exclusively breastfed for the first six months of

life, and that thereafter infants should receive nutritionally adequate and safe complementary foods while breastfeeding for up to 24 more months. However, breastfeeding by HIV-infected mothers significantly increases the risk of HIV transmission to the infant. Therefore, when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life and should then be discontinued as soon as it is feasible. To help HIV-positive mothers make the best choice, they should receive counselling and have access to follow-up care and support, including nutritional support.

U.N.: Hunger, malnutrition kill nearly 6 million children a year http://www.azcentral.com/families/articles/1122WorldHunger22-ON.html Associated Press Nov. 22, 2005 07:05 AM ROME - Hunger and malnutrition kill nearly 6 million children a year, and more people are malnourished in sub-Saharan Africa this decade than in the 1990s, according to a U.N. report released Tuesday. Many of the children die from diseases that are treatable, including diarrhea, pneumonia, malaria and measles, said the report by the Rome-based U.N. Food and Agriculture Organization. In sub-Saharan Africa, the number of malnourished people grew to 203.5 million people in 2000-02 from 170.4 million 10 years earlier, the report states, noting that hunger and malnutrition are among the main causes of poverty, illiteracy, disease and deaths in developing countries. The U.N. food agency said the goal of reducing the number of the world's hungry by half by the year 2015, set by the World Food Summit in 1996 and reinforced by the Millennium Development Goals in 2000, remains distant but attainable. "If each of the developing regions continues to reduce hunger at the current pace, only South America and the Caribbean will reach the Millennium Development Goal target," Jacques Diouf, the agency's director-general, wrote in the report, the agency's annual update on world hunger. The food agency said the Asia-Pacific region also has a good chance of reaching the targets "if it can accelerate progress slightly over the next few

years." "Most, if not all of the ... targets can be reached, but only if efforts are redoubled and refocused," Diouf said. "To bring the number of hungry people down, priority must be given to rural areas and to agriculture as the mainstay of rural livelihoods." U.S. Agriculture Secretary Mike Johanns, on a visit to Rome to meet with FAO and Italian officials, said Tuesday that free trade and economic growth were key to fighting hunger. "We have world goals in terms of reducing hunger, and in terms of long-term prospects, it really does involve the ability of countries to engage in economic relationships with each other," he said. "We want economies around the world to improve, that is really what's going to provide the long term stable base upon which people are let out of poverty." Diseases such as AIDS, malaria and tuberculosis, which kill more than 6 million people a year, hit the hungry and poor the hardest, according to the report's findings. Millions of families are pushed deeper into poverty and hunger by the illness and death of breadwinners, the cost of health care, paying for funerals and support of orphans. About 75 percent of the world's hungry and poor live in rural areas in poor countries, the report found.

HÀ NỘI, (NV) - Theo một thống kê mà UNICEF vừa thực hiện về tình trạng trẻ em trên toàn thế giới, trung bình, mỗi giờ, tại Việt Nam có ba đứa trẻ bị chết. Mỗi năm, tại Việt Nam có khoảng 26,000 trẻ tử vong trước khi tròn 5 tuổi. Ðáng lưu ý rằng, hầu hết nguyên nhân dẫn tới tử vong đều có thể phòng ngừa. Các nguyên nhân chính khiến tình trạng trẻ em Việt Nam tử vong tăng rất cao là: những nguyên nhân sơ sinh (36%), do viêm phổi (19%), do tiêu chảy (15%), do sốt rét (8%), do sởi (4%) và bị AIDS (3%). Số trẻ sơ sinh tử vong vì những nguyên nhân sơ sinh chiếm trên 50% tổng số trẻ em tử vong. Cũng theo UNICEF, tỷ lệ tử vong ở trẻ miền núi, khu vực nông thôn và các gia đình nghèo hiện gấp 3 đến 4 lần so với trẻ ở vùng đồng bằng, thành thị và các gia đình khá giả. Nguyên nhân tử vong còn liên quan đến việc chăm sóc trẻ sơ sinh cũng như nuôi con bằng sữa mẹ. Tỷ lệ trẻ được bú sữa mẹ hiện rất thấp, chỉ khoảng 58% trẻ sơ sinh được bú sữa mẹ trong giờ đầu tiên sau khi sinh và 17% được bú sữa mẹ suốt 6 tháng đầu đời. Tỷ lệ thiếu dinh dưỡng ở bà mẹ và trẻ em Việt Nam vẫn còn rất cao. Khoảng 30% trẻ em dưới 5 tuổi bị còi và 37% phụ nữ mang thai bị thiếu máu. Hầu hết gia đình ở nông thôn đang sống trong môi trường bị ô nhiễm, thiếu vệ sinh và không có những hành vi vệ sinh phù hợp dẫn đến tình trạng trẻ em bị tiêu chảy và bị nhiễm giun tăng cao, góp phần đẩy tỷ lệ trẻ tử vong lên cao. Dịp này, các chuyên gia hàng đầu về dinh dưỡng quốc tế và Việt Nam cũng đã đưa ra nhiều cảnh báo đáng ngại về tình trạng suy dinh dưỡng ở bà mẹ và trẻ em Việt Nam. Trong số ra ngày 17 tháng 1, “The Lancet”, một tạp chí hàng đầu về y học quốc tế đã xác định Việt Nam là “điểm nóng” trên thế giới về suy dinh dưỡng. Theo Tiến Sĩ S Jennifer Bryce, Ðại Học Johns Hopkin Blooberg: Tỷ lệ suy dinh dưỡng và thiếu vi chất ở trẻ em Việt Nam hiện nay thuộc loại cao nhất thế giới. 90% trẻ suy dinh dưỡng bị còi cọc, thiếu chiều còi tập trung vào 36 quốc gia nghèo đói. Trong đó có Việt Nam. Việt Nam cũng là một trong 20 quốc gia phải gánh chịu những hậu quả nặng nề nhất của tình trạng suy dinh dưỡng ở trẻ em. Số trẻ em suy dinh dưỡng bị còi cọc, thiếu chiều cao chiếm 1/ tổng số trẻ em và sẽ để lại nhiều hậu quả tai hại: Ảnh hưởng đến chiều cao khi trưởng thành, học thức kém, thu nhập thấp và lại tiếp tục sinh ra

những đứa trẻ nhẹ cân. Việt Nam đã nhận được rất nhiều khoản viện trợ để thực hiện các chương trình phòng chống suy dinh dưỡng nhưng không làm đúng cách. Ví dụ như khuyến khích nuôi con bằng sữa mẹ. Theo khảo sát, chỉ có 17% bà mẹ làm đúng, tức là cho con bú suốt 6 tháng đầu đời. Một tiến sĩ tên Nguyễn Công Khẩn, viện trưởng Viện Dinh Dưỡng Quốc Gia, cho biết, các bà mẹ Việt Nam vẫn chỉ được nghỉ hậu sản 4 tháng, khó có thể cho con bú suốt 6 tháng đầu tiên. Cũng theo các chuyên gia, một trong những nguyên nhân khác gây ra suy dinh dưỡng trầm trọng là trẻ Việt Nam hay mắc các bệnh tiêu chảy. Các chuyên gia khuyến cáo nên sử dụng kẽm trong điều trị tiêu chảy ở trẻ em Việt Nam. Hiện nay, hậu quả của tình trạng suy dinh dưỡng kéo dài trong nhiều thế hệ là suốt hai thập kỷ qua, chiều cao trung bình của người Việt Nam trưởng thành chỉ thêm 1.5cm. Vào lúc này, có từ 35%40% trẻ dưới 2 tuổi có chiều cao dưới mức trung bình.

