III. NUTRITIONAL SCENARIO. Table 3. Wasted, Stunted and Underweight Children, 1990

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1 A. Nutrition and Related Indicators III. NUTRITIONAL SCENARIO Undernutrition and malnutrition exist as part of the complex and widespread problem of poverty and deprivation that affects millions of people in Asia. Major improvements in the nutritional situation are suggested in recent assessments of trends in malnutrition from FAO and WHO, with many countries successfully addressing them. These new data show some improvement world wide, but at a substantially slower rate in the last few years than during the 1980's. This slow down is a cause for concern, being contrary to the commitments of the goals from the World Summit for Children of 1990 and the ICN of 1992, of halving the prevalence of malnutrition between 1990 and The current and achievable challenge therefore is to build upon and accelerate the progress registered in Asian countries. As supplement to the overview of the region in global perspective furnished in the introduction, this section examines some countries to identify regional trends in nutrition and related indicators followed by an exploration of Asian prospects into the next century and beyond Economically, Asia and the Pacific remains a fast growing region, with a GDP growth rate of almost 8 per cent. Although it experienced noticeable declines in infant and child mortality, the total numbers of chronically undernourished people is increasing, as is shown in Figure 2. These contradictory trends in development flow from the Asia and Pacific region being home to nearly three-fourths of the world's poor (UNDP 1997). The short- and long-term consequences of poverty and malnutrition among children are reflected in the three anthropometric measures of underweight, wasting and stunting, shown in Table 3 below. Stunting is measured as height for age, under-weight as weight for age and wasting as weight for height. Whether compared to age or height, loss of weight among children reflects a cumulative process of poor growth that can be modified, as children experience weight gains due to greater access to food or the absence of diarrhoea related diseases and other health problems. Table 3. Wasted, Stunted and Underweight Children, 1990 Wasted Stunted Underweight Region per cent number per cent number per cent number Developing countries East and South East Asia South Asia Economic Group Middle-to high-income countries Low income countries Source: The Sixth World Food Survey (Rome: FAO) 1996a. In 1990, one third of children aged 5 years and under in developing countries were underweight in contrast to more than half in South Asia, more than a third in low income countries and about one fourth in East and South East Asia. Half of the underweight children in developing countries live in South Asia. The prevalence of underweight shown in Figure 5 below highlights the wide variation among Asian countries, with high levels in the most populous LIFDCs of South Asia, in contrast to South East Asia.

2 Figure 5. Underweight Prevalence among Children under Age 5 Years (per cent) Source: The Sixth World Food Survey (Rome: FAO) Wasting is relatively less prevalent, being experienced by nearly ten per cent of children in developing countries, as shown in Table 3 above. In contrast, wasting is experienced by 17 per cent of South Asian children, 10 per cent in low income countries, and 5 per cent in East and South East Asia. Half of the underweight children in developing countries live in South Asia, in contrast to 56 per cent of the wasted children. The data shown in Figure 6 highlights the disparities among Asian countries in this regard, and accents the prevalence in South Asian LIFDCs in contrast to East Asia. Figure 6. Wasting Prevalence among Children under Age 5 Years (per cent) Source: The Sixth World Food Survey (Rome, FAO) 1996.

3 Data shown in Table 3 indicates that the prevalence of the stunting is higher than underweight or wasting. In developing countries as a whole, 41 per cent of children are stunted, and one third experience retarded growth in East and South East Asia in contrast to more than half, or 60 per cent, in South Asia. More than eighty per cent of total 215 million stunted children in developing countries live in low income countries, such as in the low income food deficit countries (LIFDCs), such as Bangladesh, India, Pakistan, Lao People Democratic Republic, Vietnam, Myanmar, and the Philippines. The high levels for stunting prevalence among children in these Asian LIFDCs are highlighted in Figure 7. Figure 7. Stunting Prevalence among Children under Age 5 Years (per cent) Source: The Sixth World Food Survey (Rome FAO) Data shown on Table 4 below highlight the prevalence of stunting among adolescents. It is most prevalent among adolescents in Mindinao in the Philippines, but more prevalent in Nepal than India. The data for India highlight significant disparities between adolescent girls and boys. Table 4. Prevalence of Stunting among Adolescents in Selected Countries, Latest Available Year Stunting prevalence (per cent) Study (<5 th percentile height-for-age) All Males Females India Nepal 47 ns ns Philippines (Cebu) 43 ns ns Philippines (Mindanao) 65 ns ns Source: Kurz K et. al., (1994). The nutrition and lives of adolescents in developing countries. ICRW. ns: statistically none significant Stunting measured in children and adolescents is the result of a long-term and cumulative process, which can begin in utero with the initial consequence of low birth weight and growth retardation continuing to about age 3 years. Stunting on the whole reflects chronic effects, wasting describes an acute situation and underweight is a compromise between the two. The long-term consequences of undernutrition as stunting among Asian mothers, followed by post-

4 partum underweight as shown in Table 5. Malnutrition of women during pregnancy not only increases the likelihood of infant and maternal mortality during childbirth, these mothers initiate an intergenerational cycle of undernutrition. These mothers are more likely than their wellnourished counterparts to experience early labour and, as a result, there is an increased probability that the infants will be premature and low birth weight. Table 5. Mean Weights and Heights of Asian Mothers (Post-Partum) Country Weight (kg) Height (cm) India 42.1 ± ± 5 Indonesia 46.0 ± 6 149± 4 Myanmar 46.9± 8 151± 5 Nepal: Rural 43.0 ± 5 150± 5 Urban 46.0 ± 6 150±5 Sri Lanka 43.5 ± 7 150± 5 Thailand 49.9± 7 153± 5 Source: WHO (1993a) Throughout the world, low birth weight (LBW) is considered the best single predictor of malnutrition. Weights less than 2,500 grams at birth are closely associated with poor growth during infancy, and throughout childhood (Bavdekar et. al, 1994, Butte et. al, 1996). The share of babies born with low birth weight is a reflection of malnourishment prior to birth and, thus, a consequence of nutritional insecurity among women of reproductive age. LBW in this context assumes significance, as it is an important indicator of foetal/intrauterine nutrition and can lead to stunting in the young child. The high prevalence and large numbers of LBW infants in South Asia results from infant malnourishment in the womb and/or from cumulative effects of malnourishment among their mothers during infancy, childhood, adolescence and pregnancy (Gillepsie, 1997). Bangladesh and India report LBW prevalence of 50 per cent and 30 per cent respectively, and it is unacceptably high elsewhere in Asia as shown in Table 6 below. Table 6. Low Birth Weight (LBW) in Selected Asian Countries, Latest Available Year (per cent prevalence) Bangladesh 50 India 30 Pakistan 25 Myanmar Nepal 23.2 Maldives 20 Sri Lanka 18 Bhutan 16 Indonesia 11 Thailand 7.25 Source: WHO (1993a) The causes of LBW are multifactorial, and include low energy intake, poor weight gain during pregnancy, low pre-pregnancy weight, short stature or stunting, anemia, malaria and female fetus. As a result of these causal relationships, the incidence of LBW deliveries must not only be viewed as an index of our public health in general maternal health in particular, but LBW must be

5 viewed as a consequence of nutritional insecurity among mothers, such as post partum underweight featured in Table 5 above. Data in Table 7 below highlight trends for some of these factors and the potential for maternal and infant mortality. Maternal mortality remains unacceptably high in South Asian countries, and it is a special cause for policy concern in Bangladesh and Nepal. In many Asian countries, these infant mortality rates remain unacceptably high where large numbers of infants are unable to survive the first month of life. Reduction in infant mortality quickly translates into longer life expectancies for women and men and sustained interventions should therefore be implemented. Table 7. Infant, Child and Maternal Mortality, and Life Expectancy, 1978 and 1998 WHO Estimates Infant Mortality Probability of dying (per 1000) Rate under age 5 between age 15 and age 59 (per 1 000) Males Females Males Females Maternal Mortality ratio (per 100 Life at birth Males Expectancy (years) Females 000) World Afghanistan Bangladesh Bhutan Cambodia China Dem. People's Rep of Korea India Indonesia Iran. Islamic Republic of Kazakhstan Lao People's Dem. Rep Malaysia Maldives Mongolia Myanmar Nepal Pakistan Philippines Sri Lanka Thailand Republic of Korea Viet Nam Source: WHO (1999) Undernourished pregnant women are not only under the threat of long-term disabilities, morbidity and possible mortality, but the process of labour is frequently initiated at an earlier period with the result of premature birth at about 36 weeks of gestation, or earlier. Premature birth is not only a major factor contributing to infant mortality, it also results in this high prevalence of LBW infants, especially in South Asian countries. Premature and LBW infants are less likely to survive infancy and childhood than their normal-birth-weight counterparts (e.g. Bhargava et. al 1985; Bhutta, 1990, 1997). Low-birth-weight survivors experience significant growth retardation, such as lower body weights, heights and head circumferences, in comparison to normal-birth-weight survivors (e.g. Bavdekar et al and Bhargava et. al 1995).

