National Plan of Action for Nutrition

u u i [1 n u E u [l D D □ EGYJJT NATIONAL PLAN OF ACTION Fot· NUTRITION 1994 P'ollow-Up JCN f l [ [: [! [j fl l1 ., (l I EGYP1, NATIONAL PLAN OF ACTION Fo1· NUTRITION 1994 Follow-Up ICN CONTRIBUTORS A. INTERMINISTEIUAL COA1MITTEE: President: Dr. Saad. Z. Nassar Coordinator: Dr. Akila S. Hamza Professor, Consultant and Supervisor for Economic Affairs of Ministry of Agriculture (MOA). Director General of Central Laboratory for Food and Feed. Agricultural Research Centre. D Members: LI LI LI D r, I l Dr. Wafaa A. Moussa Dr. Atef Abdel Ghaffar Director of Nutrition Institute (N .I). Under Secretary of :Ministry of Planning (MOP). .J J J C. 11/EA:IES PREPARATORS: Dr. Aki la S. Hamza Dr. Entisar ElSahar Dr. Mahasen AbdelFattah Dr. Mahmoud Abu ElNasr Dr. Salwa Alsaied Hassanyn Dr. Shafika Naser Dr. M. Samir Mustafa Dr. Wafaa A. Moussa Director General, Central lab for Food and Feed, Agricultural Research Centre. Director General of MCH Dept., (MOH). Chairperson, Nutrition Committee, Health Council (MOH). Undersecretary Preventive Medicine, (MOil). Ilead of Training Unit and Programme Manager of NI/WHO Collaborating Centre for Training, Nutrition Institute. Head, Dept of Community Medicine, Faculty of Medicine, Cairo University. Professor Institute of National Planning. Director of Nutrition Institute. Dr. Anwar Gal al Dr. Muhammad Samir Mustafa Dr. Muhammad A. Hussein Dr. Kamel Abdul Moneem Mr. Muhammad A. EISherbini Mr. Prince A. Radwan Mr. Muhammad M. Saad [ i I ) Dr. Shafika Naser B. COORDINATORS: Dr. Aki la Saleh Hamza Dr. Muhammad Samir Mustafa Dr. Muhammad Amr Hussein Dr. Shafika Naser Under Secretary of Ministry of Information (MOI). Professor, Institute of National Planning. Consultant, Nutrition Institute. Under Secretary, Ministry of Health (MOH), PIIC. Under Secretary, Ministry of Supply (MOH). Under Secretary, Ministry of Education (MOE). Director General (MOE), School Feeding Programme. Head, Dept of Medicine Faculty Cairo University. Community of MediciEe, I ; i t fl l11troductio11: According lo the ICN declaration and plan of action, the GOE has taken the following positive steps: ' 1. Formulation of lnterministerial Committee; By the ministerial decree No. 1287 in 1993 issued by the deputy Pri111~ Minister and l\1inister of Agriculture, the committee includes senior staff aud scientists from the C(?ncerned · ministries, Agriculture, Health, Education, lnforn1ation, Planning· and Supply. Also specialized institutes; Nutrition Institute, National Institute of Planning, and University Professors. 2. ''' Establishment of Nutrition Unit within the A1inistry of Agriculture to work in cooperation with Nutrition Institute (A1011). After several 1neetings of the conunittee, four working groups were fonnulated. Each group includes selected persons from the concerned ministries and/or professors and headed by i11termi11istcrial committee member. The responsibility of each group was clarified and the time for the work to be finished was fixed. A workshop was then held to discuss the achieven1ent of the working· groups covering the nine themes. Each one includes the problen1 and its niagnitude, objectives, action, resources, and time needed for in1ple111entation. Editing conunittee was chosen for preparing the paper in the final form. On September the 18th, 1994 a seminar was held and attended by deputy prime n1inister and n1inister of Agriculture, and ministers of Health and Supply. Selected persons from different ministries, universities and research centres were invited to participate in the discussion of the Egyptian plan of action for improve1nent of the nutrition situation of the country. Highlights raised by different ministers stressed 011 cooperation between ministries to ensure food safety by strengthening inspection capacity and enforcement of the law. Subsidy for bread and enrichment of flour, with the needed mieronutricnts. Nutrition education and consumer awareness. 1 (j (! [j The political committmcnt of the gover11111c11t lo consider nutril ion as an important factor towards health and to prevent malnutrition a111011g vulnerable groups was shown through an immediate action by the deputy prime minster to allocate an extra· L.E. 20 million for feeding young school children. The mechanism of implementation of the plan of action was discussed. The Intenninisterial. Conunitlee will supervise the implc111cntation process. Continuous working groups will be formulated for translating the plan of action into detailed applied progranunes .. After adoption of the proposed programmes, financial resources wi ll be sought either from the Government or fron1 . international Agencies. Cooperation between different ministries was found to be very po:-; iti vc. 2 l . [ r ( [ ( l: ~ [j N (; (j E E ~ ~ u u u u fl Theme No. 1: INCORPORA11NG NU1'Rl110NAL OBJECTI\IES, CONSIDERA110NS AND COA1PONE!\'TS ll\'TO DEVELOPA1ENT POLICIES AND PROGRAA1AJES. Problem: Food and nulnlmn in Egypl is nol lhe responsibility of one single Ministry or sector. Therefore, these groups of different disciplines are confined with their own responsibilities, and lack of coordination between them is clear. In addition they are too narrow lo accomplish the goals and objectives of food and nutrition policy which are based on broader considerations. In addition, socio-economic five years development plans give much efforls lo solve lhe problem of supply/demand imbalance of food over the problems of vulnerable groups. Government policies with effects on food consumption and nutrition: 1. 2. 3. Cheap food: Overvalued exchange rate for imported food has resulled in reducing food prices for all consumers. Food concessional sales under the umbrella of PL (480) enabled the Egyptian government (GOE) lo make this target possible for years. Food subsidy programme: The Egyptian ration card was initially designed lo shield lhe entire population from the high cost of production and from possible shortages of supply. Approximately 90 % of the entire population obtain either green or red ration cards. The system is defected with ils high leakage to non-qualified beneficiaries because of no means lesl. Guaranteed e111ploy1nent: From 1962 up lo 1984 the GOE was con11nilled lo provide full employmenl for ils citizens new graduates employment. 3 r I J 1 J 4. ,vagc policies: Wage policy in Egypt has been used not only to improve the supply and demand conditions in the labor market but also tu attain social goals by eliminating wage differentials and helping employees face successive pnce mcrease. l<'ood and nutrition interventions in EgJpt: 1. 