Phòng chống suy dinh dưỡng trẻ em (14/10/2006) Với quan điểm của Đảng ta coi trọng nhân tố phát triển con người trong chiến lược phát triển kinh tế xã hội “Trẻ em hôm nay thế giới ngày mai”, vấn đề cải thiện tình trạng dinh dưỡng và giảm suy dinh dưỡng trẻ em là một mục tiêu quan trọng trong chiến lược phát triển kinh tế xã hội của nước nhà. Suy dinh dưỡng là một tình trạng do thiếu nhiều chất dinh dưỡng mà biểu hiện là trẻ có cân nặng, chiều cao thấp hơn bình thường. Trẻ suy dinh dưỡng thường dẫn đến chậm phát triển về thể chất và tinh thần, trẻ thường lờ đờ chậm chạp ít năng động nên ít tiếp thu được qua giao tiếp của cộng đồng và người chăm sóc và thường hay mắc các bệnh nhiễm khuẩn, khi trở thành người trưởng thành thường thấp bé, năng lực kém. Nghèo đói và thiếu kiến thức là nguyên nhân gốc rễ của suy dinh dưỡng. Chúng ta cần phải làm ngay những việc có thể làm được và biến những việc cần phải làm thành những việc có thể thực hiện được. Trẻ em là đối tượng chính của suy dinh dưỡng, nếu không can thiệp kịp thời thì quãng thời gian phát triển nhanh nhất và quan trọng nhất sẽ trôi qua và các hậu quả của suy dinh dưỡng không có cơ hội hồi phục. Phòng chống suy dinh dưỡng trẻ em cần lấy phương châm dự phòng là chính nghĩa là đảm bảo trẻ em sinh ra khoẻ mạnh, được chăm sóc để trẻ không bị suy dinh dưỡng là chính. Tập chung vào việc cải thiện thực hành chăm sóc dinh dưỡng cho trẻ em và bà mẹ tại hộ gia đình. Để phòng chống suy dinh dưỡng có hiệu quả chúng ta cần thực hiện đồng thời các nội dung chăm sóc dinh dưỡng sau: a) Thực hiện tốt việc nuôi con bằng sữa mẹ - Cho trẻ bú sớm bú ngay trong vòng 1/2 giờ đầu sau đẻ, để tận dụng sữa non, kích thích sữa non xuống sớm. - Cho trẻ bú hoàn toàn trong 6 tháng đầu và tiếp tục cho bú đến 18-24 tháng. - Cho trẻ bú theo nhu cầu của trẻ tức là không hạn chế thời gian và độ dài của mỗi bữa bú. - Nếu trẻ ốm không bú được thì vắt sữa và cho trẻ ăn bằng thìa hoặc bằng cốc. b) Cho trẻ ăn bổ sung hợp lý - Bắt đầu cho trẻ ăn từ tháng thứ 5, không cho trẻ ăn quá sớm (trước 4 tháng) hay quá muộn (sau 6 tháng). - Cho trẻ ăn từ lỏng đến đặc, từ ít đến nhiều, tập cho trẻ quen dần với thức ăn mới. - Số lượng bữa ăn của trẻ tăng dần theo tuổi, chú ý đảm bảo số lần ăn trong ngày để đủ nhu cầu dinh dưỡng. - Thực hiện “tô màu bát bột” sử dụng các thức ăn hỗn hợp giàu dinh dưỡng và sẵn có tại gia đình, chú ý đổi bữa và thức ăn hợp khẩu vị của trẻ, chế biến bảo đảm thức ăn mềm dễ nhai và dễ nuốt. Thức ăn dùng cho trẻ gồm có 4 nhóm:

Nhóm cung cấp chất đạm gồm có: Thịt, cá, tôm, cua, trứng… Nhóm cung cấp chất béo gồm có: Dầu, mỡ, vừng, lạc. Nhóm cung cấp chất đường bột: gạo, ngô, bột mỳ, các loại củ. Nhóm cung cấp vitamin và chất khoáng: Các loại rau xanh, quả chín… - Vẫn tiếp tục cho trẻ bú mẹ càng nhiều càng tốt. Các dụng cụ chế biến thức ăn cho trẻ phải sạch sẽ, rửa tay trước khi chế biến thức ăn và khi cho trẻ ăn. Chế độ ăn bổ sung cho trẻ như sau: * 5 - 6 tháng: Bú mẹ là chính 1- 2 bữa bột loãng và nước quả. * 7 - 9 tháng: Bú mẹ 2-3 bữa bột đặc (10%) nước quả hoặc quả nghiền. * 10 - 12 tháng: Bú mẹ 3- 4 bữa bột đặc (15%) quả nghiền. * 13 - 24 tháng: Bú mẹ 4-5 bữa cháo quả chín. * 25 - 36 tháng: 2 bữa cháo hoặc súp 2 - 3 bữa cơm nát sữa bò hoặc sữa đậu nành quả chín. * Từ 36 tháng trở đi: Cho trẻ ăn cơm như người lớn nhưng phải được ưu tiên thức ăn (thức ăn nấu riêng) nên cho ăn thêm 2 bữa phụ: Cháo, phở, bún, súp, sữa... Trong một ngày không nên cho trẻ ăn một món giống nhau. Cách chế biến thức ăn cho trẻ: Trẻ càng nhỏ càng phải xay nhỏ, băm nhỏ, giã nhỏ khi bắt đầu cho ăn bổ sung phải cho trẻ ăn cả cái lẫn nước kể cả rau. Nấu bột cho trẻ 5-6 tháng tuổi: Bột gạo 2 thìa cà phê gạt (10g). Lòng đỏ trứng gà 1/2 quả hoặc 2 thìa cà phê thịt hoặc tôm hoặc cá giã nhỏ. 1 thìa cà phê rau giã nhỏ. Dầu ăn hoặc mỡ 1 thìa. Cách nấu: Cho 250ml nước sạch vào xoong cho 2 thìa cà phê bột và 2 thìa thịt khuấy đều cho tan hết, bắc lên bếp đun sôi trong vòng 5 phút sau đó cho 1 thìa cà phê rau đã được giã nhỏ khuấy đều, sau đó cho 1 thìa dầu ăn hoặc mỡ, đun sôi sau đó đổ ra bát cho trẻ ăn. Có thể thay thế thịt bằng 1/2 lòng đỏ trứng hoặc 2 thìa cá hoặc tôm đã được giã nhỏ. Nấu bột cho trẻ 7-12 tháng tuổi: Bột gạo 4 - 5 thìa cà phê. Lòng đỏ trứng gà 1 quả hoặc thay bằng 3 thìa cà phê thịt hoặc tôm, cá. 20g rau băm nhỏ. Dầu ăn 1 thìa. Cách nấu như nấu cho trẻ nhóm 5-6 tháng. Nấu cháo cho trẻ từ 13-24 tháng: Có thể nấu 1 nồi cháo trắng nhừ, đến mỗi bữa ăn múc một bát con cho vào xoong rồi cho thêm thịt, cá, trứng hoặc tôm cộng với rau xanh và dầu hoặc mỡ nấu như

nấu bột nhưng với số lượng nhiều hơn. Nấu cơm nát cho trẻ 24-36 tháng: Nấu cơm nhiều nước hơn bình thường rồi chộn canh thịt hoặc cá, tôm chộn với cơm cho trẻ ăn không nên chỉ cho trẻ ăn cơm với nước rau luộc. Trẻ trên 36 tháng cho trẻ ăn như người lớn, ưu tiên thức ăn cho trẻ, lưu ý các bữa phụ. c) Thực hiện chăm sóc dinh dưỡng tốt khi trẻ bị ốm * Chăm sóc trẻ khi bị tiêu chảy - Khi trẻ bị tiêu chảy phải tiếp tục cho trẻ bú bình thường và tăng số lần bú, trẻ trên 4 tháng tuổi vẫn tiếp tục cho trẻ ăn bình thường, cần cho trẻ ăn các thức ăn giàu dinh dưỡng như thịt, trứng, cá ... cho ăn nhiều lần và ít một, cần cho thêm dầu mỡ để tăng thêm năng lượng của khẩu phần ăn, cho trẻ ăn thức ăn mềm, nấu kỹ dễ tiêu hoá cho ăn ngay sau khi nấu để đảm bảo vệ sinh giảm nguy cơ bội nhiễm. - Sau khi khỏi tiêu chảy để giúp trẻ nhanh hồi phục không bị suy dinh dưỡng cần cho trẻ ăn thêm mỗi ngày một bữa trong vòng 2 tuần liền, với trẻ bị tiêu chảy kéo dài cần cho trẻ ăn tăng thêm mỗi ngày một bữa, tối thiểu là một tháng. - Không được tự ý sử dụng thuốc khi không có sự hướng dẫn của y, bác sĩ. * Chăm sóc trẻ bị nhiểm khuẩn hô hấp: - Trẻ nhỏ còn bú mẹ phải cho bú nhiều lần hơn và thời gian mỗi bữa bú lâu hơn bình thường, nếu trẻ không bú được người mẹ cần vắt sữa vào cốc rồi dùng thìa cho trẻ uống. - Trẻ lớn đã ăn bổ sung, nên cho trẻ ăn các loại thức ăn mềm đa dạng dễ tiêu hoá và chia thành nhiều bữa nhỏ. - Cho trẻ uống nhiều nước, nước quả tươi và ăn thêm hoa quả để bù lại lượng nước bị mất khi trẻ sốt và cung cấp vitaminA, vitamin C cho trẻ. - Khi trẻ khỏi bệnh cần cho trẻ ăn tăng thêm bữa và bồi dưỡng bằng các loại thức ăn giàu dinh dưỡng giúp trẻ nhanh hồi phục. d) Theo dõi cân nặng của trẻ bằng biểu đồ tăng trường - Tăng cân đều đặn hàng tháng là dấu hiệu quan trọng nhất của một đứa trẻ khoẻ mạnh. Mục đích của việc cân trẻ hàng tháng và theo dõi bằng biểu đồ tăng trưởng là theo dõi diễn biến cân nặng của trẻ, phát hiện sớm khi trẻ đứng cân hoặc tụt cân để giúp bà mẹ tìm cách sử trí thích hợp phòng ngừa suy dinh dưỡng. - Nếu cân trẻ thấy trẻ không tăng cân (biểu đồ nằm ngang) là dấu hiệu báo động về sức khoẻ và nuôi dưỡng chưa tốt. - Nếu thấy trẻ tụt cân (biểu đồ đi xuống) là dấu hiệu nguy hiểm cần tìm nguyên nhân để có cách sử trí đúng kịp thời và nhanh chóng. - Thường thì trẻ sẽ phục hồi và tăng cân khi được nuôi dưỡng tốt hơn được chữa bệnh ngay. Lịch cân trẻ