6 Longitudinal studies in the region also reveal that LBW infants experience retardation in motor, adaptive, personal, social and language development during the first five years of childhood (e.g. Bhargava et. al 1982 and 1984). Although there is some potential for their being able to resume normal growth, deficits persist beyond childhood into adolescence (e.g. Bhargava et. al 1995). Young children born in poverty areas, with a high incidence of LBW, already have manifested high cholesterol and blood sugar levels, abnormal insulin levels and elevated blood pressure. Other LBW survivors are significantly more likely to experience impaired glucose tolerance as young adults leading to diabetes during old age, and are twice as likely to die of cardiac disease before reaching old age, than their surviving counterparts weighing more than 4.0 kg at birth (Hoet, 1997). Recent research thus points to the potential for disease effects in adulthood and projects an entirely new dimension on LBW as posing impending threats to future prospects for nutritional security beyond There is a need for policy frameworks that respond to three research findings. First, it is not possible to reverse all the negative effects of intrauterine growth retardation (IUGR) by overcoming poverty and nutritional insecurities during postnatal life (Martorell 1994). As a result, LBW survivors are likely to suffer growth retardation and other morbidity throughout childhood, adolescence and into adulthood. Third, growth retarded adult women (e.g. who are either stunted and/or underweight) are likely to give birth to LBW babies and, thereby, contribute to perpetuating the vicious malnutrition cycle into the forthcoming century. This requires priority to poverty alleviation and special measures for achieving nutritional security for girls and women before they become mothers. The major contributor to LBW is the malnutrition among women reflected in Body Mass Index (BMI) below 18, which are more prevalent in Nepal, Bangladesh, Bhutan and India than in South-East Asian countries, as shown in Table 8 below. S. No Country Year Table 8. Nutritional Status in Selected Asian Countries, Latest Available Year Per cent of lowbirth weight babies (weighing <2500 g at birth) per cent of children <5 yrs under-weight and stunted (<2sd NCHS) wt/age and height/age respectively Per cent of women with Body Mass index < 18 Prevalence per cent) of iodine disorders in school children Prevalence ( per cent) of anaemia Vitamin A deficiency in children <5 yrs** (Bitot's spots) Wt/age Ht/age Pregnant Children women <5 yrs 1. Bangladesh Bhutan Not reported 3. India Indonesia Maldives Not reported 6. Myanmar (small study) 7. Nepal Sri Lanka Thailand Not reported Reported none ** Bitot spots >0.5 per cent: nightblindess >1.0 per cent: corneal xerosis >0.01 per cent; and corneal scars >0.05 per cent, indicate public health problems Sources: WHO Global Database, 1997 and HFA Country Reports

7 Micronutrient Deficiencies The micronutrient deficiencies of public health significance in Asia are iodine deficiency disorders (IDD), vitamin A deficiency (VAD) and iron deficiency anemia (IDA). Other micronutrient deficiencies occur under special circumstances, generally because the quantity of the micronutrients is inadequate in food and the diet. Rickets remains a problem in certain parts of the Near East and Southern and East Asia. Zinc and selenium deficiencies are reported in China and some parts of Central Asia. Approximately 1.6 billion people live in iodine deficient (IDD) environments and are therefore at risk. Over 650 million suffer from goitre, and almost half of the world's goitre sufferers are found in Asia and over half of these live in China and India. Unacceptably high prevalence of goitre among school children is featured in Table 9 below, especially in Bangladesh, India and Nepal. Among pregnant women, IDD is the most common cause of preventable mental retardation in children. Besides, IDD can impair reproductive functions, leading to increased rates of abortion, stillbirth and congenital anomaly. Table 9. Nutrition Related Indicators in South Asian Countries, Latest Available Year Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka IMR Per 1000 live births MMR Per 100,000 Live births LBW per cent < <25 per cent IDD Goitre rates school > <20 > > <20 children Malaria per 1000 Population <3 >35 < <3 < Complementary Feeding in children >75 <25 74 <25 50 >75 <25 49 >75 9 m + Breast feeding per cent per cent births attended by trained mid < < < wife, nurse or doctor Calorie average per capita per day < Food as percent of total household > >60 < expenditure Access to man made water sources > >75.75 < Access to sanitation facilities <20 74 <20 49 < > Source: UNICEF, 1996 IMR - Infant mortality rate MMR - Maternal mortality rate Vitamin A deficiency (VAD) is commonly reflected in eye diseases known as Bitot's spots, which serve as early warning signals about their increased prospects for blindness and subsequent early death. Vitamin A deficiency (VAD) as xerophthalmia is significantly greater in the WHO region of South East Asia than the Western Pacific Region of WHO (see Table 10). Table 10. Population at Risk of and Affected by Micronutrient Deficiencies (in millions), Latest Available Year Region* IDD VAD** At risk Affected (goitre) At risk Affected (xerophthalmia) South-East Asia Western Pacific Source: WHO 1992 * WHO regions, ** Pre-school children only, Including China Iron deficient or anaemic

8 Iron Deficiency anaemia (IDA) is found to affect over million people and sufferers live in nearly all Asian countries, with women and children being most affected, particularly in South Asia. Anemia has not markedly decreased in Asia and reports from India indicate 16 per cent of all maternal deaths are attributable to anemia (WHO 1993b) while the corresponding figure in Bangladesh is between 10 to 20 per cent (Chakravarty 1992). Anaemia is one consequence of malaria, which is prevalent in many Asian countries. Anaemia is associated with an increased risk of premature delivery and higher prevalence of LBW infants (Prema et al, 1981). Impaired ability to do physical work in anemic preschool and school age children has been consistently observed in India and Pakistan (Bhatia and Seshadri 1987, Satyanarayana et. al 1990, Paracha et. al 1992). Data shown in Table 11 below highlights the prevalence of anaemia among different demographic groups in some countries of South Asia, where the prevalence is quite high. Table 11. Prevalence of Anaemia in Selected Groups of South Asian Countries, Latest Available Year per cent Countries Pregnant Lactating Preschool School Adult Women Women Children Children Women Men (<11g/dl) (<11g/dl) (<11g/dl) (<11g/dl) <12g/dl <13g/dl Bangladesh Bhutan (ICN. 1992) India (Seshadri 1996) Maldives (WHO 1996) Nepal Pakistan (<10g/dl) Sri Lanka Source: UNICEF 1997 B. Some Prospects beyond 2000 Life expectancy will increase to the mid-to-high 70s in most South-East Asian countries, but it is expected to be lower, and in the 60s, for several other countries (see Table 12 below). Increases are primarily attributed to increases in the chances for life among infants, reflected in declining rates for infant mortality. These improved prospects are complemented by significant increases in the chances for longer lives among children under age 5 years, reflected in falling trends resulting from dramatic improvements in several countries. Child mortality rates will decline by more than half in Bangladesh and Nepal. As a result of these combined declines in mortality, the share of deaths under age 50 years will decline, though more significantly in some Asian countries than in others.

