III. NUTRITIONAL SCENARIO

A. Nutrition and Related Indicators

Undernutrition and malnutrition exist as part of the complex and widespread problem of povertyand deprivation that affects millions of people in Asia. Major improvements in the nutritionalsituation are suggested in recent assessments of trends in malnutrition from FAO and WHO, withmany countries successfully addressing them. These new data show some improvement worldwide, but at a substantially slower rate in the last few years than during the 1980's. This slowdown is a cause for concern, being contrary to the commitments of the goals from the WorldSummit for Children of 1990 and the ICN of 1992, of halving the prevalence of malnutritionbetween 1990 and 2000. The current and achievable challenge therefore is to build upon andaccelerate the progress registered in Asian countries. As supplement to the overview of theregion in global perspective furnished in the introduction, this section examines some countriesto identify regional trends in nutrition and related indicators followed by an exploration of Asianprospects into the next century and beyond 2000.

Economically, Asia and the Pacific remains a fast growing region, with a GDP growth rate ofalmost 8 per cent. Although it experienced noticeable declines in infant and child mortality, thetotal numbers of chronically undernourished people is increasing, as is shown in Figure 2. Thesecontradictory trends in development flow from the Asia and Pacific region being home to nearlythree-fourths of the world's poor (UNDP 1997). The short- and long-term consequences ofpoverty and malnutrition among children are reflected in the three anthropometric measures ofunderweight, wasting and stunting, shown in Table 3 below. Stunting is measured as height forage, under-weight as weight for age and wasting as weight for height. Whether compared to ageor height, loss of weight among children reflects a cumulative process of poor growth that can bemodified, as children experience weight gains due to greater access to food or the absence ofdiarrhoea related diseases and other health problems.

Table 3. Wasted, Stunted and Underweight Children, 1990

Wasted Stunted UnderweightRegion per cent number per cent number per cent numberDeveloping countries 9 48 41 215 34 179East and South East Asia 5 9 33 60 24 42South Asia 17 27 60 93 58 91Economic GroupMiddle-to high-income countries 6 8 29 40 22 31Low income countries 10 40 45 175 38 148

Source: The Sixth World Food Survey (Rome: FAO) 1996a.

In 1990, one third of children aged 5 years and under in developing countries were underweightin contrast to more than half in South Asia, more than a third in low income countries and aboutone fourth in East and South East Asia. Half of the underweight children in developing countrieslive in South Asia. The prevalence of underweight shown in Figure 5 below highlights the widevariation among Asian countries, with high levels in the most populous LIFDCs of South Asia,in contrast to South East Asia.

Figure 5. Underweight Prevalence among Children under Age 5 Years (per cent)

Source: The Sixth World Food Survey (Rome: FAO) 1996.

Wasting is relatively less prevalent, being experienced by nearly ten per cent of children indeveloping countries, as shown in Table 3 above. In contrast, wasting is experienced by 17 percent of South Asian children, 10 per cent in low income countries, and 5 per cent in East andSouth East Asia. Half of the underweight children in developing countries live in South Asia, incontrast to 56 per cent of the wasted children. The data shown in Figure 6 highlights thedisparities among Asian countries in this regard, and accents the prevalence in South AsianLIFDCs 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.

Data shown in Table 3 indicates that the prevalence of the stunting is higher than underweight orwasting. In developing countries as a whole, 41 per cent of children are stunted, and one thirdexperience retarded growth in East and South East Asia in contrast to more than half, or 60 percent, in South Asia. More than eighty per cent of total 215 million stunted children in developingcountries 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 theseAsian 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) 1996.

Data shown on Table 4 below highlight the prevalence of stunting among adolescents. It is mostprevalent among adolescents in Mindinao in the Philippines, but more prevalent in Nepal thanIndia. 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)(<5th percentile height-for-age)Study

All Males FemalesIndia 32 20 45Nepal 47 ns nsPhilippines (Cebu) 43 ns nsPhilippines (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 cumulativeprocess, which can begin in utero with the initial consequence of low birth weight and growthretardation 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. Thelong-term consequences of undernutrition as stunting among Asian mothers, followed by post-

partum underweight as shown in Table 5. Malnutrition of women during pregnancy not onlyincreases the likelihood of infant and maternal mortality during childbirth, these mothers initiatean intergenerational cycle of undernutrition. These mothers are more likely than their well-nourished counterparts to experience early labour and, as a result, there is an increasedprobability 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 ± 4 150 ± 5Indonesia 46.0 ± 6 149± 4Myanmar 46.9± 8 151± 5Nepal:Rural 43.0 ± 5 150± 5Urban 46.0 ± 6 150±5Sri Lanka 43.5 ± 7 150± 5Thailand 49.9± 7 153± 5

Source: WHO (1993a)

Throughout the world, low birth weight (LBW) is considered the best single predictor ofmalnutrition. Weights less than 2,500 grams at birth are closely associated with poor growthduring infancy, and throughout childhood (Bavdekar et. al, 1994, Butte et. al, 1996). The shareof babies born with low birth weight is a reflection of malnourishment prior to birth and, thus, aconsequence of nutritional insecurity among women of reproductive age. LBW in this contextassumes significance, as it is an important indicator of foetal/intrauterine nutrition and can leadto stunting in the young child.

The high prevalence and large numbers of LBW infants in South Asia results from infantmalnourishment in the womb and/or from cumulative effects of malnourishment among theirmothers during infancy, childhood, adolescence and pregnancy (Gillepsie, 1997). Bangladeshand India report LBW prevalence of 50 per cent and 30 per cent respectively, and it isunacceptably 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 50India 30Pakistan 25Myanmar 23.46Nepal 23.2Maldives 20Sri Lanka 18Bhutan 16Indonesia 11Thailand 7.25

Source: WHO (1993a)

The causes of LBW are multifactorial, and include low energy intake, poor weight gain duringpregnancy, low pre-pregnancy weight, short stature or stunting, anemia, malaria and femalefetus. As a result of these causal relationships, the incidence of LBW deliveries must not only beviewed as an index of our public health in general maternal health in particular, but LBW must be

viewed as a consequence of nutritional insecurity among mothers, such as post partumunderweight featured in Table 5 above.

Data in Table 7 below highlight trends for some of these factors and the potential for maternaland 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 unableto survive the first month of life. Reduction in infant mortality quickly translates into longer lifeexpectancies 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

Probability of dying (per 1000)Infant MortalityRate under age 5 between age 15

and age 59

MaternalMortality

ratio

Life at birth Expectancy(years)

(per 1 000) Males Females Males Females(per 100

000) Males Females

1978 1998 1978 1998 1978 1998 1990 1978 1998 1978 1998World 87 57 83 83 225 156 430 60 65 63 69Afghanistan 183 152 257 257 371 324 1 700 40 45 40 46Bangladesh 137 79 106 116 295 276 850 47 58 46 58Bhutan 130 63 98 94 268 225 1 600 45 60 47 62Cambodia 263 103 141 127 400 323 900 30 51 33 55China 52 41 43 54 164 101 95 64 68 66 72Dem. People's Rep.of Korea 38 22 27 25 184 108 70 62 69 69 75

India 129 72 82 97 230 182 570 53 62 52 63Indonesia 105 48 69 56 236 184 650 52 63 54 67Iran. IslamicRepublic of 100 35 52 51 170 150 120 58 69 59 70

Kazakhstan 45 35 46 36 306 133 80 60 63 70 72Lao People's Dem.Rep. 135 93 154 146 344 296 650 42 52 45 55

Malaysia 34 11 16 13 179 107 80 64 70 67 74Maldives 106 50 53 80 208 222 … 56 66 53 63Mongolia 88 51 72 75 224 166 65 55 64 58 67Myanmar 114 79 121 104 262 207 580 50 59 53 62Nepal 142 83 110 124 301 287 1 500 47 58 45 57Pakistan 130 74 108 104 192 148 340 53 63 54 65Philippines 62 36 49 38 200 151 280 58 67 61 70Sri Lanka 41 18 22 20 171 93 140 65 71 69 75Thailand 56 29 37 33 272 173 200 59 66 63 72Republic of Korea 30 10 13 13 203 98 130 61 69 68 76Viet Nam 82 38 54 57 218 147 160 54 65 58 70

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 earlierperiod with the result of premature birth at about 36 weeks of gestation, or earlier. Prematurebirth is not only a major factor contributing to infant mortality, it also results in this highprevalence of LBW infants, especially in South Asian countries. Premature and LBW infants areless 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 significantgrowth retardation, such as lower body weights, heights and head circumferences, in comparisonto normal-birth-weight survivors (e.g. Bavdekar et al. 1994 and Bhargava et. al 1995).