Trẻ từ 0-24 tháng tuổi cân 1 tháng /1 lần Trẻ Suy dinh dưỡng, trẻ không tăng cân cân 1 tháng/lần Trẻ 25-60 tháng tuổi cân 6 tháng /1 lần e) Phòng chống nhiễm giun sán ở trẻ em - Tập cho trẻ nề nếp giữ vệ sinh từ nhỏ, không để trẻ lê la dưới đất bẩn, tập cho trẻ thói quen rửa tay trước khi ăn. Thức ăn cho trẻ phải nấu chín. - Sử dụng nguồn nước sạch và đun sôi nước trước khi uống. - Đảm bảo vệ sinh môi trường xung quanh không đổ rác bẩn quanh nhà, sử dụng các loại hố xí hợp vệ sinh. - Không cho trẻ đi chân đất để tránh ấu trùng chui qua da. - Trẻ trên 2 tuổi cần tẩy giun định kỳ 6 tháng/lần. g) Chăm sóc dinh dưỡng cho bà mẹ mang thai - Khi có thai các bà mẹ phải được đăng ký quản lý thai tại cơ sở y tế khám thai ít nhất 3 lần trong 3 kỳ thai nghén và phải được tiêm phòng vaxcin phòng uốn ván. - Khi phát hiện có thai uống viên sằt folic hàng ngày càng sớm càng tốt uống liên tục mỗi ngày một viên cho tới 1 tháng sau đẻ. - Sử dụng các loại thực phẩm giàu sắt, Vitamin sẵn có tại địa phương.

THỜI SỰ - XÃ HỘI Thứ Bảy, 03/09/2005, 10:51 Khoảng cách giàu nghèo chưa được thu hẹp http://www.tienphongonline.com.vn/Tianyon/Index.aspx? ArticleID=20414&ChannelID=2 (TPO) Ngày 31/8, tại Hà Nội, Liên hiệp các Tổ chức hữu nghị Việt Nam đã tổ chức Hội thảo quốc tế về “Xóa đói giảm nghèo ở châu Á, Phi và Mỹ Latinh- Kinh nghiệm và triển vọng của các dân tộc”. Phát biểu khai mạc Hội thảo, bà Nguyễn Thị Bình, nguyên Phó Chủ tịch nước, Phó Chủ tịch tổ chức đoàn kết nhân dân Á-Phi, Chủ tịch Quỹ Hòa bình và Phát triển Việt Nam cho biết xóa đói giảm nghèo (XĐGN) đã được Liên Hợp Quốc đặt thành một trong những mục tiêu phát triển thiên niên kỷ. Các đại biểu quốc tế tham dự Hội thảo XĐGN và phát triển bền vững là một sự nghiệp có ý nghĩa chiến lược rất quan trọng, mang tính vừa cơ bản, lâu dài vừa cấp bách của nhân dân các nước trên thế giới, đặc biệt là của nhân dân các nước Á, Phi, Mỹ Latinh. Tiến sĩ Fakhry Lahib, Trưởng đoàn đại biểu Tổ chức Đoàn kết Nhân dân các nước Á-Phi (AAPSO) của Ấn Độ nhấn mạnh: Nghèo đói là một thách thức lớn nhất đối với loài người. Thực tế cho thấy 1/5 dân số thế giới, tương đương 1,2 triệu người đang phải sống trong cảnh nghèo đói. 3/ 4 người nghèo trên thế giới sống với mức thu nhập dưới 1 đô la/ngày tại các vùng nông thôn. Một nửa dân số thế giới sống với mức thu nhập dưới 2 đô la/ngày. 80% trong số họ rơi vào tình trạng nghèo đói và suy dinh dưỡng. Ở Việt Nam, những cố gắng của Chính phủ, các tổ chức nhân dân và nhân dân trong công cuộc XĐGN đã đem lại kết quả khả quan: Trong hơn 10 năm (1993-2004) tỷ lệ nghèo đã giảm hơn một nửa. Tuy vậy tỷ lệ nghèo vẫn còn cao với 25% số dân và tốc độ giảm nghèo đang chậm lại. Điều đáng lo ngại nữa là tỷ lệ nghèo ở nông thôn, nhất là các vùng dân tộc thiểu số, vùng núi cao gấp 2-3 lần tỷ lệ nghèo ở thành thị, khoảng cách giàu nghèo trong nhân dân chưa được thu hẹp. “Nhiệm vụ đấu tranh chống đói nghèo là nhiệm vụ cơ bản, cấp bách của nhân dân các nước Á, Phi, Mỹ Latinh”- Nguyên Phó Chủ tịch nước Nguyễn Thị Bình nhấn mạnh.

Khía cạnh nguy hiểm nhất của hiện tượng đói nghèo đó là khoảng cách giàu nghèo càng ngày càng mở rộng. Điều này được chứng minh qua thực tế rằng 20% dân số thế giới sở hữu 83% tài sản thế giới trong khi 20% người nghèo nhất sở hữu 4,1% tài sản thế gới. 30 năm trước đây tỉ lệ đó là 2,4%. Trao đổi tại Hội nghị, Tiến sĩ Fakhry Lahib cho biết cuộc chiến chống đói nghèo cần phải diễn ra trong một không khí của tình đoàn kết và hữu nghị anh em. Đây là một cuộc chiến chống lại bất công, bất bình đẳng xã hội và sự mở rộng về khoảng cách giàu nghèo, chống lại sự tăng chi phí sinh hoạt và thất nghiệp. Cuộc chiến chống nghèo đói là một cuộc chiến chống

Sự gia tăng bất bình đẳng giữa người giàu và lại di sản tích lũy từ nhiều năm và giờ đã đến lúc phải thay đổi nó. người nghèo Năm 1998, 20% người giàu nhất thế giới chiếm 86% tổng tiêu dùng thế giới trong khi 20% người nghèo nhất chỉ chiếm 1,3%. Tỷ lệ giữa 20% người giàu và 20% người nghèo nhất là 1:30 vào năm 1960 và tăng lên 1:60 vào năm 1990 và 1:74 năm 1998 Sự cấm vận mà các siêu cường áp đặt lên các dân tộc tạo ra những nhân tố dẫn tới tình trạng nghèo đói. Các siêu cường đặt ra những trở ngại trên con đường phát triển kinh tế và xã hội của các nước đang phát triển. Sự bùng nổ của thất nghiệp cũng là nhân tố quan trọng góp phần làm xấu hơn tình trạng nghèo đói và làm suy giảm các điều kiện phát triển của rất nhiều dân tộc trên thế giới. Người thất nghiệp càng lún sâu vào đói nghèo, mất đi sự độc lập và giá trị của mình bởi họ ngày càng bị phụ thuộc vào gia đình mà gia đình của họ có thể rất nghèo khó. Điều đó đặt những người thất nghiệp và gia đình của họ vào một thảm kịch.

“Một nhân tố rất quan trọng cần phải được đề cập khi nói về cuộc chiến chống đói nghèo, đó là thiện chí chính trị, thiện chí đổi mới. Sự nghèo đói không chỉ là một hiện tượng kinh tế hay xã hội mà chính là một thước đo chính trị. Trước hết phải có thiện chí chính trị và với một tầm nhìn chính trị mới có thể nói đến các biện pháp hiệu quả nhằm chống lại nghèo đói và đạt được những thành tựu thực tế trong cuộc chiến này”- Tiến sĩ Fakhry Lahib khẳng định. Ông P.Sharma Oli, Chủ tịch Tổ chức Đoàn kết Nhân dân các nước Á-Phi của Nêpan cũng khẳng định sự gia tăng nghèo đói tại các nước đang phát triển tại châu Á, châu Phi và châu Mỹ Latinh là một trong những mối quan ngại chính của sự phát triển. Thử thách và trở ngại lớn nhất trong quá trình phát triển tại các nước đang phát triển là mức thu nhập thấp, thất học, bệnh tật, bất bình đẳng, nợ nần, gia tăng dân số nhanh và khủng bố. Các quốc gia nghèo bị vây hãm bởi vòng xoáy nợ nần. Tham dự Hội thảo có nguyên Phó Chủ tịch nước Nguyễn Thị Bình, ông Trần Đắc Lợi, Phó Chủ tịch kiêm Tổng thư ký Liên hiệp các tổ chức hữu nghị Việt Nam, 50 đại diện các tổ chức quốc tế cùng đại diện các Bộ, ban ngành của các cơ quan, đơn vị Việt Nam.