9 Table 12. Life Expectancy, Infant & Child Mortality, Mortality under Age 50, Life Under 5 Infant Deaths GNP Expectancy Mortality Mortality under age 50 per at birth (years) Rate Rate as per cent capita Both sexes Both sexes of total US$ Bangladesh Bhutan Cambodia China Dem People's R. of Korea Fiji India Indonesia Korea, Rep. Of Lao People's Dem. Rep Malaysia Maldives Mongolia Myanmar Nepal Papua New Guinea Philippines Samoa Solomon Islands Sri Lanka Vanuatu Viet Nam Source: WHO/SEARO 1998 The projected growth in the number of Asians is among of the foremost contributory factors affecting Asian prospects for the combination of food and nutrition security. Current trends show that another 1.5 billion people will be added to the population of developing Asian countries by As these human increases coincide with rising needs for food at the global, national and household levels, they require urgent attention, especially in those Asian countries where the numbers of people are likely to double within the next two decades, as shown in Table 13 below. More than half of the global increase towards 2025 is expected to take place in South Asia. Such dramatic growth is likely to coincide with simultaneous increases in the absolute numbers of poor and malnourished people.

10 Table 13. Population (in millions) in Selected Asian Countries, Country Bangladesh 122, , , ,342 Bhutan 1,862 1,999 2,479 2,776 China 1,243,738 1,266,260 1,342,235 1,465,452 India 960, ,823 1,131,973 1,330,201 Indonesia 203, , , ,387 Malaysia 21,018 21,978 25,275 31,246 Maldives Myanmar 46,765 48,757 55,583 67,800 Nepal 22,591 24,515 30,930 40,904 Pakistan 143, , , ,904 Philippines 70,724 73,955 85, ,140 Dem P.R. of Korea 22,837 23,529 25,882 29,893 Sri Lanka 18,273 18,827 20,709 23,919 Thailand 59,159 60,230 63,844 69,705 Note: Population projected based on the annual growth rates for 1995 and 2025 developed by the United Nations, except for India, Nepal and Pakistan whose figures are based on nutrition country profiles Worldwide, the food supply is expected to rise to 3074 kcal by 2025, as shown in Table 14 below. These data depict a positive global trend continuing from 1969 to , and projected for 2010 and These data also highlight the increasing disparities in food insecurity in South Asia as compared to East and South East Asia. Table 14. Dietary Energy Supply (DES), forward, with Projections to 2025* Calories per day per person * South Asia East & South East Asia Developing Countries World Least Developed Countries Low-Income Food-Deficit Source: FAO 1993 and 1996a * Author's estimates projected on linear trend basis An estimated food surplus of about 20 per cent is needed to free market access to people, whose numbers are rapidly increasing. Worldwide, the food supply is enough to meet the energy needs of a growing number of people if it is equitably distributed according to each person's requirements, but food is not equitably distributed. As a result, despite increases in the food supply, 12 per cent of people living in the developing world will remain food insecure in 2010, as shown in Figure 8 below. Achieving significant though uneven progress towards 2010, 344 million Asians will be chronically malnourished, and most will live in low-income food-deficit countries (LIFDCs), such as China, Bangladesh, India, Mongolia, Nepal and Papua New Guinea.

11 Figure 8. Number of Food Insecure People Source: Agriculture towards 2010 Rome: FAO) 1993 and FAO Homepage, The projections for underweight children highlight prospects for overcoming malnutrition. Underweight, even in mild form increases risk of death and inhibits cognitive development in children, leads to reduced fitness and productivity among adults. It perpetuates the problem from one generation to the next, through malnourished women having birth to low-birth-weight babies. Data shown in Table 15 features trends in prevalence for underweight children from 1975 to 1990, with to Despite projected declines for South Asia, more than half of all children will be underweight in 2005, along with about a third of children in South East Asia. Table 15. Prevalence and Number of Underweight Children, under Age 5 Years, Per cent Underweight Number Underweight Eastern Asia Southeastern Asia Southern Asia Near East (Western Asia) Asia Source: ICN * Author's estimates are calculated on the basis of linear trends. In 2025, the great majority of the children at risk of VAD will continue to live in South Asia and South East Asia. Multiple ocular data, featured in Table 16 below, show that these Asian countries experienced reduction in clinical signs of vitamin A deficiency, resulting from programme support for supplement distribution. Elimination of the deficiency seems possible based on projections to 2025, calculated in terms of percentage points per 10 years (pp/10 years), but these projections are optimistic. Thus, Asian prospects for meeting its commitment to eliminate vitamin A deficiency by the end of the decade are limited. Meanwhile, Asian children remain at risk, and its resulting blindness and imminent death.

12 Table 16. Trends in Prevalence of Clinical Signs of VAD, 1975 to 2025 Calculated from Instances where Multiple Surveys have been reported Country Year Indicator Prevalance ( per cent) India 1976 X1B 1.40 Nepal Percent change Per 10 years Trend (percentage points/10 yrs) @ @ X1B @ @ 0.42 Sri Lanka X1B @ @ 0.06 Philippines 1982 Total @ @ 0.02 Bhutan 1976 Total @ @ 0.18 Source : WHO (1995) and UNICEF et. al. author's projection based on trend percentage points Poverty is the major factor limiting Asian prospects for achieving nutritional security for children, women and men. Data in Table 17 highlight the achievements of Asian countries to poverty alleviation in rural areas since the 1970s and as projected towards Several Asian countries have been able to reduce rural poverty to some extent, but much remains to be done, particularly in response to the current economic crisis and the resulting increases in poverty, though to varying degrees, as discussed in this context in Section V. Table 17. Achievements and Prospects for Alleviating Rural Poverty, Selected Asian Countries, Country 1970s 1980s Bangladesh China India? + +? + Indonesia ? Malaysia Nepal ? Pakistan Philippines -?- +? + Sri Lanka ? Thailand ? + Note: - denotes deterioration; + denotes improvement; = denotes no change;? denotes unclear; two signs for the same decade denotes a change in trend. (For example, +- denotes an improvement in the early part followed by deterioration in the later part.) Source: Islam (1990).

13 IV. NUTRITIONAL TRANSITION A. Challenges ahead Prospects for nutritional security are not only influenced by the factors giving rise to the socioeconomic problems reflected in the health and nutrition indicators, they are simultaneously limited and changing in response to a nutritional transition underway in many Asian countries. Asian countries initiated their developmental journeys towards nutrition security over 5 decades ago, with an acquired burden of under-development. While achievements are reflected in increased life expectancy, reductions in infant mortality and wider coverage through immunization and improvement in food security, many formidable challenges remain. Severe forms of nutritional disorders are less common today (Gopalan 1992), but undernutrition and micronutrient deficiencies prevail, though in varying proportions and degrees. Meanwhile, non-communicable diseases (NCDs), once thought to be prevalent mostly in the developed world are emerging as leading causes of death, illness and disability in many developing Asian countries. Dramatic increases in life expectancy accompanied by profound changes in life style are responsible for the heightened increase in the incidence of these noncommunicable diseases (WHO 1997). It is increasingly apparent that undernutrition and later overnutrition are particularly dangerous problems confronting Asian countries, and that this emerging epidemic will transform both health and nutrition needs in the years ahead. Prospects for nutritional security beyond 2000 simultaneously limited and changing in response to this nutritional transition are underway in many Asian countries. A striking feature of the nutrition transition in developing Asian countries is the rapid increase in the share of the total population living in urban areas. The urban population now represents 35 per cent of the Asian region's total population, but it is growing at about twice the growth rate of overall population (1.5 per cent/year). Coinciding with rural to urban migration, there has been an emergence of urban agriculture and home gardens in urban areas of many Asian countries. Even so, the major impact of urbanisation on the nature of the food supply arises from food being no longer available as home grown produce, nor is food as readily available in urban centres. The cash economy has assumed far greater significance in supplying food, and these rapidly expanding urban communities place increased demands on food production as well as on transport and storage systems for food distribution and preservation (WHO 1990). The evolution of these urban distribution systems facilitate greater food variety without seasonal or year to year variation and this raises prospects for improved food selection and promotion of greater variety based on nutritional principles. Urbanization profoundly affects dietary and food demand patterns. It also gives rise to growing concern about the quality and safety of food, particularly foods processed and purchased outside the home, and to modification in food preferences caused by changing life styles. B. Dietary Practices Urbanization contributes to changes in the type of demand for food, and the consumption of food outside the household is rising rapidly. In most Asian metropolitan cities, like Delhi, Bombay, Bangkok, Jakarta and Yangon, a wide range of foods including varieties of breakfasts, main meals and snacks are catered to the needs of urban dwellers, both rich and poor. Such foods sold in the urban slums are based on traditional food items, and are generally freshly prepared and served hot.