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 persistbeyond childhood into adolescence (e.g. Bhargava et. al 1995). Young children born in povertyareas, with a high incidence of LBW, already have manifested high cholesterol and blood sugarlevels, abnormal insulin levels and elevated blood pressure. Other LBW survivors aresignificantly more likely to experience impaired glucose tolerance as young adults leading todiabetes 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 anentirely new dimension on LBW as posing impending threats to future prospects for nutritionalsecurity beyond 2000. There is a need for policy frameworks that respond to three researchfindings. First, it is not possible to reverse all the negative effects of intrauterine growthretardation (IUGR) by overcoming poverty and nutritional insecurities during postnatal life(Martorell 1994). As a result, LBW survivors are likely to suffer growth retardation and othermorbidity throughout childhood, adolescence and into adulthood. Third, growth retarded adultwomen (e.g. who are either stunted and/or underweight) are likely to give birth to LBW babiesand, thereby, contribute to perpetuating the vicious malnutrition cycle into the forthcomingcentury.

This requires priority to poverty alleviation and special measures for achieving nutritionalsecurity for girls and women before they become mothers. The major contributor to LBW is themalnutrition among women reflected in Body Mass Index (BMI) below 18, which are moreprevalent in Nepal, Bangladesh, Bhutan and India than in South-East Asian countries, as shownin Table 8 below.

Table 8. Nutritional Status in Selected Asian Countries, Latest Available Year

per cent ofchildren <5 yrsunder-weightand stunted

(<2sd NCHS)wt/age andheight/age

respectively

Prevalence ( percent) of anaemia

Vitamin Adeficiency inchildren <5

yrs**(Bitot'sspots)

S. No Country Year

Per centof low-birth

weightbabies

(weighing<2500 g at

birth)Wt/age Ht/age

Per centof

womenwithBodyMassindex< 18

Prevalenceper cent) of

iodinedisorders in

schoolchildren

Pregnantwomen

Children<5 yrs

1. Bangladesh 1993–95 50 58.0 55.0 49.9 74 73 0.782. Bhutan 1995 16 38.0 54.0 14 68 58 Not reported3. India 1993 30 53.4 52.0 2.3–68.8 87.5 56 0.704. Indonesia 1995 11 36.0 38.0 27.2 51 40.5 0.35. Maldives 1995 20 38.0 30.1 23.6 68 81.5 Not reported6. Myanmar 1995 23 44.0 42.0 33.8 52 48 0.38 (small

study)7. Nepal 1996 33 47.0 63.0 40.0 68 79 0.848. Sri Lanka 1995 18 40.0 25.0 18.0 40 45 0.69. Thailand 1995 7.2 18 Not

reported5.6 13.4 15 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 problemsSources: WHO Global Database, 1997 and HFA Country Reports

Micronutrient Deficiencies

The micronutrient deficiencies of public health significance in Asia are iodine deficiencydisorders (IDD), vitamin A deficiency (VAD) and iron deficiency anemia (IDA). Othermicronutrient deficiencies occur under special circumstances, generally because the quantity ofthe micronutrients is inadequate in food and the diet. Rickets remains a problem in certain partsof the Near East and Southern and East Asia. Zinc and selenium deficiencies are reported inChina and some parts of Central Asia.

Approximately 1.6 billion people live in iodine deficient (IDD) environments and are therefore atrisk. Over 650 million suffer from goitre, and almost half of the world's goitre sufferers arefound in Asia and over half of these live in China and India. Unacceptably high prevalence ofgoitre among school children is featured in Table 9 below, especially in Bangladesh, India andNepal. Among pregnant women, IDD is the most common cause of preventable mentalretardation in children. Besides, IDD can impair reproductive functions, leading to increasedrates 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 LankaIMR Per 1000 live births 70–126 70–126 44–126 15–44 70–126 70–126 15–44MMR Per 100,000 Live births 450–600 300–399 300–399 150–299 450–600 300–399 30–149LBW per cent 45–65 35–44 25–65 <25 25–34 25–34 <25per cent IDD Goitre rates schoolchildren

>40 20–29 <20–>40 20–29 >40 30–39 <20

Malaria per 1000 Population <3 >35 <3–35 - <3 <3 13–35Complementary Feeding in children 6–9 m + Breast feeding per cent

25–49 >75 <25–74 <25 50–>75 <25–49 >75

per cent births attended by trained midwife, nurse or doctor

<20 20–49 <20–100 50–74 <20 20–74 75–100

Calorie average per capita per day 2000–2300 - 2300–2400

2400 <2000 2300–2400

2000–2300

Food as percent of total householdexpenditure

>60 - 50–59 - >60 <40 40–49

Access to man made water sources >75 50–74 25–>75 .75 <25–49 50–74 50–74Access to sanitation facilities 20–74 50–74 <20–74 <20–49 <20–49 50->75 50–74

Source: UNICEF, 1996IMR - 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 andsubsequent early death. Vitamin A deficiency (VAD) as xerophthalmia is significantly greater inthe 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)Iron deficient or

anaemicSouth-East Asia 280 100 138 10.0 616Western Pacific• 405 30 19 1.4 1058

Source: WHO 1992* WHO regions, ** Pre-school children only, • Including China

Iron Deficiency anaemia (IDA) is found to affect over 2 000 million people and sufferers live innearly all Asian countries, with women and children being most affected, particularly in SouthAsia. Anemia has not markedly decreased in Asia and reports from India indicate 16 per cent ofall maternal deaths are attributable to anemia (WHO 1993b) while the corresponding figure inBangladesh is between 10 to 20 per cent (Chakravarty 1992). Anaemia is one consequence ofmalaria, which is prevalent in many Asian countries. Anaemia is associated with an increasedrisk of premature delivery and higher prevalence of LBW infants (Prema et al, 1981). Impairedability to do physical work in anemic preschool and school age children has been consistentlyobserved 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 differentdemographic 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 centAdultCountries Pregnant

Women(<11g/dl)

LactatingWomen

(<11g/dl)

PreschoolChildren(<11g/dl)

SchoolChildren(<11g/dl)

Women<12g/dl

Men<13g/dl

Bangladesh 77 77 73 40 – 74 70 -Bhutan(ICN. 1992)

59 - 58 - - -

India(Seshadri 1996)

87 77 – 95 67 50 – 90 -

Maldives(WHO 1996)

68 - 82 62 -

Nepal 67 - 79 - 68 -Pakistan 29 –33

(<10g/dl)- 65 – 78 - - -

Sri Lanka 39 - 45 58 45 -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 isexpected to be lower, and in the 60s, for several other countries (see Table 12 below). Increasesare primarily attributed to increases in the chances for life among infants, reflected in decliningrates for infant mortality. These improved prospects are complemented by significant increasesin the chances for longer lives among children under age 5 years, reflected in falling trendsresulting from dramatic improvements in several countries. Child mortality rates will decline bymore than half in Bangladesh and Nepal. As a result of these combined declines in mortality, theshare of deaths under age 50 years will decline, though more significantly in some Asiancountries than in others.

