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An FFQ is a way to estimate the food consumed over an extended period 6—12 months. An FD is a more specific and detailed assessment conducted over a number of days to quantify what one actually eats. There is no standardized pattern or agreed types of foods included in these forms of dietary assessments.

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The foods consumed can be considered specific to a region or country of origin, and the foods vary between studies, as they have been conducted in different countries and geographic areas. Generally, the food intake is recorded as it is relevant to the specific cohort under investigation.

The FFQ has been found to be reproducible and have good comparative validity. The FFQ has demonstrated dietary intervention effects to be relatively accurate 94 — When converted to different languages, the validity of the FFQ was also reproducible, such as with the Brazilian, Chinese, and Italian populations 97 — Across the 18 studies, there was no standardization of the most appropriate FFQ. There was a large variation in the FFQs adopted, and the selection of food groups ranged from 70 to different groups.

It is also important to consider portion sizes, as some studies used food frequency alone. It is more appropriate for comparison to include portion size by food groups with respect to gender and ethnicity Portion size needs to be determined based on the norms for the country under investigation and reported in grams per day for equivalence. The adherence to a standardized pattern of a MedDiet as demonstrated in the initial research conducted in , Trichopoulou et al.

This original research, which forms the focus of many of the studies conducted to date, used 14 all-inclusive food groups that were evaluated in grams per day, and consequently prospective studies need to adhere to this specific pattern of evaluation to ensure valid comparisons can be made. To ensure that direct correlations can be made between studies, it would be of value to have a standardized computer-based FFQ that is easy to administer and simple to review. The use of a standardized FFQ that utilizes 14 all-inclusive food groups all evaluated to grams per day, and this would enable more accurate portions of food taken grams per day to be evaluated to obtain a MedDietS.

Interestingly, positive cognitive effects were found in countries around the world, including those outside of the Mediterranean region. Many of these positive studies used an approach where a mean or median is determined for each food category, and adherence for the individual is scored relative to this mean or median.

In this way, habitual dietary habits are normalized with respect to the local region. Change over time is assessed relative to baseline scores to assess whether or not greater adherence supports better cognitive health. While this makes it difficult to compare absolute measures of dietary adherence in relation to a more traditional Mediterranean diet 26 , it is encouraging that measurable shifts in adherence within a local population are effective in improving cognition or retarding cognitive decline.

An important challenge will be to demonstrate a sustainable long-term shift in diet within a population that also confers cognitive benefits. This review has analyzed longitudinal and prospective trials in accordance with the specified criteria to gain an understanding of how a MedDiet may impact cognitive processes. The level of adherence to the MedDiet has subsequently been evaluated against various cognitive domains to ascertain the potential protective nature of this diet pattern with respect to minimizing cognitive decline, improving cognitive decline, or reducing the incidence of conversion of MCI to AD.

The overall outcome from this review indicates that there is encouraging evidence that a higher adherence to a MedDiet is associated with improving cognition, slowing cognitive decline, or reducing the conversion to AD. With few studies available to assess benefits of a MedDiet intervention in a healthy older population, it is recommended that further randomized controlled trials need to be conducted.

These trials need to include a standard food consumption assessment that can be validated to determine the impact of cognitive changes over time. It is also recommended that future RCTs utilize validated computer-based cognitive batteries that are sensitive to cognitive faculties, which are compromised with age and potentially amenable to interventions, such as a MedDiet. Future studies should also consider the use of blood, cardio, and fecal biomarkers that will allow for mechanisms of action to be evaluated. Biomarkers will provide more direct measures of dietary status and will potentially elucidate important biological changes that relate to brain function and modifiable risk factors.

Further focused research in this area is important due to the expected extensive population aging over the next 20—30 years. The utilization of such a dietary pattern will be essential as part of the armamentarium to maintain quality of life and reduce the potential social and economic burden of dementia. There have been substantial contributions to the conception and design of this review by all authors, and all authors have been involved in revising the work critically for important intellectual content.

The final approval of the version to be published has been agreed by all authors, and an agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work has been appropriately investigated and resolved. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The resources of Centre for Human Psychopharmacology, Swinburne University of Technology, Melbourne, Australia and the Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia have been utilized to produce this review, and their contribution is extremely appreciated. There have been no funding sources provided to any author in the development and final submission for this review. Cognitive impairment and dietary habits among elders: the Velestino Study. J Med Food 16 4 — Molecular mechanisms of life- and health-span extension: role of calorie restriction and exercise intervention.

Appl Physiol Nutr Metab 32 5 — Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction — final report of the Lyon Diet Heart Study. Circulation 99 6 — Oxen England: Blackwell publishing Google Scholar. Mediterranean diet and cognitive decline over time in an elderly Mediterranean population.

