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Community Nutrition for Developing Countries

This book is dedicated to Anthony and Katie
Norman


The two most special people in my life:
my husband Maxwell George Hounsell and my daughter Simone Steyn
Nelia

CONTENTS

Foreword: Frits Pannekoek

Preface

Introduction

PART 1
THE FOOD AND NUTRITION SITUATION IN DEVELOPING COUNTRIES

  Chapter 1   A Human Rights–Based Approach to Community and Public Nutrition: Theoretical Underpinnings and Evolving Experiences

Wenche Barth Eide and Eleni M. W. Maunder

  Chapter 2   Food Security, Dietary Diversity, and Biodiversity: Food and Nutrition Security in Developing Countries

Mieke Faber and Friede Wenhold

  Chapter 3   Food Cultures

Folake Samuel and Neelam Makhani

  Chapter 4   The Nutrition Transition in Developing Countries

H. H. Esté Vorster and Lesley T. Bourne

PART 2
LIFECYCLE NUTRITION

  Chapter 5   Nutrition During the First Thousand Days of Life, Part I: Pregnancy and Lactation

Lisanne M. du Plessis and Celeste E. Naude

  Chapter 6   Nutrition During the First Thousand Days of Life, Part II: Infant Feeding and Development

Lisanne M. du Plessis, Celeste E. Naude, and Rina Swart

  Chapter 7   Nutrition for School-age Children: Assessment, Analysis, and Action

Friede Wenhold, Ellen Muehlhoff, and H. Salome Kruger

  Chapter 8   Nutrient Requirements and Factors Affecting Nutritional Status in Older Adults

Karen E. Charlton, Monica Ferreira, and Jean M. Fourie

PART 3
THE ROLE OF NUTRITION IN THE PREVENTION AND TREATMENT OF DISEASE

  Chapter 9   Nutritional Management of Multiple Nutrient Deficiencies

Michael K. Hendricks, H. Salome Kruger, and Thandi Puoane

Chapter 10   Nutritional Management of HIV/AIDS, TB, and Other Infectious Diseases

Celeste E. Naude, Lisanne M. du Plessis, and Michael K. Hendricks

Chapter 11   Nutritional Management of Diarrhoea

Joy Fraser and Alice N. Brako

Chapter 12   Nutritional Management of Chronic Diseases

Renée Blaauw, Martani J. Lombard, Nelia Steyn, and Petro Wolmarans

Chapter 13   Nutrition and Chronic Disease: Looking at the Big Picture

Norman J. Temple

PART 4
FROM FOOD GUIDES TO NUTRITION EDUCATION

Chapter 14   Dietary Recommendations, Food Guides, and Food Labels

Norman J. Temple and Lesley T. Bourne

Chapter 15   Nutrition Education

Jane Sherman and Ellen Muehlhoff

PART 5
KEY COMPONENTS OF COMMUNITY-BASED NUTRITION PROGRAMMES

Chapter 16   Planning of Nutrition Programmes: An Outline

Jacob Setorglo and Matilda Steiner-Asiedu

Chapter 17   Achieving Success in Community-Based Nutrition Programmes

Jacob Setorglo, Matilda Steiner-Asiedu, Thandi Puoane, David Sanders, and Kingsley K. Asare Pereko

Chapter 18   The Evaluation of Community-based Nutrition Programmes

Oyediran Oyewole

PART 6
POPULATION NUTRITION AND THE ROLE OF GOVERNMENT

Chapter 19   Barriers to Progress Towards a Healthier Diet: The Need for Government Action

Norman J. Temple

Chapter 20   The Development of Government Policies on Food and Nutrition

Jacob Setorglo, Matilda Steiner-Asiedu, and Ahmed Adu-Oppong

PART 7
ASSESSING NUTRITION STATUS

Chapter 21   Nutrition Surveillance

Jacob Setorglo and Matilda Steiner-Asiedu

Chapter 22   Assessing Nutritional Status: Dietary Intake, Anthropometry, Clinical Signs and Symptoms, and Laboratory Tests

Alice N. Brako, Zandile Mchiza, and Whadi-ah Parker

PART 8
FOOD SERVICES AND FOOD SAFETY

Chapter 23   Providing Meals in Institutional Settings

Ronette Lategan, Pontsho Malibe, and Luzette van Niekerk

Chapter 24   Food Quality and Food Safety

Wilna H. Oldewage-Theron and Abdulkadir A. Egal

PART 9
A BROADER PERSPECTIVE

Chapter 25   The Nutrition Profession in Africa: Meeting Current and Future Challenges

Tola Atinmo and Oyediran Oyewole

Chapter 26   The Problem of Misleading and Unscientific Information Regarding Nutrition

Norman J. Temple, Alice N. Brako, and Jacob Setorglo

Chapter 27   Nutrition Challenges of a Changing World

Norman J. Temple, Megan Jamieson, and George Winter

   Appendix I   Sources of Reliable Information on Nutrition

 Appendix II   Aids to Calculations

Appendix III   Dietary Reference Intakes (DRI)

List of Contributors

PREFACE

Until now, courses in community nutrition taught at universities and colleges in developing countries have relied, in the main, on American or British textbooks. But the nutrition-related health challenges with which developing countries must grapple differ considerably from those found in highly industrialized Western nations, as do the community settings in which health services and nutrition programmes are delivered. The present book owes its existence to an earlier volume, Community Nutrition Textbook for South Africa: A Rights-Based Approach (2008), on which we also collaborated. As its title indicates, that book focused specifically on South Africa. We soon realized, however, that a pressing need existed for a similar book aimed at developing countries more broadly.

The overriding goal of this book is to enhance the health and well-being of low-income populations throughout the world by improving the quality of nutrition programming available in local communities. Well-educated nutrition professionals are, of course, essential to this goal. Community nutritionists work in diverse settings, including schools, hospitals, workplaces, and local clinics, as well as health departments. (The term public health nutritionist is to some extent synonymous, although that term often implies a somewhat narrower range of duties carried out in the context of a government department.) Nutrition professionals are charged with assessing the nutritional status and requirements of individuals and groups and with planning, implementing, and evaluating programmes designed to address those needs. This volume is for those studying to become such professionals, in hopes of working to better people’s lives.

Existing textbooks on community nutrition tend to be prohibitively expensive for most students in developing countries. As an open access publication, this book can be downloaded from the Internet by anyone, anywhere, at no cost from the AU Press website. This innovative approach to textbook publishing clearly holds great potential for overcoming a major barrier that separates students in developing countries from high-quality textbooks. We therefore applaud Pamela Holway–for her hard work and dedication to this volume–and Athabasca University Press, located in Edmonton, Canada, for seeing it through to publication. We also thank the Food and Agriculture Organization of the United Nations for allowing us to use material from our previous book.

Three dozen authors collaborated in the writing of this book. Their collective wealth of experience comes from having worked in diverse countries spread across Africa, Europe, Australia, and North America. Most of them now hold university positions, but some are employed in government departments or by research organizations. In assembling this multi-talented team, we have, we hope, created a rich mixture of knowledge, experience, and deep understanding.

Nutrition is very much a work in progress. We are confident that today’s generation of students and young researchers will build on the ideas of today, adapt to the new realities of change in developing countries, and help solve the many challenges that confront us.

Norman J. Temple and Nelia Steyn

INTRODUCTION

Norman J. Temple and Nelia Steyn

Back in the 1960s the nutrition and health situation in such countries as the UK and USA was dramatically different to that in Africa. The UK and USA were (and still are) dominated by the Western diet and Western diseases. But the vast majority of Africans were still eating a traditional low-fat, high-fibre diet. Their disease pattern was also completely different from the British and American experience: instead of Western diseases, they had such problems as nutrient deficiencies and infectious diseases. Of course, there were pockets of people eating a Western diet and developing Western diseases. The white population in South Africa is one obvious example.

Fast forward to today and we see a radically changed world. Africans, whenever they have enough money, are as fond of Western food as are those in the UK and USA. And, following in the footsteps of the Western diet, they are experiencing an epidemic of Western diseases. To exemplify, the available evidence indicates that whereas undernutrition is still rife on the African continent, the prevalence of obesity now rivals that of severe stunting. We can point to countries like Mauritania and Lesotho where severe stunting in children younger than five years is estimated at 16.5% and 15.0%, respectively, while obesity in women between the ages 15 and 49 is estimated to be at 16.5% and 16.1%, respectively. But much of Africa, especially its poor rural areas, has only taken a few steps down this road. As a result people residing in those areas have a similar disease pattern as did their parents and grandparents.

This scenario repeats itself across much of the developing world. Some countries (Bangladesh, for example) resemble in many ways the poor rural areas of Africa. By contrast, more and more developing countries have adopted a pattern of diet and disease that is fast “catching up” with that of the UK and USA. This phenomenon is now commonly referred to as the nutrition transition. Typically it refers to the habitual consumption of a diet which is high in energy, total fat, saturated fat, trans fats, sodium, and added sugar. Generally, it is low in fibre, many essential micronutrients, and fruit and vegetables. It is commonly referred to as an energy-dense and low micronutrient-dense diet because it has a high caloric value with a poor intake of many essential nutrients such as vitamins A and C, iron, and calcium. This is also the typical reflection of a diet associated with the development of obesity, particularly when coupled with physical inactivity. This scenario is associated with the surge of obesity taking place in many developing countries, in both children and adults. It further explains the increasing prevalence of chronic diseases of lifestyle such as type 2 diabetes in low-income countries.