Table 12. Life Expectancy, Infant & Child Mortality, Mortality under Age 50, 1995–2025

Life Under 5 Infant Deaths GNPExpectancy Mortality Mortality under age 50 per

at birth (years) Rate Rate as per cent capitaBoth sexes Both sexes of total US$

1997 2025 1997 2025 1997 2025 1997 2025 1995Bangladesh 58 70 104 34 80 29 60 28 240Bhutan 53 67 142 50 105 41 70 43 420Cambodia 54 67 131 44 104 40 69 33 270China 70 75 40 17 38 16 24 8 620Dem People's R. ofKorea

72 77 25 13 22 11 27 8 ..

Fiji 73 77 23 8 20 8 29 8 2440India 62 71 90 45 73 38 48 22 340Indonesia 65 73 59 26 49 18 43 15 980Korea, Rep. Of 72 77 12 5 10 5 26 5 9700Lao People's Dem. Rep. 53 67 140 46 87 39 72 43 350Malaysia 72 77 21 8 11 7 30 10 3890Maldives 65 74 65 16 50 15 58 26 990Mongolia 66 74 69 33 53 28 46 21 310Myanmar 60 71 90 29 79 25 53 22 ..Nepal 57 70 108 33 83 30 63 33 200Papua New Guinea 58 68 80 34 62 30 57 30 1160Philippines 68 75 42 16 36 14 44 16 1050Samoa 69 76 68 38 58 35 45 23 1120Solomon Islands 72 77 27 10 23 9 43 17 910Sri Lanka 73 78 18 8 15 6 24 8 700Vanuatu 67 75 48 16 39 14 47 23 1200Viet Nam 67 75 51 21 38 18 43 20 240Source: WHO/SEARO 1998

The projected growth in the number of Asians is among of the foremost contributory factorsaffecting Asian prospects for the combination of food and nutrition security. Current trends showthat another 1.5 billion people will be added to the population of developing Asian countries by2025. As these human increases coincide with rising needs for food at the global, national andhousehold levels, they require urgent attention, especially in those Asian countries where thenumbers 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. Suchdramatic growth is likely to coincide with simultaneous increases in the absolute numbers ofpoor and malnourished people.

Table 13. Population (in millions) in Selected Asian Countries, 1997–2025

Country 1997 2000 2010 2025Bangladesh 122,013 127,209 145,019 157,342Bhutan 1,862 1,999 2,479 2,776China 1,243,738 1,266,260 1,342,235 1,465,452India 960,178 999,823 1,131,973 1,330,201Indonesia 203,480 210,269 233,399 303,387Malaysia 21,018 21,978 25,275 31,246Maldives 273 297 380 433Myanmar 46,765 48,757 55,583 67,800Nepal 22,591 24,515 30,930 40,904Pakistan 143,831 157,232 202,002 268,904Philippines 70,724 73,955 85,048 105,140Dem P.R. of Korea 22,837 23,529 25,882 29,893Sri Lanka 18,273 18,827 20,709 23,919Thailand 59,159 60,230 63,844 69,705

Note: Population projected based on the annual growth rates for 1995 and 2025 developed by the UnitedNations, 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 14below. These data depict a positive global trend continuing from 1969 to 1990–1992, andprojected for 2010 and 2025. These data also highlight the increasing disparities in foodinsecurity in South Asia as compared to East and South East Asia.

Table 14. Dietary Energy Supply (DES), 1969–1971 forward, with Projections to 2025*

Calories per day per person1969–1971 1979–1981 1990–1992 2010 2025*

South Asia 2060 2070 2290 2401 2674East & South East Asia 2060 2370 2680 2948 3745Developing Countries 2140 2330 2520 2730World 2440 2580 2720 2856 3074Least Developed Countries 2060 2040 2040Low-Income Food-Deficit 2060 2230 2450

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, whosenumbers are rapidly increasing. Worldwide, the food supply is enough to meet the energy needsof a growing number of people if it is equitably distributed according to each person'srequirements, but food is not equitably distributed.

As a result, despite increases in the food supply, 12 per cent of people living in the developingworld will remain food insecure in 2010, as shown in Figure 8 below. Achieving significantthough uneven progress towards 2010, 344 million Asians will be chronically malnourished, andmost will live in low-income food-deficit countries (LIFDCs), such as China, Bangladesh, India,Mongolia, Nepal and Papua New Guinea.

Figure 8. Number of Food Insecure People

Source: Agriculture towards 2010 Rome: FAO) 1993 and FAO Homepage, 1999.

The projections for underweight children highlight prospects for overcoming malnutrition.Underweight, even in mild form increases risk of death and inhibits cognitive development inchildren, leads to reduced fitness and productivity among adults. It perpetuates the problem fromone generation to the next, through malnourished women having birth to low-birth-weightbabies. Data shown in Table 15 features trends in prevalence for underweight children from 1975to 1990, with to 2005. Despite projected declines for South Asia, more than half of all childrenwill 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, 1975–2005

Per cent Underweight Number Underweight1975 1990 2005 1975 1990 2005

Eastern Asia 33 21 17 47.4 25.4 18.5Southeastern Asia 48 38 32 24.6 21.6 18.4Southern Asia 68 62 57 91 107.6 112.3Near East (Western Asia) 22 15 12 2.9 2.9 3.1Asia 49 44 41 163.1 154.7 149.3

Source: ICN. 1992 * 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 andSouth East Asia. Multiple ocular data, featured in Table 16 below, show that these Asiancountries experienced reduction in clinical signs of vitamin A deficiency, resulting fromprogramme support for supplement distribution. Elimination of the deficiency seems possiblebased 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 toeliminate vitamin A deficiency by the end of the decade are limited. Meanwhile, Asian childrenremain at risk, and its resulting blindness and imminent death.

Table 16. Trends in Prevalence of Clinical Signs of VAD, 1975 to 2025Calculated from Instances where Multiple Surveys have been reported

Country Year Indicator Prevalance( per cent)

Percent change Per10 years

Trend (percentagepoints/10 yrs)

1976 1.401979 0.90

1988–90 0.70 -42.00 -0.582000@ 0.44

India

2025@

X1B

0.151979–80 0.60

1981 0.64 -10.00 -0.061996 0.50

2000@ 0.49

Nepal

2025@

X1B

0.421975–76 1.10

1987 0.33 -60.00 -0.642000@ 0.20

Sri Lanka

2025@

X1B

0.061982 3.201993 0.50 -78.00 -2.50

2000@ 0.20

Philippines

2025@

Total

0.021976 1.30 -35.60 -0.461989 0.70

2000@ 0.47

Bhutan

2025@

Total

0.18Source : WHO (1995) and UNICEF et. al. (1997b) @ author's projection based on trend percentage points

Poverty is the major factor limiting Asian prospects for achieving nutritional security forchildren, women and men. Data in Table 17 highlight the achievements of Asian countries topoverty alleviation in rural areas since the 1970s and as projected towards 2025. Several Asiancountries 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, 1970–2025

Country 1970s 1980s 2000 2025Bangladesh - +- +- +-China + + + +India ? + +? +Indonesia + + - +?Malaysia + -+ + +Nepal - - - +?Pakistan + +- +- +Philippines - ?- +? +Sri Lanka - - - +?Thailand + -+ +? +

Note: - denotes deterioration; + denotes improvement; = denotes no change; ? denotes unclear; two signsfor 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).

IV. NUTRITIONAL TRANSITION

A. Challenges ahead

Prospects for nutritional security are not only influenced by the factors giving rise to the socio-economic problems reflected in the health and nutrition indicators, they are simultaneouslylimited and changing in response to a nutritional transition underway in many Asian countries.Asian countries initiated their developmental journeys towards nutrition security over 5 decadesago, with an acquired burden of under-development. While achievements are reflected inincreased life expectancy, reductions in infant mortality and wider coverage throughimmunization and improvement in food security, many formidable challenges remain. Severeforms of nutritional disorders are less common today (Gopalan 1992), but undernutrition andmicronutrient deficiencies prevail, though in varying proportions and degrees.