Eur J Nutr 54 8 — Peters R. Ageing and the brain. Postgrad Med J —8. Assessing the efficacy of nutraceutical interventions on cognitive functioning in the elderly. Curr Top Nutraceutical Res 8 2—3 — Christensen H, Kumar R. Cognitive changes and the ageing brain. In: Sachdev PS, editor. Ann N Y Acad Sci — Finch CE. Neurons, glia, and plasticity in normal brain aging. Neurobiol Aging S—7. Insulin-like growth factor-I and neurogenesis in the adult mammalian brain. Brain Res Dev Brain Res 1—2 — A longitudinal study of brain volume changes in normal aging using serial registered magnetic resonance imaging.

Arch Neurol 60 7 — Trends Neurosci 27 10 — Potential benefits of adherence to the Mediterranean diet on cognitive health. Proc Nutr Soc 72 1 — Mathers JC. Nutrition and ageing: knowledge, gaps and research priorities. Proc Nutr Soc 72 2 — Functional significance of adult neurogenesis. Curr Opin Neurobiol 14 2 — Ambulatory blood pressure and brain atrophy in the healthy elderly. Neurology 59 5 —9.

Can Med Assoc J 17 :E— Nutrients 7 6 — Salthouse TA. Does the level at which cognitive change occurs change with age? Psychol Sci 23 1 — Nutrition, inflammation, and cognitive function. Neuroimmunomodulation: From Fundamental Biology to Therapy. Malden, MA: Wiley-Blackwell Kirkwood TBL. Understanding the odd science of aging.

Cell 4 — Dauncey MJ. New insights into nutrition and cognitive neuroscience. Proc Nutr Soc 68 4 — Nutrition, the brain and cognitive decline: insights from epigenetics. Eur J Clin Nutr 68 11 — Modification of brain aging and neurodegenerative disorders by genes, diet, and behavior. Physiol Rev 82 3 — Adherence to a Mediterranean diet and survival in a Greek population.

N Engl J Med 26 — Development of a short dietary intake questionnaire for the quantitative estimation of adherence to a cardioprotective Mediterranean diet. Eur J Clin Nutr 58 11 —2. Ageing Res Rev 3 4 — Mediterranean diet and cognitive decline. Public Health Nutr 7 7 — Vaynman S, Gomez-Pinilla F. J Neurosci Res 84 4 — Diet quality is associated with better cognitive test performance among aging men and women. J Nutr 10 —9. Mediterranean diet and cognitive function in older adults.

Cognitive impairment following high fat diet consumption is associated with brain inflammation. J Neuroimmunol 1—2 — Adherence to a Mediterranean-type dietary pattern and cognitive decline in a community population. Am J Clin Nutr 93 3 —7. Cherbuin N, Anstey KJ. The Mediterranean diet is not related to cognitive change in a large prospective investigation: the PATH through life study. Am J Geriatr Psychiatry 20 7 —9. Plasma total homocysteine and cognitive performance in a volunteer elderly population. J Nutr Biochem 13 8 — Exercise reverses the harmful effects of consumption of a high-fat diet on synaptic and behavioral plasticity associated to the action of brain-derived neurotrophic factor.

Neuroscience 2 — Fish consumption and incidence of stroke — a meta-analysis of cohort studies. Stroke 35 7 — Prospective-study of alcohol consumption and risk of dementia in older adults. JAMA 11 — Alcohol intake in relation to brain magnetic resonance imaging findings in older persons without dementia.

Am J Clin Nutr 80 4 —7. PubMed Abstract Google Scholar. Kennedy DO. B vitamins and the brain: mechanisms, dose and efficacy — a review. Nutrients 8 2 Gomez-Pinilla F. Brain foods: the effects of nutrients on brain function. Nat Rev Neurosci 9 7 — Influence of supplementary vitamins, minerals and essential fatty acids on the antisocial behaviour of young adult prisoners. Randomised, placebo-controlled trial. Morris MC. Symposium 1: vitamins and cognitive development and performance nutritional determinants of cognitive aging and dementia. Proc Nutr Soc 71 1 :1— Morley JE.

Cognition and nutrition. Novel insights into the effect of vitamin B and omega-3 fatty acids on brain function. J Biomed Sci Fish consumption, long-chain omega-3 fatty acids and risk of cognitive decline or Alzheimer disease: a complex association. Nat Clin Pract Neurol 5 3 — Effects of Omega-3 supplementation on brain structure and function in healthy elderly subjects. J Psychophysiol — The influences of diet and exercise on mental health through hormesis.

Ageing Res Rev 7 1 — Regular fish consumption and age-related brain gray matter loss. Am J Prev Med 47 4 — The diet and year death rate in the 7 countries study. Am J Epidemiol 6 — Adherence to a Mediterranean diet and risk of fractures in French older persons. Osteoporos Int 24 12 — Mediterranean diet, cognitive function, and dementia: a systematic review. Epidemiology 24 4 — Neurology 56 9 — Low folate status is associated with impaired cognitive function and dementia in the Sacramento Area Latino Study on aging. Am J Clin Nutr 82 6 — Health benefits of the Mediterranean diet: an update of research over the last 5 years.