This very brief and broad overview of diet and disease around the world explains why this book is so vitally important. A nutritionist working in a small town in Africa or India needs to understand the changing dietary patterns that characterize the developing world, as well as the accompanying pattern of diseases. The book is primarily intended for community nutritionists, often referred to as public health nutritionists. We are confident that the book will serve as an invaluable resource for anyone engaged in that type of work. But the book is actually more than that: it will be of much value to people working in such areas as medicine, nursing, and public health. A government official charged in developing health-care policies, for instance, would be well advised to keep a copy close at hand.

The book starts with a chapter that examines issues of human rights in relation to community and public nutrition. This serves to remind us that food security is a fundamental human right. The chapter includes a full explanation on the Millennium Development Goals. This is followed by Chapter 2 that makes a detailed exploration of the challenge of food insecurity. Following this Chapter 3 discusses dietary patterns in different countries, especially in Africa and South Asia. Together these three chapters form a theoretical base for the tenets of nutrition in the developing world. It covers common theories and constructs to support the nutritionist who has to face the challenges of promoting a healthy diet in a developing environment. It also reinforces what is known and common to many developing countries and equips the health professional of today with important facts.

Chapter 4 provides a detailed account of the concept of the nutrition transition. The chapter is an excellent framework for a better understanding of some of the factors and mechanisms responsible for the changing patterns of diet and disease around the world. Indeed, many readers of this book will see the nutrition transition at work in their everyday lives. The nutrition transition can today be regarded as one of the most serious nutritional health challenges which the community nutritionist or dietitian has to cope with in the twenty-first century. Since it is growing at an alarming rate across the world, the health professional will need to find innovative ways of dealing with this while at the same time still trying to cope with the outcomes of undernutrition and its legacies.

Next come four chapters on nutrition challenges across the lifecycle (Section 2). It is, of course, crucially important for community nutritionists to have a sound understanding of the nutrition challenges when managing such high-risk groups as pregnant women, children, adolescents, and the elderly. While this information forms the basis of most textbooks on nutrition, the current text focuses on the essential elements of the lifecycle in developing countries who are still dealing with poverty and inadequate health services. In a sense these chapters encapsulate the services which can be provided with few resources even under adverse conditions of health and poverty.

The book then turns to a range of critically important issues concerning the place of nutrition in both the prevention and nutritional therapy of various nutritional and health disorders (Section 3). The first of these chapters looks at the sometimes insufficiently appreciated multiple nutrient deficiencies, which are still, alas, a subject of huge importance across much of the developing world. This is followed by a chapter on the management of HIV/AIDS, TB, and other infectious diseases, which are still major causes of morbidity and mortality in low-income countries. After this comes a chapter on diarrhoea, another condition associated with poverty and poor health which is likely to remain with us until such time as good environmental health is a way of life in all countries. The rest of the section reflects the sharp contrast of dietary imbalances and excesses associated with the major nutrition-related chronic diseases, namely cardiovascular disease, type 2 diabetes, obesity, and cancer. This section perfectly illustrates why this book is destined to play a vital role in the training of tomorrow’s generation of community dietitians and nutritionists: it tells the full story and underscores the importance of nutrition in relation to health and disease as it will present itself to practitioners in developing countries. Once again the emphasis is on prevention and management under conditions of poverty and poor health resources.

A fully competent community nutritionist should not only have a broad knowledge of the issues presented in the earlier sections of the book, but such a practitioner must also be skilled at translating, simplifying, and conveying this information in the local context. The first chapter of Section 4 surveys and critically evaluates the topics of food guides, food labels, and food tables that reflect current recommendations for the intake of nutrients. This information is important for two major reasons: first, so that community nutritionists properly understand these issues and can therefore explain them to others, and, second, so that when the opportunity presents itself, readers are well informed and can play an active role in the development of policies in this area. The second chapter in Section 4 presents in-depth advice on the delivery of nutrition education. That chapter can be regarded as the weapon of defence of health professionals who operate under conditions of poverty and lack of resources. Teaching people to fish for themselves is an essential tenet underlying community nutrition principles. Often, however, this is one of the most difficult aspects of improving health, especially when people expect pills for cures and are reluctant to accept responsibility for their own health.

Section 5 addresses intervention strategies and comprises three chapters that cover the vitally important subject of community-based nutrition programmes. These chapters provide much valuable information for anyone planning such an activity in relation to successful experiences in different settings around the world. The section will no doubt help contribute to nutrition practitioners moving away from “doing something,” the Achilles tendon of many interventions, to “doing something sound,” with a high probability of making a difference. This section also emphasizes the importance of people “owning” their own health. This implies that they should be involved in all the phases of interventions if these are to be successful. The concept of sustainability is another theme that runs through all health interventions; lack of sustainability is illustrated by interventions which have failed to make a difference.

All previous sections have aimed to improve population nutrition by extolling the benefits associated with improved nutritional practices. This is based, almost entirely, on voluntary choices. But the degree of success achieved by this approach is, typically, quite modest. For instance, if education was enough, on its own, to persuade people to adopt a healthy lifestyle, then cigarette smoking would have disappeared long ago! A major part of the reason for continued poor choices is that the environment around us is not always supportive of a healthy lifestyle. The limited degree of success of strategies based on persuading populations to voluntarily adopt healthy practices brings us to the vital and very thorny issue of government policy. In many areas – food prices, food advertising, and the amount of salt added to food, to give but three examples – government policy can potentially achieve much improvement in population health. In many such cases, this approach is considered, by some practitioners at least, to be far more cost-effective than alternative strategies, such as education or medical treatment. The two chapters dealing with issues of policy (Section 6) are therefore crucially important.

Nutritionists and dietitians of the future will need to be more aggressive in their approach to developing effective policies. This can be done by providing governments with sufficient and irrefutable evidence so that they accept the need for the development of appropriate policies. This evidence also needs to show the cost-effectiveness of policies in relation to money which governments have to spend on health care to deal with such health problems. In many instances the cost savings alone can make a difference to how governments act.

Section 7 equips the practitioner with guidelines and selected tools to measure and assess the nutritional status of individuals and populations. The equally important Section 8 provides guidelines and tools for planning meals for institutions and approaches to addressing issues of food quality and food safety. Both these chapters provide simple general information with an emphasis on low-income settings.

Section 9, a nutritional mosaic, addresses topics which can be considered to be only loosely related to community nutrition. It includes: the state of training of dietitians in Africa; nutrition misinformation (both naïve and deliberate), which is widespread across continents; the rapid pace of population growth; the very real dangers posed by climate change; biofuels (does their production do more harm than good?); the crisis in the world’s fisheries; global problems of water shortages; foods made from genetically modified (GM) plants; and globalization. The aim of this section is to make you think and to show you that as a health professional all these global issues are also of vital importance to you as a nutritionist or dietitian. These are not problems that “others” have to deal with but problems that all health professionals need to embrace in order to find solutions.

Taking the book as a whole one sees a remarkable wealth of information and ideas. Trying to translate this book into practice is clearly an ambitious undertaking. Common wisdom expressed long ago by Hippocrates (c. 460–377 B.C.) stated: “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” This is the general foundation of the principles of health. Today, despite our better understanding, albeit still rudimentary, we still struggle – practitioners and the public alike – to select “the right amount of nourishment and exercise” to improve our health. The great challenge is the many and very complex determinants of health. This book will undoubtedly prove to be a significant contribution to the ever-elusive Hippocratic doctrine.

PART 1

THE FOOD AND NUTRITION SITUATION IN DEVELOPING COUNTRIES

CHAPTER 1

A HUMAN RIGHTS-BASED APPROACH TO COMMUNITY AND PUBLIC NUTRITION

Theoretical Underpinnings and Evolving Experiences

Wenche Barth Eide and Eleni M. W. Maunder

Outline

•  Human rights in community nutrition

•  Nutrition, social justice, and human rights

•  Protecting human rights in the context of economic and social development

•  Economic, social, and cultural rights especially relevant to nutrition

•  Implementation of rights at the country level

Objectives

At the completion of this chapter you should be able to:

•  Explain the origin of the concept of universal human rights

•  Describe the Millennium Declaration and the Millennium Development Goals of the United Nations

•  Understand the difference between a rights-based approach and a charity-based approach to nutritional problems

•  Describe the UNICEF conceptual framework for the causes of malnutrition

•  Explain your understanding of social injustice in relation to nutrition and health

•  Explain the obligations of the state as a “duty-bearer”

•  Describe the seven core principles of a human rights–based approach

•  Describe the United Nations international human rights system

•  Understand what is meant by a “right to food”

•  Explain the terms progressive realization and available resources in relation to the right to food

1. HUMAN RIGHTS AND COMMUNITY NUTRITION

1.1 The Concept of Human Rights

Human nutrition was, for many years, viewed within a medical framework. In development circles, however, the emphasis has recently shifted towards a more integrated approach to addressing problems of human nutrition – within the concept of human rights. This approach recognizes that human nutritional status is not determined simply by biological factors but also by social and political forces. While these forces can work to promote good nutritional status, they can also contribute to glaring social inequalities, with the result that certain population groups become especially vulnerable to economic and social changes that affect their food security and nutritional health. When adequate nutrition is understood to be a right, then one can reasonably say of the undernourished that one of their human rights has been violated.