14 A distinct response to this adaptive response to urban life, therefore, is the rapid proliferation of wayside or improvised eating facilities. In Indonesia and the Philippines, urban households spend over 25 per cent of their food budget on street foods, and 90 per cent of Bangkokians regularly purchase food from outside sources. Simultaneously, there are changes in dietary practices among the groups of urban elites, involving increased preference for fast food items, such as hamburgers and pizza. Similarly among the urban middle class and poor in South Asian countries, fried food items like fritters, rice based pancakes and the like are preferred. At the same time, rural to urban migration leads to food shifts and more diversified diets. Table 18. Dietary Energy Supply (DES) from Major Food Groups, Selected South East Asian Countries, and Dietary Energy Supply (DES) kcal/person/day Indonesia Food, total Vegetable products Animal products Cereals Starchy roots Non cereal/non root vegetable products Malaysia Food, total Vegetable products Animal products Cereals Starchy roots Non cereal/non root vegetable products Philippines Food, total Vegetable products Animal products Cereals Starchy roots Non cereal/non root vegetable products Thailand Food, total Vegetable products Animal products Cereals Starchy roots Non cereal/non root vegetable products Vietnam Food, total Vegetable products Animal products Cereals Starchy roots Non cereal/non root vegetable products Source: FAO, 1999.

15 The nutritional transition underway in Asian countries during the last decade is illustrated by the food shifts shown in Table 18 below. These involve shifts from basic staples, such as millets towards other cereals such as rice and wheat that require less preparation, and, simultaneously, towards consumption of milk and livestock products, fruits and vegetables, and processed foods. Traditional Asian diets are cereal based, but as societies move up the socio-economic scale, changes take place in both dietary structures and patterns (Gopalan 1992). In all the countries shown, energy intake has progressively increased during the last decade, and there is a trend towards greater consumption of animal sources as compared to vegetable sources in the diet. There is concern over increased consumption of animal products, such as meat from livestock, which not only requires twice as much water for production than plant foods, but livestock production encourages deforestation and further reduces the total food supply (DES) available for direct human consumption. This trend toward urbanisation coincides with rising concerns about water scarcity and the probable diversion of water from agriculture to other sectors. It is predicted by many that increasing water scarcity might result in higher prices for basic food items, especially irrigated food items, with more severe impact on the poorer segments of the population. Diets are shifting from vegetables such as cereals to non-cereal food sources, and within food grains there are shifts from starchy roots and tubers to polished rice and refined wheat. The most undesirable features of this nutritional transition include the substitution of millet (coarse grains) by more prestigious and more refined cereals, especially wheat and rice, with a progressively trend towards preference for the highly polished varieties of rice. As this trend usually coincides with reductions in the total intake of cereals, the net effect is a major decrease in the fiber content of Asian diets of more than 50 per cent. Another undesirable feature involves the continued low intake of green leafy vegetables (GLV), which come to be scorned as poor man's food. C. Evolving Concerns Coinciding with urbanization and changing diets, there is increasing awareness about food contamination leading to the evolution of concern about consumer protection and the nutritional impact of environmental pollutants and industrial toxicants. Particularly in urban areas, there is increased concern about food safety from foods produced outside the home, especially street foods. Salmonellosis and related food contamination pose threats to future prospects of inexpensive sources of street foods. Even though they are widely relished, they are sometimes be unsafe and harmful. Food contamination poses serious threats to wholesome food in the context of modern development, especially contamination introduced by pesticides, industrial pollution, and pollutants from untreated sewage that is discharged into fields and rivers. Of special concern is the interaction of nutritional status with exposure to environmental pollutants and industrial toxicants. Another major concern is intergenerational consequences of exposure by pregnant and lactating women, and the extent to which toxicants affect the fetus or contaminate breast milk. There is growing concern in Asian countries about the nutritional aspects of the rising incidence for degenerative diseases. Precise data are not yet available for changing trends in degenerative diseases, but small scale data from selected countries illustrate the transition underway throughout the region. Increasing prevalence of certain kinds of cancer in many Asian countries is related to over consumption of fat and possibly to food trends in degenerative diseases, but small scale data from selected countries illustrate the transition underway throughout the region. Increasing prevalence of certain kinds of cancer in many Asian countries is related to over

16 consumption of fat and possibly to food contamination, especially toxic substances from uncontrolled environmental hazards and industrial pollutants, and possibly due to increased use of pesticides and improper use of modern agricultural technology. Kachondham et. al (1991) reports cancer now ranks as the third leading cause of death in Thailand. However, this at present remains at best an epidemiological link and efforts should be made to address the causes. Incidence rates of cancer in all sites in India are generally lower than in Thailand, but cancers of upperaerodigestive tracts are much higher than those reported in other countries of the world (Notani 1990). The victims of oral and oesophageal cancers in India are most prevalent among low socio-economic groups, where dietary deficiencies rather than excesses predominate. Research highlights the relationship to oral and oesophageal cancers of lower intakes of carotene and riboflavin in the diet as well as low levels of serum albumin, vitamin A, E, folate and zinc. Obesity as a nutritional concern and problem has increased dramatically in many Asian countries. This is of profound significance, because of the clearly defined ill effects of obesity, especially when centrally distributed, in relation to diabetes, coronary heart disease and other chronic diseases of life style. Genetic and environmental factors play an important role in determining the propensity of obesity in populations and individuals. Lack of physical activity reportedly contributes to the increasing rates of obesity observed in many countries and may be a factor in whether an individual who is at risk will become overweight or obese. Excess energy in any form will promote body fat accumulation and will lead to obesity if energy expenditure is not increased. The Nutrition Division in Thailand reports that the prevalence of diabetes has nearly doubled during the last 2 decades and current figures may be even higher. The incidence of diabetes is also on the rise in India, especially among the affluent population aged 40 to 50 years. A Singaporean investigation covering Indians, Malays and Chinese (Thai et. al 1987) shows major increases in diabetes prevalence during the last 15 years. There is increasing concern about diseases of the heart, as illustrated by research findings showing the prevalence of hypertension as high as 17 per cent in Bangkok and in other regions of Thailand. Studies from Malaysia show the simultaneous emergence of obesity, hypertension and hypercholesterolemia as public health problems, of special concern in rural communities. Coronary heart disease (CHD) has become a major public health problem in India, where it is most prevalent among both males and females with higher socio-economic status. Studies at the National Institute of Nutrition (NIN) in India show rising incidence of obesity among the affluent and a rising potential for obesity due to reduced physical activity associated with economic activity, in urban as compared to rural areas. Studies among adult Indian women find increased incidence of obesity during the last decade (NIN 1993, NNMB 1996). With increasing affluence in Singapore over the last 3 decades, disease patterns have undergone a great change, giving rise to simultaneous and dramatic increases in diseases of affluence (e.g. certain cancers, heart disease, stroke and diabetes) that are attributed to changing food consumption patterns. On the whole, the nutrition transition throughout Asia is increasingly associated with a shift in the structure of the diet, reduced physical activity and rapid increases in the prevalence of obesity (Popkin 1994). In response to growing concern about obesity, nutrition indicators are beginning to be collected to determine the prevalence of obesity. Surveys conducted in some Asian