Behind the face of malnutrition: What causes malnutrition? Simple lack of food is not always the answer. It could be fungal toxins, damage by free radicals or lack of protein 17 February 1990 From New Scientist Print Edition. Subscribe and get 4 free issues.  CATHY READ
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MALNUTRITION in childhood presents two starkly different images. Brittle, bleached, blonde hair, dry, mottled skin and exhausted, hollow eyes belong to both. But while one child is shrunken and withered like a prune, the other has an exaggerated toddler's pot belly and swollen legs and feet. For years, scientists believed that protein explained the difference. Whereas the shrunken child (suffering from marasmus) was short of all types of food, the pot-bellied child (suffering from kwashiorkor) particularly lacked protein. Adequate levels of protein in the blood are vital to keep blood pressure normal and to stop fluid from leaking from blood vessels into the surrounding tissues. The fine walls of small blood vessels, called capillaries, function as semi-permeable membranes: water molecules can pass through them. Several different forces control the movement of fluid and nutrients across the walls of the capillaries. While water pressure inside the capillaries tends to force fluid out into surrounding tissues, proteins in the blood plasma tend to draw fluid back into the blood vessels. When levels of proteins in the plasma fall, the capillaries no longer effectively 'hold' water, so fluid steadily leaks into surrounding tissues. This steady seepage causes tissues to swell, a condition called oedema. Back in the 1950s, nutritionists believed that this was the mechanism that caused tissues to swell in kwashiorkor. According to this 'protein energy malnutrition theory', children with this form of malnutrition were short of protein. At that time, researchers believed that small children needed much more protein than current theories advocate. In 1948, scientists defined a child as being at risk of protein deficiency if it received less than 13 per cent of its energy from protein in the diet. By 1968, the UN was coming up with proposals to plug the 'protein gap'. A report entitled International Action to Avert the Impending Protein Crisis outlined several solutions. One idea was to fortify cereals with synthetic amino acids (the building blocks from which proteins are made). A second proposal was to produce and distribute concentrated protein made from fish. Despite millions of dollars in financial backing, both projects foundered. There were many reasons: distributing the supplements, particularly to people with low incomes, was difficult; people did not always find it easy to incorporate

flour made from fish into their diets; and the price of fish rose. Above all, there was doubt about the relevance of using protein concentrates to reduce malnutrition. The perceived protein crisis, it seemed, did not exist. By 1974, the nutritionists had revised their definition of protein deficiency: they deemed that children were at risk only if they received less than 6 per cent of their energy from protein. The idea that lack of protein in the diet is the main cause of kwashiorkor is now falling out of favour. For example, Mike Golden, head of the Tropical Metabolism Research Unit at the University of the West Indies in Jamaica, points out that there appears to be no difference in the amount of protein eaten by malnourished children who subsequently develop kwashiorkor and those who develop marasmus. Furthermore, if kwashiorkor resulted from a low intake of protein, it should be more common than marasmus in areas where protein is in short supply. This is not always the case. Golden also argues that, if kwashiorkor were simply a matter of protein deficiency, it should be easy to reproduce it in experimental animals. In fact, researchers have only once managed to reproduce the condition convincingly in this way. Finally, Golden points to two experiments carried out at the Tropical Metabolism Research Unit. The first experiment showed that a diet low in protein could reduce the degree of oedema without any change in the levels of albumin, one of the most important proteins in the blood. If levels of protein in the plasma were critical in the development of oedema, levels of albumin in the blood should rise before oedema starts to disappear. In the second experiment, Golden showed that there was no relationship between the amount of protein in the diet and the rate at which children recovered from kwashiorkor. Golden thinks that kwashiorkor could result from damage to the body by free radicals. Free radicals of oxygen are highly reactive molecules, such as superoxide and hydrogen peroxide, generated in response to a wide range of stimuli. The body normally mops up free radicals with molecules that scavenge them. Golden suggests that kwashiorkor results from an imbalance between free radicals generated in the body and the protective mechanisms that remove them. Toxins in food and infections, both common in the developing world, can provoke the formation of free radicals. The body fights infection by producing free radicals in sufficient quantities to kill the invading organisms. Stimulated white blood cells, for instance, release large amounts of superoxide and hydrogen peroxide. Infections such as measles often precipitate kwashiorkor. A build-up of free radicals damages tissues and explains many of the features of kwashiorkor. The bleached, sometimes reddish hair colour of children with kwashiorkor is the result of an abnormal peroxidation reaction. Butter eventually turns rancid when fats in it become oxidised. In children with kwashiorkor, cell membranes throughout the body suffer the same kind of damage. Golden believes that the oedema of kwashiorkor probably arises

when free radicals damage cell membranes, letting fluid leak out into the surrounding tissues, causing them to swell. Peroxidation may also cause fat to build up in the liver; so-called 'fatty liver' is common in malnourished children, in whom the liver sometimes swells to occupy almost the entire abdomen. No one knows how this happens, but the answers will almost certainly lead to a better understanding of other diseases. Alcoholics and people with heart failure also develop fatty livers. Malnourished children with poor liver function tend to have the worst outlook. Golden's team is currently trying to establish whether these children have the highest levels of free radicals. Researchers at the unit are measuring the children's levels of glutathione, which scavenges free radicals, and mercapturic acid, which forms when glutathione reacts with free radicals. They will then compare these measurements with levels of liver enzymes in the blood, which rise when the liver suffers damage. Most of the biochemical pathways that mop up free radicals require minute quantities of substances such as zinc, selenium and vitamins A and E. A severe deficiency of any of these so-called 'micronutrients' will lead to a loss of protection from free radicals. Even a mild deficiency of several of these vitamins or minerals could be enough to tip the balance. Free radicals that are not safely removed generate peroxides. Normally, the enzyme glutathione peroxidase (GPX), which contains selenium, breaks down any peroxides that form. But malnourished children have reduced amounts of both selenium and GPX and so their bodies remove organic peroxides inefficiently. Peroxides that persist can form toxic aldehydes that may be even more damaging than free radicals. Contrasting theories Glutathione itself can scavenge free radicals. Golden believes that this substance is crucial to a child's ability to deal with free radicals. It was glutathione that originally led him to his theory of how free radicals cause kwashiorkor: children with the disease had abnormally low levels of glutathione in their blood. In contrast, normal children and those with marasmus had normal levels. Studies of children suffering from kwashiorkor showed that levels of glutathione stayed low so long as oedema was present. Golden has also shown that glutathione may be in short supply even when there is no shortage of the amino acids that it contains. He concludes that glutathione is used up as peroxides are detoxified in kwashiorkor. Ralph Hendrickse, head of tropical paediatrics at the Liverpool School of Tropical Medicine, favours a different theory. He believes that fungal toxins known as aflatoxins may play a role in the development of kwashiorkor. He first considered the possibility while living in Nigeria in the mid-1960s when he found a heavy growth of mould on a suit of clothes during one rainy season. He thought that if a suit could support a heavy growth of mould, then local food might be even more contaminated.

The geographical distribution of kwashiorkor supports the idea that aflatoxins have a key role in its development. Marasmus occurs worldwide; in contrast, kwashiorkor is found only in tropical and subtropical areas. In the tropics, it is most prevalent in warm, humid climates. Aflatoxins are present in a wide range of crops from many countries but they mainly affect foods in the tropics and subtropics where warm, damp conditions aid the growth of the mould. Studies by Hendrickse in Sudan have shown that aflatoxins are frequently present in produce in the local markets, such as groundnuts, sorghum, millet, wheat, rice, lentils, dried meat, fish and milk. Cooked foods and breast milk may also contain aflatoxins. Hendrickse has shown that aflatoxins occur more often and in higher concentrations in the blood of children with kwashiorkor than in normal children or children with marasmus. Aflatoxins have numerous adverse effects in the body, but the organ that suffers most is the liver. Hendrickse has examined the livers of more than 50 children who died as a result of malnutrition. He frequently found aflatoxins in the livers of children who died of kwashiorkor, but never in the livers of children who suffered from marasmus. Hendrickse argues that aflatoxins cause kwashiorkor by damaging the liver, which becomes unable to manufacture albumin. Low levels of albumin then lead to the disease. Ways of treating and preventing kwashiorkor differ, depending on which explanation you accept. According to Hendrickse, improved ways of storing food could help to control the disease, while removing aflatoxins from the diet should enable the liver to recover its normal function. With Golden's theory, treatment focuses on free radicals. Golden is treating severely malnourished children with vitamin E, an antioxidant, and selenium, which must be present for glutathione peroxidase to work. He is also using desferrioxamine, an agent that mops up iron. Free iron is an important catalyst in reactions that result in the formation of free radicals; children with kwashiorkor have large stores of iron. Golden argues that removing iron from the body will reduce the load of free radicals. Golden suggests that if his hypothesis is correct, several practices common in the treatment of malnourishment could be inappropriate or even dangerous. UNICEF recommends adding oil to a mixture of dried skimmed milk and sugar in order to boost the energy intake of severely malnourished children. Golden says that this practice could be hazardous. Loading the diet with polyunsaturated fatty acids could increase levels of free radicals in children whose mechanisms for removing them are inadequate. Staff at the Tropical Metabolism Research Unit used to supplement diets with peanut oil, which is high in polyunsaturates. Studies of children taking extra peanut oil showed high levels of mercapturic acid in their urine. Mercapturic acid forms when glutathione reacts with free radicals, so levels of this acid reflect the body's load of free radicals. As a result of the finding, the unit now uses coconut oil, which has a lower proportion of fatty acids, and which results in less mercapturic acid being excreted.