2. I<'ood interventions: a. Targeted: b. School feeding programmes for certain seg111e11l of studc111 s. Feeding workers in certain hard jobs. Non-targeted: Food-Ration cards. Food production inputs subsidies (fertilizers, credit, seeds, nrnchinery). Balady bread subsidy for all population. Nutrition intervention: a. Targeted: Preventing micro-nutrient deficiency (iodized salt for the population). Nutrition education programmes. 4 t ! l : f'. r-: r. [ [ [j u [j ~ [1 u ~ n b. Non-targeted: Promotion and protection of breast-feeding. Public utilities intervention (water, sewage). 1-leallh care facilities for prevention aud control of malnutrition. Action: 1. Strengthening the technical and managerial capacities at both the community and intermediate levels for identifying and solving nutritional problems. 2. Incorporating nutritional considerations into the objectives of all sectors would ensure that their efforts are nutritionally beneficial. 3. 4. 5. People's participation in selecting and implementing projects, so that it becomes more responsive to their own needs. Given more emphasis on gender planning and woman empowerment issues in order to decrease the gender gap especially among rural underdeveloped regions and thus alleviate poverty. Nutritional issues should be on the agenda of concerned ministries, where the focus of attention aims at the improvement of the nutrition situation, especially among vulnerable groups. The above mentioned measures have to be translated into progranunes and projects with nutritional components to be implemented by different ministries. The analysis of these projects will include requested funds to be provided by different financing agencies (Governmental, International) to be used in improving the nutritional status of different population groups according to their assigned roles. Time elapse till action: According to the proposed programmes presented by the lnterministerial Committee and after adoption by the government, time is calculated according to what is proposed in each programme. 5 r r I [: f r j ' [, ' r , f! Ii . .i r-1 u fl : l LI iil ~ :J J . I l j r l Ll J J :J '' . I Time for action: Continuous l\1ointoring and Evaluation: Use of nutritional status indicators through the proposcJ nutrition surveillance system. 6 I r l [ r: L I ..... (; l\ L ~ Ll ll r l I ~J ~ l J r, ', u r1 u r: l l ;111eme No. 2: Jll1PROVJNG JJOUSEJJOL/J FOOD SECUR/1T Problems: 1. E1nploy1nent Levels: Labor force (as % of total population) estimated at 27. 8 in 1986 tompared with 30.7 % in 1976. The percentage of females in labor force reached 10.9 % compared with 8.9 % in 1976. According to 1986 population census 35. 7 % of total labor force were occupied in agriculture, 18.2 % in industry and 46.1 % in services. 2. Changes in real wages and purchasing power: Data on real wage trends during the period (1973-1992) by economic sector shows that wages have not kept up with the consumer price index for both rural and urban areas. In the government sector there is a substantial decline from a base value of 100 1973 to 58.1 in 1992. This implies a reduction by nearly one-half of the welfare levels of these governmental employees. In the case of the private sector real wage levels are slightly above those in 1973. As % of total population, poor persons were estimated at 33.9 % m 1990, while ultra poor were accounted to 7 .6 % . 3. Dietary energy supply: Egyptian wheat imports represents about 50 % of wheat requirements. Also Egypt imports sugar and oils. At the same time Egypt exports rice, vegetables and fruits in addition to cotton. Average daily caloric per capita supply amounted to 3700 calorie / <lay or (135 % of requirements according to food balance sheet). Cereals which is the main source of per capita energy supply in Egypt provided 70.7 % of daily calorie per capita. Inequity of food distribution at community and household levels affocts food security. 7 r l f f [l u u u lJ [1 [] LI LI [l 4. l\1arkct prices: The implementation of economic reform policy in Egypt since 1987 and the liberalization of the agricultural sector, have negatively affected low income groups. A recent survey conducted by the Nutrition Institute shows that increase in food prices has affected consumers in two ways: Shift from rich foods to less expensive foods (Legumes .. .. roots) irrespective of nutritive vale. Reduction of rich foods and its frequency. 5. Rural - urban gap is the main cause of rural migration to urban cities which adds an extra burden to big cities over and above its carrying capacity and results in slum areas. Action: The root cause of household food insecurity is low incomes and poverty. ! The implementation of success[ ul integrated socio-economic development plans ! will result in higher income shares of lowest income groups. Currently, the ! GOE is launching economic policie~ and programmes aiming at increasing : employment opportunities and income levels. On the other hand, increasing '. food production to bridge food gap. In addition liberalizing price, marketing, ; land and credit policies as well as improving rural infrastructure can improve : household food security in a significant way. Also, some policies arc 1 recommended to achieve food security. I 1. Rural development: Integrated rural development is an i effective approach to assault rural poverty and improve household food security : (HFS). I 2. Increasing employment opportunities: Social development fund I can play an important role in financing youth projects. Also, public works i programmes can reach the food insecure population by giving priority to the · less developed regions. (Upper Egypt and border governorates). 8 r . l r i ' r r ' ' ' n b.l [ l ! J I , ,; u u D D Li D Li LI 3. Giving credit to poor households provide liquid money for the development of small projects to raise their income (chicken farm, dairy ! production ... etc) also for personal consumption. Poor women head of : household should be given equal access to credit facilities exactly as men. I 4. Increasing household nutritional awareness which results in 1 improving nutritional levels and intra-family food distribution, with emphasis 1 on mothers and children. I 1 Authorities responsible for action: All concerned ministries and NGOs. I Time elapse till action: I One year. Time for action: Continuous. Monitoring and evaluation: Number of families benefited from income generating projects. Demand and supply indicators, in terms of quantities of available food versus needs and net import need versus import capacity (self satisfactio11 indicators). Indicators of nutritional status through the proposed nutrition surveillance system. 