Human rights are grounded in values and moral principles that are deemed to apply to all human beings. These rights have been enshrined in international law and, in some cases, in the laws of specific nations. All people have the same human rights, regardless of their skin colour, gender, age, language, religion, political affiliations, national or ethnic origin, innate physical and mental endowments, level of education, wealth, social class, and so on. The overriding goal of an approach based on human rights is to identify and protect those who may have been overlooked, if not more or less deliberately ignored, in development processes that in fact put their interests and needs at risk. As Judith Asher (2004, p. 2) explains in The Right to Health, “When health is not described simply in terms of needs but also in terms of rights, governments find it far more difficult to justify the withholding of basic provisions and services on account of alleged financial constraints or because of discriminatory priorities” (Asher, 2004, p. 2).

A clear difference exists between a rights-based approach and one based on charity. The latter sees the world’s hungry and malnourished as passive recipients of handouts from the state or benevolent individuals or groups. Whereas charity depends on the moral will and compassion of the giver, who chooses to provide food to people who are hungry or who suffer from food insecurity, a rights-based approach regards hungry people as active citizens deserving of respect and dignity. A right-based approach is founded on the belief that hunger and malnutrition are largely the product of man-made injustices, sometimes compounded by random factors such as natural disasters. Such an approach holds that it would be immoral of a state and its citizens to stand by and do nothing when people are in danger of starvation. Such an approach therefore firmly establishes a legal obligation of states to address hunger and malnutrition.

1.2 Human Rights and the Legacy of the United Nations

Questions concerning the fundamental rights of human beings have been debated for centuries, but it was the United Nations (UN) that formulated the modern concept of universal human rights and made it a core element of international law. When the UN was founded, in 1945, the leaders of the world’s nations hoped that the atrocities of the Second World War would never be repeated. They therefore joined hands to establish this new international organization, with the goal of fostering peace and protecting all populations against insecurity and injustice. The work of the UN is founded on the principles outlined in the Charter of the United Nations, to which all member nations are expected to adhere. Chapter I, Article 1, of the charter lays out the organization’s overarching goals (see Box 1.1).

This first article sets as one purpose of the UN to encourage “respect for human rights and for fundamental freedoms for all.” Peaceful relations among nations are unlikely to be achieved, however, if gaping disparities exist in economic and social circumstances of the world’s people. Article 55, in Chapter IX (“International Economic and Social Cooperation”), accordingly recognizes that “conditions of stability and well-being,” in which respect for human rights can flourish, are essential to international harmony (see Box 1.2). The creation of such conditions depends in part on solving the problems that contribute to the economic and social gaps among nations, including poverty, disease, and malnutrition.

Box 1.1: Article 1 of the Charter of the United Nations

The Purposes of the United Nations are:

1.  To maintain international peace and security, and to that end: to take effective collective measures for the prevention and removal of threats to the peace, and for the suppression of acts of aggression or other breaches of the peace, and to bring about by peaceful means, and in conformity with the principles of justice and international law, adjustment or settlement of international disputes or situations which might lead to a breach of the peace;

2.  To develop friendly relations among nations based on respect for the principle of equal rights and self-determination of peoples, and to take other appropriate measures to strengthen universal peace;

3.  To achieve international cooperation in solving international problems of an economic, social, cultural, or humanitarian character, and in promoting and encouraging respect for human rights and for fundamental freedoms for all without distinction as to race, sex, language, or religion; and

4.  To be a centre for harmonizing the actions of nations in the attainment of these common ends.

Box 1.2: Article 55 of the Charter of the United Nations

With a view to the creation of conditions of stability and well-being which are necessary for peaceful and friendly relations among nations based on respect for the principle of equal rights and self-determination of peoples, the United Nations shall promote:

a.  higher standards of living, full employment, and conditions of economic and social progress and development;

b.  solutions of international economic, social, health, and related problems; and international cultural and educational cooperation; and

c.  universal respect for, and observance of, human rights and fundamental freedoms for all without distinction as to race, sex, language, or religion.

Human rights and fundamental freedoms needed to be formulated more specifically, however. Thus, in 1948, the UN General Assembly formulated the Universal Declaration on Human Rights (UDHR), which was adopted on December 10 – a day that has come to be known as Human Rights Day. Article 1 of the UDHR states: “All human beings are born free and equal in dignity and rights.” In other words, human rights are innate. The UDHR contains general provisions for civil, political, economic, social, and cultural rights.

Starting in the early 1950s, however, the Cold War developed between capitalist nations and communist ones. The advent of the Cold War complicated the understanding of human rights as one integrated “package,” as individual UN member states adopted differing approaches to safeguarding these rights, privileging some over others. The Eastern bloc – the Soviet Union and communist Eastern Europe – took the position that it was the responsibility of the state to feed and care for its people but placed little value on personal freedoms, such as free speech. In contrast, Western states, led by the United States, strongly promoted civil and political rights, while limiting the state’s responsibility to secure the material well-being of its citizens. This divide prevailed until 1989, when the fall of the Berlin Wall precipitated changes that brought the Cold War to an end.

1.3 A Renewed Interest in Human Rights

The end of the Cold War made it possible to adopt a more unified perspective on human rights. In 1993, a World Conference on Human Rights was held in Vienna. It underlined that human rights are universal, interrelated, interdependent, and indivisible. Throughout the 1990s, interest in economic, social, and cultural rights, alongside civil and political rights, was growing, as was the understanding that these rights should be understood as an integrated whole.

Still, it took time to incorporate human rights into broader international debates and plans for economic and social development, including those rights particularly relevant to food security and nutrition. In 2000, at the turn of the millennium, the leaders of all UN member states gathered in New York for a “Millennium Summit,” which resulted in the Millennium Declaration. In this document, the leaders of the world’s nations agreed that, in addition to their responsibilities to their own populations, they had “a collective responsibility to uphold the principles of human dignity, equality and equity at the global level” and “a duty therefore to all the world’s people, especially the most vulnerable and, in particular, the children of the world, to whom the future belongs” (I, 2).

The Millennium Declaration also listed certain fundamental values seen as essential for good international relations in the twenty-first century: freedom, equality, solidarity, tolerance, respect for nature, and shared responsibility (I, 6). In order to translate these shared values into actions, they identified the following key objectives of special significance:

•  Peace, security, and disarmament

•  Development and poverty eradication

•  Protecting our common environment

•  Human rights, democracy, and good governance

•  Protecting the vulnerable

•  Meeting the special needs of Africa

•  Strengthening the United Nations

These objectives were to be pursued in an integrated manner so that they would mutually reinforce each other.

Under the objective “Development and poverty eradication,” a series of development goals was listed, for the time being formulated in relatively broad terms. These goals included targets such as the reduction in the proportion of hungry people, of under-five mortality, and of maternal mortality. These goals were later refined and condensed into the eight Millennium Development Goals (MDGs), with specific targets set for 2015 (further described in section 2.6). But while these eight goals are widely used to promote and assess progress in different countries and the world, there is an unfortunate flaw in the way they were originally presented: they did not explicitly indicate how they were to be pursued, namely, in combination with the fourth objective, “Human rights, democracy, and good governance” (Alston, 2005). Many may have assumed that the link would automatically be recognized, but this is unfortunately not yet always the case. Many governments, as well as people in general, know relatively little about human rights, or they are not interested in them, or they may see them as running counter to their own political and economic interests. Nevertheless, from the end of the last century and into the new millennium, the world has witnessed a revitalized concern with human rights.

1.4 Human Rights and the Community

The term community has both a narrower and a wider meaning. The word is most often understood in its narrower sense, as referring to the locality in which an individual or a family lives and functions, such as a village. This sense of the term is important, because it suggests that a lot can be accomplished through alliances of people living and sharing the same conditions in a specific locality. There may, of course, be different interests within such a community, which can be a cause of conflict. Here, human rights should protect those weaker and sometimes marginalized groups.

But alliances among and/or on behalf of those sharing the same interests can stretch beyond circumscribed geographical areas. Thus we can think of a “community” in a more abstract manner – as a collection of groups who live in different localities but who have common goals that they wish to achieve. Examples would be a national, or even international, community of small-scale farmers, local fishermen, or women in city slums who have limited access to health care for themselves and their children. This understanding of community is useful in relation to the social inequalities that arise when certain groups lose out in the process of development. This chapter therefore gives a rather broad interpretation to the term community.