Angiology 66 4 — N Engl J Med 7 — Homocysteine and cognitive performance in the Framingham Offspring Study: age is important. Am J Epidemiol 7 — Van Dyk K, Sano M. The impact of nutrition on cognition in the elderly. Neurochem Res 32 4—5 — Ordovas JM. Nutrition and cognitive health. In: Science T. Foresight Mental Capital and Wellbeing Project. London: The Government Office of science Mediterranean diet and cognitive function: a French study.

Am J Clin Nutr 97 2 — More than the sum of its parts?

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Nutrition 26 7—8 — Ferry M, Roussel AM. Micronutrient status and cognitive decline in ageing. Eur Geriatr Med 2 1 — Damaging effects of a high-fat diet to the brain and cognition: a review of proposed mechanisms. Nutr Neurosci 17 6 — Eur J Nutr 53 1 :1— Aging Milano 6 6 — Mediterranean diet adherence and self-reported psychological functioning in an Australian sample.

Appetite —9. Mediterranean diet, Alzheimer disease, and vascular mediation. Arch Neurol 63 12 — Mediterranean diet pyramid: a cultural model for healthy eating. Adherence to a Mediterranean diet, cognitive decline, and risk of dementia.

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JAMA 6 — Mediterranean diet and mild cognitive impairment. Arch Neurol 66 2 — J Alzheimers Dis 22 2 — Behavioural effects of a day Mediterranean diet. Results from a pilot study evaluating mood and cognitive performance. Appetite 56 1 —7. Adherence to the Mediterranean food pattern predicts the prevalence of hypertension, hypercholesterolemia, diabetes and obesity, among healthy adults; the accuracy of the MedDietScore.

Prev Med 44 4 — Mediterranean diet and cognitive decline in women with cardiovascular disease or risk factors. J Acad Nutr Diet 6 — The development of the Mediterranean-style dietary pattern score and its application to the American diet in the Framingham Offspring Cohort. J Nutr 6 —6. J Neurol Neurosurg Psychiatry 84 12 — Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain.

Br J Nutr 12 — Long-term adherence to the Mediterranean diet is associated with overall cognitive status, but not cognitive decline, in women. J Nutr 4 —9. Mediterranean diet and cognitive function in older age. Epidemiology 24 4 —9. Reproducibility and validity of an expanded self-administered semquantitative food frequency questionnaire among male health-professionals. Am J Epidemiol 10 — Mediterranean diet and incidence of and mortality from coronary heart disease and stroke in women.

Circulation 8 — Mediterranean diet habits in older individuals: associations with cognitive functioning and brain volumes. Exp Gerontol 48 12 —8. In other words, agreements on resource reallocations achieved in adjustment operations usually must be accompanied by specific projects aimed at strengthening institutional delivery. During the past three years. Such a loan is being planned for Costa Rica, and additional loans are expected to carry such agreements in the future.

A very important Bank operation in Jamaica is the Social Sector Resource Development Program, which is a mixture between an adjustment and a project operation.

INTRODUCTION

It focuses on broad policy reforms in the social sector, particularly on targeting issues, while disbursing against a fairly small part of the overall social-sector investment programme. The Venezuela structural adjustment loan The Venezuela SAL, approved by the board of the World Bank in June , supported a comprehensive programme of reform of the incoming administration, including the unification of exchange rates and the reduction of significant subsidies to the inputs into agriculture and agro-industries such as fertilizers and inputs into the cattle and poultry industries.

These subsidies were deemed to be not only inefficient but also inequitable. They heavily subsidized the consumption of meat across the overall population. The SAL supported a programme aimed at replacing general subsidies by targeted subsidies to the most vulnerable groups, directly financed by the budget, in six areas: grants cash and food vouchers to school-age and preschool children to be provided through schools in low-income neighbourhoods; feeding programmes for school-age children through schools in low-income neighbourhoods; nutrition and health care for pregnant women and infants in low-income areas; improved nutrition for preschool children through an expanded day-care system; housing improvements in the barrios; and provision of improved public services in the barrios such as water, sanitation, and power.

TABLE 1. Venezuela has increased resources to these programmes nine-fold in US-dollar values. The number of beneficiaries has also increased sharply. The number of cash grants will increase from 1. The Bank also plans to support present efforts through specific projects aimed at improving the delivery of existing programmes. A social development project will assist the government in improving the efficiency and distribution of targeted nutrition assistance.

By the proposed project would increase health and nutrition service coverage from about , to , pregnant women, from about 80, to , postnatal women, from , to , infants under two years of age, and from , to , children between two and six years of age. The second Mexico agricultural-sector loan To protect the real income of consumers and promote domestic food production, Mexico has had a programme of subsidizing the consumption and sometimes the production of particular foodstuffs AGSAL. Because in the past many of these subsidies were untargeted, they have resulted in large fiscal outlays, and some of the neediest groups have not benefited from the policy.

The government of Mexico is now in the process of transferring these subsidies to more targeted programmes. On the basis of an extensive joint study on food consumption and the evaluation of existing programmes, the loan will support implementation of a comprehensive strategy in this area, with particular emphasis on rural areas. The Tortibonos and milk programmes have been able to protect poor urban households. The rural poor, however, do not usually buy tortillas, and it is too costly and cumbersome to distribute liquid milk in rural areas.