9 n u n u Theme 3: PROTEC11NG CONSUA1ERS TJJROUGJJ JA1PROVEJJ FOOD QUALin' AND SAFETY Problc111: 1. 2. 3. 4. 5. There are more than eight agencies responsible for the food quality and safety. There is overlappir:g in responsibilities between goven1111cnt agencies which complicate the work and make it more expensive. There are different regulations through many laws, ministerial decrees and standards which define the responsibilities of different agencies and requirements for different food commodities. Some of these laws and decrees are very old not matching with the govermnental new policy. Egypt imports large quantities of food commodities (Table 1). The process of importation passes through different channels in different concerned agencies. Food processing is gaining an increasing importance in the industrial sector in Egypt. Contamination and adultration of processed food could occur through poor production methods, bad handling, poor packaging and illegal or excessive levels of food additives. Food processing also suffer from lack of efficient quality control system particularly those produced by small private sector plants. Uncontrolled use of chemicals such as pesticides, fertilizers, and growth promoters is still one of the major problems inspite of the positive measure taken by the Ministry of Agriculture for reducing the use of pesticides (Table 2, 3). Goals: ; 1. 2. Ensuring that the health conditions and nutrient composition are retained during the food chain i.e production, post harvest techniques, storage, handling, processing, packaging and preparation. Raising consumers' awareness against being offered foods that are injurious to health, unfit for human consumption or are nutritionally or economically debased. 10 r [ [, r: L ll r: .. [l [] D ~ u Ll Li D D rJ u I Objectives: 1. '2. Preventing and controlling 50 % of biological and chemical contamination of food in the field before year 2000. Promoting hygienic practices throughout the food inc.lust ry hy cstabl isli i 11g codes and standards. A strong con1111ittcc for standardization should he established within six months. Training of 30 % of food processing and handling personnel 111 two years. Promoting a safe and honestly presented food supply by 50 - 60 % requiring composition and nutrient information on food labels within three years. 1 Action: 11. Institutional restructuring: I I Formulation of food safety council. The council can lead the ! coordinating task of different concerned agencies. Different specific working : groups could be formulated by the council including technical persons from . different concerned agencies, business people from the food industry and non · governmental organizations (NGOs). The council can refer to the interministerial committee for decision makers. 2. Reviewing and updating legislation: Legal advisers of different concerned agencies should cooperate with technical key persons and work together for updating laws and regulations clarifying the responsibilities of each agency. 3. Monitoring and infonnation systen1: Programmes of routine collection of samples from the market could reflect the present status and help the council to take the quick suitable actions in due time. 11 I : I 4. Quality assurance in food processing and qualit)' control: Industry should be aware of the different elements of quality assurance system and its application to prevent contamination of foods during production, processing and storage. Build a partnership between different kinds of laboratories in the area of standard and quality assurance of the analytical and administrative topics. 5. Good agricultural practices: Continuous educational programmes for farmers to protect the food crops from being contaminated with different types of contaminants and also to keep the quality and nutritive value of different food crops. Advanced post harvest techniques should be developed. 6. Establishing a monitoring systen1 for food born diseases. 7. Promotion of consmner awareness: An effective food control infrastructure must include effective educational programmes. These programmes should cover food quality, safety and nutrition in an integrated fashion. Such programmes should be designed to assure that consumers have sufficient information on how to feed themselves adequately and safely and protect themselves against food related problems. The programmes should also be evaluated to determine how effective they have been in achieving their goals. In Egypt, appropriate measures have already been taken in concerned ministries: Ministry of Education , Ministry of Information , Ministry of Agriculture ' Ministry of Health (MOE). (MOI). (MOA). (MOH). All these programmes are implemented without coordination. This could D , be one of the important tasks of the working groups. □ 12 ~l 8. Design a programme for upgrading the street food vendors scchff. 9. Encouraging the role of the consumer protection societJ. 10. Supply of safe water. 11. Participation of the counh°}' in Codex to food safety has to IJe strengthened. Authorities responsible for action: Ministry of Agriculture (MOA). Central Department for Plant Protection and Quarantine. General Organization for veterinarian Services: Animal Abattoirs. Animal Quarantine. Animal Health Research Institute. Food Hygiene Research Section. Central Laboratory For Food and Feed. Quality control. Nutrition Unit. Ministry of Health (MOH). Central Department for Food Safety and Control. Public Health Laboratories. Nutrition Institute. Ministry of Industry (MO Industry). Egyptian Organization for Standardization and Quality Control. General Organization For Industrial Control. Ministry of Economy and Foreign Trade (MOEFT). General Organization for Import and Export Control. Atomic Energy Organization. 13 r . ; I I Ministry of Supply (MOS). Ministry of Education (MOE). Department for Basic Education. School Feeding Programme. Ministry of Information (MOI). All means could be used for consumer awareness in collaboration with other Ministries. Universities and Research Centres. Ti1ne elapse till action: 6 months. According to each item. Tiine for action: Formulation of food safety council within 3-5 months. Reviewing and updating legislation within one year. Educational programmes for farmers and consumers will be continuous. Setting the monitoring and information system will take 6 months and then work continuously. Resoruces: MOH. MOA. MO Industry Private Sector. NGOs. Interested International and Bilateral Organizations. 