Roger Whitehead, director of the Dunn Nutrition Unit in Cambridge, is alarmed at Golden's suggestion that adding oil to children's diets could be dangerous. Severely malnourished two-year-olds need 150 to 200 kilocalories per kilogram of body weight per day, twice the energy intake of a normal child. The only way to get that amount of energy into children too sick to eat is to give some of it as oil, he argues. Whitehead believes that neither Golden's nor Hendrickse's theories can, on its own, account for why some children develop kwashiorkor while others do not. The origins of kwashiorkor are far too complex for a single theory to explain, he believes. Free radicals must be involved because they are ubiquitous in illness, he says, but protein deficiency is still an important contributory factor. Diet, diarrhoea and disease Whitehead cites the example of two countries where scientists funded by Britain's Medical Research Council have studied malnutrition. In Uganda, where kwashiorkor is the prevalent form of malnutrition, the staple food (matooke, also known as plantain) is so low in protein that children eating little else inevitably become deficient in protein. By comparison, in the Gambia, 90 per cent of children with malnutrition suffer from marasmus. Weight for weight, the staple food, rice, contains more than twice as much protein as matooke, so protein deficiency is rare. Children who develop kwashiorkor in the Gambia often have diarrhoea. They lose protein into the gut, and their levels of albumin drop. Infections such as measles can also bring on kwashiorkor, by damaging the lining of the gut, allowing protein to leak out. According to Whitehead, the differing causes of malnutrition suggest a variety of solutions. Extra food rich in protein would help to prevent kwashiorkor in children in Uganda, but not in children in the Gambia. Once nutritionists have established what the ideal diet for malnourished children should be, providing it is another matter. Many socioeconomic problems contribute to malnutrition . In view of such difficulties, are scientists' efforts to put things right redundant? Philip Payne, professor of human nutrition at the London School of Hygiene and Tropical Medicine, says: 'It may well be that there are few simple interventions that scientists can make.' Yet he believes that the traditionally close relationship between scientists and international aid agencies is unlikely to break up. In the past, he says, scientists have used agencies, such as the UN, to propound and test their theories. In their turn, politicians and agencies have exploited scientists: 'If they think there's some magic formula around, they tend to promote it regardless of the evidence.' Aid agencies also find that poverty in developing nations is a sensitive issue. Purveying the ideas of scientists is more acceptable than repeating the dictates of politicians.

Payne has the last word: 'In a scientific sense, it obviously helps to understand the mechanisms. Whether in practice it turns out to be important is very difficult to say. In the end, it comes down to demands on management systems that just can't be met. The analytical approach is to persuade policy makers that there is no short cut. People need basic health services, knowledge about health, and food security. We're asking countries to do things that we couldn't possibly have done when we were as poor as that.' *** The backdrop of poverty, disease and debt AN ESTIMATED 40 000 children die each day - 14 million or so a year - from diseases such as measles and diarrhoea that are commonly associated with poverty, overcrowding and malnutrition. The children become caught in a vicious cycle. Sick children lose their appetites. When they do eat, they absorb nutrients only poorly, or lose them in diarrhoea, putting them at risk of malnourishment. And malnourished children are more likely to succumb to disease and infection. About 60 per cent of deaths in children under the age of five in developing countries are thought to be related to malnutrition. Millions more children survive on the edge of starvation. Doctors measure malnutrition by assessing a child's weight in relation to height. A moderately malnourished child is one whose weight is only 70 to 80 per cent of the normal for its height. At less than 70 per cent of normal weight for height, a child is suffering from severe malnutrition. At below 60 per cent, the child is unlikely to survive without very specialised care. Philip Payne, professor of human nutrition at the London School of Hygiene and Tropical Medicine, believes that international aid agencies are now coming to terms with the idea that a low weight-for-height ratio means far more than lack of food. People used to see malnutrition as a problem of food production. Then the challenge became one of distribution. Now, it appears to be a far more complex issue. Payne thinks that many people now doubt whether child deaths and poor growth are simply due to lack of food. 'Yet it is clear that people in some places and at some times do experience hunger,' he says. UNICEF notes in its 1989 report that even families that have money to buy food, or a plot of land on which to grow food, still bring up undernourished children. According to UNICEF, an indispensable part of the fight against malnutrition is to ensure that parents have access to basic nutritional information, such as that contained in Facts for Life, a booklet on child health that the fund prepared with the World Health Organization and UNESCO. The pamphlet tells parents that breast milk is the best food for the very young, that they should add other foods to the diet when the child reaches about four

to six months, and that they should feed children under the age of three five or six times a day. It adds that parents should fortify children's food with vegetables and small amounts of oil. UNICEF suggests that parents and health workers could help to put that knowledge into practice by weighing children regularly and monitoring their growth. In the past, however, busy health workers have not always explained to mothers what they should do if their children are not gaining as much weight as they should be. Many other factors contribute to a child's risk of becoming malnourished. Kwashiorkor, a Ghanaian word that describes one of the main types of malnutrition, means 'the sickness that the older child gets when the next baby is born'. According to the World Fertility Survey, the chances of two children surviving are reduced if there is less than two years between their births. Pregnant women who are undernourished are likely to give birth to very small babies who will be at high risk of malnutrition during their early years. Solutions to malnutrition cannot stop with strategies to educate people and control disease. The problem is closely linked to the economic health of many developing countries, and the 1980s have left a dismal legacy for the world's poor. Africa, Latin America and the Caribbean have borne the brunt of world recession. In many countries in Africa and Latin America, average incomes have fallen by 10 to 20 per cent during the 1980s. According to UNICEF, the world's 37 poorest nations have halved spending on health and cut spending on education by a quarter. In Burma, Burundi, the Gambia, Guinea-Bissau, Jamaica, Nigeria, Paraguay and the Philippines, all countries that collect reliable statistics, malnutrition is on the increase. UNICEF estimates that world recession and debt is now responsible for the deaths of more than half a million young children every year. The debt of the developing world now totals more than Pounds sterling 625 billion. The annual repayments of many countries add up to more than all new aid and loans received each year. To meet their debts, the governments of developing countries have adopted 'adjustment' policies. This usually means devaluing currency, withdrawing food subsidies and cutting spending on health and education. UNICEF has called for 'adjustment with a human face' to protect the poor during periods of austerity. With help from the fund, the government of Ghana has raised Pounds sterling 52 million for a programme designed to cushion its poorest people from the current economic recession. The scheme is financing the building of roads, wells and latrines in the poorest parts of the country. It is also providing food for those who need it and credit for small farmers, as well as funding projects that will create jobs. UNICEF has also argued that governments and commercial banks should cancel some debts owed by the most severely affected nations. The plea has

had some effect. Last spring, Nicholas Brady, treasury secretary of the US, put forward proposals to reduce Mexico's debt to international banks by 35 per cent. The proposals have forced banks to make provisions for nonpayment of debts from many other developing countries. Last August, the four largest clearing banks in Britain wrote off Pounds sterling 2 billion of debts owed by the Third World. The write-off devastated banking profits for the year and led one bank, the Midland, to declare a loss.