The main programmes aimed at the rural poor are the Conasupo rural country stores and the maize flour subsidy, a semitargeted programme that benefits basically those who buy maize rather than grow it. The new strategy being supported by AGSAL is to improve the targeting of programmes by gradually using the health system as the mechanism to identify the groups at risk, specifically through monitoring pregnant and lactating mothers and the nutrition status of small children, particularly those under five years of age.

These will be the priority groups in the reallocation of resources. In the short run, the feasibility of using the health system as the main vehicle for nutrition interventions will be tested in two ways. First, the present PASSPA model of providing health care will be used to extend the delivery of basic health and nutrition assistance to 13 million uninsured individuals in Oaxaca, Chiapas, Hidalgo, Guerrero, and the Federal District, especially undernourished pregnant and nursing women and children under age five.

Second, a pilot project will test the capability of the health system to provide expanded nutrition and basic health care programmes in the poor rural areas of Nuevo LeTamaulipas, San Luis Potosand Mexico. The pilot project will cover 45, families.

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Based on these two experiences and on evaluation of all continuing programmes, the government of Mexico will develop an action plan for to expand the coverage of such interventions and to reallocate funds to the most effective ones. In that way a major improvement in the food consumption and nutrition of the poor can be achieved at a fiscally acceptable cost. Sectoral analyses indicate that the enormous drop in budgetary resources for the social sectors that occurred in the late s has resulted in the progressive deterioration of health, nutrition, and education services.

The government has begun a comprehensive economic stabilization and structural adjustment programme while providing a safety net for the most vulnerable groups in the society. The structural adjustment loan includes an agreement to put in place a targeted nutrition assistance programme and to increase the share of government expenditures for health and education. To improve the nutrition status of the most vulnerable groups, particularly children under 12 years old and lactating mothers, the government identified the target populations to receive assistance and will first introduce a pilot programme jointly with the World Food Programme.

The government prepared a pilot project to distribute nutritionally fortified cookies to schoolchildren that began at the beginning of the school year in March At a second stage, the government will expand the programme, specifically the distribution of the fortified cookies to schoolchildren, the introduction of infant foods through health posts, and the initiation of a pilot project to distribute food coupons to the most vulnerable groups. A companion social-sector rehabilitation project in fiscal year will ensure that nutrition, health, and education resources are used effectively.

The principal objectives are to assist the government in restructuring and strengthening the ministries of Health and Education and the social-sector department of the Ministry of Planning. The project will also assist the government in developing a nutrition component as part of a basic health care package that will include a nutrition surveillance system, improvement in training programmes, and expansion and improvement of child growth-monitoring programmes.

The third Costa Rica structural adjustment loan Costa Rica is one of the more advanced countries in Latin America in adjustment. It has gone through important deregulations in its price and trade regime, and is gradually recovering growth. Its public sector, however, needs additional reforms to consolidate and clarify the role of different agencies, improve the budgetary process, and reduce the fiscal burden of the social security system. On the social side, Costa Rica is well known for its advances. Nutrition indicators are among the best in Latin America.

Nevertheless, there are still important differences in these indicators across counties cantones , and a significant portion of nutrition and food programmes benefit groups with no malnutrition.

Review ARTICLE

A large fraction of expenditures goes to school feeding programmes with little targeting, whereas those better targeted, such as those delivered by nutrition centres to reduce severe malnutrition, receive a small share of resources. In addition, a large portion of the cost of school feeding programmes is spent on personnel costs.

The SAL III, currently being prepared, will support public-sector reforms to be undertaken by the new government and also a plan of action to improve the efficiency of existing nutrition programmes and improve its targeting. The possibility of a food-stamp programme for the most vulnerable families is being explored with the technical assistance of the Regional Office for Technical Assistance.

In addition, ways to improve the efficiency of the school lunch programmes are being studied, including subcontracting the services to mothers in the community, micro-enterprises, and cooperatives. The coordination of programmes will be improved through the creation of a national registrar of beneficiaries. The Jamaica social sectors development project Among countries of comparable income per capita, Jamaica has ranked high in conventional indicators of social development. However, economic decline in the s, followed by a period of economic adjustment in the s, resulted in significant economic hardship for important segments of the population.

By late the government of Jamaica was acutely aware of the need to improve the programme's targeting, quality, and coverage. The Bank was requested to assist in the design of a human resources development programme HRDP and to take the lead in securing further external financing at favourable terms. The HRDP, which covered broad social-sector investment and policy reform was presented to potential donors at a special meeting in June , and additional external financing for health, nutrition, and education activities was successfully secured.

An important result of this process was the rationalization of food and nutrition policies in Jamaica, comprising general food subsidies, food stamps, and school feeding programmes. As nutrition aid is increased for carefully targeted beneficiaries while general food subsidies are phased out, the overall cost is being kept under control. Eligibility criteria have been tightened and made more transparent, targeting of benefits has improved, and programme administration and service delivery have been streamlined.