17 countries, featured in Figure 9 below, highlight this concern for obesity among children under age 5 years. Figure 9. Obesity Prevalence among Children under Age 5 Years Source: The Sixth World Survey (Rome: FAO) Studies among school-age children highlight the trend towards childhood obesity that is initiated among children under age 5 years. In Jakarta, the prevalence is suggested to be as high as 31 per cent among boys and 7 per cent among girls. Recent reports in Thailand show obesity ranging from 9 to 19 per cent among school-aged children, and from 20 to 30 per cent among urban adults. An increased incidence of obesity also is observed among adolescent youth in Asian countries, where it coincides with selective undernutrition and the rising prevalence of anorexia nervosa among girls and boys. Studies show that even modest advances in prosperity in low GNP developing countries are associated with marked increases in degenerative diseases. The transition leads to increased consumption of fat and rising intake of animal protein, especially among affluent households where result is often obesity. The incidence of osteoporotic hip fracture (HP) increased two to three times during the last decade in Hong Kong, Singapore and Japan. Though the current incidence of HP in the Asian population remains lower than the Caucasians, by the year 2050 it is estimated that about 3.2 million people in Asia will suffer from HP. Joint diseases like osteoarthritis and rheumatoid arthritis are reported for older women in India. Women are especially vulnerable, e.g. 89 per cent of older women in Thailand consume less than two-thirds of recommended daily requirements of calcium, which puts them at risk to osteoporosis. Calcium intake needs to be increased both from readily available bony fish as well as milk. These risk factors need to be studied from an Asian perspective, with due regard to the roles of genetic-heredity, nutrients and exercise on achieving peak bone mass and in the prevention of osteoporosis. Data on the bio-availability of calcium from non-milk foods to help Asians meet their calcium intake is also necessary, in view of the urbanization and sedentary lifestyles sweeping over most of Asia, especially among the new affluent groups. Adoption of a prudent diet with adequate calcium intake and increases in physical activity may serve as preventive

18 measures against the development of osteoporosis. These concerns are likely to increase in response to population ageing of Asian countries. D. Population Ageing This nutritional transition throughout Asian countries coincides with a global process of population ageing, and their linkage has yet to be fully understood and adequately reflected in a responsive policy framework. Between 1950 and 2025, the total world population will experience a three-fold increase, and the number of older persons, aged 60 and over, will increase six fold. As the older share of the population increases from five to nearly ten per cent, the child share (under age 5 years) of the world total will shrink to less than ten per cent. This new older share will exceed the child share of the total world population for the first time in human history. The projections for population ageing, shown in Table 19 below, highlight the magnitude of this global process in Asia. Most developing countries are ill-prepared for population ageing, especially as regard to the associated health and nutritional problems, such as increased prevalence of both under- and over- nutrition among older persons, as well as osteoporosis. The design and implementation of effective strategies and measures responding to the combination of nutritional concerns among older people, the majority of whom are women, are important determinants of Asian prospects beyond Table 19. Estimates and Projections for the Total Population, Aged 60 Years and above, Selected Asian Countries, (in thousands, with per cent in parentheses) Country Bangladesh 3 792(4.3) 6 504(4.3) (7.5) Bhutan 65 (5.02) 110(5.42) 238(7.52) DPR Korea 1 028(5.02) 1912(7.02) 4 715(12.55) India (4.96) (6.83) (11.85) Indonesia (5.03) (7.50) (12.67) Mongolia 84 (5.03) 174 (6.48) 409(10.37) Myanmar 2155(6.11) 3671(6.66) 7447(9.13) Nepal 719(5.03) 1276(5.67) 2544(7.57) Sri Lanka 943(6.37) 1800(8.54) 4084(15.21) Thailand 2330(4.95) 4496(6.55) (13.52) Source: WHO/SEARO, 1990

19 V. STRATEGIES AND MEASURES TOWARDS NUTRITIONAL SECURITY A. Effective Strategies and Measures Here-to-fore the discussion has elaborated on the complex linkages between various sociocultural issues and socio-economic factors influencing the potential for achieving nutritional security beyond Asian countries have made great strides over the past 5 decades in dealing with problems of poverty, malnutrition and other aspects of nutrition insecurity. Food production has increased, child malnutrition has declined along with infant and child mortality. Despite these impressive gains, Asians continue to suffer from poverty, hunger and malnutrition in staggering proportions (ACC/SCN, 1997). Strategies and measures that can be adopted, adapted and implemented by Asian countries, hold the key to the 21st century in terms of linking nutrition and development outcomes. Past international initiatives were seriously concerned with the hunger and malnutrition and several plausible sets of interventions and actions evolved. While many of these initiatives also showed concern for the poor, not all were able to translate the concern for improving nutritional wellbeing into action (FAO 1996). As a result, identification of successful ways and means for achieving progress is especially important. Planners and policy makers need an effective policy and programme framework for making decisions and formulating workable and effective interventions. These not only need to easily adapt to different country situations, but they also need to be sensitive and responsive to the Asian socio-cultural contexts and complexities, especially since the socio-economic situation is rapidly changing, urbanizing and encountering threats of excess and deficits in both food and nutrition insecurity. Additional features of effective measures involve nutritional surveillance and provision of nutritional security in emergency situations and during the current economic crisis underway in Asian countries. Malnutrition being complex in its determinants, requires the use of broad based economic policies as a means of its elimination on the one hand, and the use of more targeted interventions on the other. What is typically needed is a combination of different types of macro-economic policies and measures that effectively alleviate poverty and malnutrition while also serving countries as support for sustainable nutritional security. Selected examples of effective policy and programme activities undertaken by South Asian and South-East Asian countries featured in Appendices C and D depict some of the steps taken towards overcoming nutrition insecurity or its threat, in the Asian region. National Plans of Action for Nutrition (NPANs) were designed in response to the the International Conference on Nutrition and these mark a major achievement of Asian countries. These plans often reflect the concerns and effective networking among national organizations, non-governmental organizations (NGOs), academia, private sector/industry and communities, and they call for collective action and initiatives regarding nutrition. Over the past five decades, there also have been a number of scientific and action-oriented conferences, which influenced both the philosophy and technical focus of these nutrition action plans. As a result, there is a shift in focus towards nutritional well-being of future generations, food needs of growing populations, and sustainable strategies and mechanisms for overcoming nutrition problems. Building effective frameworks for implementing plans with this focus evolves from discussion of successful measures for implementing these strategies and achieving goals beyond 2000.