The Hunger Quiz (taken from World Legacy website) 1. Hunger is caused when finite food-producing resources of the world are stretched to the limit by too much demand. False. The world today produces enough grain alone to provide every human being on the planet with 3500 calories a day -- enough to make most of us fat! And we're just talking grain here. If we counted many other commonly eaten foods --vegetables, beans, nuts, root crops, fruits, grass-fed meats, fish -- enough is available to provide each man and woman, boy and girl with at least 4.3 pounds of food per person per day. The real problems are the 'people' ones: politics, economics, access, distribution, food safety, war, and, above all, poverty, plus the organizational ones: transportation, spoilage, contamination. Through your participation with World Legacy, we can provide nutritious food to those who don't have access to food. It's not a matter of not enough food to go around. It's a matter of getting the available food to those who are without it. 2.Most of the world’s hunger occurs because people live in countries where food shortages are commonplace -- countries in Latin America, Asia and especially Africa. False. There are poor and hungry people worldwide, often living right next to people who have plenty of food. In many countries excess agricultural products are exported (for example metric tons of soybeans for livestock feed) while many people right there starve to death, because in many developing countries in Asia, Africa and Latin America, there are no welfare programs to help feed those whose incomes fall below the poverty level. Through your participation with World Legacy, we can provide nutritious food to the poorest of the poor, people who simply don’t have access to food, because mainstream economy practices have passed them by. 3. When a person is starving to death it clearly indicates that their deepest need is their physical need for food. False. The most immediate urgent need does not mean that is a person’s deepest need. Feeding a starving person is crisis intervention only. The deepest need is more far reaching. That’s why to both the critical life saving, and life building needs must be provided for. The underlying goal must be to break the inheritance of poverty for both this life and for a legacy of generations to come. Some of these means include introducing improved seeds, teaching people to grow drought-resistant crops and to use improved farming and storage methods, providing a source of clean, safe water and making available a program of preventative health care, shelter for the homeless, education and training, and assistance to families in starting small businesses. Often it takes just a few simple resources for impoverished people to be able to grow enough food to become self-sufficient. (Source UNICEF)

4. Hunger affects the young and old, men and women, boys and girls equally. False. Not all of the sufferers suffer equally. The vast majority (75%) of the 24,000people that die everyday because of hunger or diseases related to hunger and malnutrition are boys and girls under 5, then the elderly and women. Typically women will give the food to the men and children first, and themselves only after that. 5.The poor are the hungry and the hungry are the poor, because they perpetuate their own vicious circle. False The hungry are the poor. The poor are the hungry. It is not a case of people being stuck in self-defeating behavior, it a case of being defeated by the circumstances of their situation. Poverty is lack of food among other things such as opportunity, of safety, of shelter. Poverty is not being able to go to school, not knowing how to read (today just under half of the world is illiterate), not being able to speak properly. Poverty is not being able to find a job, get a job, or even being able to work. Poverty is being sick and not being able to see a doctor. Poverty is living in fear, one day at a time, not being able to make a survival plan, let alone a lifetime plan. Poverty is losing family members to illness brought about by unclean water because of lack of environmental knowledge. Poverty is being born into debt in a developing country with a per-person debt that your government incurred on your behalf that you (and they) cannot repay. More than anything, poverty is a situation people want to escape to run away from. Many hunger experts believe that ultimately the best escape is through education. Educated people are best able to breakout of generations of inherited poverty that causes hunger. (Source UNICEF) 6. easy to identify and to remedy. False. Starving people's bodies often swell so they look surprisingly healthy. But it is an illusion; the ballooning effect is a buildup of water, not tissue. Death comes stalking these hunger victims on tiptoe. As it approaches they turn listless, apathetic, and even resigned. The end is quiet, usually silent. The brain and other organs, drained of energy, just give up. Today that happens to nearly 12 million children under 5 each year. 7. Famine False. and Wars cause the most deaths by starvation. The starving person is

Famine and wars cause just 10% of hunger deaths, although these tend to be the ones you hear about most often. The majority of hunger deaths are caused by chronic malnutrition. People simply cannot get enough to eat. This in turn is caused by extreme poverty. Hunger doesn't just kill, it can cripple. As bad as actual starvation is, the halfway stage called malnutrition is perhaps more insidious. In this sort of"living death," the body gets food, but not enough- or, more often, not enough of the right components -to keep functioning properly. This entirely preventable evil comes in different forms. A basic diet may have too little fat or carbohydrate to provide a reasonable amount of energy. It may have too little protein to create muscle, brains, or blood cells. Our it may be deficient in minerals such as iron, iodine, and zinc that when missing cause permanent impairment, just like a shortage of vitamin A in childhood will cause

permanent blindness. Or vitamins may be in too short a supply for the body to properly rebuild its worn or damaged parts. Malnourished children often suffer the loss of precious mental capacities. They fall ill more often. If they survive, they usually grow up with lasting mental and physical disabilities. Families suffer. The entire community suffers. It is a waste of potential beyond measure. (Statistics by the Institute for Food & Development Policy) 8. World hunger is fueled by the world's population explosion. It is a losing battle; whatever aid we give will make no difference until population growth slows. Besides, if people are poor they should know enough to stop having babies they can't afford to feed. False. Fertility and population-growth rates are, in fact, declining worldwide. According to the United Nations, population density nowhere explains today's widespread hunger. Rapid population growth, or poor birth control practices (or basic knowledge) are not the root cause of hunger, but are -- like hunger – a consequence of social inequities that deprive the poor of the security and economic opportunity necessary for them to choose fewer children. To bring human population into balance with economic resources, societies must address the extreme maldistribution of access to resources -land, food, jobs education and health care. However, despite the 'population explosion' we are in fact gaining on it. Today, about 24,000 people die every day from hunger or hunger-related causes. This is down from 35,000 ten years ago, and 41,000twenty years ago. Three-fourths of the deaths are children under the age of five. Today 10% of children in developing countries die before the age of five. This is down from 28% fifty years ago. (Statistics from the United Nations Hunger Project and CARE) 9. Droughts, floods and other catastrophic "Acts of God" beyond human control are the main underlying causes of famine. It's really not anybody's fault. False. Droughts, floods, earthquakes, etc. devastate regions of the U.S. every year, yet we never see widespread famine in the U.S. The problems that aggravate world hunger are: politics, economics, transportation, access, distribution, food safety, war, drought, spoilage, contamination, and, above all, poverty. When one or more of these underlying problems combine during a natural disaster, the poorest of the poor -those living on the edge of destruction --suffer the most. A single negative event -famine, flooding, earthquake, war and pestilence -- added to their current plight, can render them absolutely desolate. 10. A reasonable minimum goal would be to provide a child regularly with enough food to satisfy "feeling hungry". At less than2 cents a day to feed a child, that sounds like the goal. False. It's not a simple matter of whether a child can satisfy his or her appetite enough to stop "feeling hungry". It's about getting the right quantities and combinations of nutrients. Three quarters of the children who die worldwide of causes related to malnutrition are what nutritionists describe as mildly to moderately malnourished and betray no outward signs of problems to a casual observer. Besides causing death, chronic malnutrition also causes impaired vision, listlessness, stunted growth, and greatly increased susceptibility to disease. Malnourished people are unable to function at even a basic level A diet that merely satisfies a hungry child's appetite may have

too little fat or carbohydrate to provide a reasonable amount of energy. It may have too little protein to create muscle, brains, or blood cells. Minerals such as iron, iodine, and zinc can be missing. Or vitamins may be in too short a supply for the body to properly rebuild its worn or damaged parts. It is estimated that some 800 million people in the world suffer from hunger and malnutrition, about 100 times as many as those who actually die from it each year. (Statistics from Oxafam)

Health and the Links to Nutrition: Maternal Health is Key http://www.unfpa.org/news/news.cfm?ID=441 Thirty First Session of the Standing Committee on Nutrition, New York Statement by Thoraya Ahmed Obaid, Executive Director 22 March 2004 Good afternoon, ladies and gentlemen. Today, at this second, a baby girl is being born somewhere in the world. She is being born to a mother who is undernourished. The mother herself is young, 18 years old. It is likely that the baby is stunted in height and low in weight, even though she was born at full term. If she survives, her growth will be more likely to falter. Her ability to learn will be irreversibly damaged, as will her ability to develop other skills needed for the labour market, home and community. She will also be more susceptible to infectious diseases. Later in life, she will be more likely to suffer from the so-called diseases of affluence such as diabetes, coronary heart disease and diet-related cancer. Throughout her life, her options—and her power to make choices about those options—will be as stunted as her growth will be. During her childbearing years, she will bear low birth weight babies of her own, continuing the cycle of poverty and illhealth from one generation to the next. And society will be worse off, both socially and economically. Ladies and gentlemen, the scenario I have just painted for you is lived by one in three infants in the developing world. The food security and nutrition status of an infant reveals much about her history to date and tells us much about her forward trajectory through life. And this status is determined in large part by the health and nutrition status of her mother. And the health and nutrition status of the mother is determined in part by the status of women in society. Today, in my talk, I would like to stress three major points: 1. To improve nutrition and health, we must improve the status of women. 2. We must target three groups with nutrition interventions: pregnant and breastfeeding women, infants up to the age of 2, and adolescents, particularly adolescent girls, and