The benefits from this programme, which was not targeted, were regressive. The poorest quintile of the Jamaican population received about half the direct consumption benefits per person per year received by the richest quintile. Under the Bank's social sectors development project, which supports the HRDP, the government of Jamaica agreed to phase out general food subsidies completely over two years. Eligible beneficiaries include pregnant and lactating women and children under five who receive health care at public health clinics, the elderly poor, very poor families, and persons already enrolled in one of the other welfare programmes.

The programme is thus well targeted and progressive. Under agreements reached with the Bank, the amount has been tripled since In addition, the government has removed unqualified recipients from the rosters, reducing the number of targeted beneficiaries from , to about , As of 31 December about ,00 beneficiaries were being reached.

The government has recently taken steps to improve the distribution mechanism, and it is expected that about , will be reached during TABLE 2. Food stamps. Does not include administrative costs Under the Bank's social sectors development project, school feeding programmes have been progressively targeted towards poorer schools, and coverage of the bun and milk programme financed with assistance from the World Food Programme and USAID has broadened from about , students in to about , students at present. Another , students continue to be covered under the traditional programme in which food is cooked and distributed at the schools.

Table 2 summarizes the distributive effect of general and targeted food subsidies in Jamaica. Transferring resources to the food-stamp programme increases sharply the subsidy received by the lowest income groups in the population. This definition has two critical implications: first, that decision making should be relative to interventions or activities at the population level, in contrast to decisions made at the level of the individual on a case-by-case basis; and, second, that the information issuing from nutrition surveillance should actually be used in decision-making.

The ultimate purpose is to provide pertinent and timely information to enable policy makers better to take nutrition considerations into account and programme planners and managers better to design and implement interventions to protect nutrition [2]. It has been recognized that nutrition surveillance can be classified operationally into four different types: a timely warning information system, a means to manage and evaluate programmes, a means to establish policy and planning [2], and, more recently, a means to identify problems and provide advocacy.

Although the underlying principles and general goals for all these subtypes are basically the same, their differentiation in terms of implementation and of the specific policy served by the information is situation dependent. In this paper, we will discuss only one of these: nutrition surveillance for policy and planning. We chose this topic because China is now considering establishing nutrition surveillance, and pilot data collection is already proceeding. This effort is intended ultimately to cover all of China, not just a few provinces.

Those involved want information for policy formulation and programme planning for decisions about economic development, health, and food security. At some future time it may be necessary to be concerned about improving the efficiency and efficacy of programmes. One may hope that never again will a timely warning nutrition surveillance system be needed to institute short-term prevention measures against famines; however, other needs for rapid interventions may become apparent as China's food and nutrition circumstances become better understood.

Thus we are not belittling the future importance of these other kinds of surveillance but are only concentrating first on what is most immediate. The role of the information user in designing nutrition surveillance The major goal of nutrition surveillance for policy and planning is to make nutrition and nutrition-related information available to decision makers. However, the nutrition of populations cannot be protected adequately if it has not been considered in the policies that affect populations. Analogously, nutrition cannot be considered if the information needs of decision makers are not taken into account during the process of information generation.

The information should not only enable policy makers to foresee nutrition problems but also provide insights into how to prevent them. Because of the heterogeneous nature of the causes of these problems, all government and non-government sectors that affect economic and physical well-being also affect the nutrition of the population. Decision makers in all these sectors could use information from surveillance to be sure that the impact of their decisions on nutrition is taken into account, even if the action to be taken has non nutrition objectives. However, in order to use surveillance information, the potential users must know that it is available, have it available at the moment they need it, and understand its implications.

Sectors and agencies whose policies affect nutrition and food security The best way to be sure that users have the right information at the right time is to involve them in the design of the surveillance system to be sure that the data coming from the system meet their needs. The Chinese Academy of Preventive Medicine is undertaking user surveys as a first step to involve these decision makers and their advisers.

The purposes of the surveys are 1 to make decision makers and their advisers aware of the proposed nutrition surveillance system, 2 to identify major users of the information, in particular, some of each kind of user with whom the surveillance unit can work more closely to ensure that all users of that kind receive relevant and timely information, and 3 to ascertain the users' concerns about specific policy issues so as to incorporate their needs into deciding the timing and format of the information presentation.

A pilot survey was conducted in to ascertain what kinds of influential persons would use the data and for what purposes. Twenty-three potential users, representing a wide range of agencies and backgrounds, who were known to be interested in food and nutrition were chosen by the senior staff of the Chinese Academy of Preventive Medicine. The survey was done by a questionnaire, followed by personal interviews. Most of those interviewed responded that they had used some sort of food and nutrition information from various sources before.

All of them agreed strongly that such information was useful and requested that it be provided to them. Neither of these answers was surprising in view of the selection process. We grouped the potential users into four categories relative to policy-making: seven administrators. Five policy consultants, eight researchers and scientists, and three people working in mass media. As expected, only the administrators said they had direct influence on setting policies and planning programmes, but the high-level consultants and researchers had direct access to decision makers and influenced their decisions.