14 I • r f : f 1 I . l : r I . ~ l [l K [l n u u Li D 0 0 0 LI n . I Legislation: Available: Laws and ministerial decrees defining the job of each ministry for consumers' protection. Needed: The recent economical reform of the Egyptian policy led to more freedom in marketing. Such new policy of free trade needs: An adequate food quality and safety legislation. Reviewing and updating the already available legislations. Introduction of strong enforcement measures. Application of penalties for violation of the laws and regulations. Monitoring and evaluation: ! Check samples from the market will be taken and analysed in an irregular basis and report will be submitted to decision makers. Inspection of processing plants and processed food on regular base. Regular visits to storage plants every three months. 15 "i I 'I n n Table (1): Quantity of l 1ood Co1111uodity l111ported during year 1993/94. LC'o11zi1iodity .. .·.;: Q1id11titJi/tous Co111111odifJ1 Quantity/tons Wheat 3,946,478 Luncheon Meat 338 Flour 405235 Poultry 3450 Sugar 224500 Turkey 38 Tea 58863 Frozen fish 131693 Corn oil 10278 Tuna 6033 Palm oil 129610 Milk Dried 7845 Soybean oil 127724 Skim Milk 14508 Palm Kernel oil 94040 Ghee 15989 Sunflower oil 136980 Butter 30603 Coconut oil 5131 Cheese 20367 Olive oil 209 Tomato Sauce 893 Frozen Meat 154163 cacao 3816 Frozen Kidney 2450 Cinnamon 163 Frozen liver 30706 Sheep alive 22025/head Cumin 1718 Cows alive 240931 /head Sesame 14264 Green Coffee 5992 Black Pepper 3540 Milled Coffee 37 Cloves 239 Corn beef 1181 Beans 57882 Canned beef 298 Lentils 83004 16 I. f L r: r: • l I J J '1 j Table (2): Yearly agricultural co11su111ptio11 Total a111ou11t of Year pesticide, 111etric tons 1981 /82 18778 1982/83 14368 1983/84 16315 1984/85 16378 1985/86 23461 1986/87 20718 1987/88 17152 1988/89 17997 1989/90 15099 1990/91 11700 1991/92 5393 17 r r f [ r [ [ u u E E [I u [J u u D n I ' ·, I ' Table (3 ): E.xa111ple of J>esticide Consunzption used for cotton, inzported by the gOl'CrJllllCll(. Year· A11101111t tons .-.·-•····•·<>••····<•··••··•··••····•··•·- ·•-· 87/88 4389 88/89 4832 89/90 3145 90/91 3088 91/92 3380 92/93 2288 93/94 'It is important to be noted that there was no i111portation of :pesticides during the year 93/94. I ·1 I A.11zounts inzported by p1ivate sector: 78/88 6604 88/89 3591 89/90 3242 90/91 1404 91/92 2892 92/93 3329 18 I : r [j [i r: Ll ri Ll u n M D 0 u u D D D D LI LI fl 11zcme 4: PREVEN11NG AND AIANAGING INFECTIOUS /Jl. \'h'ASh'.\' I I Proble111: I Infections prevalent in our communities include: 2. 3. 4. Goal: Diarrheal Diseases: Diarrheal diseases is an important cause of child morbidity and mortality in Egypt. As regards morbidity, studies revealed that the child has at least 3 attacks of diarrhea in average per year. As mortality, diarrhea is responsible for about 30 % of child mortality "under 5 years". Acute Respiratory Tract Infections "ART". ART is considered the 2nd cause of child morbidity and the leading cause of child mortality "under 5 years". Vaccine Preventable Diseases: As T.B, measles, diphtheria, whooping cough, poliomyelitis, tetanus and infective B hepatitis. These diseases are nowadays uncommon due to compulsory immunization and the high rate of immunization coverage. There are other infections prevalent m our communities as enterica, streptococcosis and others. Parasitic infections as amoebiasis, giardiasis, Ascariasis, Bilharziasis and others. To improve the nutrition status of the population through prevention amJ control of infectious diseases. Objective: To reduce both morbidity and mortality rates from infectious diseases particularly among infants and young children by 50 % "by year 2000 ''. 19 f : i l [ 7 l Action: a. b. General l\1casures: Sanitary environment: potable water supply, proper sewage disposal, food control in addition to improvement of the infrastructure. Proper feeding and adequate nutrition including breast feeding for health promotion. Health education as regards mode of transmission, in1munization and other measures for prevention. Specific Meas~res: Increase immunization coverage for the vaccine preventable diseases. Early detection and prompt treatment of infectious diseases. Appropriate dietary management of the case during illness. Rehydration in diarrhea and Vit. A supplements to cases of measles, ART, and acute diarrhea. Control measures of communicable diseases should be conducted for cases, contacts, carriers and environment. □ Disease surveillance. ~ ; Authorities responsible for action : D D LJ u r l u r l Ii i i I Ministry of Health with all its concerned facilities. Ministry of Education schools, universities. Ministry of Information. Agency for Environn1ental Affairs. Veterinary service organization. Resources: All responsible ministries and agencies mentioned arc available resources. Extra funds are needed to strengthen the ongoing and suggested activities. 20 r [ [. [ : [ L u ri ~ ~ u u E u u u u u u fl I • ,Legislation: I . I Compulsory immunization (already implemented). Control measures for infectious diseases (already implemented). Control of zoonosis (already implemented). Updating legislation for food safety. Tilne elapse till action: I I I I It is an ongoing process. rrin1e for action: I Continuous. Monitoring and evaluation: Morbidity and mortality rates from infectious diseases particularly among infants and young children. Immunization coverage rate. Percentage of population provided by pure water supply, proper disposal of sewage etc. 21 rJ 11zeme 5: PROA1011NG BREAST FEEDING. Problem: Late initiation of breast feeding and introduction of prclacteal feeds. Ignorance of many mothers about benefits of colostrum and advantages of breast milk. Mass media and commercials announcmg advantages of breast milk substitutes. Low rate of exclusive breast feeding which does not exceed 8 % . Adoption of bottle feeding. Mother employment. Lack of maternal preparation for breast feeding during antenatal care. Poor guidance and support of the lactating mother. Difficulties of breast feeding with debilitated mother or debilitated newly born. :Goals: I... I Protecting and promoting breast feeding. Improving the nutritional and health status of infants, pregnant and lactating mothers. Increasing social and health awareness about the importance of breast feeding. Implementation of the components of the international code and follow up its continuity in breast feeding and other health care facilities. 