3. By doing these two things – improving women’s status and reaching these three groups with better nutrition – we will build a foundation for achieving the Millennium Development Goals. I will also stress a fourth point—that better nutrition is needed to combat HIV/AIDS and malaria. Ladies and gentlemen, Nutrition is a fundamental human right and it plays a key role in health. Eradication of hunger ranks high among international goals because good nutrition is essential for the health and human capacity needed to achieve so many of the other Millennium Development Goals. Freedom from hunger is a sound foundation for economic growth in the world’s most impoverished nations. Wellnourished people learn better, produce more, and can more effectively fight off disease, and provide better care for their children and the environment. Yet, malnutrition and low weight in children and mothers persist, and are leading causes of disease worldwide. In the poorest regions of the world, they are also the major contributors to loss of healthy life. The effects extend beyond the individual and the family to the society at large because malnourished people are unlikely to be able to fully participate in whatever economic opportunities may be available. Today, the majority of the developing world’s 846 million hungry people reside in Asia. However, sub-Saharan Africa is the region of the world that is witnessing the largest increases in the numbers of the hungry. And it is the region that is farthest from progress in achieving the international goal to reduce extreme hunger by 2015. Today, the high economic costs of hunger and the economic benefits of good nutrition are increasingly understood. We also have greater understanding of the causes of hunger. We know that the main causes of malnutrition include inadequate access to food and nutrients, inadequate care of mothers and children, inadequate health services and unhealthy environments. We also know that hunger and poverty are perpetuated by lack of access to assets, lack of access to institutions that give voice and provide opportunities, and by vulnerability. The fact is that grossly unequal social conditions and exclusionary practices frequently prevent access to food, health, sanitation and education. And this inequality and discrimination hit hardest on women, girls, infants, ethnic minorities and other vulnerable

groups. It is this exclusion and discrimination that is a major cause of poor nutrition and poor health of women and girls, which leads to malnutrition in infants and across generations. Promote gender equality and empower women That is why the empowerment of women and girls is so essential. They need education, better nutrition, and better treatment, including access to reproductive health services, so they can take better care of themselves and their children. It is well documented that women’s low status in the household and within society is an important cause of poor nutrition. Women’s low social status, lack of decision-making power, and lack of control over income have a significant adverse effect on health-seeking behaviours and child health and nutrition outcomes. According to Joan Holmes, President of the Hunger Project, chronic hunger occurs: “when people lack the opportunity or are systematically denied the opportunity to earn enough money, to produce enough food, to be educated, to learn the skills to meet their basic needs, and to have voice in the decisions that affect their lives”. There is growing international recognition that discrimination against women is a major cause of hunger and malnutrition. For when we speak of hungry people, we are most likely talking about women and children. It is also true that women have significant productive roles in developing countries. Rural women are responsible for half of the world’s food production and produce 60 to 80 per cent of the food in most developing countries. This is particularly true in South Asia and in Africa. Women food farmers produce 80 per cent of Africa’s food, and do the vast majority of the work to process, transport and market this food. Yet, they own only one per cent of the land, and receive less than 10 per cent of the credit given to small-scale farmers. Sub-Saharan Africa is the only region in the world where average food production per person has been declining during the past 40 years. In much of rural sub-Saharan Africa, women are subsistence farmers. Yet, they are often given small and marginalized plots of land. They have less access to credit, extension services and technological inputs than do men, which puts them at a disadvantage in terms of food production.

There is a great deal of research showing that the greater the per cent of household income earned by women, the greater the food security of the household. Studies show that women put more of the money they earn into the health and welfare of the family and the children, compared to men. Yet, low wages and poor work conditions leave women with few adequate child care options, and studies show that malnutrition is significantly more likely among young children when their mothers have to work under such conditions. So, we see here a vicious circle. On the one hand, the mother is working and contributing her earnings to her family, yet she is barely able to survive and her children stand a high chance of suffering from malnutrition. The poor nutritional status of infants and women has implications for overall development in terms of productivity losses throughout the life cycle of both boys and girls. Hence, not only are improvements in the status of women needed to improve nutrition, but better nutrition for girls and women can also help to identify policies and interventions that can reduce gender inequality. This can be done by both promoting level playing fields and by promoting catch-up in terms of women’s status. These policies will benefit women, their children, and overall economic development. This has been shown to be the case in the African nation of Burkina Faso. It was found that women had less access than men to food, information, assets, institutional services, and rights. They also had less access to agricultural inputs, which resulted in a loss of agricultural output and productivity. But when they gained equal access, their productivity increased and so did the yield of crops. It is clear that greater efforts are needed to empower women and increase their equal access to food and other vital assets, resources and services to reduce hunger and malnutrition. As I stated at the beginning of my statement, malnutrition often begins at conception. When a pregnant woman consumes an inadequate diet, has an excessive workload, or is frequently ill, she will give birth to smaller babies with a variety of health problems. Children born to malnourished mothers are more likely to die as infants. If they survive, by the second year of life, they may have permanent damage, including brain damage, which cannot be reversed. For this reason, pregnant and breastfeeding women, and children under 2 years of age should be priority target groups for nutrition interventions. Other critical groups include pre-adolescents and adolescents, particularly girls. Let’s face it: healthy mothers have healthy infants. Ladies and gentlemen,

The images of hunger that fill television screens tend to be of infants and children that are acutely malnourished – victims of famine. But famines account for less than 10 per cent of hungerrelated deaths. The remaining 90 per cent are the result of chronic, persistent hunger—the silent, day-by-day killer that takes the lives of some 20,000 people each day. Research has shown that even moderate and mild forms of malnutrition in children are important predisposing factors to child death. All degrees of malnutrition – severe, moderate and mild – are linked with the deaths of over 6 million children, over one half of all child deaths each year. All over the world, child malnutrition is linked to poverty, low levels of education, and poor access to health services, including reproductive health services and family planning. It is widely known, for instance, that having babies too closely together increases the chance of poor nutrition in both the mother and child. Studies show that waiting at least two to three years between births allows the mother to replenish nutritional reserves. We must also remember that health services during pregnancy and childbirth provide vital entry points for nutrition interventions. It also true that adequate health services, especially emergency obstetric care, are needed during childbirth to ensure a healthy outcome for both mother and child. Studies show that the death of a mother reduces the chances of a healthy life for children who are left orphaned. So, clearly all of these interventions are mutually reinforcing. This is important because malnourishment in infants and children, even moderate, increases their risk of death, inhibits their cognitive development and affects health status later in life. Studies show that the under-nutrition of a foetus is linked to chronic disease in adulthood. It is also known that the effect of malnutrition during the first two years of life is mostly irreversible, and actions thereafter have little or no impact on underweight rates and physical and mental problems. Undernourished infants tend to enter primary school later and drop out earlier. When they are in school, they tend to be less able to learn as compared to better-nourished individuals. Yet, despite this knowledge, malnutrition continues to affect millions of poor infants and young children: Every year, some 30 million infants are born in developing countries with impaired growth due to poor nutrition during foetal life. • Every minute, 11 children under five die of hungerrelated causes.

Ladies and gentlemen, This does not have to be the reality at the beginning of the 21st century. This sad scenario can be changed. These deaths are preventable. The world possesses the know-how and the resources to turn this crisis situation around. An investment in preventing foetal under-nutrition is a highly effective investment because it not only improves maternal and infant nutrition, but it may also slow down or prevent the onset of chronic disease later in life. Improving maternal health and nutrition is key. Improve maternal and infant health Maternal malnutrition is not only associated with malnutrition in a developing foetus, it is also directly associated with the ill-health, and possible death, of the mother. Poor nutritional status may affect the chances of maternal mortality in various ways. For one thing, if the mother is malnourished, she may have experienced stunted growth, resulting in a small pelvis, which can result in obstructed labour, one of the main causes of maternal mortality. Other causes of death during childbirth are associated with micronutrient deficiencies. Over 100,000 pregnant women die each year from severe irondeficiency anaemia. This equals one fifth of all annual maternal deaths. Iron deficiency during pregnancy is also associated with multiple adverse outcomes for both mother and infant, including an increased risk of haemorrhage, sepsis, low birth weight and increased overall infant mortality. Serious iodine deficiency during pregnancy may result in stillbirths, miscarriages and congenital abnormalities. Iodine deficiency disorders jeopardize children’s mental health and often their very lives. Childhood anaemia can begin when mothers have the ailment before or during pregnancy, and the infant is born with low iron stores. The health consequences of iron deficiency for children include premature birth, low birth weight, infections and elevated risk of death. Later physical and cognitive development is impaired, resulting in lowered school performance. Deficiency in vitamin A is also a major threat to health. In pregnant women, vitamin A deficiency increases maternal mortality and causes night blindness. Infants born to women who consume too

little vitamin A have low stores at birth. The breast milk of those women is also low in vitamin A. Although severe vitamin A deficiency is declining, sub-clinical deficiency still affects up to 250 million pre-school children, contributing significantly to raised morbidity and mortality in highrisk populations. Vitamin A deficiency is the leading cause of preventable blindness in children and raises the risk of disease and death from severe infections. Between 100 million and 140 million children are vitamin A-deficient and an estimated 250,000 to 500,000 vitamin Adeficient children become blind every year, half of them dying within 12 months of losing their sight. Since breast milk is a natural source of vitamin A, promoting breastfeeding is the best way to protect babies from vitamin A deficiency. However, if the mother is deficient, supplements are needed for both mother and child. In a recent trial in Nepal, lowdose vitamin A supplementation reduced maternal mortality by 44 per cent. For deficient children, the periodic supply of high-dose vitamin A in swift, simple, low-cost, high-benefit interventions has produced remarkable results, reducing mortality by 23 per cent overall and by up to 50 per cent for acute measles sufferers. Zinc deficiency presents another threat to pregnant women and babies. It is associated with long labour, which increases the risk of maternal and infant death, especially in areas where there is limited access to health services. Another deficiency that threatens pregnant women is folate deficiency, which is associated with a high risk of pre-term delivery and low birth weight. Folate deficiency also contributes to anaemia, especially in pregnant and lactating women, and may be associated with increased risk of maternal morbidity. Overall, malnutrition lowers the body’s ability to resist infection and leads to longer, more severe and more frequent episodes of illness – thus increasing mortality risk. The publication, Nutrition Essentials (BASICS/WHO/UNICEF, 2000), highlights six key nutrition interventions: exclusive breastfeeding for about six months; appropriate complementary feeding with continued breastfeeding for two years; adequate nutritional care during illness and severe malnutrition; adequate vitamin A intake for women, infants, and young children; adequate iron intake; and adequate iodine intake. Adolescent nutrition: a neglected dimension