This contrasted with those from the mass media, who concentrated on more general information diffusion and affected decisions in this way. However, the consultants and researchers said that they also wrote articles and reports to advocate improvements. The major findings were that researchers and consultants prefer regular reports, whereas mass media and administrators want information when they need it, often at irregular intervals. All preferred long and comprehensive reports, but most also wanted short summaries. One administrator requested summaries only. Based on the results of this first survey, a second survey is being designed that will go beyond identifying potential users of nutrition surveillance information to identify the kinds of policy and Programme planning needs that must be met.

Special attention is being given to the sectors named in figure I and the agencies in these sectors. This information should help to ensure that policies in education, development, welfare, health, food marketing, and food supply will result in eliminating conditions of want e. As indicated above, these surveys are but a first step in what must be a continuing dialogue with the users of nutrition surveillance information so that the system can better serve them.

Height of seven-year-old boys in China. Rural development policies address this issue by identifying possible reasons for this discrepancy and correcting them. For instance, in China one reason may be that the government bought food at much lower prices than farmers could sell it on the free market by exacting quotas from the farmers.

This food was then sold to urban dwellers at subsidized prices. Thus farmers earned less and urban dwellers ate cheaper foods than if the food had been bought and sold on the free market. For the farmers. The result of this policy may be one reason why rural children did not eat enough to grow properly. Figure 2 shows the height of seven-year-old boys in the lao-shao-bian-qiong old, ethnic, border, poor areas, which are thought to be the poorest rural areas, all rural areas, suburban areas, all urban areas, and large cities.

It also shows the evolution of these heights over time. Some of the data include all children and others only healthy children; the 2-cm difference in height between the two is taken into account in the figure. Dotted lines join data points from different surveys in similar populations to make it possible to visualize the secular trends more easily. These data capture the deterioration in growth during World War II but do not show the effects of the famines of , which took some 30 million lives-more deaths than in any other famine in history [7].

The stunting of the famine survivors is undocumented. In spite of all these reversals and uncertainties. The same is true for suburban children in the s and for many rural children in the s. However, the growth of urban children is levelling off well below the likely growth potential of Chinese children as indicated by international growth standards [8] based on a well-nourished population. The mean growth of well-fed children in all populations is within 1 or 2 cm of these two standards [9, 10]. The reason for the levelling off in urban children in the s is not clear.

This is worrisome. Even more worrisome is the growth of levelling off in suburban children at double the degree of mean stunting as measured by the standards of urban children, which bodes ill for a continued rise in the growth of rural children above these stunted levels. Of greatest concern is the fate of children in the lao-shao-bian-qiong areas, who are three times as stunted as the urban children and have shown no improvement over the past decade. The major differences in the growth of these young boys are not due to any racial factors but to the rural urban discrepancy in socio-economic status and an inadequate diet [9].

Endemic diseases such as diarrhoea cannot produce so much stunting when an adequate diet is available [11]. This kind of information about the rural-urban discrepancy in growth and some ideas about its causes are typical of what one should expect from nutrition surveillance. It can be used to advocate policies and programmes to improve rural well-being. It can help to identify reasons for inadequate nutrition that can be remedied by policies and programmes. It can also target development programmes to areas of greatest need for these interventions, such as the government allocation of poverty-relief aid to lao-shao-bian-qiong areas, which attempts to redistribute certain resources at the national level to underdeveloped rural areas and regions at risk of famine.

Finally, it can monitor the improvement of nutrition status brought about by policies and programmes. Thus, for instance, the Chinese economic reforms are known to have improved the income of some farmers [12]. Is this a general phenomenon, or are there some who have not benefited or who are even worse off and who therefore need policies and programmes to protect their nutrition even while the benefits of economic reform are retained?

Nutrition surveillance, especially of the growth of children, can monitor this evolution. It appears in China that the size of two- and three year-old children is the best indicator, because growth is stunted most severely between 6 and 24 months of age [6]. For nutrition surveillance purposes, growth is a more easily interpreted indicator of nutritional wellbeing than is dietary intake [13], although food data are essential to understand what has to be done. When food intake is marginal or inadequate, disease affects nutrition status adversely [ Monitoring the effects of the Chinese restructuring of health services on nutrition and the growth of children is therefore particularly important in poorer areas with stunted children.

With the dissolution of rural agricultural communes, local collectively financed support for basic health workers has disappeared in many areas [14]. With the management of health services returned to the private sector, it is estimated that nearly half of more than , village-level health stations require substantial payment for services and medicines [14]. This cost of medical care may deter the use of this service by the poor.


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Backed by the new commitment of the government to restructure the rural primary health care system [15] to attain "Health for all by the year ," nutrition surveillance can play an important role in quickly identifying any detrimental effects of these changes in health services and in assisting policy makers in directing limited resources to the areas and populations that most need them.

Again, the growth of children is the most satisfactory indicator. In these poorer populations breast-feeding and good weaning practices are important. This is particularly true where environmental sanitation is poor [5, 16]. Thus nutrition surveillance must not only collect data about breastfeeding and weaning but also deliver information about the adequacy of water and sanitation so as to target appropriate interventions to the most needy populations. Another area of health concern is a marked rise in the consumption of animal foods.