Meanwhile, non-communicable diseases (NCDs), once thought to be prevalent mostly in thedeveloped world are emerging as leading causes of death, illness and disability in manydeveloping Asian countries. Dramatic increases in life expectancy accompanied by profoundchanges in life style are responsible for the heightened increase in the incidence of these non-communicable diseases (WHO 1997). It is increasingly apparent that undernutrition and laterovernutrition are particularly dangerous problems confronting Asian countries, and that thisemerging epidemic will transform both health and nutrition needs in the years ahead. Prospectsfor nutritional security beyond 2000 simultaneously limited and changing in response to thisnutritional transition are underway in many Asian countries.

A striking feature of the nutrition transition in developing Asian countries is the rapid increase inthe share of the total population living in urban areas. The urban population now represents 35per cent of the Asian region's total population, but it is growing at about twice the growth rate ofoverall population (1.5 per cent/year). Coinciding with rural to urban migration, there has beenan 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 foodbeing no longer available as home grown produce, nor is food as readily available in urbancentres.

The cash economy has assumed far greater significance in supplying food, and these rapidlyexpanding urban communities place increased demands on food production as well as ontransport and storage systems for food distribution and preservation (WHO 1990). The evolutionof these urban distribution systems facilitate greater food variety without seasonal or year to yearvariation and this raises prospects for improved food selection and promotion of greater varietybased on nutritional principles. Urbanization profoundly affects dietary and food demandpatterns. It also gives rise to growing concern about the quality and safety of food, particularlyfoods processed and purchased outside the home, and to modification in food preferences causedby changing life styles.

B. Dietary Practices

Urbanization contributes to changes in the type of demand for food, and the consumption of foodoutside 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, mainmeals and snacks are catered to the needs of urban dwellers, both rich and poor. Such foods soldin the urban slums are based on traditional food items, and are generally freshly prepared andserved hot.

A distinct response to this adaptive response to urban life, therefore, is the rapid proliferation ofwayside or improvised eating facilities. In Indonesia and the Philippines, urban households spendover 25 per cent of their food budget on street foods, and 90 per cent of Bangkokians regularlypurchase 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. Similarlyamong 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 tofood shifts and more diversified diets.

Table 18. Dietary Energy Supply (DES) from Major Food Groups, Selected South East AsianCountries, 1980–1982 and 1990–1992

Dietary Energy Supply (DES)kcal/person/day

1980–1982 1990–1992IndonesiaFood, total 2510 2696Vegetable products 2438 2590Animal products 72 106Cereals 1675 1775Starchy roots 189 157Non cereal/non root vegetable products 574 658MalaysiaFood, total 2697 2817Vegetable products 2296 2358Animal products 401 458Cereals 1308 1174Starchy roots 70 75Non cereal/non root vegetable products 918 1110PhilippinesFood, total 2219 2292Vegetable products 1972 2020Animal products 247 272Cereals 1203 1270Starchy roots 137 98Non cereal/non root vegetable products 632 652ThailandFood, total 2218 2374Vegetable products 2016 2134Animal products 202 240Cereals 1450 1381Starchy roots 40 24Non cereal/non root vegetable products 526 728VietnamFood, total 2117 2203Vegetable products 1990 2026Animal products 127 177Cereals 1534 1602Starchy roots 247 157Non cereal/non root vegetable products 209 268

Source: FAO, 1999.

The nutritional transition underway in Asian countries during the last decade is illustrated by thefood shifts shown in Table 18 below. These involve shifts from basic staples, such as milletstowards 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 countriesshown, energy intake has progressively increased during the last decade, and there is a trendtowards 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 livestockproduction encourages deforestation and further reduces the total food supply (DES) availablefor direct human consumption. This trend toward urbanisation coincides with rising concernsabout water scarcity and the probable diversion of water from agriculture to other sectors. It ispredicted by many that increasing water scarcity might result in higher prices for basic fooditems, especially irrigated food items, with more severe impact on the poorer segments of thepopulation.

Diets are shifting from vegetables such as cereals to non-cereal food sources, and within foodgrains there are shifts from starchy roots and tubers to polished rice and refined wheat. The mostundesirable 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 progressivelytrend towards preference for the highly polished varieties of rice. As this trend usually coincideswith reductions in the total intake of cereals, the net effect is a major decrease in the fiber contentof Asian diets of more than 50 per cent. Another undesirable feature involves the continued lowintake 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 foodcontamination leading to the evolution of concern about consumer protection and the nutritionalimpact of environmental pollutants and industrial toxicants. Particularly in urban areas, there isincreased concern about food safety from foods produced outside the home, especially streetfoods. Salmonellosis and related food contamination pose threats to future prospects ofinexpensive sources of street foods. Even though they are widely relished, they are sometimes beunsafe and harmful.

Food contamination poses serious threats to wholesome food in the context of moderndevelopment, especially contamination introduced by pesticides, industrial pollution, andpollutants from untreated sewage that is discharged into fields and rivers. Of special concern isthe interaction of nutritional status with exposure to environmental pollutants and industrialtoxicants. Another major concern is intergenerational consequences of exposure by pregnant andlactating 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 incidencefor degenerative diseases. Precise data are not yet available for changing trends in degenerativediseases, but small scale data from selected countries illustrate the transition underwaythroughout the region. Increasing prevalence of certain kinds of cancer in many Asian countriesis related to over consumption of fat and possibly to food trends in degenerative diseases, butsmall 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 contamination, especially toxic substances fromuncontrolled environmental hazards and industrial pollutants, and possibly due to increased useof 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 atpresent 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 ofupperaerodigestive 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 amonglow socio-economic groups, where dietary deficiencies rather than excesses predominate.Research highlights the relationship to oral and oesophageal cancers of lower intakes of caroteneand 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 Asiancountries. 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 otherchronic diseases of life style. Genetic and environmental factors play an important role indetermining the propensity of obesity in populations and individuals. Lack of physical activityreportedly contributes to the increasing rates of obesity observed in many countries and may be afactor in whether an individual who is at risk will become overweight or obese. Excess energy inany form will promote body fat accumulation and will lead to obesity if energy expenditure isnot increased.

The Nutrition Division in Thailand reports that the prevalence of diabetes has nearly doubledduring the last 2 decades and current figures may be even higher. The incidence of diabetes isalso on the rise in India, especially among the affluent population aged 40 to 50 years. ASingaporean investigation covering Indians, Malays and Chinese (Thai et. al 1987) shows majorincreases in diabetes prevalence during the last 15 years.

There is increasing concern about diseases of the heart, as illustrated by research findingsshowing the prevalence of hypertension as high as 17 per cent in Bangkok and in other regionsof Thailand. Studies from Malaysia show the simultaneous emergence of obesity, hypertensionand 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 ismost prevalent among both males and females with higher socio-economic status. Studies at theNational Institute of Nutrition (NIN) in India show rising incidence of obesity among the affluentand a rising potential for obesity due to reduced physical activity associated with economicactivity, in urban as compared to rural areas. Studies among adult Indian women find increasedincidence of obesity during the last decade (NIN 1993, NNMB 1996).

With increasing affluence in Singapore over the last 3 decades, disease patterns have undergonea 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 foodconsumption patterns.

On the whole, the nutrition transition throughout Asia is increasingly associated with a shift inthe 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 beginningto be collected to determine the prevalence of obesity. Surveys conducted in some Asian

countries, featured in Figure 9 below, highlight this concern for obesity among children underage 5 years.

Figure 9. Obesity Prevalence among Children under Age 5 Years

Source: The Sixth World Survey (Rome: FAO) 1996.