I have just described interventions needed for pregnant and breastfeeding women, and for infants up to 2 years of age. Now, I would like to talk about a group that is often ignored, and that is adolescents. Today, there are about 1.2 billion adolescents in the world, comprising one in five persons on earth. These 10- to 19-year-olds face a series of serious nutritional challenges, which affect not only their growth and development, but also their livelihood as adults. Yet, adolescents remain a largely neglected, difficult-to-measure and hard-to-reach population, with the needs of adolescent girls, particularly, ignored. Adolescence is a unique period in life because it is a time of intense physical, psychosocial and cognitive development. Caloric and protein requirements are maximal. Increased physical activity, combined with poor eating habits and other considerations, such as the onset of menstruation and pregnancy, contribute to the potential risk for adolescents of poor nutrition. Studies show that community-based approaches are needed for the sustained strengthening of household food security with emphasis on nutritional adequacy for adolescent girls. Mass information and awareness programmes are needed to alert governments and communities to the importance of health and nutrition for adolescent girls. In particular, there is an urgent need to ensure a sustainable adequate intake of iodine by all adolescent girls and women of childbearing age prior to conception – in the long term through iodized salt and, if necessary, in the short term through distribution of iodized oil capsules. Combat HIV/AIDS, malaria and other diseases I would now like to talk about nutrition, HIV/AIDS and malaria. The magnitude and depth of HIV/AIDS impacts in sub-Saharan Africa are staggering. Livelihoods are being devastated and the food and nutrition security of millions of households seriously undermined. In fact, inadequate access to food is one of the first signs of distress in a HIV/AIDS-impacted household. Malnutrition, in turn, increases both the susceptibility to HIV infection and the vulnerability to its various impacts. Malnutrition also has a strong negative impact on those suffering from malaria. Nearly 57 per cent of malaria deaths are attributable to malnutrition. Nutrition, therefore, plays a critical role in all four of the main strategies for combating HIV/AIDS: prevention, care, treatment and mitigation, and in combating malaria.

At an individual level, HIV infection essentially accelerates the vicious circle of inadequate dietary intake and disease that leads to malnutrition, while malnutrition increases the risk of HIV transmission from mothers to babies and the progression of HIV infection. Mother-to-child transmission (MTCT) of HIV has nutritional implications. In a recent study, exclusive breastfeeding has been seen to confer a significantly lower risk of HIV transmission than partial breastfeeding. Infants of mothers who have an adequate vitamin A status might have a reduced risk of vertical transmission. More studies on these issues are still needed. The nutritional status of those infected and affected plays a large part in determining the individuals’ current welfare and their ability to further develop their livelihoods towards activities that help to mitigate the impacts of AIDS and prevent the spread of HIV. With regard to nutrition, HIV/AIDS significantly impacts individuals and households, by accelerating the vicious circle of inadequate dietary intake and disease, and by diminishing the capacity to ensure the essential food, health and care preconditions of good nutrition. It is also clear that when farmers fall sick, they cannot tend the crops. The losses caused by HIV/AIDS affect every determinant of food security, including health status, income, capacity to care for children, ability to participate in governance, ability to work on farms and other productive activities, as well as to participate in social networks. The good news is that nutritional support has the potential to significantly postpone HIV/AIDS-related illness and prolong life. Food aid has significant potential for improving the situation of HIV/AIDS-impacted households and communities, and reducing early death from malaria. Conclusion I would like to conclude by charting a way forward. The International Conference on Nutrition (ICN) framework for nutrition identifies household food security, health services and a healthy environment, as well as care for women and young children as the three underlying determinants of malnutrition. It is necessary to address all three to improve nutrition outcomes. Therefore, one of the key policy priorities is to empower women and invest in girls.

The Hunger Task Force, in its recommendations, also says that the empowerment of women is a key part of an overall strategy to achieve the hunger MDG. It also emphasizes that increased investments are needed to raise agricultural productivity, improve the market functioning for poor producers and consumers and increase the nutrition status of adolescent girls and women. Given the rise in world wealth, increases in international inequality and the widespread application of human rights principles to development, the case for making these investments has never been stronger. The common denominator in the many failures to achieve the global promise of hunger reduction can be branded as a lack of political will. The world can achieve the hunger MDG if it chooses to do so. Such a choice is political, and political choices can be influenced by targeted and sustained advocacy. One needs to stress the contributions of improved nutrition status to the attainment of the MDGs. In terms of the poverty goal, for example, improvements in nutrition status are urgently needed during pregnancy and the crucial first two years of life to boost the lifetime well-being of an individual and help break the intergenerational cycle of poverty. For the actions in improving nutrition of mothers and children and empowering women to be most effective, or perhaps effective at all, they need to operate in a supportive policy context. In essence, this means a political class that is supportive of improving the status of women. Women who cannot access the information, education, assets and time necessary to improve their nutrition and that of their children will be unable to influence decisions that affect their lives. The inability to make these claims and to engage with men in jointly delivering them will diminish the chances of any nutrition action from being successful. We must also realize that, in improving the nutrition of mothers and children and empowering women, the role of men is crucial. If these actions are to be framed solely as actions for women, lobbied for by women, and enacted by women, they will be doomed to failure. Without the buy-in of men – as to the need for these interventions and for their active participation in creating the choices for women and time to act on those choices – the responsibility on women will become a counterproductive burden. Providing immediate assistance through woman-centred and lifecycle-oriented nutrition programmes will address chronic and acute hunger and ensure that the most vulnerable groups can benefit

from hunger-reduction strategies that are based on income generation and increasing agricultural productivity I would also like to stress, as does the Hunger Task Force, that the private sector has to be a part of the solution. The nutrition community has historically avoided partnership with the private sector, largely due to the negative experiences relating to the undermining of exclusive breastfeeding. However, there may be some roles, responsibilities and situations in which the private sector has a comparative advantage. For example, private industry has been a key player in the fortification of food with micronutrients. One fortification success story, still unfolding, is the massive reduction in iodine deficiency through salt iodization. An important step is for health sector planners to work with nutritionists to identify the most critical nutrition interventions, how they will be provided, and how to sustain them through capacity development, quality assurance and supervision. Although all of this has cost implications, planners should recognize that neglecting nutrition costs more. Finally, I would like to endorse the findings of the Standing Committee on Nutrition, which earlier today released its 5th Report on the World Nutrition Situation. In the report, the Committee stresses that nutrition status – both the attainment of it and how it is attained – has much to offer those who seek to strengthen governance, reduce poverty and make trade liberalization and health-sector reform work for the poor. For health-sector reform, the huge and largely unappreciated role that malnutrition plays in the global burden of disease, together with the existence of a range of cost-effective health-sector interventions to improve nutrition, makes nutrition activities among the best ways to improve the efficiency and quality of health services. And, since malnutrition affects the poor and most vulnerable (women and children) most, addressing malnutrition also addresses inequities in health. In addition, a focus on malnutrition inevitably involves a focus on individuals who are socially disadvantaged and, hence, especially vulnerable to risk. Recently, nutrition components have been successfully incorporated into anti-poverty and safety net programmes on a large scale in Mexico and Central America (for example, transferring cash or food in return for school attendance and the attendance of pre-schoolers at health clinics with a focus on growth-promoting activities). These programmes have combined to reduce poverty today, while safeguarding human capital accumulation for the next generation.

The potential of the nutrition community to accelerate broader development goals is clear. The potential of the broader development community to mobilize resources for malnutrition reduction is equally apparent. For this “win-win” situation to materialize, the nutrition community needs to recast itself. It must see itself as the part of the development community that is concerned with nutrition. It must forge new connections across unfamiliar divides. If it does not, nutrition status might be relegated to simply being an indicator of the attainment of the Millennium Development Goals, rather than an essential foundation for their attainment.

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