20 B. Building Effective Frameworks The diversity among Asian countries with programme interventions to enhance food and nutritional security is featured in appendices C and D. Review of these interventions gives rise to identification of several major components for building a national framework for designing interventions to achieve nutritional security beyond An effective framework thus would contain these basic components: Responsive macro-economic and trade regimes Diversification of food production and marketing Income and employment generation Equity Women Functional literacy Food subsidies and rationing, and food stamps Nutritional surveillance Nutrition education and dietetic counseling Food based dietary guidelines Food quality and safety HIV/AIDS Partnerships The following discussion identifies some of the features for these components by giving emphasis to their support for effective strategies and measures. Illustrations of successful interventions are identified and supplemented by elaboration in the appendices of specific policies and programmes undertaken by South Asian and South-East Asia countries to achieve nutritional security beyond Responsive macro-economic and trade regimes. Over the past decade or so, some important changes are underway with significant impact on macro-economic policies supporting food production and trade, including developing food standards (Orriss 1998). Although industry and national regulators strive for production and processing systems which ensure that all food be safe and wholesome, complete freedom from risks is an unattainable goal. Food safety and wholesomeness are related to a level of risk that society regards as reasonable, and in context and comparison with other risks in life. As risk analysis will play a vital role in the future work of the WTO, it has been introduced as the discipline of standarisation in the SPS Agreement, whereby member states are expected to justify levels of protection higher than those in Codex standards by using risk assessment techniques. Food safety risk analysis is the fundamental methodology underlying the development of food safety standards, giving rise to an estimate of the probability and severity of the adverse health effects in exposed populations, consequential to hazards in food (FAO 1997). Risk assessment involves policy guidelines that are documented so as to ensure consistency and transparency. Examples include establishing the population(s) at risk, establishing criteria for ranking of hazards, and guidelines for application of safety factors, such as Hazard Analysis and Critical Control Point (HACCP) System. Risk profiling entails describing a food safety problem and its context, in order to identify those elements of the hazard or risk relevant to various risk management decisions. This risk profile identifies those aspects of hazards given emphasis in decisions about priorities and assessment policy, and other aspects of the risk that are relevant to the choice of safety standards and management options. Risk management entails the process of

21 weighing policy alternatives in the light of the results of assessment and, if required, selecting and implementing appropriate control options, including regulatory measures. Risk management encompasses risk evaluation, risk management option assessment, implementation and review. Risk evaluation identifies food safety problems, establishes these profiles, ranks hazards as priorities for assessment and management, establishes assessment policy for conduct of assessments, commissions assessments, and considers the assessment results. Risk management option assessment entails three activities; namely, identification of available management options, selection of the preferred management option taking account of appropriate safety standards, and the final management decision. The protection of human health is the primary consideration in arriving at decisions, with other factors (such as economic costs, benefits, technical feasibility, risk perceptions) being considered as appropriate. Risk communication is an essential component of risk analysis, involving the exchange of information and opinions concerning the risk and risk-related factors among risk assessors, risk managers, consumers and other interested parties (FAO 1998d). In order to harmonise sanitary and phytosanitary measures on a wide a basis as possible, WTO members are encouraged to base their measures on international standards, guidelines and recommendations where they exist (WTO Home Page, June 1999). However, members may maintain or introduce measures which result from higher standards if there is scientific justification or as a consequence of consistent risk decisions based on an appropriate risk assessment. The SPS Agreement spells out procedures and criteria for the assessment of risk and the determination of appropriate levels of sanitary or phytosanitary protection. It is also expected that WTO members would accept the sanitary and phytosanitary measures of others as equivalent if the exporting country demonstrates to the importing country that its measures achieve the importing country's appropriate level of health protection. The SPS agreement includes provisions on control, inspection and approval procedures. Diversification of food production and marketing. In the developing countries of the world and especially in Asia, any discussion of achieving the combined objectives of food and nutritional security flows from the view of agriculture as the engine of food production. Recognition of the impinging role of agriculture on food and nutrition thus becomes essential to sustainable development. Increasing food production to meet the needs of a rapidly rising population is the major challenge facing Asian countries in the area of food security. Increasing the diversification of food production as essential to nutritional security. Achieving the objectives of these twin pillars requires a combination of strategies to guard against possible evils arising from the indiscriminate use of potential resources, and measures responding to these two essential factors: Diversity is the key to sustainability. Variety is the key to adaptability. Biological diversity in nature's gene pool not only facilitates development of hardy species, it also supports varieties capable of surviving new environmental challenges. A wide range of crops, animals, fish and forest products not only make food production and, thus, food and nutrition security more secure from season to season, but such farming systems also are less damaging to the environment. This approach to dietary diversification supports production and utilization of a diversified and nutritious food base, beyond what is currently available in Asia, shown in Figure 10, below. This approach needs support from social marketing strategies promoting food diversification in agricultural development in the context of nutrition communication and education.

22 Figure 10. Food Groups as Shares of Dietary Energy Supply (DES) of Asia and Pacific Countries, Source: FAOSTAT, Rome, 1999 Home Gardens not only maintain their importance as major sources of a diversified and nutritious food base, they also provide self-sustaining occupations and essential income for small scale farmers, women and communities throughout Asia. Women and especially children also contribute foraged and traditional foods. Forestland, meadows, wetlands, fallow land and even weeds in cultivated fields usually supply the variety (and micronutrients) in diets. It is desirable to preserve these lands either in the natural or wild states or encourage communities to wisely husband them. Marketing of food crops, indigenous foods, traditional foods, also contributes to improving food security through provision of increased income and promotion of employment generation, whereby gains in real income from marketing typically translate into gains in food consumption and diversity in nutrition. As a result, those affected can acquire more food, reduce their work

23 loads and thus improve child care, enhance household sanitation and housing environments, improve water availability in terms of both quantity and quality, and at the same time, strengthen effective demands for both preventive and curative health care. Further, raising income typically exerts a positive and significant effect on nutrition (von Braun, 1995). Biotechnology has a long history of use in food production and processing, as it combines traditional practices and the latest techniques based on molecular biology. Use of modern biotechnological techniques open up great possibilities of rapidly improving the quantity and quality of food available. Its benefits include providing resistance to crop pests to improve production and reduce chemical pesticide usage, thereby making major improvements in food quality and their nutritional value. Biotechnology is also being used as food additives and for a wide range of applications to food fermentation. Recognition of its potential benefits is accompanied by worldwide concern and renewed efforts to guard against the uncertainties and potential risks associated with their use (FAO/WHO 1996). These efforts are directed towards identifying criteria for risk assessment, using scientific methods and analysis of food safety appropriate to biotechnology research. International instruments guide these efforts. Assessing its contribution requires ensuring that biotechnology also plays a major role in improving the quality of life on a long-term basis. Further development, testing and micro-implementation of appropriate technologies for diverse agroecologies remains a challenge for future decades and beyond. Income and employment generation. Malnutrition and nutrition insecurity are overcome by innovative mechanisms for generating and diversifying employment and income. Major interventions feature employment in exchange for cash or food, and credit to the poor to support consumption stabilization and self employment. Other income generation schemes, such as home gardening and livestock production, have become important features of national strategies. These mechanisms address three central problems facing Asian countries today: food and nutrition insecurity, growing unemployment and poor infrastructure (von Braun, 1995). Some employment schemes lend viable support for land and water systems and other infrastructure improvements. Equity in nutrition is an inseparable part of equity within rural communities and between rural and urban areas of the country. Extreme socio-economic inequities, leading to widespread destitution appears to be the cause of malnutrition in Asia, especially in South Asian countries. An equitable system facilitates access by the lowest income people in communities to an acceptable level of basic services. Achieving equity in nutrition thus decreases differences in access to and utilization of food and nutrition services. Socially disadvantaged groups and ethnic minorities are commonly affected, but the complex socio-cultural factors giving rise to these inequities are often ignored. An explicit focus on women is essential to successful strategies and mechanisms. Recognition of the need to involve women in their design evolves not simply from a limited concern about equity of women with men as both beneficiaries and contributors to development. Rather, women need to be active participants because they have experience with successful achievements in ensuring community and household food and nutrition security evolving throughout centuries in the socio-cultural contexts of Asian countries. These successful strategies and measures for food production, processing, preservation for storage or exchange are major features of the socio-cultural traditions passed on from grandmothers to mothers to daughters throughout Asian countries. As a result, Asian women offer cumulative knowledge, but their potential remains untapped. The involvement of poor and rural women may be most essential