Studies among school-age children highlight the trend towards childhood obesity that is initiatedamong children under age 5 years. In Jakarta, the prevalence is suggested to be as high as 31 percent among boys and 7 per cent among girls. Recent reports in Thailand show obesity rangingfrom 9 to 19 per cent among school-aged children, and from 20 to 30 per cent among urbanadults. An increased incidence of obesity also is observed among adolescent youth in Asiancountries, where it coincides with selective undernutrition and the rising prevalence of anorexianervosa among girls and boys.

Studies show that even modest advances in prosperity in low GNP developing countries areassociated with marked increases in degenerative diseases. The transition leads to increasedconsumption of fat and rising intake of animal protein, especially among affluent householdswhere result is often obesity.

The incidence of osteoporotic hip fracture (HP) increased two to three times during the lastdecade in Hong Kong, Singapore and Japan. Though the current incidence of HP in the Asianpopulation remains lower than the Caucasians, by the year 2050 it is estimated that about 3.2million people in Asia will suffer from HP. Joint diseases like osteoarthritis and rheumatoidarthritis are reported for older women in India. Women are especially vulnerable, e.g. 89 per centof older women in Thailand consume less than two-thirds of recommended daily requirements ofcalcium, which puts them at risk to osteoporosis. Calcium intake needs to be increased both fromreadily available bony fish as well as milk.

These risk factors need to be studied from an Asian perspective, with due regard to the roles ofgenetic-heredity, nutrients and exercise on achieving peak bone mass and in the prevention ofosteoporosis. Data on the bio-availability of calcium from non-milk foods to help Asians meettheir calcium intake is also necessary, in view of the urbanization and sedentary lifestylessweeping over most of Asia, especially among the new affluent groups. Adoption of a prudentdiet with adequate calcium intake and increases in physical activity may serve as preventive

measures against the development of osteoporosis. These concerns are likely to increase inresponse to population ageing of Asian countries.

D. Population Ageing

This nutritional transition throughout Asian countries coincides with a global process ofpopulation ageing, and their linkage has yet to be fully understood and adequately reflected in aresponsive policy framework. Between 1950 and 2025, the total world population willexperience a three-fold increase, and the number of older persons, aged 60 and over, willincrease 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. Thisnew older share will exceed the child share of the total world population for the first time inhuman history.

The projections for population ageing, shown in Table 19 below, highlight the magnitude of thisglobal process in Asia. Most developing countries are ill-prepared for population ageing,especially as regard to the associated health and nutritional problems, such as increasedprevalence of both under- and over- nutrition among older persons, as well as osteoporosis. Thedesign and implementation of effective strategies and measures responding to the combination ofnutritional concerns among older people, the majority of whom are women, are importantdeterminants of Asian prospects beyond 2000.

Table 19. Estimates and Projections for the Total Population, Aged 60 Years and above,Selected Asian Countries, 1980–2050 (in thousands, with per cent in parentheses)

Country 1980 2000 2050Bangladesh 3 792(4.3) 6 504(4.3) 16 819(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 33 936(4.96) 65 655(6.83) 146 224 (11.85)Indonesia 8 012 (5.03) 14 908 (7.50) 31 287 (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) 12 179 (13.52)

Source: WHO/SEARO, 1990

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 socio-cultural issues and socio-economic factors influencing the potential for achieving nutritionalsecurity beyond 2000. Asian countries have made great strides over the past 5 decades in dealingwith problems of poverty, malnutrition and other aspects of nutrition insecurity. Food productionhas increased, child malnutrition has declined along with infant and child mortality. Despitethese impressive gains, Asians continue to suffer from poverty, hunger and malnutrition instaggering proportions (ACC/SCN, 1997).

Strategies and measures that can be adopted, adapted and implemented by Asian countries, holdthe key to the 21st century in terms of linking nutrition and development outcomes. Pastinternational initiatives were seriously concerned with the hunger and malnutrition and severalplausible sets of interventions and actions evolved. While many of these initiatives also showedconcern for the poor, not all were able to translate the concern for improving nutritional well-being into action (FAO 1996). As a result, identification of successful ways and means forachieving progress is especially important.

Planners and policy makers need an effective policy and programme framework for makingdecisions and formulating workable and effective interventions. These not only need to easilyadapt to different country situations, but they also need to be sensitive and responsive to theAsian socio-cultural contexts and complexities, especially since the socio-economic situation israpidly changing, urbanizing and encountering threats of excess and deficits in both food andnutrition insecurity. Additional features of effective measures involve nutritional surveillanceand provision of nutritional security in emergency situations and during the current economiccrisis underway in Asian countries.

Malnutrition being complex in its determinants, requires the use of broad based economicpolicies as a means of its elimination on the one hand, and the use of more targeted interventionson the other. What is typically needed is a combination of different types of macro-economicpolicies and measures that effectively alleviate poverty and malnutrition while also servingcountries as support for sustainable nutritional security. Selected examples of effective policyand programme activities undertaken by South Asian and South-East Asian countries featured inAppendices C and D depict some of the steps taken towards overcoming nutrition insecurity orits threat, in the Asian region.

National Plans of Action for Nutrition (NPANs) were designed in response to the theInternational 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-orientedconferences, which influenced both the philosophy and technical focus of these nutrition actionplans. 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 overcomingnutrition problems. Building effective frameworks for implementing plans with this focusevolves from discussion of successful measures for implementing these strategies and achievinggoals beyond 2000.

B. Building Effective Frameworks

The diversity among Asian countries with programme interventions to enhance food andnutritional security is featured in appendices C and D. Review of these interventions gives rise toidentification of several major components for building a national framework for designinginterventions to achieve nutritional security beyond 2000. An effective framework thus wouldcontain 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 givingemphasis to their support for effective strategies and measures. Illustrations of successfulinterventions are identified and supplemented by elaboration in the appendices of specificpolicies and programmes undertaken by South Asian and South-East Asia countries to achievenutritional security beyond 2000.

Responsive macro-economic and trade regimes. Over the past decade or so, some importantchanges are underway with significant impact on macro-economic policies supporting foodproduction and trade, including developing food standards (Orriss 1998). Although industry andnational 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 andwholesomeness are related to a level of risk that society regards as reasonable, and in context andcomparison with other risks in life. As risk analysis will play a vital role in the future work of theWTO, it has been introduced as the discipline of standarisation in the SPS Agreement, wherebymember states are expected to justify levels of protection higher than those in Codex standardsby using risk assessment techniques. Food safety risk analysis is the fundamental methodologyunderlying the development of food safety standards, giving rise to an estimate of the probabilityand severity of the adverse health effects in exposed populations, consequential to hazards infood (FAO 1997).

Risk assessment involves policy guidelines that are documented so as to ensure consistency andtransparency. Examples include establishing the population(s) at risk, establishing criteria forranking of hazards, and guidelines for application of safety factors, such as Hazard Analysis andCritical Control Point (HACCP) System. Risk profiling entails describing a food safety problemand its context, in order to identify those elements of the hazard or risk relevant to various riskmanagement decisions. This risk profile identifies those aspects of hazards given emphasis indecisions about priorities and assessment policy, and other aspects of the risk that are relevant tothe choice of safety standards and management options. Risk management entails the process of

weighing policy alternatives in the light of the results of assessment and, if required, selectingand 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 theseprofiles, ranks hazards as priorities for assessment and management, establishes assessmentpolicy for conduct of assessments, commissions assessments, and considers the assessmentresults. Risk management option assessment entails three activities; namely, identification ofavailable management options, selection of the preferred management option taking account ofappropriate safety standards, and the final management decision. The protection of human healthis the primary consideration in arriving at decisions, with other factors (such as economic costs,benefits, technical feasibility, risk perceptions) being considered as appropriate. Riskcommunication is an essential component of risk analysis, involving the exchange of informationand 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, WTOmembers are encouraged to base their measures on international standards, guidelines andrecommendations where they exist (WTO Home Page, June 1999). However, members maymaintain or introduce measures which result from higher standards if there is scientificjustification or as a consequence of consistent risk decisions based on an appropriate riskassessment. The SPS Agreement spells out procedures and criteria for the assessment of risk andthe determination of appropriate levels of sanitary or phytosanitary protection. It is also expectedthat WTO members would accept the sanitary and phytosanitary measures of others asequivalent if the exporting country demonstrates to the importing country that its measuresachieve the importing country's appropriate level of health protection. The SPS agreementincludes provisions on control, inspection and approval procedures.