2. NUTRITION, SOCIAL JUSTICE, AND HUMAN RIGHTS

2.1 Shifting Perspectives on the Problem of Nutrition

Those who work in the area of community nutrition use several different terms to refer to their field: community nutrition, public health nutrition, and public nutrition. The distinction is to some extent historical, in that it reflects evolving perspectives on how best to approach the problem of undernourishment and other community health issues. The term used in this book, community nutrition, generally suggests a focus on specific interventions designed to help prevent disease and improve the health, nutrition, and well-being of individuals and groups within local communities. These communities may be defined by their setting, such as a village, school, or workplace), or they may consist of groups who have common health concerns, such as breast-feeding mothers. Community nutrition programmes are often sponsored by government agencies, but they may also involve international bodies such as the World Health Organization (WHO).

Closely allied with community nutrition is public health nutrition. Public health nutritionists are somewhat more likely to be employed in government departments and are commonly concerned with the application of public health principles (Hughes, 2003). As Beaglehole et al. (2004) point out, the concept of public health exists within an ethical framework, in that implicit in it is the recognition that individual choice is not free but is constantly constrained by environmental and socio-economic factors. This view of public health, they argue (2004, p. 2084), “affirms the positive obligations by governments and communities to protect and improve the health of all their citizens and is based on the assumption that all lives are of equal worth.” Such a perspective forges a link between public health and human-rights approaches.

The term public nutrition, which came into use in the mid-1990s, is more explicitly connected to the notion of human rights. It encompasses both community nutrition and public health nutrition but shifts the emphasis to collective problem solving and the development of integrated policy, with the goal of realizing the human right to adequate food (Beaudry & Delisle, 2005). A public nutrition approach draws on governmental organizations in many sectors (health, agriculture, education, trade, transport, planning), along with the human and material resources available within a country, and directs them towards the improvement of the nutrition, health, and well-being of the public at large (Rogers & Schlossman, 1997). As Beaudry et al. (2004, p. 375) explain, “Public nutrition targets research, training and intervention. In line with health promotion, it focuses not only on an assessment of the problems and the analysis of their determinants, but also, and above all, on the concerted action required by civil society, the private sector and the government to solve them.” Public nutrition thus involves collective action aimed at achieving sustained improvements in the nutritional status and overall health of the population. Such action requires formulating policies that address environmental issues, the need for agricultural development, social inequities, and substandard living conditions, while also promoting “the empowerment of individuals to adopt healthy food habits and to exercise better control over their health generally” (Beaudry et al., 2004, p. 375).

2.2 Recent Trends in Nutrition Policy

Over the past few decades, our understanding of the conditions necessary to the creation and maintenance of human nutritional health has likewise evolved. Nutrition now includes epidemiological studies of the prevalence and causes of malnutrition and ill health in various societies and population groups. Such studies provide the evidence base for interventions designed to improve nutritional status.

There has been a steadily growing awareness of the need to link economic, agricultural, and health issues with nutrition. Since the early 1990s, the important issues of food availability and food access have been widely studied and are now accepted as part of mainstream nutrition science and practice, with implications for food and nutrition policy. Interest in these areas developed during the 1990s in part through a series of global conferences organized by UN agencies, some of which were directly focused on food and nutrition. In 1992, the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) jointly organized the International Conference on Nutrition, hosted by the FAO, in Rome (FAO, 1992). Then came the important “World Food Summit” in 1996, followed by the “World Food Summit: Five Years Later” in 2002, and a third “World Summit on Food Security” in 2009, also hosted by FAO in Rome (FAO, 1996, 2002a, 2002b, 2009a, 2009b). All were particularly significant regarding the further development of a human rights approach to food and food security.

2.3 The Global and National Food Security Situation

In 2013, the FAO estimated that 842 million people were undernourished (FAO, 2013, p. 8). Thus, around one in eight people in the world are likely to have suffered from chronic hunger, not having enough food for an active and healthy life. The vast majority of them live in developing regions. However, enough food exists to feed everyone in the world. In fact, notwithstanding disparities, most countries possess enough food to feed their population. In reality, most hunger is due to poverty and inequalities in food access.

Food security is not merely a matter of having enough food to supply energy. Food security is defined as having physical and economic access to food that is of sufficient quantity and nutritional quality to satisfy dietary needs (implying an adequate macro- and micronutrient intake) and that is safe and culturally acceptable (FAO, 1996). In other words, it is not enough simply to prevent undernutrition: people everywhere are entitled to a diet that will not cause obesity and associated chronic diseases, such as diabetes. Access to such a diet is often impossible for people living in poverty, as cheap foods are often energy dense but nutrient poor. Food security can only be achieved when individuals and households have the resources needed to obtain nutritionally adequate food. In an urban environment, this normally means having enough money to buy healthy foods; in a rural environment, it often means that people must have the agricultural resources to produce food, as well as money to purchase what they cannot grow themselves.

2.4 The Causes of Malnutrition: The UNICEF Conceptual Framework

Nutritional status and well-being depend on both dietary intake and overall health status. There are, however, many varied causes or determinants of malnutrition, as shown in the UNICEF conceptual framework (see Figure 1.1). Several important features of this framework should be noted. First, it is generic and thus can be used to analyse malnutrition in any context. That is, it does not apply only to specific situations. The framework includes a number of possible causes of malnutrition, and some, but not necessarily all, of these causes will apply in a given context. Second, information about the relative contribution of the varied causes of malnutrition in a specific context can be determined using this framework. Finally, the possible causes of malnutrition are presented in a hierarchy. This allows us to analyse the causes of malnutrition at different levels, as follows:

•  The obvious immediate causes of inadequate food and nutrition intake and possible confounding infectious disease factors

•  The underlying causes that can be clustered around food insecurity or inadequate access to food, inadequate care of the vulnerable, and inadequate control and prevention of disease, including adverse environmental sanitary conditions and inadequate health services

•  The basic causes of malnutrition related to the resources available within a society and how they are used and controlled

Those who exercise power do not always use available resources – natural, financial, organizational, or human – in the best interests of those most in need of them. In practice, the distribution of resources is determined by prevailing economic, ideological, and political conditions. A change in the underlying and basic causes of malnutrition and hunger will therefore require redressing fundamental social, economic, and political inequities. In other words, nutrition should be seen as a problem area that may require solutions at a variety of levels – the individual, the household, the local community, and the broader society.

2.5 Social Injustice

Social injustice means that individuals or groups of people are treated very unequally: they do not have the same access to resources or opportunities, such as schooling, paid work, or good health care. The huge discrepancies in the average standard of living in different countries, as well as the discrepancies within countries, are of great concern, for two reasons. First, enormous numbers of people have an unacceptably low standard of living; this results in malnutrition, poor mental and physical development, ill health, and premature death. Second, it is now clear that in addition to the direct material deprivation suffered by those with a low standard of living, the presence of inequalities in society also leads to increased malnutrition, poor mental and physical health, and premature death. Globally and for practically all countries in the world there is enough food to satisfy people’s energy requirements. Thus, the fact that there are nearly one billion people who are undernourished tells us about the extent of social injustice on a vast scale.

A human rights approach has the aim of eliminating social injustices. As we saw earlier in this chapter, Article 1 of the UDHR reads: “All human beings are born free and equal in dignity and rights.”

The fulfilment of human rights and the elimination of social injustices, including hunger and malnutrition, would be ensured in a fair society, in terms of social and health policies and political and economic arrangements. In a report published in 2008, the WHO Commission on Social Determinants of Health called attention to existing inequities in global health and issued a call for change (see Box 1.3).

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Figure 1.1: The UNICEF conceptual framework for understanding the causes of malnutrition. Adapted from The State of the World’s Children (UNICEF, 1998).

Box 1.3: A New Global Agenda for Health Equity

Our children have dramatically different life chances depending on where they were born. In Japan or Sweden they can expect to live more than 80 years; in Brazil, 72 years; India, 63 years; and in one of several African countries, fewer than 50 years. And within countries, the differences in life chances are dramatic and are seen worldwide. The poorest of the poor have high levels of illness and premature mortality. But poor health is not confined to those worst off. In countries at all levels of income, health and illness follow a social gradient: the lower the socio-economic position, the worse the health.

It does not have to be this way and it is not right that it should be like this. Where systematic differences in health are judged to be avoidable by reasonable action, they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities – the huge and remediable differences in health between and within countries – is a matter of social justice. Reducing health inequities is, for the Commission on Social Determinants of Health, an ethical imperative. Social injustice is killing people on a grand scale. (WHO Commission on Social Determinants of Health, 2008: Executive Summary)

2.6 The Millennium Development Goals (MDGs)

As explained above, as part of an effort to reduce social injustice, in the year 2000 the countries of the world agreed on the Millennium Declaration, out of which evolved the eight Millennium Development Goals (MDGs). These goals and their associated targets are shown in Box 1.4. As we suggested in section 1.3, the MDGs need to be promoted in the context of human rights, democracy, and good governance; this was the idea brought forward in the Millennium Declaration. It is therefore important that the principles of an approach based on human rights are applied in all efforts to reach the MDGs. Thequestion of human rights will be discussed below, in section 3. As students or as nutrition professionals, we can reflect on how the MDGs can be achieved as we read through the eight MDGs and their associated targets. We should also consider the extent to which success in reaching several of the MDGs depends on developments in nutrition programmes and services. Nutritionists and dietitians can actively use the MDGs to promote their causes and help politicians and planners see the direct links to good nutrition status.

