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Scholar-in-Residence, Food and Nutrition Board, Institute of Medicine, National Academies, Washington, D.C. 20001
2 To whom correspondence should be addressed. E-mail: bunderwo{at}adnc.com.
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ABSTRACT |
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 TOP ABSTRACT LITERATURE CITED |
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KEY WORDS: • micronutrients • nutrient security • interventions • evidence based
A food- and nutrition-secure world would look quite different from the reality of today's world, where annually 30 million babies are born undernourished, 10 million children under 5 y of age die from preventable diseases, and among those who survive, 33% are stunted and 27% are underweight (1). Both men and women also suffer calorie undernutrition, particularly reproductive-age women in the developing world, and ironically, a growing number are becoming obese. Micronutrient deficiencies are prevalent among adults and children; e.g., iron deficiency and its anemia affect 3.5 billion, vitamin A deficiency 140–250 million and iodine deficiency 
750 million people (1). Other trace mineral and vitamin deficiencies undoubtedly also occur but are poorly documented as public health problems. In contrast to this snapshot of the global situation today, a food-secure world, according to the Food and Agriculture Organization (FAO),3 would be one where all people at all times have physical, social and economic access to an adequate, nutritious, culturally acceptable and safe supply of food to meet their dietary needs and preferences for an active healthy life (2).
Historical and current context
A food-secure world is not a concept recently introduced in international political forums. The World Food Conference of 1974 recognized the right to adequate food, or aspects of it, and this has been reaffirmed by numerous international conferences thereafter especially in the last decade; e.g., the 1990 World Summit for Children, the 1991 Conference on Ending Hidden Hunger, the 1992 International Conference on Nutrition and the 1996 World Food Summit. It was a central theme at the 2002 "World Food Conference + 5" recently convened by the FAO in Rome. In preparation for World Food Conference + 5, the FAO 2001 Report on the World Food Situation notes that notwithstanding continued population growth, decreasing available land for agriculture and increasing environmental degradation, the current global food supply is sufficient and likely to remain so for at least the next two decades although at a decreasing margin of security (2). The global supply, however, is not equitably distributed. The FAO estimates that today the world houses 815 million food-insecure households: 777 million in developing countries, 27 million in transition countries and 11 million in industrialized countries (2). Furthermore, progress toward reaching the goal set in 1996 of cutting in half the number of food-insecure households by 2015 is occurring too slowly. Since 1996, the numbers of hungry have only fallen by 6 million annually, whereas the rate of decrease needed to achieve the goal by 2015 is 22 million annually (2). Hence, despite a quarter-century of growing political awareness and commitments, the world's poor populations remain far from achieving food security, which by definition includes access to diets that are adequate in trace minerals and other micronutrients.
Micronutrient deficiencies
Global food insecurities are associated in large part with micronutrient deficiencies. Among those for which there are global data, iron deficiency and its anemia, vitamin A-deficiency disorders and iodine-deficiency disorders together affect up to 4.5 billion with young children and reproductive age women most vulnerable (3, 4). Political commitments made early in the 1990s to eliminate or substantially reduce these deficiencies as public health problems within a decade were not met (5). Nonetheless, perhaps the most important achievements of the decade were a change in political perception and awareness of the magnitude of the problem of micronutrient malnutrition and the broad but hidden consequences for both humans and national development (6).
Scientists and political commitments
The contributions of scientists, particularly those engaged in establishing associations through epidemiological studies and those who subsequently confirmed causation through randomized clinical trials (RCT), were essential to changing perceptions and setting the stage for political commitments to the time-bound action goals. Studies that demonstrated that iodine, iron and vitamin A malnutrition affects mortality, morbidity, cognitive development and performance, and work productivity shaped the change in perceptions by also offering politicians a mixture of potentially cost-effective solutions if resources were mobilized (7).
Although the micronutrient decade goals were not met, political commitment toward their achievement into the next decade was reaffirmed at the United Nations Special Session on Children that was held in New York, May 7–9, 2002 (8). Participants reached consensus on 21 global goals for achieving a "world fit for children." Seven of these goals deal with promoting healthy lives, three of which are indirectly related to nutrition: 1) reduction in the mortality rate for infants and children < 5 y old, 2) reduction in the maternal mortality ratio; and 3) reduction in child malnutrition among children < 5 y of age with special attention to children < 2 y of age and reduction in the rate of low-birth-weight infants. Of the 25 strategies and actions that delegates pledged to implement, number 22 reset the time clock for eliminating deficiencies in iodine (by 2005) and vitamin A (by 2010) and reducing by one-third the prevalence of anemia (by 2010) including iron deficiency (8). Other micronutrient deficits are also to be addressed through a mixture of interventions. There are of course multiple nonnutritional challenges that must also be addressed to achieve these three broad health goals, but the goals surely will not be achieved without sustaining the progress made in the previous decade and moving forward in overcoming micronutrient inadequacies.