Diversification of food production and marketing. In the developing countries of the world andespecially in Asia, any discussion of achieving the combined objectives of food and nutritionalsecurity flows from the view of agriculture as the engine of food production. Recognition of theimpinging role of agriculture on food and nutrition thus becomes essential to sustainabledevelopment. Increasing food production to meet the needs of a rapidly rising population is themajor challenge facing Asian countries in the area of food security. Increasing the diversificationof food production as essential to nutritional security. Achieving the objectives of these twinpillars requires a combination of strategies to guard against possible evils arising from theindiscriminate 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, italso supports varieties capable of surviving new environmental challenges. A wide range ofcrops, animals, fish and forest products not only make food production and, thus, food andnutrition security more secure from season to season, but such farming systems also are lessdamaging to the environment. This approach to dietary diversification supports production andutilization 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 strategiespromoting food diversification in agricultural development in the context of nutritioncommunication and education.

Figure 10. Food Groups as Shares of Dietary Energy Supply (DES) of Asia and PacificCountries, 1994–1996

Source: FAOSTAT, Rome, 1999

Home Gardens not only maintain their importance as major sources of a diversified andnutritious food base, they also provide self-sustaining occupations and essential income for smallscale farmers, women and communities throughout Asia. Women and especially children alsocontribute foraged and traditional foods. Forestland, meadows, wetlands, fallow land and evenweeds in cultivated fields usually supply the variety (and micronutrients) in diets. It is desirableto preserve these lands either in the natural or wild states or encourage communities to wiselyhusband them.

Marketing of food crops, indigenous foods, traditional foods, also contributes to improving foodsecurity through provision of increased income and promotion of employment generation,whereby gains in real income from marketing typically translate into gains in food consumptionand diversity in nutrition. As a result, those affected can acquire more food, reduce their work

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, strengtheneffective demands for both preventive and curative health care. Further, raising income typicallyexerts a positive and significant effect on nutrition (von Braun, 1995).

Biotechnology has a long history of use in food production and processing, as it combinestraditional practices and the latest techniques based on molecular biology. Use of modernbiotechnological techniques open up great possibilities of rapidly improving the quantity andquality of food available. Its benefits include providing resistance to crop pests to improveproduction and reduce chemical pesticide usage, thereby making major improvements in foodquality and their nutritional value. Biotechnology is also being used as food additives and for awide range of applications to food fermentation.

Recognition of its potential benefits is accompanied by worldwide concern and renewed effortsto 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 scientificmethods and analysis of food safety appropriate to biotechnology research. Internationalinstruments guide these efforts. Assessing its contribution requires ensuring that biotechnologyalso plays a major role in improving the quality of life on a long-term basis. Furtherdevelopment, testing and micro-implementation of appropriate technologies for diverse agro-ecologies remains a challenge for future decades and beyond.

Income and employment generation. Malnutrition and nutrition insecurity are overcome byinnovative mechanisms for generating and diversifying employment and income. Majorinterventions feature employment in exchange for cash or food, and credit to the poor to supportconsumption stabilization and self employment. Other income generation schemes, such as homegardening and livestock production, have become important features of national strategies. Thesemechanisms address three central problems facing Asian countries today: food and nutritioninsecurity, growing unemployment and poor infrastructure (von Braun, 1995). Someemployment schemes lend viable support for land and water systems and other infrastructureimprovements.

Equity in nutrition is an inseparable part of equity within rural communities and between ruraland urban areas of the country. Extreme socio-economic inequities, leading to widespreaddestitution 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 anacceptable level of basic services. Achieving equity in nutrition thus decreases differences inaccess to and utilization of food and nutrition services. Socially disadvantaged groups and ethnicminorities are commonly affected, but the complex socio-cultural factors giving rise to theseinequities are often ignored.

An explicit focus on women is essential to successful strategies and mechanisms. Recognition ofthe need to involve women in their design evolves not simply from a limited concern aboutequity of women with men as both beneficiaries and contributors to development. Rather,women need to be active participants because they have experience with successfulachievements in ensuring community and household food and nutrition security evolvingthroughout centuries in the socio-cultural contexts of Asian countries. These successful strategiesand measures for food production, processing, preservation for storage or exchange are majorfeatures of the socio-cultural traditions passed on from grandmothers to mothers to daughtersthroughout Asian countries. As a result, Asian women offer cumulative knowledge, but theirpotential remains untapped. The involvement of poor and rural women may be most essential

flowing from their vast experience with efforts to identify cost-effective and energy efficientmeasures that are workable within the constraints of low income and limited access to productiveresources.

Women farmers need to be recognised as major food producers and this requires their fair accessto land ownership, water and other natural and productive resources (e.g. technology) andsupport 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 andtrade policies. The active participation of women is essential to identify ways of overcoming thebias limiting nutrition adequacy to girls from infancy throughout childhood. The nutrition-inequity 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, arecritical indicators of equitable assess to nutritional security and prospects for the future. Thus, theresultant inequities need priority attention in policy frameworks for Asian countries, especially inSouth Asia.

Overcoming basic and functional literacy, especially among girls and women, is an essentialcomponent of successful programmes. Overcoming urban/rural disparities in access and qualityof education is essential. The production and use of education materials and curricula reflectingrural perspectives, and including emphasis on rural concerns and strategies for achieving foodand nutritional security are essential elements.

Food subsidies and rationing, food stamps, and food distribution systems. Food related incometransfers are often used to improve nutrition, but they involve price subsidies that are high interms of fiscal and economic costs. These programmes incorporate a combination of targetingmethods, including the targeting of commodities and beneficiaries. Geographical targeting ofbeneficiaries 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 beeffective in the context of assuring nutrition security, food stamp programmes should be directedtowards those who are very poor. Food distribution systems are established as public distributionsystems PDS) in countries subject to food shortages to meet the food and nutrition security needsof 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, toanalyse the underlying causes of undernutrition and overnutrition, to develop indicators ofprogress towards achieving targets and, to this end, to identify indicators that will be regularlymonitored (FAO, 1998). Nutrition surveillance systems produce the basic information formonitoring the environment and, at the same time, it produces warning signals that triggeractions to overcome nutrition insecurity. Nutrition surveillance is defined as an on-going systemfor generating information about the current and future magnitude, distribution and causes ofundernutrition and micronutrition deficiencies in populations for policy formulation, programmeplanning, management and evaluation (WHO 1976).

In the absence of an effective surveillance system furnishing information and explanation, lackof 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, problemidentification and sensitisation or advocacy, macro-and micro-level planning, timely warning,and programme monitoring and evaluation. Continuous monitoring and assessment of thenutritional scenario discussed in Section III, when supplemented by development of timely

warning systems focused on national and household food and nutritional insecurities, preparegovernments to more effectively respond to any adverse situations, such as the emergencysituations.

Nutrition surveillance systems with these features, therefore, need to be institutionalized withinthe existing infrastructure of the Government. The Food Insecurity and Vulnerability InformationMapping Systems (FIVIMS) is being developed as a model for this purpose. The systems notonly identify undernourised people and those who are at risk, they also provide informationabout 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 threatof hunger. FIVIMS use existing information-gathering systems (e.g. indicators discussed inSection III) and promote the sharing of information between partners, at national andinternational levels, to cut costs and save time. Focusing on nutrition goals and responsesrequires information supporting assessment and analysis of nutrition problems, as well asinformation for monitoring and evaluation of outcomes of programmes and projects discussed asstrategies and measures. The early warning and rapid response features of these food andnutrition surveillance systems are essential during emergency situations.