The UN estimates that there have been significant advances towards meeting the MDGs, albeit with important setbacks in some areas. For example, regarding child mortality (MDG 4), annual deaths of children under 5 years of age fell to 8.8 million in 2008, down by 30% from 1990. Similarly with Goal 1 and its target to reduce hunger, children’s nutrition has improved: the percentage of underweight children is estimated to have declined from 25% in 1990 to 16% in 2010. However, 104 million children are still undernourished. Stunting in children under 5 years old has decreased globally from 40% to 27% over the same period. In the UN Africa Region, unfortunately, the number of stunted children is projected to increase from 45 million in 1990 to 60 million in 2010.

Box 1.4: Millennium Development Goals

Goal 1: Eradicate extreme poverty and hunger

•  Reduce by half the proportion of people living on less than a dollar a day

•  Reduce by half the proportion of people who suffer from hunger

Goal 2: Achieve universal primary education

•  Ensure that all boys and girls complete a full course of primary education

Goal 3: Promote gender equality and empower women

•  Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015

Goal 4: Reduce child mortality

•  Reduce by two thirds the mortality rate among children under five

Goal 5: Improve maternal health

•  Reduce by three quarters the maternal mortality ratio

Goal 6: Combat HIV/AIDS, malaria, and other diseases

•  Halt and begin to reverse the spread of HIV/AIDS

•  Halt and begin to reverse the incidence of malaria and other major diseases

Goal 7: Ensure environmental sustainability

•  Integrate the principles of sustainable development into government policies and programmes

•  Reverse loss of environmental resources

•  Reduce by half the proportion of people without sustainable access to safe drinking water

•  Achieve significant improvement in the lives of at least 100 million slum dwellers by 2020

Goal 8: Develop a global partnership for development

•  Develop further an open, rule-based, predictable, and non-discriminatory trading and financial system

•  Include a commitment to good governance, development, and poverty reduction – nationally and internationally

•  Address the least developed countries’ special needs

•  Include tariff and quota-free access for their exports

•  Enhance debt relief for heavily indebted poor countries

•  Cancel official bilateral debt

•  Give more generous official development assistance for countries committed to poverty reduction

•  Address the special needs of landlocked and small island developing states

•  Deal comprehensively with developing countries’ debt problems through national and international measures

•  Make debts sustainable in the long term

•  Develop decentralized productive work for youth

•  Cooperate with developing countries

•  Provide access to affordable essential drugs in developing countries

•  Cooperate with pharmaceutical companies

•  Make available new technologies, especially information and communications technologies

•  Cooperate with the private sector

NOTE: Since the MDGs were formulated, a proposal for a worldwide goal for the prevention and control of chronic diseases of lifestyle has been made (Strong et al., 2005); the target is a 2% reduction per year in death rates attributable to the major chronic diseases of lifestyle (heart disease, stroke, cancer, diabetes, and chronic respiratory diseases).

2.7 Nutrition Professionals: Exploring a Human Rights–Based Approach

The abolition of hunger and malnutrition should be a priority for the governments of all developing countries. From both a nutritional and a human rights perspective, it is important that the current substantial differences in living standards, nutrition, and health are significantly reduced. This will require the coordinated input of many sectors and departments and will be important in achieving the MDGs.

There is also a strong case for using an approach based on human rights in community nutrition. Human rights provide a specific perspective and opportunity that nutrition professionals need to be aware of when addressing nutritional problems (Maunder & Khoza, 2007). A rights-based approach to nutrition aims to ensure that the resources in a country are managed and utilized justly and equitably; this will help to secure adequate nutrition and health for all. This applies at both a community and household level. Such an approach may be pursued in the context of national constitutional rights, or, if they do not exist, of international human rights law – the majority of countries have now ratified the human rights conventions relevant to food and nutritional health.

Nutrition professionals need to have an understanding of their countries’ obligations – constitutional or otherwise – for the achievement of human rights, as will be explained in section 3.2. More specifically they need to understand the meaning of a human rights perspective on nutrition and food security. Nutrition professionals need to work with government agencies and institutions, non-governmental organizations, and civil society in the development and implementation of programmes promoting the right to adequate food and other rights important in the promotion of good nutrition and health.

3. PROTECTING HUMAN RIGHTS IN THE CONTEXT OF ECONOMIC AND SOCIAL DEVELOPMENT

3.1 Human Rights as Goals and Means in Development

To understand what can be gained by applying a human rights approach to community nutrition, some basic information is first needed about the nature and meaning of human rights. Such information is not an end in itself; rather, it will open a window to a different way of thinking and working with national and human development as the realization of human rights. We may also think of the realization of human rights as the condition for development. Thus we can view human rights both as goals and also as means to national and human development.

3.2 Rights and Duties

When people have a right, there are always others who have a duty to help fulfil that right. Who, then, have rights and can thereby be named “right-holders,” and who have duties and therefore become “duty-bearers”?

In the international legal system of human rights protection and promotion the state is the primary duty-bearer, with obligations towards all people under its jurisdiction to help them realize their human rights. This applies to states that have formally agreed to – or “ratified” – a human rights convention. But what is “the state”? First, there is the state authority proper, which is the government ministers or other politicians; their role as duty-bearers is to prepare laws that promote human rights as well as the policies for implementing them. In addition, there are many other duty-bearers on behalf of the state. They consist of institutions and individuals through whom the central or local government works to execute laws and implement policies and programmes: for example, by delivering various services according to state authority commitments. Governance is a term used to mean “the act of governing.” Good governance has come to mean governing based on some clearly expressed values, which ought explicitly to include human rights as primary.

A community nutritionist or dietitian, who is an employee of a government-run district health station or clinic, has a duty to help realize human rights within their scope of work. To assess whether this actually happens must be done with an understanding of the often quite limited capacity of many institutions and their staff. For example, in nutrition within primary health care, the limitations may arise from broader shortcomings in the health delivery system, such as insufficient training and resources.

Community nutritionists can help clarify obligations of the state by gathering and analysing data that can be used to expose shortcomings and indicate better solutions to nutrition problems. Nutritional data are irrefutable as evidence of whether the rights to food, health, and care have actually been fulfilled, or whether efforts towards it are at least going in the right direction. Community nutritionists can also show respect for exposed people and groups by drawing them into analysing and working on their own situation and helping them clearly understand that they have rights that can be claimed.

3.3 Where Do We Find Human Rights – and How Are They Used?

3.3.1 The meaning of human rights “instruments,” binding and non-binding

The word instrument has different meanings. In the present context it can be a certain law; in international law it is typically called a convention (or treaty), in national law it is the constitution or specific legislation, or official directives of various kinds set by the government.

Generally, an international instrument is either “binding” or “non-binding.” A binding convention (or treaty) requires that (1) the state should incorporate its content into its own legislation and also implement it in practice, and (2) the state should periodically report on its implementation to special committees set up by the UN to monitor how this is followed up in various countries.

In human rights work, binding human rights conventions as well as numerous non-binding declarations have been issued over the years. A declaration is a statement from participants at a meeting of the UN or other organization expressing broad agreement on some issues of concern and how to address them. There may also be codes of conduct on how governments should behave, and there may be guidelines for more specific action. In neither case is there an explicit obligation to follow up, as is the case for a binding convention. These so-called “soft-law” human rights instruments can only guide governments already interested in trying to meet the human rights of everybody, and especially help vulnerable people and communities to act on their own situation.

3.3.2 “Signatures” versus “ratification” of binding human rights instruments

At the time of formulation and initial adoption of a human rights convention (or treaty) by the UN General Assembly, a member state may sign the convention. This means the member state has the intention to later fully accept the convention by ratifying it. For that to happen, the convention must first go through the main legislative body in the home country, usually the parliament. Here there may be different political opinions about whether the country should ratify the convention. If it decides not to ratify, the country is not bound by the convention. If it decides to ratify, the country becomes a State Party to the convention. This move has important implications for how the government should govern that country in the best interests of its people. It will also be exposed to regular monitoring by specific committees set up for that purpose for each convention, called human rights convention committees or human rights treaty bodies. The country’s own compulsory reports, as mentioned above, become one of several tools those committees have for such monitoring. At the same time, civil society organizations are invited to submit reports.

This system of ratification and monitoring is a potentially forceful means for human rights defenders in exposing what their governments do or not do in the interest of people’s human rights of all kinds. All state and alternative reports, as well as the committees’ concluding observations on each country, are freely available on the internet. Community nutritionists can be important actors in gathering and analysing information that can eventually be used by these committees, whether through formal or informal channels.

3.3.3 The key international human rights instruments

An overview of key international human rights instruments is shown in Figure 1.2. The origin is the United Nations Charter, adopted at the birth of the organization in 1945, serving as its “constitution.” The human rights parts (some cited in section 1) were further spelled out in the Universal Declaration of Human Rights in 1948, followed by two international conventions in 1966, the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR). Together the three are called the International Bill of Human Rights.