In the decade pork consumption doubled in rural communities and beef consumption almost doubled in urban areas [17]. These animal foods are unhealthy when eaten in excess because they are rich in fats associated with cardiovascular disease [18]. Figure 3 shows how the proportion of energy from fat increases with income in both rural and urban areas. There is a large increase in this proportion among those with incomes above yuan per year in urban areas, which is surprising because one expects a smooth progression of increasing energy from fat with increase in income.

Is this because these urban households benefit from hidden subsidies so that their real income is greater than what they earn? In any case, this rise in fat consumption is unhealthy. Percentage of energy from fat by income level calculated from refs. Fat from mammalian sources and eggs is considered less healthy than that from fish, poultry, and vegetables. Unfortunately, intake of mammalian and egg fat will continue to go up with increased income in groups with higher fat consumption [19].

On the other hand, when a diet has too little fat, it is not rich enough in energy for young children. It is even lower in the poorest quintile, among whom fat provides only This is a probable explanation of the poor growth in these children. Fortunately, small increments in income among those poor will go preferentially to increasing the fat content in their diet [20], which may be a sensitive indicator of the effectiveness of programmes and policies to increase their income.

An increase of energy intake is another characteristic of increasing income in China [19, 20]. This is beneficial among the rural poor, whose intakes relative to energy expenditures are probably marginal. Among the urban rich, who tend to expend less energy in work, it leads to obesity. Obesity is the main determinant of diabetes, which rises to high proportions among the overweight [21] and also contributes to hypertension [18]. Monitoring and characterizing the obese through nutrition surveillance will indicate ways to reduce obesity and where to target these interventions. Such interventions will have to go beyond price policies in the context of food security, and must include nutrition education and exercise.

If activities directed toward food security take the unhealthy effects of a high mammalian and egg fat intake into account, they will also include food pricing and other marketing interventions to reduce consumption of these items. Here we discuss only national food security, which is concerned with ensuring that enough food is available to meet demand. National food security is a prerequisite for, although not a guarantee of, the security of market food i. Ensuring national food security requires monitoring food production and supply, which is usually done by agricultural and food data systems that lie outside the purview of nutrition surveillance.

These systems generally rely on historical information about consumption to estimate future needs. The estimates are satisfactory so long as food consumption behaviour does not change. However, they lead to serious errors when behaviours change, as when famine occurred in Indonesia even though the food supply was adequate. Extremes in seasonal loss of income meant that people could not buy food in the traditional way, and thus many died, not for lack of food in the marketplace but for lack of access or entitlement to that food [22].

China faces an analogous problem at the national level, but the cause will be increases rather than decreases in purchasing power with continued improvement in socio-economic development, especially if it is equitably distributed among all Chinese. The first finding from the new Chinese Nutritional Surveillance System is that eating behaviour will change markedly as people have more money to spend on food [17, 19, 20]. Families will turn more and more to animal foods, most of which will be from grain-consuming animals, and this will increasingly be the case as family income rises.

The Chinese agricultural potential for grain may not be able to support a major shift to higher-quality grain-fed livestock, which consume three to six times more grain to produce a given quantity of calories for human consumption than if people ate the grain themselves [23]. In this sense, grain-fed animal food is inefficient.

Just as important as changes in behaviour in response to improved income are the changes caused by differences in prices of food. Policies and programmes that increase the price or decrease the availability of inefficient foods and decrease the prices of more efficient foods can reduce the growth in demand for agricultural production. The changes in food purchasing behaviour with increases in income and changes in food prices can be estimated from the nutrition surveillance data collected by the State Statistical Bureau [19, 20].

As indicated above, modern knowledge of nutrition shows that many of the most inefficient foods are unhealthy, and their consumption should be discouraged not only for food security reasons but also for health reasons [18]. As we begin nutrition surveillance in China, it is essential to give special attention to these inefficient foods and to identify healthier and more efficient foods in order to predict how their consumption will change with improved socioeconomic development and how changes in relative price and availability between the healthy and unhealthy foods can decrease consumption of the latter.

With this knowledge from nutrition surveillance, policy makers and planners can devise and implement ways to encourage greater production and sale of efficient, healthy foods relative to inefficient, unhealthy foods. Thus, for an equal proportional drop in prices they will increase their consumption twice as fast for chicken as for pork. The same information can be elicited less quantitatively by asking people whether they would prefer to eat chicken or pork if both had the same price; the answer overwhelmingly favours chicken.

Incidentally, this finding is similar to that in most populations around the world. Thus the only reason more pork is eaten in China right now is that chicken is so much more expensive. The implications of this finding are important. It means that by investing to improve efficiency in chicken production and marketing so as to bring the price of chicken below that of pork, as it is already in much of the world, and not investing in pork production and marketing so that pork prices do not fall commensurably, it would be possible to foster a shift in the consumption of the richer populace from less healthy, inefficient pork to healthier, more efficient chicken.