Nutrition education and dietetic counselling. The most effective tool for nutritional educationand dietetic counselling are food based dietary guidelines (FBDGs) that reflect dietary traditionsand 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 nutritionsituation of the target population. Asian FBDGs also promote preservation of the traditional dietand of traditional ways of producing and processing food. To minimise the negativeconsequences of the nutritional transition beyond 2000, they promote the merits of cereal-baseddietary practices in Asia, such as the nutritional importance of fiber intake, and the beneficialeffects of the fatty acid profile in the ‘invisible fat’ contained in cereals (Achaya 1986, Gopalan1988). High intakes of vegetables also are promoted. FBDGs restore traditional methods ofprocessing by promoting them as yielding nutritional benefits, e.g. malting of grains, sproutingof legumes, and hand pounding of grains.

Besides, there is need for innovation and versatility in health and nutrition services to furnishinformation and support for overcoming undernutrition and emerging problems, arising due toovernutrition. There is need for targeted efforts, with special emphasis on general education andnutrition education, and counseling. The FAO package on nutrition education, entitled “Get thebest from your food” furnishes one illustration of the type of educational tool that needs to beutilised in Asian contexts. Nutrition education through the mass media, in health centers, schoolsystem and health programmes need to incorporate sensitive and responsive measures takingaccount of the process of population ageing and its socio-economic consequences for nutritionalinsecurity among older people, especially among older women and widows.

Food Quality and Safety. Three major areas of concern deserve special attention to enhanceAsian prospects beyond 2000. The first involves responses to concerns about the safety of foodsproduced and processes outside the household, such as street foods. The second responds to thequalitative inadequacies of micronutrients in the food supply, and the third involves thestrengthening of food control systems and promoting good manufacturing practices along withappropriate nutrition education highlighting consumer protection. Educating households andcommunities about appropriate food handling is essential to reduce food contamination andrelated illnesses. Food is subject to harmful contamination from the soil it is grown in, from the

plant or animal it is derived from, from handling during processing and preparation, and from thedish it is served on.

Formal and non-formal education and media are important contributions to increasing awarenessabout consumer protection needs of families and communities. These elements of nutritioneducation are viewed as important components of primary and secondary school curricula; andfor curricula in the education and agricultural sectors, food and nutrition sciences, and healthsciences; and as mechanisms for nutritional intervention in medical facilities. Besides, specialefforts to promote non-formal education are necessary to increase nutritional awareness andcompliance with FAO/WHO Codex standards among policy-makers, and especially amongemployees within food export and inspection agencies and among food industry operators.

Setting standards, identifying codes for practice and designing regulations in compliance withinternational standards adopted by the Codex Alimentarius Commission ensure food quality andsafety. Effective strategies involving people's participation to improve the quality and safety ofstreet foods are being implemented in Calcutta and Bangkok. A strong relationship among theauthorities and the hawkers' representatives led to the preparation of policy guidelines for theregulation of street foods in Calcutta (Chakravarty and Canet 1996). Thailand developed a ten-step code of practice for street food vendors that is used and monitored by local authorities tomotivate implementation (Dawson et al 1996).

FAO provides technical assistance to member countries in food quality control, including safetyand such assistance are made available more for the developing countries in order to establish orstrengthen the food control systems. The effective strategies towards achieving nutritionalsecurity, therefore, would call for strengthening such technical assistance from FAO.Specifically, there is a need for technical assistance in establishing the infrastructure for anenhanced food control programme, assessing laboratory service requirements, providingguidance to develop legislation and procedural manuals, setting up reputable inspection andcertification systems, and providing training and staff development. FAO member countriesincreasingly recognise that both the SPS Agreement and the TBT Agreement have implicationsfor the work of the Codex Alimentarius Commission. Increasing consumer interest in foodsafety, the SPS and TBT Agreements of WTO, harmonisation initiatives, and the need for moretransparency, is leading to increased scientific, legal and political demands being made on thestandards, guidelines and recommendations elaborated by Codex.

Food fortification is an essential feature of nutrition strategies to alleviate micronutrientdeficiencies (FAO 1995). As illustration, salt is one of the most suitable vehicles for iodinefortification 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 widelyused vehicles for iron fortification, although many others, such as milk products, sugar, currypowder, soya sauce and cookies, have been successfully used. Foods successfully fortified withvitamin A include margarine, fats and oils, milk, sugar, cereals, and instant noodles. A limitednumber of food vehicles are suitable for vitamin D fortification, e.g. margarine, vegetable oilsand dairy products. Vitamin E, as tocopherol acetate, is added to fats and oils includingmargarine and fat spreads and breakfast cereals. There are technologies available for vitamin Cfortification of fruit juices, fruit juice drinks, other related beverages, dairy products and somebreakfast cereals. There are no problems related to the technology of the addition of B vitaminsto cereals and grains.

Food regulations need to cover the fortification of foods with micronutrients, and these should bein compliance with international standards adopted by the Codex Alimentarius Commission. As

illustration, food labels need to be clear and easy to understand with attention to harmonizinglabeling requirements. Better information on nutrient analysis and food composition is needed onfood labels. Measures to assist individuals with food intolerances need to be implemented, andlabels need to show greater sensitivity to socio-cultural diversity. Claims in food labeling oradvertising need to be carefully monitors, and regulations adopted and enforced that prohibitfalse or misleading claims. National Codex Committees need to be established and/orstrengthened to assist the process of ensuring a safe food supply (See Appendix E for nationallevel Codex contact points).

HIV/AIDS. More than 90 per cent of all adults living with HIV/AIDS live in developingcountries. Not only is the incidence increasing in Asian countries, but the numbers are growingin alarming proportions in South-East and South Asia, with more than half of all new infectionsoccurring among children and young people under age 25 years. HIV/AIDs also seems likely tointensify rural poverty. Malnutrition as inherent to the AIDS syndrome, not only contributes topoor health status, but by extension, to low labour productivity, low incomes and livelihoodinsecurity. People with AIDS are particularly vulnerable because without a good diet, theycannot maintain good health and live a longer life to provide for their children. Copingmechanisms often disintegrate soon after adult death, and food intake frequently declines sharplyamong surviving members.

HIV/AIDS morbidity and mortality intensify nutritional insecurity in several ways. They triggerfood 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 alsois an increase in the frequency and extent of food insecurity in these households. For design ofeffective interventions, policy makers, planners and nutritionists need a comprehensiveunderstanding of the interrelationships of HIV/AIDS to insecurities of food, nutrition and socio-economic deprivation, with socio-cultural sensitivity to family dynamics and copingmechanisms.

Partnerships of wide range are essential if governments are to effectively design and implementstrategies and measures to achieve nutritional security beyond 2000. As illustration formicronutrient malnutrition, successful approaches to introduce food fortification requires strongsupport from a range of private and public sector partners. Co-operation of the food industry isusually sought at a very early stage of programme development, but planners, practitioners andpolicy makers at various levels of government make the initial and vital contributions tofortification efforts. These partnerships contribute to long term food diversification strategies byproviding improved preservation technologies, techniques, improved semi-processed foods, andby promoting consumption of locally available micro nutrient rich foods in the diet or as a foodfortificant. Several successfulul partnerships are operating in Asian countries. Thus, simplenutritional and technological solutions exist and considerable progress has been made throughpartnerships. Mandatory compliance is ensured through legislation and regulations, andsupplemented by political and financial incentives furnished in many forms and from varioussources 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 strifein the country and other related conditions requiring relief and rehabilitation when individualsand households become vulnerable and are at high risk of deteriorating nutritional status. Themost vulnerable households include those headed by poor women; urban slum dwellers; poor

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 rapidinterventions for rehabilitation flowing from effective monitoring, evaluation and mobilizationstrategies. Effective responses require decisions be made in collaboration with the victims, whoare 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 andorganized 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 emergencysituations.