The overview includes the numbers of ratifications by UN Member States (as of November 2010) for each of the binding instruments. As regards the UDHR, it is established that any state that wants to be and is accepted as a member of the UN automatically thereby commits itself to adhere to both the UN Charter and the UDHR.

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Figure 1.2: Overview of the key international human rights instruments. Numbers in parentheses are the date of adoption by the UN General Assembly and the date of entry into force. Boxes indicate those instruments especially relevant to nutrition.

Source: Adapted from Eide and Kracht, 2005, with the number of ratifications updated as of 1 November 2010.

3.3.4 Regional human rights instruments

There are also regional human rights instruments that further underpin the international ones, but adapt and enrich them according to special circumstances in the regions. So far there are general human rights instruments (charters, conventions) in the African, Inter-American, and European regions, but not yet in the Asian region.

3.3.5 The nature and categories of obligations of a state

In states that have ratified a human rights convention, the government must help ensure the rights of individuals and their families. How can this be generally expressed in terms of duties or obligations? In international human rights language, three categories of obligations have been identified for the state: to respect, to protect, and to fulfil a certain right, where fulfil has been divided into facilitate and provide (Eide A, 1987; CESCR, 1999). This categorization is particularly important in the case of economic, social, and cultural rights, and will be illustrated for the right to adequate food in section 4.

3.4 A Human Rights–Based Approach to Development Efforts

3.4.1 Basic needs and human rights

A rights-based approach to development efforts focuses on the fact that the rights of access to certain goods and services are regarded as human rights. It implies, as we have seen, that the state has an obligation to respond to human needs and that people can claim and defend these rights. This differs from the “basic needs approach,” which often views people as passive objects and recipients of protection and care. A rights-based approach, by contrast, recognizes people as active and participatory subjects. But rather than replacing a needs-based approach, a rights-based approach therefore adds value to it by empowering people – especially the most marginalized – to demand justice as a right rather than as charity, participate in policy formulation, and hold accountable those who have a duty to act (UNHCHR, 2006).

3.4.2 Process and outcome

A basic needs approach can be implemented by merely aiming for a desired goal or outcome regardless of how that outcome is achieved. But a human rights–based approach also requires attention to a good process leading to that outcome. This may be critical for achieving the end result and for sustaining it. As described below, applying certain values drawn from core human rights principles in designing a project or programme or in organizing a particular service may go a long way to ensuring a process that is respectful of the felt needs and contributions of the groups in question, and that may therefore have a chance of being sustained after the external project or programme has ended.

3.4.3 Core principles of a right-based approach

There are seven core principles of a rights-based approach. These are participation, accountability, non-discrimination, transparency, human dignity, empowerment, and the rule of law. As coined by the FAO, the first letter in each principle forms the acronym PANTHER. The principles are not mere rhetorical or inspirational values: they are preconditions for a meaningful and dignified human existence:

1.  Participation underscores the importance of involving all players in decisions affecting their lives and the development of their own well-being. It is based on the notion, mentioned above, that people must not be treated as passive objects but as active participants in decisions affecting them. A rights-based approach emphasizes active, free, and meaningful participation of all affected segments of society. In the context of community nutrition this means people should be consulted when conducting surveys and gathering statistics. Furthermore, they should be involved in developing and implementing nutrition policies affecting their communities.

2.  Accountability is a particularly important democratic and human rights principle. The state, as the primary duty-bearer, can be held accountable for its commitments and promises that are relevant to the realization of the right to food. A rights-based approach encourages the development of targets, indicators, and benchmarks to measure progress. These are essential preconditions to holding governments accountable. In keeping with human rights norms, they must be developed with participation of the community members.

3.  Non-discrimination requires that the guaranteed right to food be essentialy the same for every person. People must therefore not be treated unequally, or discriminated against, on the basis of age, race, gender, sex, culture, or religion. In the context of nutrition, this can mean that people of certain cultural groups must not be deprived of their traditional ways of producing food.

4.  Transparency is closely associated with accountability. It means making information publicly accessible and available. When nutrition-related policies are being developed, the state should consult with the public. People should also be provided with essential information about the decision-making process and who is accountable and responsible for what.

5.  Human dignity is an essential principle of a rights-based approach. It refers to the absolute and inherent worth that people possess simply because they are human, not by virtue of any social status or particular powers. It is concerned with the dignified treatment of all. It discourages the notion of charity or handouts, because of the indignity this can entail for poor and marginalized groups. It encourages an environment in which people can obtain food through dignified work.

6.  Empowerment is concerned with the ability of people to meaningfully participate in decisions affecting their lives. This means, for example, that people must be made aware of services they are entitled to and the associated responsibilities attached to receiving those services.

7.  The rule of law deals with legal issues and redress mechanisms. It encourages the government and society to respect the rights of individuals. If people’s rights are violated, there must be means of redress available, such as administrative mechanisms, “tribunals,” or the courts. The rule of law also refers to the environment in which people are working, and it is a safeguard against arbitrary use of state authority and lawless acts of both individuals and organizations. For example, it is not possible for school feeding schemes to function well and achieve their objectives if there is theft of the food stocks.

Some of these principles, especially participation and transparency, have existed for decades in typical “development language.” The specificity of human rights lies in the absolute and non-negotiable emphasis on the principles of human dignity, non-discrimination, accountability, and – by implication – respect for the rule of law. While human rights principles are derived from ethical and moral values, they have potentially a much stronger foundation in that these values have been transformed into legal principles and can be used to defend the rights of the most vulnerable groups in society and make it more likely that such groups will enjoy the fruits of economic and social development.

Finally, an approach based on human rights deviates from many conventional development approaches in that it (1) sets clear demands to governments to do what they have promised and (2) finds ways to hold a government accountable for its promises.

3.5 Claiming One’s Rights: What Options Exist?

The realization of human rights depends on good governance at all levels of the state and requires that the people themselves or their representatives (in parliament, in local government) be listened to and enabled to participate in democratic decision-making. It means they must be able to voice their concerns, ideas, and demands via their own organizations, such as non-governmental organizations (NGOs) and community-based organizations (CBOs).

Politicians are expected to take these considerations into account, but whether they eventually do is another story. If they don’t, then rights-holders should be able to claim their rights through so-called remedial measures. This could consist of bringing, for example, right-to-food violations before the courts. But there are also many other possible recourse mechanisms through which to claim one’s rights and obtain reparation for violations. In a number of countries, such functions are exercised by national ombudsmen or human rights commissions.

4. ECONOMIC, SOCIAL, AND CULTURAL RIGHTS ESPECIALLY RELEVANT TO NUTRITION

4.1 From Causality to Normative Analyses and Aspirations

We have now presented some basic information regarding human rights. We shall now bring it all back to nutrition. How can human rights provide a new perspective on problems of hunger and malnutrition in all forms and contribute to their solution, given that the problems are often rooted in social inequalities and injustice?

The conceptual framework shown in Figure 1.1 depicted a range of immediate, underlying, and basic causes of malnutrition. We can talk about a similar range of conditions for achieving good nutrition, conditions that permit the realization of the rights to adequate food, to good health, and to adequate care. Human rights law obliges a government to ensure that the resources of the country (or province, district, or municipality) are controlled, managed, and utilized in a way that benefits the whole population. This requires policies and measures that guarantee the basic conditions for the realization of these rights, which in turn become the underlying conditions for an individual’s adequate food intake and absence of disease – those immediate conditions for good nutritional status that all community nutritionists will strive to ensure.

A normative framework such as that shown in Figure 1.3 will suggest the factors that may affect the immediate as well as the underlying conditions for good nutrition. It will also suggest changes that are needed at several more basic levels – local, national, or international. Many of these changes are beyond the scope of what nutritionists and dietitians are able to accomplish on their own, but this framework will help them understand both the constraints and opportunities that influence their work. This in turn will help them make that work as effective as possible, preferably in collaboration with people employed in other sectors who carry out complementary analyses and action.

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Figure 1.3: Normative framework depicting the conditions necessary for ensuring good nutrition at the national level, with specific reference to human rights.

Source: Adapted from the UNICEF conceptual framework for understanding the causes of malnutrition shown in Figure 1.1.

4.2 The Human Right to Adequate Food: Legal Provisions and Evolving Interpretations

Each of the three underlying conditions for good nutrition or nutritional well-being in Figure 1.3 is reflected in human rights law. Here we focus on the meaning of the right to food (the same kind of reasoning applies to the other two rights).

The state has an obligation to take reasonable measures to ensure the right to food. In common with other economic and social rights, the realization of the right to food is constrained by important notions such as “progressive realization” and “to the maximum of a country’s available resources.” Most states can normally only help realize the right progressively, over time. However, a plan should be made with clear targets as well as indicators and benchmarks for ascertaining progress. At the same time, the urgent needs of those in desperate circumstances must be addressed as far as possible on an urgent basis. Some states use the “available resources” constraints to justify why they cannot fulfil a right. Such an argument becomes unacceptable, however, when their budget clearly favours privileged groups in society at the expense of disadvantaged groups, such as children and women.