Sustaining progress and moving forward
Analytical reviews of what has worked in moving nutritional science to effective programs with impact on food security suggest that ideally a succession of research and participatory processes are needed. The progression begins with bench laboratory science to establish physiological roles and efficacious and safe intake levels of nutrients; epidemiological studies to establish associations with risk factors and their mitigation; RCT to establish causation and efficacy of specific nutritional interventions; field applications to determine effectiveness in practical settings; and finally, with communities participating, integration of the intervention into the fabric of community and household livelihoods (9– 11).
Magic bullet and short-cut solutions. The idealistic progression toward sustainability frequently is not considered necessary by program sponsors because of their felt urgent need to show progress and impact. For example, a meta-analyses of several RCT showed that restoring vitamin A nutritional status through periodic high-dose supplements, weekly low-dose supplements at levels achievable through diets or incorporated through a fortified condiment into the daily food supply reduced preschool child mortality risk on average by 23% (12). Funding agencies immediately provided support to broad, untargeted, periodic distribution of high-dose vitamin A supplements [recently using campaign approaches linked to polio eradication (13)], hence bypassing effectiveness trials or efforts to integrate into community systems. It was assumed that the mortality-reduction effects from RCT would occur if broad coverage with vitamin A supplements occurred, and that periodic supplementation was the quickest and most cost-effective route to follow. Confirmation of mortality and morbidity impact in noncontrolled settings associated with distribution, however, has not occurred. And now, as the campaign for polio eradication reaches closure, countries are struggling to identify alternative biannual delivery systems that will sustain high coverage. A dearth of examples exists where scientists and program planners explored alternative delivery routes tied closely to local community infrastructures for integrating micronutrient control into ongoing community health and development programs.
Process-driven and contextually relevant interventions. Experience is minimally available where context is considered using a community participatory process to develop integrated delivery systems for supplements along with appropriate mixtures of supportive strategies (11). A recent noteworthy exception is the Micronutrient and Health (MICAH) project in five African countries (Malawi, Ethiopia, Ghana, Tanzania and Senegal) sponsored by World Vision, Canada (14). Three objectives constituted phase 1 of the integrated strategy, i.e., to increase intake and bioavailability of micronutrients, to decrease prevalence of diseases that influence micronutrient status and to build local capacity for delivery systems to improve micronutrient status. At baseline, > 10,250 households were involved and in the assessment evaluation after 3 y, > 15,500 were included. A participatory process with the community developed actions tailored to regional variations rather than a predesigned uniform strategy. The evaluation after 3 y revealed that substantial improvements occurred in health and micronutrient status in each of the five African countries including reduction in iron-deficiency anemia, sustained broad coverage with vitamin A supplements, improved dietary diversity and community development and empowerment. A phase 2 expansion is planned that builds on lessons learned to improve the process. Additional time is needed to confirm that the impressive achievements to date reflect the first incremental step in moving the participating populations toward sustainable food security.
Mandated solutions and informed choice. Universal and mandatory fortification of food products with micronutrients currently is promoted. Universal salt fortification with iodine is without doubt a remarkable cost-effective success story in developing countries. Public and private sector cooperation and government enforcement have led to a recent global estimate that access to iodized salt is nearly 70% in households in developing countries and almost 90% in most of Latin America and the Caribbean (15). As this broad coverage explains, success is halving the global iodine deficiency diseases in at-risk populations within a decade (1). United Nations Children's Fund claims that 90 million newborns are protected annually from loss of learning ability, which is attributed to the program (8). Recipients do not have to change food-consumption habits and need not understand how iodized salt benefits them; i.e., they can be passive recipients of the benefits of choiceless compliance. However, recent experiences in India (16) and Guatemala (17) demonstrate how political and economic considerations rather than nutrition and health can change government priorities for mandated programs and result in their reversal. Turning around such decisions requires informed consumers who demand continuation of public health-oriented programs that provide personal health benefits that they recognize; i.e., the voters when political elections occur.
The mandatory fortification of food products with micronutrients (other than salt with iodine) is unlikely to become global policy, although individual nations may elect to do so. The variety of foods that are potentially fortifiable is too great, and the economic implications, due to globalization of free-trade policies, are too risky. Nonetheless, these two examples indicate that scientific proof of program effectiveness as well as legislative tools are necessary, but they are insufficient to support and sustain programs in the developing world where food insecurities are prevalent. The lesson learned is that for public health-directed interventions to be sustainable, consumers must be informed and convinced that the interventions are to their personal benefit even when they are slightly more costly.