As support for policy and intervention strategies, indicators need to be identified for monitoringboth progress and effectiveness of relief and rehabilitation provisions. Effective interventions aresensitive to the socio-cultural situation, especially the local governing culture, traditions andwork procedures. Effective indicators highlight changes in the overall impact of the emergencysituation 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 theeffectiveness of indicators, such as climate, market prices, prevalence of conflict of violence inthe community, and a range of socio-cultural factors which differentiate people, such as ethnicityand religion.

Effective intervention strategies during natural calamities, civil war and strife in the country andother related conditions combine relief and rehabilitation when individuals and householdsbecome vulnerable and are at high risk of deteriorating nutritional status. These strategiesinvolve the promotion of home production of food, improved utilization of food, and foodprocessing using appropriate technology. They entail increasing the purchasing power ofhousehold members and enhancing community capacities for response to emergency situations.While food aid is often an essential initial response to furnish relief, sustainable strategies fornutritional well being combine relief with rehabilitation strategies involving the promotion ofhome food production.

Capacities of communities need to be enhanced following emergency situations. Communityorganizations most frequently identified as targets include women's groups, farmer co-operatives, saving and credit groups, water users' associations, children's groups, andorganizations of youth and senior citizens. Older persons are particularly effective in Asiancommunities, as senior members of most households exercise major influence in communitydecisions. Existing skills need to be identified and, thereafter, supplemented by training andinvestments.

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 andtemporary staff, and provision of good supervision and training in the field. As capacities at bothnational, regional and community levels also need to be strengthened, effective co-ordinationensures that nutrition security becomes an integrated components of all activity responses toemergency situations.

E. Nutritional Impact of Economic Crisis

The current economic crisis that has engulfed much of South East Asia appears to have impingedon various spheres of development as well as nutritional status. While information on its specificimpact on nutritional status of the community is yet to be made available from countries in theregion, the situation indeed calls for integrated and sustained community action to address thenutrition problems that are evolving as formidable challenges in the near future. Comments onthe impact of the socio-economic crisis in Asian countries with reference to the food andnutrition situation and status constitute this section (FIVIMS Expert Consultation. 1998).Notably, the developing countries most affected by the crisis have not yet established adequatesocial 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 majorcrises. The World Bank estimates shown in Figure 11 below highlight the negative impact of areversal in poverty alleviation in all three countries, although in varying degrees (World Bank1999). Poverty lines are set at around one US$/day for Indonesia, two US$/day in Thailand, andfour US$/day in the Republic of Korea. Between 1997 and 1998, poverty doubled in Indonesiaand it nearly tripled in urban areas in the Republic of Korea. Indonesia and Thailand areelaborated subsequently (Soekirman 1999; Tontisirin and Bhattacharjee 1998).

Figure 11. Poverty Incidence, World Bank Estimates (per cent)

Source World Bank News Release, 2 June 1999.

In Indonesia, the impact of the economic crisis is being rapidly transformed into a nutritionalcrisis with serious implications for the future. Major food shortages and accelerating food pricesduring 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). Thisdrop is immediately translated into reduced purchasing power and limited ability of householdsto access their basic needs of food and health care. Qualitative dietary studies (HKI 1998) showdecreased consumption of relatively expensive foods such as milk, eggs and fortified noodles inJawa, Kalimantan and South Sulawesi. The proportion of mothers and children who drank milkbefore the crisis (in June 1996) was twice that during the crisis (in June 1998).

Coinciding with these findings, the prevalence of severe malnutrition (marasmickwashiorkor)increased from 5 per cent to 10–18 per cent in 1996–1997 and as much as 12 to 30 per cent in1998. There is evidence of a shifting pattern for weight gains among children under age 5 years,whereby, on 45 per cent of children gained weight during the crisis in 1998 in contrast to 75 percent in 1997, before the crisis. Besides, vitamin A deficiencies are re-emerging among women,e.g. the prevalence of night blindness is higher than observed 12 months ago. Childhood anaemiaalso has increased.

Poverty alleviation is a major component of long term national policy to achieve food andnutrition objectives in Thailand. The Poverty Alleviation Plan (PAP) initially focused onimproving the quality of life of 7.5 million poor people in the northern, northeastern and extremesouthern regions. To achieve its objectives and to promote equity, PAP adheres to five principles:1) priority is given to specified areas where poverty is concentrated; 2) living standardssupporting a subsistence level of living for all people; 3) emphasis to people eventuallybecoming self-reliant; 4) low cost and affordable technology, and handled by the peoplethemselves; and 5) people's participation and promotion of self-reliance in decision making andproblem solving.

The declining trends for the prevalence of poverty, shown in Table 20 below, are due to PAPimplementation through this multi-sectoral approach. Further evidence is featured in Figure 11above, where World Bank estimates show relatively small increases in poverty due to theeconomic crisis, from 11.4 per cent in 1996 to 12.9 per cent in 1998.

Table 20. Poverty Incidence in Thailand, 1988–1996 (per cent)

Region 1988 1990 1992 1994 1996Central 32.9 20.7 15.4 7.2 6.2East 15.5 19.4 11.9 7.5 3.8West 32.0 26.4 13.1 12.5 9.3North 32.0 23.2 22.6 13.2 11.2Northeast 48.4 43.1 39.9 28.6 19.4South 32.5 27.6 19.7 17.3 11.5Bangkok 6.1 3.5 1.9 0.9 0.6Total average 32.6 27.2 23.2 16.3 11.4Total (millions) 17.9 15.3 13.5 9.7 6.8

Source: The Poor Thai 1998

The economic crisis in Thailand is giving rise to poverty and declines in earnings, as suggestedby a 13.6 per cent decline in the standard of living (World Bank 1999). Rural areas are mostaffected. Available evidence, newspaper reports and economic records suggest four additionaleffects; namely, adoption of prudent life styles with reductions in consumption, varying degreesof psychological stress among severely affected individuals, declines in nutritional adequacy interms of total daily dietary energy, and declines in both food supplies and micronutrients.Available evidence about the current nutrition situation suggests that the progressiveimprovements in nutrition experienced over the past two decades as part of poverty alleviationare being sustained.

The economic crisis has here-to-fore not become manifest as food insecurity, due partly to the‘food safety net,’ established in the country through the long term efforts of the Royal Familyand co-operative efforts between the government and non-governmental organizations (NGOs).The Royal Family promotes ‘self-sufficiency of food’ through improvement programmes ofagriculture and food production operating throughout the country, with special efforts directed to

people in the vulnerable regions bordering Thailand. His Majesty the King of Thailand givespriority to food production as a priority for consumption, followed by economic improvement.

These holistic prevention and control strategies for addressing nutritional problems have beendeveloped and are being implemented at various levels through the agriculture, health andnutrition services and systems within the country, utilising a participatory communityinvolvement approach. Integrated farming systems are practised to optimise the use of availableland. A typical land distribution for use of existing resources among most rural households isoutlined in Table 21 below, which His Majesty the King of Thailand encourages this optimal useof land by rural households. This combination of measures supports a simple, self sufficientsystem of food production for home consumption that is well established in most ruralhouseholds.

Table 21. Typical Land Use by Rural Households in Thailand

Land purpose Proportion for use(per cent)

Housing 10Reservoir of water Fish ponds 30Home gardens Fruit trees, raising poultry 30Cultivation of staples (rice) 30

Source: Tontisirin and Bhattacherjee 1998

Government support schemes have been set up in response to the economic crisis. For instance, asocial investment fund links communities with NGOs supporting community based activities.This support fund is used to provide investment for assistance with such activities as, small-scalefarming, food enterprises, fruit processing, and self-help activities. Various food production,processing and marketing schemes for the unemployed are also components of this governmentsupport, and these activities are supported by training programmes. The government alsoestablished credit co-operatives at the community level to support rural and urban groups. Thisassistance also enables groups to meet the nutritional and income needs of the most economicallydisadvantaged.