We are not talking here about people being given access to food on demand – the requirement is for the state to create environments conducive to people being able to feed themselves through their own labour, whether in production or other work that ensures sufficient revenue (Khoza, 2007). Or, in the words of the UN Special Rapporteur on the right to food, Olivier De Schutter (2010, p. 1):

The right to food is not primarily the right to be fed after an emergency. It is the right, for all, to have legal frameworks and strategies in place that further the realization of the right to adequate food, as a human right recognized under international law. By directing the adoption of these policies, the right to food is a compass to ensure that policies are geared towards alleviating hunger and malnutrition.

Having examined the situation in various countries, De Schutter also points to the importance for countries to give “concrete meaning to the right to food principles in their constitutions, laws, courts, institutions, policies and programmes, and for various food security topics, such as fishing, land, focus on vulnerable groups, and access to resources.” And he concludes: “These processes, while much less visible than plain increase in food production, are key steps for lasting progress” (De Schutter, 2010, p. 1).

4.3 The Right to Food Guidelines

At the second World Food Summit in 2002, a decision was made to develop a practical tool for governments to use in taking action to help realize the right to food. The process led to the Voluntary Guidelines to Support the Progressive Realization of the Right to Adequate Food in the Context of National Food Security. Adopted by the FAO Council in 2004 (FAO, 2005), these guidelines are now commonly known as the Right to Food Guidelines.

Nineteen of the Right to Food Guidelines cover a broad area of concerns and issues, with Guideline 10 dealing specifically with nutrition. However, all the others are also relevant to nutrition at different levels of societal organization, and all can be fitted into the normative framework described above. They provide measures that practitioners can choose from, according to their different professional domains and specialties. Besides Guideline 10, students and professionals in community nutrition will also find ample inspiration in many of the other guidelines, some dealing also with economic aspects, including the role of market forces. The Right to Food Guidelines are now frequently referred to and made use of in the international debate and action on the right to food. Combined with the Millennium Development Goals described earlier in this chapter, the Right to Food Guidelines will be useful in community nutrition with regard to most of the dimensions dealt with in this book.

4.4 Other Material of Use in a Human Rights–Based Approach to Community Nutrition

A lot of other material is helpful for the promotion of nutrition in the community, especially as regards its dietary dimensions. Here we briefly mention three organizations involved in using a human rights approach: the FAO, the WHO, and the Food First Information and Action Campaign (FIAN). Links that can provide useful material from these three sources are provided at the end of this chapter, in the “Additional “Resources” section.

The FAO is the most active UN agency in promoting and enriching the right to adequate food concept. In 2005, it established a Right to Food Unit – from 2009 called the Right to Food Team – to further promote the right to food, among other things through developing educational material and various tools for use in practical work.

The WHO has not as yet developed specific health-related aspects of nutrition in terms of human rights; however, the organization has an excellent Health and Human Rights Team whose role is to:

•  strengthen the capacity of the WHO and its member states to integrate a human rights–based approach to health,

•  advance the right to health in international law and international development processes, and

•  advocate for health-related human rights.

The Food First Information and Action Campaign (FIAN) is the most significant non-governmental organization working solely with the right to food – or “The right to feed oneself,” which is their slogan. FIAN has its headquarters in Heidelberg, Germany, and works in many countries, producing a wealth of interesting country-based information.

4.5 Other Rights of Immediate Relevance to Community Nutrition

Good nutrition involves more than having enough food and water of adequate quality. Achieving good nutrition is especially challenging in areas prone to infectious or chronic nutrition-related diseases where the sanitary environment and personal hygiene is poor, or in areas where income-earning activities of mothers compete with their time for caring for their young children. All this impacts both on the biological and psycho-social dimensions of an individual’s nutritional status and general well-being.

But there are also other economic, social, and cultural rights with important direct impact on the food and feeding situation in a family. These include the right to adequate clothing, housing, and to the continuous improvement of living conditions. Each of these rights is within the concerns of a community nutritionist. Where conditions are unacceptably poor, community nutritionists can help draw awareness to this amongst politicians, international organizations, public planners and programmers, civil society groups, and the general population.

Finally, a range of other human rights may impact nutrition even more significantly, such as the right to work, right to social security, and right to free speech – to mention just a few. A broad, open mind allows a community nutritionist/dietitian to see his or her own work in the context of social, economic, cultural, civil, and political failures while also looking for opportunities by which conditions can be reported and hopefully addressed.

5. IMPLEMENTATION OF RIGHTS AT THE COUNTRY LEVEL

There is no blueprint for the realization of the right to adequate food and other nutrition-relevant rights at the national level. Nevertheless, as we have seen, the conceptual developments and refinements over recent years – of the right to food as well as economic, social, and cultural rights more generally – have served to identify a number of key principles that now make it easier to analyse and plan for a rights-based approach to community nutrition in any country. Common denominators are the different categories of obligations of states for economic, social, and cultural rights in general that were described in section 3, and those particular attributes of a right to adequate food that were described in section 4.

But each situation presents a more or less different picture and challenge according to context, just as the UNICEF conceptual framework indicates. For a country or a population group within it, the economic situation, the culture and customs, religion, the prevailing political ideology at any time, attitudes to gender, and other factors all set limits to and/or open opportunities or conditions for how far human rights, including the right to food, will be respected, protected, and fulfilled. Nutrition professionals need to work with human rights practitioners in promoting and protecting the right to food (Maunder & Khoza, 2007).

Since the mid-1990s there has been considerable and increasing interest in giving the right to food a more concrete and operational content. Whilst there is an international framework for the right to food and nutrition security in several international human rights instruments, the implementation at the national and global level is lacking, despite adequate food supplies. Progress has been made in some countries but this needs further development. Intersectoral and interdisciplinary work are required to ensure that legal frameworks, policy frameworks, programmes, the involvement of civil society, awareness, capacity building, and resource allocation will fulfil the rights to adequate food and nutritional health.

As a community nutritionist you can play a critical role in these endeavours. Keep that in mind when studying the rest of this book.

DISCUSSION QUESTIONS AND EXERCISES

1.  Identify which MDG and specific associated targets demand special attention to nutrition in order to be achieved.

2.  Outline the international historical milestones of the human rights conventions and declarations relevant to the right to adequate food

3.  What does it mean when a government signs and/or ratifies a human rights convention?

4.  List the main principles of a rights-based approach and explain the meaning of each.

5.  Does every person have the right to be fed by the state? Explain your answer.

6.  Explain what is meant by “the right to food” in the context of your country.

7.  Based on your observations and personal experiences, discuss how well the right to food is being realized in your country.

8.  Design a normative framework depicting the conditions needed to ensure good nutrition in the context of a household, with reference to the human rights involved. Use the normative framework in Figure 1.3 as a starting point.

9.  Compare what your country’s constitution has to say about human rights with the Universal Declaration of Human Rights.

10.  Discuss the importance of capacity in relation to responsibilities.

11.  Discuss whether you would consider community nutritionists employed by the government to be duty-bearers. If yes, what are the implications of this?

12.  Use the matrix shown in Table 1.1 (below) to give examples of the obligations of the state with regard to the right to adequate food. You should be able to fill in at least some of the empty boxes from your own knowledge and experience. You can also discuss possible answers with colleagues and friends, who can contribute ideas and thereby help provide a “rich picture” of the constraints and opportunities that surround the right to food. You may also wish to consult the Right to Food Guidelines referred to in section 4.3, which can be downloaded from the FAO Right to Food home page, www.fao.org/righttofood. These guidelines (which are available in six languages) bring a wealth of ideas and suggestions for policies and measures that can be included in the matrix.

Table 1.1: The right to food matrix: an aid to conceptualization for analysis and planning.
Source: Adapted from Oshaug et al., 1994.

image

REFERENCES

Alston P. 2005. Ships passing in the night: The current state of the human rights and development debate seen through the lens of the Millennium Development Goals. Human Rights Quart, 27: 755–829.

Asher, Judith. 2004. The Right to Health: A Resource Manual for NGOs. London: Commonwealth Medical Trust and Washington, D.C.: AAAS Science and Human Rights Program.

Beaglehole R, Bonita R, Horton R, Adams O & McKee M. 2004. Public health in the new era: Improving health through collective action. Lancet, 363: 2084–6.

Beaudry M & Delisle H. 2005. Public(’s) nutrition. Public Health Nutr, 8: 743–8.

Beaudry M, Hamelin A-M & Delisle H. 2004. Public nutrition: An emerging paradigm. Can J Public Health, 95: 375–7.

CESCR (Committee on Economic, Social and Cultural Rights). 1999. Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights. General Comment No. 12: The Right to Adequate Food. United Nations Economic and Social Council. UN Doc. E/C.12/1999/5. https://www.unhchr.ch/tbs/doc.nsf/0/3d02758c707031d58025677f003b73b9.

De Schutter O. 2010. Countries Tackling Hunger with a Right to Food Approach: Significant Progress in Implementing the Right to Food at National Scale in Africa, Latin America and South Asia. Briefing Note 01, May. https://www.srfood.org/images/stories/pdf/otherdocuments/20100514_briefing-note-01_en.pdf.