New directions in nutrition research and public partner perceptions
Completion of the human genome project as well as the genomes of some plant and animals are the most significant scientific accomplishments of the last several months. Entire new vistas for research are now open including research with the potential to reduce food insecurity and micronutrient malnutrition worldwide. L. E. Hood phrased this in the keynote address at a recent National Institutes of Health symposium as a paradigm shift in thinking among scientists to 1) the advent and feasibility of systems approaches to biology and 2) dramatically altered views of predictive and preventive medicine (18). He attributes the shift in part to the genetic "parts list" resulting from : sequences of the human genome that allow scientists to systematically understand the human organism. And, in the May 23, 2002 Washington Post, the National Institutes of Health National Human Genome Research Institute was reported to announce six new candidates, from chimpanzees to single-celled fungi, for elucidation of their genomes over the next several years. This will reveal a vast array of genes and allow comparative genomic research that promises a whole new realm of understanding of the evolution of metabolic and disease processes.
Plant genomics also is actively being pursued with direct implications for food security worldwide. Draft genomes of two subspecies of rice were announced recently (19). Rice feeds an estimated 3 billion people, and many of these are among the poorest in developing countries; these are the same populations that are most afflicted by calorie and micronutrient deficiencies. Scientists envision that the genetic knowledge and "parts list" provided by the sequences will help address formerly intractable problems that limit cereal food-crop production and quality in the developing world (20). Even before the rice genome sequences were known, gene-insertion research had enhanced micronutrient content and bioavailability (21, 22), and researchers introduced ß-carotene into this dietary staple that is long associated with populations at risk of vitamin A deficiency (23). Development of quality-protein maize, which contains superior lysine and tryptophan, a more favorable profile of other amino acids and enhanced agronomic characteristics has the potential to further boost the micronutrient density of maize (24). Provided that efforts are fostered to strengthen the long-neglected link between specialists in agriculture and specialists in biochemistry, the potential for applied biotechnology extends far beyond rice and maize to other major food crops that are distinctive to regional micronutrient-poor diets in the developing world.
For scientists, the exciting fundamental information gained from biotechnology and gene-modification research provides knowledge links in the chain between molecular biology and improvements in human, animal and plant conditions. The public, however, is unsure whether the potential risks of unknown side effects on health and environment are outweighed by the potential benefits asserted by scientists, many of which must still be verified in humans and judged safe by regulatory bodies. To date, no genetically modified food crop is commercially available for human use, although some might be close to commercialization. Public doubts have stalled progress on several fronts. Until this impasse is resolved, scientific potential of biotechnological innovations alone will not reduce world food insecurities.
A way forward
Scientific research has rapidly moved forward with new tools to address innumerable issues of life even before adequately dealing with the ethical, moral and safety ramifications of their applications. Ismail Serageldin, Director of the Library in Alexandria Egypt, categorizes these times as the third global revolution, the first being the agrarian revolution that settled people in small communities, and the second being the industrial revolution (25). He states (25), "Our world is undergoing a third transformation, one so profound that its contours can only be dimly perceived, its driving forces barely understood, and its momentous consequences hardly imagined." Is it any wonder that during this transformation, the public needs reassurance that scientists and regulatory bodies that are responsible for monitoring safety have health and environmental issues foremost in their decisions? New paradigms and strategic linkages between scientists, regulatory agencies and the public must be developed to deal adequately with the new era. Transparency is of utmost importance for developing trust and respect: admitting the risks and unknowns and weighing them against potential gains and allowing the public to be partners in decision-making processes that will move emerging science forward to implementation for the public good.
Scientific research is essential to reducing food insecurities worldwide, and unprecedented opportunities exist for applying traditional and new technologies to solve the problem. To be influential, however, research must be received by a receptive political, legislative and social environment. To be sustainable, interventions must be appropriate to regional and local needs as determined by partnerships with community decision-makers. Public demand and opportunities for making informed choices are important for stabilizing nutrition and health-program interventions even when these are government mandated. Last, the 2010 micronutrient targets set by United Nations Special Session on Children for the next decade are achievable and sustainable if present and potential available resources are harnessed, the public is engaged in determining contextually appropriate interventions for their use and trusting partnerships are fostered for creating informed choice for improving global food and nutrition security.
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FOOTNOTES |
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3 Abbreviations used: FAO, Food and Agriculture Organization; RCT, randomized clinical trials.