24 flowing from their vast experience with efforts to identify cost-effective and energy efficient measures that are workable within the constraints of low income and limited access to productive resources. Women farmers need to be recognised as major food producers and this requires their fair access to land ownership, water and other natural and productive resources (e.g. technology) and support services (e.g. agricultural extension, credit and training in agriculture, food and nutrition. Women also need to participate in design and review of food friendly macro-economic and trade policies. The active participation of women is essential to identify ways of overcoming the bias limiting nutrition adequacy to girls from infancy throughout childhood. The nutritioninequity interaction is strongly influenced by the degree and form of subordination of women. Maternal malnutrition and childhood wasting, especially for the girl child and adolescent, are critical indicators of equitable assess to nutritional security and prospects for the future. Thus, the resultant inequities need priority attention in policy frameworks for Asian countries, especially in South Asia. Overcoming basic and functional literacy, especially among girls and women, is an essential component of successful programmes. Overcoming urban/rural disparities in access and quality of education is essential. The production and use of education materials and curricula reflecting rural perspectives, and including emphasis on rural concerns and strategies for achieving food and nutritional security are essential elements. Food subsidies and rationing, food stamps, and food distribution systems. Food related income transfers are often used to improve nutrition, but they involve price subsidies that are high in terms of fiscal and economic costs. These programmes incorporate a combination of targeting methods, including the targeting of commodities and beneficiaries. Geographical targeting of beneficiaries support the establishment of systems in food deficit areas with poor populations. Food stamp programmes serve as vehicles to provide incomes to poor households. In order to be effective in the context of assuring nutrition security, food stamp programmes should be directed towards those who are very poor. Food distribution systems are established as public distribution systems PDS) in countries subject to food shortages to meet the food and nutrition security needs of the very poor. (Dreze and Sen 1988). PDS are most effective when buffer stocks are available, but when they are not, imports may be necessary substitutes. Nutritional surveillance. There is thus the need to develop national information systems, to analyse the underlying causes of undernutrition and overnutrition, to develop indicators of progress towards achieving targets and, to this end, to identify indicators that will be regularly monitored (FAO, 1998). Nutrition surveillance systems produce the basic information for monitoring the environment and, at the same time, it produces warning signals that trigger actions to overcome nutrition insecurity. Nutrition surveillance is defined as an on-going system for generating information about the current and future magnitude, distribution and causes of undernutrition and micronutrition deficiencies in populations for policy formulation, programme planning, management and evaluation (WHO 1976). In the absence of an effective surveillance system furnishing information and explanation, lack of information or misinformation becomes the most important influence on understanding and, therefore, on limiting decision making about actions. Effective nutritional surveillance systems, thus, are envisaged to embody four primary objectives (Gillepsie 1995), namely, problem identification and sensitisation or advocacy, macro-and micro-level planning, timely warning, and programme monitoring and evaluation. Continuous monitoring and assessment of the nutritional scenario discussed in Section III, when supplemented by development of timely

25 warning systems focused on national and household food and nutritional insecurities, prepare governments to more effectively respond to any adverse situations, such as the emergency situations. Nutrition surveillance systems with these features, therefore, need to be institutionalized within the existing infrastructure of the Government. The Food Insecurity and Vulnerability Information Mapping Systems (FIVIMS) is being developed as a model for this purpose. The systems not only identify undernourised people and those who are at risk, they also provide information about the causes of their food insecurity and vulnerability, factors as diverse as poverty, inadequate marketing infrastructure, drought or civil strife that leave them exposed to the threat of hunger. FIVIMS use existing information-gathering systems (e.g. indicators discussed in Section III) and promote the sharing of information between partners, at national and international levels, to cut costs and save time. Focusing on nutrition goals and responses requires information supporting assessment and analysis of nutrition problems, as well as information for monitoring and evaluation of outcomes of programmes and projects discussed as strategies and measures. The early warning and rapid response features of these food and nutrition surveillance systems are essential during emergency situations. Nutrition education and dietetic counselling. The most effective tool for nutritional education and dietetic counselling are food based dietary guidelines (FBDGs) that reflect dietary traditions and culinary practices of the complex and diverse array of socio-cultures in Asian countries. Their initial design responds to scientifically accurate and technically sound information and, thereafter, is regularly reviewed and modified as appropriate in response to recent research, especially findings pertaining to nutrient requirement, consumption patterns and the nutrition situation of the target population. Asian FBDGs also promote preservation of the traditional diet and of traditional ways of producing and processing food. To minimise the negative consequences of the nutritional transition beyond 2000, they promote the merits of cereal-based dietary practices in Asia, such as the nutritional importance of fiber intake, and the beneficial effects of the fatty acid profile in the invisible fat contained in cereals (Achaya 1986, Gopalan 1988). High intakes of vegetables also are promoted. FBDGs restore traditional methods of processing by promoting them as yielding nutritional benefits, e.g. malting of grains, sprouting of legumes, and hand pounding of grains. Besides, there is need for innovation and versatility in health and nutrition services to furnish information and support for overcoming undernutrition and emerging problems, arising due to overnutrition. There is need for targeted efforts, with special emphasis on general education and nutrition education, and counseling. The FAO package on nutrition education, entitled Get the best from your food furnishes one illustration of the type of educational tool that needs to be utilised in Asian contexts. Nutrition education through the mass media, in health centers, school system and health programmes need to incorporate sensitive and responsive measures taking account of the process of population ageing and its socio-economic consequences for nutritional insecurity among older people, especially among older women and widows. Food Quality and Safety. Three major areas of concern deserve special attention to enhance Asian prospects beyond The first involves responses to concerns about the safety of foods produced and processes outside the household, such as street foods. The second responds to the qualitative inadequacies of micronutrients in the food supply, and the third involves the strengthening of food control systems and promoting good manufacturing practices along with appropriate nutrition education highlighting consumer protection. Educating households and communities about appropriate food handling is essential to reduce food contamination and related illnesses. Food is subject to harmful contamination from the soil it is grown in, from the

26 plant or animal it is derived from, from handling during processing and preparation, and from the dish it is served on. Formal and non-formal education and media are important contributions to increasing awareness about consumer protection needs of families and communities. These elements of nutrition education are viewed as important components of primary and secondary school curricula; and for curricula in the education and agricultural sectors, food and nutrition sciences, and health sciences; and as mechanisms for nutritional intervention in medical facilities. Besides, special efforts to promote non-formal education are necessary to increase nutritional awareness and compliance with FAO/WHO Codex standards among policy-makers, and especially among employees within food export and inspection agencies and among food industry operators. Setting standards, identifying codes for practice and designing regulations in compliance with international standards adopted by the Codex Alimentarius Commission ensure food quality and safety. Effective strategies involving people's participation to improve the quality and safety of street foods are being implemented in Calcutta and Bangkok. A strong relationship among the authorities and the hawkers' representatives led to the preparation of policy guidelines for the regulation of street foods in Calcutta (Chakravarty and Canet 1996). Thailand developed a tenstep code of practice for street food vendors that is used and monitored by local authorities to motivate implementation (Dawson et al 1996). FAO provides technical assistance to member countries in food quality control, including safety and such assistance are made available more for the developing countries in order to establish or strengthen the food control systems. The effective strategies towards achieving nutritional security, therefore, would call for strengthening such technical assistance from FAO. Specifically, there is a need for technical assistance in establishing the infrastructure for an enhanced food control programme, assessing laboratory service requirements, providing guidance to develop legislation and procedural manuals, setting up reputable inspection and certification systems, and providing training and staff development. FAO member countries increasingly recognise that both the SPS Agreement and the TBT Agreement have implications for the work of the Codex Alimentarius Commission. Increasing consumer interest in food safety, the SPS and TBT Agreements of WTO, harmonisation initiatives, and the need for more transparency, is leading to increased scientific, legal and political demands being made on the standards, guidelines and recommendations elaborated by Codex. Food fortification is an essential feature of nutrition strategies to alleviate micronutrient deficiencies (FAO 1995). As illustration, salt is one of the most suitable vehicles for iodine fortification to prevent iodine deficiency problems. It has been successfully and, in general, safely used for over seventy years in programmes around the world. Cereals are the most widely used vehicles for iron fortification, although many others, such as milk products, sugar, curry powder, soya sauce and cookies, have been successfully used. Foods successfully fortified with vitamin A include margarine, fats and oils, milk, sugar, cereals, and instant noodles. A limited number of food vehicles are suitable for vitamin D fortification, e.g. margarine, vegetable oils and dairy products. Vitamin E, as tocopherol acetate, is added to fats and oils including margarine and fat spreads and breakfast cereals. There are technologies available for vitamin C fortification of fruit juices, fruit juice drinks, other related beverages, dairy products and some breakfast cereals. There are no problems related to the technology of the addition of B vitamins to cereals and grains. Food regulations need to cover the fortification of foods with micronutrients, and these should be in compliance with international standards adopted by the Codex Alimentarius Commission. As