Lowering the price of chicken, which can more easily be accomplished through appropriate investments than could similarly lowering the price of pork, would also benefit the poorer Chinese, who could then more easily afford this healthy meat. Equally important, improving the availability and decreasing the costs of healthy, efficient foods not only improves the health of the population but also assures food security for the nation. Finally, nutrition surveillance can monitor the success of programmes and policies to improve nutrition, health, and food security.

This monitoring is essential because the programmes and policies will inevitably be less than perfect at the beginning. Good surveillance data will be necessary to permit fine-tuning them efficiently. These examples touch on only some of the issues of concern to users of nutrition surveillance information, but they give a good idea of the relationship between such information and its use in policy-making and planning. Issues relating to data and their analysis Various data sources in China are already part of the nutrition surveillance system e. To be useful, the sources must be able to deliver valid, relevant, and timely information to decision makers on a continuous basis.

Some examples of data sources appear useful for nutrition surveillance. The latest national nutrition survey in China was done in , and the national-level aggregated results were published in [24]. Further disaggregated analyses would have been useful, but significant changes can reasonably be expected to have occurred in the nutrition status in the population since because of economic reform, and thus some of this information may now be irrelevant.

The problems are twofold. We need more up-to-date information, which would require more frequent surveys. But more frequent surveys are not useful unless the data can be analysed in a timely fashion. This latter is the real bottleneck, which the Chinese Academy of Preventive Medicine and the State Statistical Bureau have addressed so that information from more frequent surveys can be generated quickly enough that increasing their frequency will be justified.

Monitoring over time requires that the data be comparable from period to period. This has not historically been the case for anthropometry, because different kinds of children have been sampled, as indicated above. Even national data from [25] and [26] are not comparable for this reason. Nutrition surveillance requires stability in survey design and data collection to ensure data comparability over time.

For this reason, data from monitoring the growth of children in the context of primary health care have never been successfully used for national policymaking and planning anywhere in the world. Such data are not collected to help in making decisions for policies and planning but rather for use in patient care. Therefore, the samples are poorly described and usually inadequate, with the result that one cannot be sure who and what kind of persons were measured.

Caution with this approach is therefore urged because of the bad experiences of many countries which have spent a great deal on growth-monitoring data that then could not be put to practical use. Other approaches for the local use of growth-monitoring data are more promising [27] but still are not relevant for making decisions at the national level.

Principles for nutrition surveillance for policy and planning From the above examples, certain principles can be summarized. Nutrition surveillance for policy and planning should meet the needs of the decision makers. Linking the information directly to the policymaking process is the single most crucial step and also the most obvious difference between this and other data-generating processes.

At present, China is beginning surveillance at the national level for national decision makers. In the future, as more and more autonomy is given to the provinces, expansion may be necessary to ensure adequate sample sizes for more local information. The timing of information for policy and planning is also important.

Policy-making and Programme planning are usually long-range endeavours with predictable cycles. Therefore, the necessary linkages to the policy-making process must be built even before the information is generated so as to be sure the timing is correct. Establishing such links is also a remedy for a common difference in perception between scientists and decision makers about the utility of the information.

The information necessary to guide policies and programmes almost always requires data that go beyond those usually considered related to nutrition such as dietary intake and anthropometry, because most decisions have to take into account the economic, sociocultural, and biological determinants of nutrition. Thus the information required often has to cover not only dietary intake and outcome data but also the other important determinants of nutrition status, including income, food prices, sanitation, education, mortality, and morbidity.

Certain prerequisites for a national nutrition surveillance system require careful consideration. First, designing the data collection, implementing it to adequate levels of data and sampling quality, and analysing the data collected require highly skilled, stable, and well-motivated personnel. Second, the skills for all these activities across all the disciplines are rarely found in one institution. Even then, more information can always be obtained from the data than even the largest consortium of data-collection agencies can deliver.

This argues for methods to release data to other analysts quickly and efficiently so that more information can be generated. This is difficult to implement, less for technical than for bureaucratic reasons, as we know from experience [28]. A clear policy should be enunciated that methods and means will be found to release data quickly to other agencies with qualified analysts e. This policy has to be made now at this early stage before bureaucratic tradition makes changes difficult.

Another reason why it is important that data from the nutrition surveillance system be analysed widely is that relevant information will come from various sources, which will make it more likely that relevant issues will be considered at the time decisions are made, especially those decisions that have non nutrition objectives. Different information sources have access to decision makers in different sectors and know how to present the information in the language and format that all of these individuals understand.

INTRODUCTION

Releasing the data to a wide range of qualified information sources will be facilitated by the food and nutrition advisory committee that is presently being formed. Finally, the system itself should be put under surveillance to be sure that it is associated with a policymaking process and is available for use in policy considerations. The quality of the information delivered by the system and its availability to decision makers should be differentiated from the specific decisions made on the basis of the information. Wise decisions from a nutrition point of view may be frustrated because nutrition is often not a major consideration in the development of policies that have major impact on nutrition, such as income generation, taxation and subsidies, and even food security.

Nutrition surveillance information only makes it more likely that these issues will be taken into account. Special thanks are given to Dr. References 1.


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