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LITERATURE CITED |
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TOPABSTRACTLITERATURE CITED |
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1. United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition (ACC/SCN) in collaboration with International Food Policy Research Institute. (2000) Fourth Report on the World Nutrition Situation: Nutrition throughout the Life Cycle. UN ACC/SCN, Geneva, Switzerland.
2. Food and Agricultural Organization (FAO) (2001) Food insecurity: when people live with hunger and fear starvation. The State of Food Insecurity in the World 2001. FAO, Rome.
3. United Nations Children's Fund (UNICEF)/World Health Organization (WHO)/International Council for Control of Iodine Deficiency Disorders (ICCIDD) (1999) Progress Towards the Elimination of Iodine Deficiency Disorders (IDD). WHO/NHD/99.4, WHO, Geneva.
4. Mason, J. B., Lotfi, M., Dalmiya, N., Sethuraman, K. & Deitchler, M. (2001) The Micronutrient Report: Current Progress and Trends in the Control of Vitamin A, Iodine, and Iron Deficiencies. Micronutrient Initiative, International Development Research Center, Ottawa, Canada.
5. UNICEF (2001) We the Children: Meeting the Promises of the World Summit for Children. UNICEF for the United Nations, NY.
6. Underwood, B. A. (1998) From research to global reality: the micronutrient story. J. Nutr. 128: 145–151.
7. World Bank (1994) Enriching lives: overcoming vitamin and mineral malnutrition in developing countries. The World Bank, Washington, D.C.
8. UNICEF (2002) A World Fit for Children (unedited advanced copy, 15 May 2002). p. 4. UNICEF, NY.
9. Gillespie, S., Mason, J. & Martorell, R. (1996) How nutrition improves. ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 15. ACC/SCN, Geneva, Switzerland.
10. Allen, L. & Gillespie, S. (2001) What works? A review of the efficacy and effectiveness of nutrition interventions. Nutrition Policy Paper No. 19, Asian Development Bank (ADB) Nutrition and Development Series No. 5. ACC/SCN, Geneva, in collaboration with the ADB, Manila.
11. Underwood, B. A. & Smitasiri, S. (1999) Micronutrient malnutrition: policies and programs for control and their implications. Annu. Rev. Nutr. 19: 303–324.[Medline]
12. Beaton, G. H., Martorell, R., Aronson, K. J., Edmonston, B., McCabe, G., Ross, A. C. & Harvey, B. (1993) Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 13. ACC/SCN, Geneva, Switzerland.
13. Goodman, T., Dalmiya, N., de Benoist, B. & Schultink, W. (2000) Polio as a platform: using national immunization days to deliver vitamin A supplements. Bull. World Health Organ. 78: 305–314.[Medline]
14. World Vision Canada. (2002) MICA Phase 1 Results 1995–2001. World Vision Canada, Ontario.
15. Houston, R., Lotfi, M., Nathan, R. & Pandax, C. (1999) Assessing Country Progress in Universal Salt Iodization Programs. Micronutrient Initiative, Ottawa, Canada.
16. India revokes mandatory iodized salt. (2000) ICCIDD Monthly Update, May 2000.
17. Dary, O. (2001) Free-trade vs. public health: a history of the fighting for the sugar fortification program in Guatemala. XX International Vitamin A Consultative Group (IVACG) Meeting, Vietnam, Feb. 12–15, 2001 (abstract).
18. National Center for Toxicogenomics, National Institute of Environmental Health Sciences & National Institutes of Health (2001) Summary of the Symposium on Gene Expression and Proteomics in Environmental Health Research, Dec. 3–4, 2001. National Institutes of Health, Bethesda, MD.
19. Normile, D. & E. Pennisi (2002) Rice: boiled down to bare essentials. Science 296: 32–36.
20. Cantrell, R. P. & Reeves, T. G. (2002) The cereal of the world's poor takes center stage. Science 296: 53.
21. Welch, R. M. (2002) Breeding strategies for biofortified staple plant foods to reduce micronutrient malnutrition globally. J. Nutr. 132: 495S–499S.
22. Raboy, V. (2002) Progress in breeding low phytate crops. J. Nutr. 132: 503S–505S.
23. Beyer, P., Al-Babili, S., Ye, X., Lucca, P., Schaub, P., Welsch, R. & Potrykus, I. (2002) Golden rice: introducing the ß-carotene biosynthesis pathway into rice endosperm by genetic engineering to defeat vitamin A deficiency. J. Nutr. 132: 506S–510S.
24. Vasal, S. K. (1999) Quality protein maize story. Workshop: Improving Human Nutrition through Agriculture: The Role of International Agricultural Research, October 5–7, 1999.
25. Serageldin, I. (2002) World poverty and hunger—the challenge for science. Science 296: 54–58.
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