22 [] [l ~ u u u □ D Ll D 'l I I I• i I Objectives: I To maintain and supporting B.F. practice rate to be over 90 % by year 2000. To increase exclusive B.F rate in the first four months to be 50 % by year 2000. To ensure the implementation of the Egyptian version of the international code of marketing breast milk substitutes within one year. 1 Action: Upgrading the performance of health care facilities by training of human resources in the field of B.F. and provide them with training curriculum, training materials and equipments. Trained staff should be of an adequate number, under constant guidance, supervision and evaluation. I - Creation of popular awareness towards importance of 13.F. by: Formulation of local committee for B. F. in all governoratcs. Disseminating the national B. F. policy to all governorates. Formulating mass media messages on benefits and advantages of B.F. Establishing new branches of Egyptian Breast Feeding Friends Society in governorates. Community participation through mother support groups. Decreasing the market impact on distribution am.I consumption of milk substitutes. Increase the free paid maternity leave from 3 months to 6 months with full or partial salary II at least 4 months II by legislation. 23 □ ~ u u D Li D D D Completing the activities of baby friendly hospital initiative in PHC units and other health care facilities. Issuing measures to control milk distribution through lhl' Egyptian code of marketing breast milk substitutes. In the field of information: legislation: Preparation of a nation wide information programmes in the field of B.F. Health education programmes on B.F. 111 PHC units and other health care facilities. Advertising campaign to disseminate the national policy of B.F. promotion and protection. Issuing laws and legislation which allows the working mother to have the right of promotion and protection of B. F. Egyptian code of marketing breast milk substitutes. Authorities responsible for action: MOH. Nutrition Institute National steering committee "B.F." and local committee. MOE. MOL ~1OSA. MOA. MOL. Supreme council of mothers and children. NGOs and Syndicates. 24 . ,, I \ l J •- j n LI D D D LI 0 0 n RcsomTcs: Funds are needed for: Training, Audio-visual Aids and messages, booklets amt posters. transportation for supervision and monitoring. rv1aintcnance or MCH cards and information system. Researches. This could be obtained through: MOH budget. Grants and loans from international agencies. MOH and other related ministerial man power and equipments. NGOs. Private sector resources. Time elapse till action: Already started. Time for action: Continuous . Monitoring and evaluation: Rate of exclusive B.F. Rate of B .F. till end of 1st year. Rate of B .F. till end of 2nd year. Rate of bottle feeding. Percentage of milk distributing companies. Medical team knowledge, attitude and practice towards breast feeding. 25 r ' 111eme 6: CARING FOR TI/E SOCJO-ECON01HIC /JEl'RIVl~/J ANn r NUTR/110NALLY VULNERABLE [ I td [ ! .I [} u [] D [j fl l : lJ [ I Problem: In Egypt, the national nutrition survey conducted on 1976 and updated on 1986 revealed that nearly 50 % of children under 5 years suffer from PET\1 and 38 % suffer from anemia. For women in the child bearing period, pregnant and lactating women were found to suffer from anemia at a rate of 22 % and 25 % respectively. In nonpregnant, non lactating, 17 % were found to suffer from anemia. A111ong school children a good proportion suffer from retardation of growth and anemia particularly those in rural areas. Iodine deficiency disorders is highly prevalent in New Valley and occurs to a lesser extent in 9 other governorates. Other nutritionally vulnerable groups include the ultrnpoor, the elderly, the unemployed as well as the disabled and the displaced exposed to environmental hazards as earthquakes, floods and others. Goals: To promote the nutritional status of vulnerable groups particularly infants, young children, pregnant and lactating mothers and combating al I forms of nutritional deficiency disorders. To reduce low birth weight resulting from maternal malnutrition. To promote the health status of vulnerable groups by adequate health care. To ensure that adequate nutrition and safe diet is a basic human right. Measures should be taken to help the socio economically deprived people have access to adequate nutrition. 26 r· ! 1k j r\ ' I \ I [1 u D E u u Objectives: To decrease infant and child mortality rates by 50 % by year 2000. To decrease low birth weight (LU\\') by 50 % by year 2000. To decrease prevalence of nutritional deficiency diseases by 50 % and IDD to be eliminated by year 2000. Action: A. B. Infants and young children: I. 11. Ill. Adoption of breast feeding policy. Proper child feeding and weaning practices through an appropriate nutrition education programmes at MCI I centres, Agriculture Extension services, formal and non-formal education and mass media. Health care services to be provided to infants and young children to ensure proper growth and development. This includes growth monitoring, immunization, health education, prov1smn of supplements, treatment of infections and parasites and nutrition rehabilitation for the undernourished. Mothers: I. II. Ill. Antenatal care. prov1smn of supplements during pregnancy and lactation, health and nutrition education as well as family planning services. Social support of women to cope with stressful situations. through various safety nets, help them with income generating activities and with access to training and credit. Recognizing the rights and needs of women 111 education. employment, earning income, decisions making an<l protection from heavy work load. 27 [j D (j rl C. D. School children: School feeding programmes should cover all primary school children specially those in rural areas. Health care should be provided as well to ensure proper growth and development, well being and productive life later 011. Other groups: Encourage all forms of community part1c1pation to eliminate hunger and malnutrition particularly in rural areas through proper organization of agricultural, social and income earning activities. Integration of health care services for elderly people into system of PHC to combat nutritional disorders among them. The disabled should be supported and helped lo cope with disabilities and skills training. Identification and Social. NGOs can play an important role in identifying and supporti11g lhL· nutritional vulnerable groups and families. Authorities responsible for action: MOH. MOE. MOL MOA. MOSA MO Interior & MO Defence "Schools". Governorates and local government. NGOs. Resources: All responsible ministries and agencies mentioned are available resources. Extra funds are needed to strengthen the ongoing and suggested activities. Other resources include private sector resources, grants and loans from international agencies. 