27 illustration, food labels need to be clear and easy to understand with attention to harmonizing labeling requirements. Better information on nutrient analysis and food composition is needed on food labels. Measures to assist individuals with food intolerances need to be implemented, and labels need to show greater sensitivity to socio-cultural diversity. Claims in food labeling or advertising need to be carefully monitors, and regulations adopted and enforced that prohibit false or misleading claims. National Codex Committees need to be established and/or strengthened to assist the process of ensuring a safe food supply (See Appendix E for national level Codex contact points). HIV/AIDS. More than 90 per cent of all adults living with HIV/AIDS live in developing countries. Not only is the incidence increasing in Asian countries, but the numbers are growing in alarming proportions in South-East and South Asia, with more than half of all new infections occurring among children and young people under age 25 years. HIV/AIDs also seems likely to intensify rural poverty. Malnutrition as inherent to the AIDS syndrome, not only contributes to poor health status, but by extension, to low labour productivity, low incomes and livelihood insecurity. People with AIDS are particularly vulnerable because without a good diet, they cannot maintain good health and live a longer life to provide for their children. Coping mechanisms often disintegrate soon after adult death, and food intake frequently declines sharply among surviving members. HIV/AIDS morbidity and mortality intensify nutritional insecurity in several ways. They trigger food insecurity of households. They render some households chronically food insecure and, thus, their members become chronically undernourished. The most vulnerable members are infants, young children, pregnant and lactating women, and older persons, especially widows. There also is an increase in the frequency and extent of food insecurity in these households. For design of effective interventions, policy makers, planners and nutritionists need a comprehensive understanding of the interrelationships of HIV/AIDS to insecurities of food, nutrition and socioeconomic deprivation, with socio-cultural sensitivity to family dynamics and coping mechanisms. Partnerships of wide range are essential if governments are to effectively design and implement strategies and measures to achieve nutritional security beyond As illustration for micronutrient malnutrition, successful approaches to introduce food fortification requires strong support from a range of private and public sector partners. Co-operation of the food industry is usually sought at a very early stage of programme development, but planners, practitioners and policy makers at various levels of government make the initial and vital contributions to fortification efforts. These partnerships contribute to long term food diversification strategies by providing improved preservation technologies, techniques, improved semi-processed foods, and by promoting consumption of locally available micro nutrient rich foods in the diet or as a food fortificant. Several successfulul partnerships are operating in Asian countries. Thus, simple nutritional and technological solutions exist and considerable progress has been made through partnerships. Mandatory compliance is ensured through legislation and regulations, and supplemented by political and financial incentives furnished in many forms and from various sources as contributions to strengthening these partnerships. C. Nutrition Security in Emergency Situations Nutritional insecurity is a likely outcome in situations of natural calamities, civil war and strife in the country and other related conditions requiring relief and rehabilitation when individuals and households become vulnerable and are at high risk of deteriorating nutritional status. The most vulnerable households include those headed by poor women; urban slum dwellers; poor

28 rural households, and especially those without land; and refugee or displaced persons' households. The most vulnerable people in these households are infants, preschool children, adolescents, pregnant and lactating women, older persons, the disabled and orphans. Emergency situations require a policy framework supporting quick decisions and rapid interventions for rehabilitation flowing from effective monitoring, evaluation and mobilization strategies. Effective responses require decisions be made in collaboration with the victims, who are often skilled and productive forces but currently either under-employed or unemployed. Their potential can become an essential resource and their assistance can be mobilized and organized as a major component of community responses to emergency situations. To this end, victims need to actively participate in decision making about appropriate responses to emergency situations. As support for policy and intervention strategies, indicators need to be identified for monitoring both progress and effectiveness of relief and rehabilitation provisions. Effective interventions are sensitive to the socio-cultural situation, especially the local governing culture, traditions and work procedures. Effective indicators highlight changes in the overall impact of the emergency situation and changes introduced by intervention strategies on the target area and its population. It is also necessary to assess other factors which influence these strategies and thereby the effectiveness of indicators, such as climate, market prices, prevalence of conflict of violence in the community, and a range of socio-cultural factors which differentiate people, such as ethnicity and religion. Effective intervention strategies during natural calamities, civil war and strife in the country and other related conditions combine relief and rehabilitation when individuals and households become vulnerable and are at high risk of deteriorating nutritional status. These strategies involve the promotion of home production of food, improved utilization of food, and food processing using appropriate technology. They entail increasing the purchasing power of household members and enhancing community capacities for response to emergency situations. While food aid is often an essential initial response to furnish relief, sustainable strategies for nutritional well being combine relief with rehabilitation strategies involving the promotion of home food production. Capacities of communities need to be enhanced following emergency situations. Community organizations most frequently identified as targets include women's groups, farmer cooperatives, saving and credit groups, water users' associations, children's groups, and organizations of youth and senior citizens. Older persons are particularly effective in Asian communities, as senior members of most households exercise major influence in community decisions. Existing skills need to be identified and, thereafter, supplemented by training and investments. There is a major role for international agencies in alleviating emergency situations, e.g. furnishing suitable technical expertise on short notice, updating skills of existing permanent and temporary staff, and provision of good supervision and training in the field. As capacities at both national, regional and community levels also need to be strengthened, effective co-ordination ensures that nutrition security becomes an integrated components of all activity responses to emergency situations.

29 E. Nutritional Impact of Economic Crisis The current economic crisis that has engulfed much of South East Asia appears to have impinged on various spheres of development as well as nutritional status. While information on its specific impact on nutritional status of the community is yet to be made available from countries in the region, the situation indeed calls for integrated and sustained community action to address the nutrition problems that are evolving as formidable challenges in the near future. Comments on the impact of the socio-economic crisis in Asian countries with reference to the food and nutrition situation and status constitute this section (FIVIMS Expert Consultation. 1998). Notably, the developing countries most affected by the crisis have not yet established adequate social safety net programmes, similar to those found in industrialized countries (FAO 1999). Typical examples of Indonesia, the Republic of Korea and Thailand are in the midst of major crises. The World Bank estimates shown in Figure 11 below highlight the negative impact of a reversal in poverty alleviation in all three countries, although in varying degrees (World Bank 1999). Poverty lines are set at around one US$/day for Indonesia, two US$/day in Thailand, and four US$/day in the Republic of Korea. Between 1997 and 1998, poverty doubled in Indonesia and it nearly tripled in urban areas in the Republic of Korea. Indonesia and Thailand are elaborated subsequently (Soekirman 1999; Tontisirin and Bhattacharjee 1998). Figure 11. Poverty Incidence, World Bank Estimates (per cent) Source World Bank News Release, 2 June In Indonesia, the impact of the economic crisis is being rapidly transformed into a nutritional crisis with serious implications for the future. Major food shortages and accelerating food prices during the first three months of 1998 triggered rioting and social unrest. The most obvious impact is a 24.4 per cent drop in standards of living (World Bank 1999). This drop is immediately translated into reduced purchasing power and limited ability of households to access their basic needs of food and health care. Qualitative dietary studies (HKI 1998) show decreased consumption of relatively expensive foods such as milk, eggs and fortified noodles in Jawa, Kalimantan and South Sulawesi. The proportion of mothers and children who drank milk before the crisis (in June 1996) was twice that during the crisis (in June 1998).