28 ' ' I ·: I l f: r r r L [J D Ll 0 u q Li 0 fl Legislation: To increase the maternity leave to six months or at least four months. To enforce the Egyptian version of the lnlcrnalinnal Code of marketing breast milk subslitutes. Nutrition programmes can be tied to the convention on the rights of the child. Thne elapse till action: Most of activilies are ongoing programmes. Time for adion: Conlinuous. l\1onitoring and evaluation indicators: The use of morbidity and mortality rates. 0 0 0 0 Infant mortality rate (IMR). Preschool mortality rate. Mortalily from diarrheal diseases. Prevalence of malnutrition diseases. 29 111eme 7: PREVENTING ANIJ CONTROL-LING SPECIFIC r Af ICRONVTRIENT DEFICIENCIES r l ' ' [1 [! ~ ~ Ll D D D LI rJ 1. Iron Problem: Goal: Many studies were done to investigate iron deficiency anemia among hi!!h risk groups (preschool age children, schoolers, pregnant and lactating women). Results revealed that prevalence of iron deficiency anemia among preschoolers was 38 % , lactating women 25 % , pregnants 22 % , nonpregnant non-lactating mothers 17 % and school children 40 % . Prevention and control of iron deficiency anemia among high risk groups. Objective: To reduce prevalence of iron deficiency anemia by 30 % in mothers and preschool age children before year 2000. Action: Supplementation of high risk groups for prevention & treatment Prevention & control of infectious diseases (viral, bacterial and parasitic). Fortification of flour with iron. Nutrition education considering the following: 1. Promote consumption of iron, vitamin C ;ind protein rich sources. 2. Reduce consumption of tannins and phytic acid sources which decrease absorption of iron. 30 I [ r r [ [! [l Authorities responsible for action: Ministry of Health (MOH) supported by \VI-IO and UNICEP. Nutrition Institute (NI). Primary Health Care Centres (PHC). Preventive I lealth offices. Pharmaceutical companies. Ministry of Agriculture Ministry of Supply Ministry of Information Resources: (MOA). (MOS). (MOI). The needed supply for iron capsules. Equipments needed for diagnosis and follow-up as well as iron fortification of flour. Training of personnel for the required activities. Legislation: Needed for iron fortification of flour. Time elapse till action: 1 year for iron fortification of flour and strengthening for other ongoing activities. Time for action: Continuous. Monitoring and evaluation: Hemoglobin determination for high risk groups through nutrition surveillance in PHC. 31 r [j [1 u u [l Ll 0 u u LI n 11. Iodine Problem: Goal: A National Survey was done during 1992 including all governorates except Aswan, Gharbia, Red Sea, and North Sinai. This study was done by NI in collaboration with WHO. It was revealed that prevalence of total goitre rate (TGR) was more than 5 % in 9 governorates: New Valley, Kafr El-Sheikh, EI-Sharkia, Matrouh, Sohag, Oakahlia, Alexandria, Oomietta and Cairo. In the New Valley the problem was severe (around 80 % ) as found by other 2 indepth studies. Prevention of iodine deficiency among vulnerable groups. Objectives: To ensure National lodization of salt before end of 1995. To eliminate 100 before the year 2000. Action: Fortification of salt with iodine at the national level for both human and animal consumption. Prevention and treatment of target groups in areas of severe affection using iodized oil orally which gives 1-2 years protection. Nutrition education to promote use of iodized salt, consumption of iodine rich food sources (fish-milk-egg and dairy products) and avoidance of goitrogenic foods (cabbage - onion). 32 l ! I I r-, l l [\ • l J . ' J J u J ., I . ' Authorities 1·csponsi1Jlc for action: Ministry of Health (MOH) in collaboration with WHO & UNICEF. Nutrition Institute (NI). Primary I Ieallli Care (PIIC). Ministry of Industry Ministry of supply Ministry of Information Resources: (.MOI). (MOS). (MOI). The needed supply for industries and companies for national iodization of salt and for follow-up evaluation. Cost of oral iodized oil. Cost of training of primary health care staff wilh needed supply. Legislation: Law or ministerial decree to indicate that iodized salt is the only salt to be used for human and animals all over the country. Time elapse till action: 1 year till fortification of salt with iodine. Oral iodine therapy and nutrition education should start immediately. Time for action: Continue oral iodized oil till universal use of iodized salt. Continuous nutrition education and treatment of target groups ti II eradication of the problem. Monitoring and evaluation: Follow- up through urinary iodine in a group of individuals living in tile affected areas (not less than 40 individuals). The urinary iod i11e should exceed 10 µg/ml in 50% of the sample or more. Clinical examination for TGR which should not exceed 5 % in primary school children age 6-8 years or it is a public health problem. 33 . ... : I r I I I 'i 1 LI n '.I LI D i;.,; J J , I •-' J J J J ,., I • I 111. Vita111in A Problem: Goal: In the Nation.al Survey conducted by N. I 111 1978 affection with B itot spots was 0.04 % so vitamin A deficiency was not considered a public health problem. Studies conducted during 1985 - 1987 showed that almost 40 % of studied individuals (toddlers, schoolers, mothers and fathers) didn't get their RDA of vitamin A. A study (1987) in an urban slum within preschoolers with diarrhea, 20 % had eye signs, and 75 % did not cover their RDA of vitamin A. There is no recent data about the situation of vitamin A in Egypt. Is it a public healtl~.,.problem or not?. Prevention of vitamin A deficiency and its complications in tile high risk groups (presohool age children 6 M .- 6 Y., pregnant and laclal i11g women). Objectives: To assess the present situation regarding vitamin A status i11 Egypt. To reduce vitamin A deficiency by 50 % within 3 years and eliminate before year 2000. 34 n I i l.l u D ~ [\ u u u D 0 Li 0 □ 0 fl Action: National survey on children aged 6-72 months to determine magnitude of vitamin A deficiency problem in Egypt. Supplementation of vitamin A capsules to high risk children (6 l'\'lo11flis 72 Months) and to lactating womc11. Nutrition education in the primary health care centers and mass media for dietary diversification to promote of vitamin A intake according to RDA, from available sources in the community. Authorities responsible for action: Ministry of Health (MOH) and support of WHO and UNICEF. Nutrition Institute II N .I 11 • Primary Health Care Centres (PHC). Pediatric clinics in hospitals. Ministry of Agriculture (MOA) through its respective sectors. Ministry of Information (MOI). Resources: The needed supply for chemicals, equipments and training of personnel needed for survey. . Supply of vitamin A capsules through MOH and the support of WHO and UNICEF. Supply needed to train the personnel in PHC and Agriculture Extension Agents for nutrition educatio11. Time elapse till action: 6 months 35 I ., u u D □ Time for action: Six months for National Survey for vitamin A assessment. Supplementation by capsules should continue till the magnitude of thl' problem is recognized through national survey. Nutrition education is continuous. Monitoring and evaluation: Nutrition surveillance in areas of high rate of affection for: Vitamin A deficiency signs. Blood samples for vitamin A "retinol" level every 6 months for 2 years. Levels below 10 µgldl denote deficiency. 36 r I . I . r L I r: ,..., ' ' f/ LI n 1. I n Theme 8: l'ROAIOTING Al'l'ROl'RIATE DIETS AND 1/EAJ.,T/J}' /.,/FR STYLES I. CARDIO-VASCULAR DISEASES Problem: A. 1SCIIAE1\11C HEART DISEASES: (lllDs): The prevalence of IHDs was 5. 7 % among urban population and 1 . 5 % among rurals in the age group 20-60 years in 1976. Diet is one of the major factors associated with development of ischaemic heart diseases in Egypt. In 1981 it was found that the IHDs patients under 50 years old and over consumed higher energy and higher animal fat than their controls; 118 and 103.5, 130 and 108 of energy % RDA respectively. The coronary heart disease patients reported higher percentage of animal fat intake as compared to their controls. B. HYPERTENSION: Health profile of Egypt (1988) showed that the prevalence rate of systolrc hypertension was 11. 35 % for the total sample, being slightly higher among females than males and among urban than rural. The prevalence rate of hypertension increased steadily with advance of age. The prevalence of diastolic hypertension was 4. 7 % for the total sample. and took the same trend as systolic hypertension. Unlike systolic hypertension, residency has a slight effect 011 the prevalence of diastolic hypertension, being 4.9 % for the urban sample and 4.6 % for the rural sample. A national hypertension project has been initiated in Egypt in I 9lJJ tn study the prevalence of hypertensi,m in samples of adult population. Tile preliminary results reported suggested the highest rates ever documented in tile region. 37 r [j u u r l II. OBESITY From several national studies in the period 1978-1986, it was found that the prevalence of overweight and obesity starts at the age group fro111 12- 15 years ( 16.2 % ) & steadily increased by increasing age, to reach its peak among mothers (63.1 %). A recent study carried out in 1993 by the Nutrition Institute to Compare two communities of different social and economic status revealed that the overall prevalence of obesity among adults > 18 years was 39. 7 % from the low socio-economic community and 50.9 % from the high socio-economic community. Obesity among males was 17.5% and among females was 65.5%. III. DIABETES l\1ELLITUS From several studies carried out in Egypt in the period 1976-1988, it was found that the prevalence of diabetes mellitus ranged between 3.19 % - 4.8 % . The prevalence of diabetes mellitus in the desert population ( 1 % ) is much less than rural and urban population (4 % and 5.5 % respectively) in 1993. To find out the role of diet in development of diabetes mellitus a study was carried out in the Diabetic Centre of Health Insurance in Alexandria (1981). Results revealed that newly diagnosed diabetics had higher, energy, protein, fat and carbol,1ydrates intake than their non diabetic siblings. Screening for diabetes among representative sample of Alexandria school · students representing primary, preparatory and secondary schools revealed that · the prevalence of glucosuria was 0. 7 % out of those 0. I 3 % were diagnosed as diabetes mellitus. From a study carried out through the Health Profile of Egypt ( I 988), the prevalence of glucosuria among total population was I 0.2 % . The most recent study carried out by the Diabetic Institute in Cairo (1993-1994) revealed that diabetes was much more prevalent among Urban population than rural population (15 % and 5 % respectively). The available data indicates difference in the prevalence of glucosuria and diabetes and suggest an increasing trend in recent years. 38 n u r1 u [I • 1 J J D J J • I l w Goal: To develop a comprehensive strategy for the primary prevention of <liet related non-communicable diseases. The prevention should start in early childhood and continue throughout. youth in order to avoid the emergence of established risk factors in adults. Objective: To reduce the prevalence of chronic non conimunicable diseases by 50 % before year 2000. Action: 1. 2. 3. 4. Early detection of hypertension by routine measuring of blood pressure in outpatient clinics, preparatory and secondary schools, universities when they first join and annually. The same thing might be done among governmental and private sector employees particularly, at risk groups. Early detection of diabetes by routine urine .analysis in school~, universities and among employees and in particular pregnants to avoid maternal complications and perinatal complications in infants of diabetic mothers. Initiate action for appropriate management to prevent long-term complications of diabetes such as vision - threatening retinopathy and end-stage renal failure. Preparation of dietary guidelines to advise people, base<l on: Reduction of cholesterol intake below the average 300 mg for adults . Reduction of saturated fat in diet by its replacement with mono and poly unsaturated fat. To have fat energy ratio between 20-30 % . and emphasize the following: Reduction of salt used in cooking. 39 D u u u 5. 6. 7. Not to use canned foods and eat only fresh meals, vegetables and fruits. Encourage eating ,vhitc meals only. If red meal is used. it sltnuld be lean meal. To increase consumption of complex carbohydrate derived from vegetables, fruits, whole grains and legumes which are high in fibre. Prohibiting smoking m all governmental premises, hospitals, clinics.· Encourage exercise for children and young adults and continue for all age groups which can play an active role in prevention and control of over weight, high blood pressure, hyperlipidemia :tml non-insulin dependent di1betes. Promotion and protection of breast-feeding. Controlling obesity as it is considered a major risk factor for the occurrence of non-insulin dependant diabetes. Disseminate information through: T. V spots & drama. Local newspapers. Family health file for every family including all the health details of each member of the family. Food labelling with nutrition information. 40 r r [: [ fi r: u [l I [I u u D Ll u ll u u r: Authorities responsible for action: t\101-I. o Nutrition Institute (NI). o Pl-IC. o Hospital~. o School health. o Health Iilsurance. MOA. MOE (formal & informal education). MOL MOL (Industry). MOSA. Private sector (Syndicates and NGOs). Interested international and bilateral organizations to provide technical and financial support. Universities and Research Institutes. Resources: Fund for preparation of dietary guidelines. Fund for printing learning materials to be distributed in diabetic clinic.~. obesity clinics and CVDs clinics in hospitals and private clinics and hospitals. Fund for training health workers or social workers from different sectors (PHC, schools ... etc.). 41 I: [: r (i [j [/ [l E ri ~ u u ~ u u u u u u u f1 ~ Legislation: Legislation to enforce periodic examination of the employees at private and governmental sectors. Tirue elapse till action: Two years. According to each item (maximum 2 years). Thue for action: Continuous. Monitoring and evaluation: Measuring blood pressure regularly, mainly of late adulthood, old age and married females. Determination of cholesterol level among over weight and obese individuals. BMI. Determination· of glucose in urine. Morbidity rate, for chronic non-communicable diseases. Specific mortality rate. 42 i .i ·1 J D B a u D 0 D u u 111eme 9: ASSESSING, ANALrZJNG AND /HON/TOR/NG NUTRITION SITUA110NS Problem : Several nutrition surveys were carried out starting 1978, covering only special groups. The demographic and health survey of 1988 and 1992 includes · information on nutritional and health status and also some qualitative food intake data. This is not a regular system of nutrition su·rveillance. However a study conducted by ·FAO and Egyptian Ministry Of Agriculture in last twtJ · years in two governorates can serve as a base for establishing a nutrition · surveillance system. Goal: To establish a nutrition surveillance system based on the regular activities and information collected by PHC teams and Agriculture Extension Agents regarding nutritional status of the population and its determinants. Objectives: To establish the nutritional surveillance system in 6 governorates within· 2 years. To expand the system gradually to cover the 26 governorates within I 0 years. Action: . * * Study the results of the previous nutrition surveillance project comJucteu ·· by FAO and nutrition unit of the Ministry Of Agriculture to be modificu for setting the national surveillance system. Target groups: · Newly born. Infants and preschool children. School children. Mothers particularly pregnant and lactating women. Young adults particularly military recruits. 43 • I i i .. , . , I I ,.I [1 * * * * Choice of representative sample. Collection of regular information: A. Nutritional status information: Weight, length/height. Positive clinical deficiency signs. Hb concentration . B. Determinants of nutritional status: Food availability. Food consumption. Food prices. Economic information. Infrastructure (non targeted nutrition intervention e.g water supply and sanitation). Morbidity rates of infectious diseases. Rate of breast feeding. . Availability and utilization of health care facilities including rate of immunization coverage. Choice of indicators: Percentage of newborn with birth wt. < 2.5 kg. Percentage of under -5 children with wt/A <- 2 S.D. Percentage of under -5 children with ht/A <- 2 S.D. Percentage of adult males and females with BMI > 25. Percentage of targets with systolic blood pressure > 140. Percentage of targets with diastolic blood pressure > 90. Prevalence rates of nutrition deficiency diseases. Percentage of preschoolers and pregnants with Hb < 1 lgm % . Percentage of nonpregnant mothers with B b < 12 gm%. Percentage of young adults with Hb < 13- gm%. Percentage of targets with glucosuria. Dietary indicators (minimum food basket). Establishment of sentinel surveillance units in representative governorates in the suitable place mainly PHC units and Agriculture Extension units both working together in the assessment of nutrition situation. This should be connected to a central surveillance unit via the district and governorate levels. 44 l .l ·1 I ,; I ·1 D D D D LI 0 D D f1 * Formulation of a steering committee to administer the surveillance system from the Ministry Of Health and f\1inistry Of Agriculture and nutrition experts from universities and research centers. The steering committee will refer directly to the interministerial committee for proposals to decision makers. Feedback to the peripheral level is essential. Resources: 1. The Nutrition Institute including the Computer Unit and Training Unit. 2. A wide network of health facilities including Computer Units at governorate level. Computer center at Ministry Qf Health "MOH" linked with all governorates. 3. 4. 5. Computer Center within the Ministry Of Agriculture "MOA" linked with all governorates. Training Center with all needed tra111111g requirements and accommodation facilities, restaurants ... etc. at MOA. Well equipped training centers within MOH in selected governorates. 6. The Nutrition Unit of Ministry Of Agriculture and other related units. 7. 8. 9. A wide network of Agriculture Extension services and training units. Nutrition experts in Universities and Research In~titutes. Training facilities within Universities and Institutes e .g Center for Social and Preventive. Medicine, Cairo University. Funds are needed for upgrading the already available resources (equipment, . training ... etc). 45 , I t "1 I j ] u J ( J l .J ] J ] ] ] ] ] J Autho.-ities responsible for action: MOH: Nutrition Institute (NI). MOH primary health care units; MCI-I. school health and health insurance. MOA: Nutrition Unit. Agriculture Eextension units and training units in different governor ates. Collaboration between the two Ministries is important. Time elapse till action: Start January 1995. Time for action: This should be a continuous process. Monitoring and Evaluation: Improvement of the indicators already stated. 46