Eide A. 1987. The Right to Adequate Food as a Human Right: Final Report. Report prepared for the UN Sub-Commission on the Promotion and Protection of Human Rights. UN Doc. E/CN.4/Sub.2/1987/23. Subsequently published as The Right to Adequate Food as a Human Right, Human Rights Study Series No. 1. Geneva and New York, United Nations, 1989.

Eide WB & Kracht U. 2005. The right to adequate food in human rights instruments: Legal norms and interpretations. In: WB Eide & U Kracht, eds., Food and Human Rights in Development, Volume I, Legal and Institutional Dimensions and Selected Topics. Antwerp, Intersentia. Pp. 99–118.

FAO (Food and Agriculture Organization of the United Nations). 1992. World Declaration on Nutrition. 1992 World Conference on Nutrition, Rome. https://www.fao.org/ag/agn/nutrition/ICN/ICNCONTS.HTM.

FAO. 1996. Rome Declaration on World Food Security and World Food Summit Plan of Action. World Food Summit, Rome, 13–17 November 1996. https://www.fao.org/docrep/003/w3613e/w3613e00.HTM.

FAO. 2002a. Draft Declaration of the World Food Summit: Five Years Later. Rome, 10–13 June 2002. https://www.fao.org/docrep/MEETING/004/Y6948E.htm.

FAO. 2002b. World Food Summit: Five Years Later reaffirms pledge to reduce hunger. FAO Summit News, 27 August 2002. https://www.fao.org/worldfoodsummit/english/newsroom/news/8580-en.html.

FAO. 2005. Voluntary Guidelines to Support the Progressive Realization of the Right to Adequate Food in the Context of National Food Security. Rome, FAO. ftp://ftp.fao.org/docrep/fao/009/y7937e/y7937e00.pdf.

FAO. 2009a. Declaration of the World Summit on Food Security. World Summit on Food Security, Rome, 6–18 November 2009. ftp://ftp.fao.org/docrep/fao/Meeting/018/k6050e.pdf.

FAO. 2009b. World Summit on Food Security, Rome, 16–18 November 2009. https://www.fao.org/wsfs/world-summit/en/.

FAO, IFAD and WFP. 2013. The State of Food Insecurity in the World 2013: The Multiple Dimensions of Food Security. Rome, FAO. https://www.fao.org/docrep/018/i3434e/i3434e.pdf

Hughes R. 2003. Definitions for public health nutrition: A developing consensus. Public Health Nutr, 6: 615–20.

Khoza S. 2007. Socio-economic Rights in South Africa: A Resource Book, 2nd ed. Socio-Economic Rights Project of the Community Law Centre, University of the Western Cape.

Maunder EMW & Khoza S. 2007. Towards enhanced efforts to advance the right to food: A case of national training in nutrition and human rights in South Africa. In: WB Eide & U Kracht, eds., Food and Human Rights in Development, Volume II, Evolving Issues and Emerging Applications. Antwerp, Intersentia. Pp. 547–62.

Oshaug A, Eide WB & Eide A. 1994. Human rights: A normative basis for food and nutrition-relevant policies. Food Policy, 19: 491–516.

Rogers BL & Schlossman NP. 1997. Public nutrition: The need for cross-disciplinary breadth in the education of applied nutrition professionals. Food Nutr Bull, 18: 120–33.

Strong K, Mathers C, Leeder S & Beaglehole R. 2005. Preventing chronic diseases: How many lives can we save? Lancet, 366: 1578–82.

UNHCHR (United Nations High Commissioner for Human Rights). 2006. Frequently Asked Questions on a Human Rights–Based Approach to Development Cooperation. Office of the UN High Commissioner for Human Rights, New York. https://www.ohchr.org/Documents/Publications/FAQen.pdf.

UNICEF (United Nations Children’s Fund). 1998. The State of the World’s Children. New York, UNICEF. https://www.unicef.org/sowc98/.

WHO (World Health Organization) Commission on Social Determinants of Health. 2008. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization. https://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf.

ADDITIONAL RESOURCES

United Nations

General website, information on the United Nations and the United Nations Charter: www.un.org

Charter of the United Nations: https://treaties.un.org/doc/publication/ctc/uncharter.pdf

United Nations Millennium Declaration: https://www.un.org/millennium/declaration/ares552e.htm

Millennium Development Goals: https://www.un.org/millenniumgoals/bkgd.shtml

Office of the UN High Commissioner for Human Rights

General website: www.ohchr.org

Frequently Asked Questions on a Human Rights–based Approach to Development Cooperation of the UN Office of the High Commissioner for Human Rights: https://www.ohchr.org/Documents/Publications/FAQen.pdf

General Comment No. 4 on the Right to Adequate Housing: https://www.unhchr.ch/tbs/doc.nsf/0/4694d91a9378221c12563ed0053547e

General Comment No. 12 on the Right to Adequate Food: https://www.unhchr.ch/tbs/doc.nsf/0/3d02758c707031d58025677f003b73b9

General Comment No. 14 on the Right to the Highest Attainable Standard of Health: https://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En

General Comment No.15 on the Right to Water: https://www.unhchr.ch/tbs/doc.nsf/0/a5458d1d1bbd713fc1256cc400389e94

UN Special Rapporteur on the Right to Food

General website: www.srfood.org

The current SR on the right to food is Hilal Elver of Turkey; she is the third to fill this position since it was established in 2000. His website contains a wealth of information through his various reports to the UN Human Rights Council and the General Assembly, as well as speeches, documents, and briefing notes.

Food and Agriculture Organization of the United Nations (FAO)

General website: www.fao.org

Right to food site: www.fao.org/righttofood

See especially the link to the Right to Food Guidelines (FAO, 2005). These are available in six languages. See also:

•  Right to Food e-learning course: A Primer to the Right to Adequate Food (part of the e-learning curriculum “Right to Food in Practice”): https://www.fao.org/righttofood/knowledge-centre/distance-learning/a-primer-to-the-right-to-adequate-food/en/

•  Right to Food – Making It Happen: Progress and Lessons Learned Through Implementation: https://www.fao.org/righttofood/publications/publications-detail/en/c/124301/

•  The Right to Food Methodological Toolbox, which offers a series of downloadable publications, including a guide for conducting a right to food assessment, information about methods of monitoring, a guide to legislating for the right to food, and an outline for curriculum development: https://www.fao.org/righttofood/knowledge-centre/rtf-methodological-toolbox/en

World Health Organization (WHO)

General website: https://www.who.int

Health and human rights site: https://www.who.int/topics/human_rights/en/

See especially links to Health and Human Rights Publication series: https://www.who.int/hhr/activities/publications/en/

This includes:

•  25 Questions & Answers on the Right to Health, and

•  Human Rights, Health, and Poverty Reduction Strategies, a tool for health policy-makers to design, implement, and monitor a poverty reduction strategy through a human rights–based approach.

Foodfirst Information and Action Network (FIAN)

This is the world’s largest non-governmental organization working specifically on the right to food in its many dimensions. Its head office is in Heidelberg, Germany. There are national FIAN organizations in many countries.

General website: www.fian.org

Books

Eide WB & Kracht U, eds. Food and Human Rights in Development.

Volume I: Legal and Institutional Dimensions and Selected Topics, 2005.

Volume II: Evolving Issues and Emerging Applications, 2007.

These two volumes contain a large number of original contributions from human rights, development, and right to food experts working in various disciplines and sectors. The books can be ordered from the publisher, Intersentia (https://www.intersentia.com/).

Kent G. 2005. Freedom from Want: The Right to Food as a Human Right. Washington, D.C., Georgetown University Press. A PDF of the book is available online at https://press.georgetown.edu/sites/default/files/978-1-58901-055-0%20w%20CC%20license.pdf.

A wealth of other useful sources, many relating to the larger global issues of current concern, such as climate change, land grabbing, biofuel production, and food trade, can be found simply by searching the Web for “the right to food.”

ACKNOWLEDGEMENTS

This chapter is based in part on a chapter in an earlier book:

Maunder EMW, Khoza S, Kuzwayo P & Eide WB. A right-based approach to community nutrition in South Africa. In: Steyn NP & Temple NJ, eds. 2008. Community Nutrition Textbook for South Africa: A Rights-based Approach. Cape Town, South African Medical Research Council. Pp. 1-32.

We acknowledge the contribution of Sibonile Khoza and Pauline Kuzwayo as co-authors with us of that chapter. The present chapter has been completely rewritten and updated for an international readership.

We thank Asbjørn Eide, Norwegian Centre for Human Rights, University of Oslo; Per Ole Iversen, University of Oslo; Marie Paterson, University of KwaZulu-Natal, South Africa; and Arne Oshaug, Akershus University College, Norway, for reviewing the chapter and giving useful suggestions.

CHAPTER 2

FOOD SECURITY, DIETARY DIVERSITY, AND BIODIVERSITY

Food and Nutrition Security in Developing Countries

Mieke Faber and Friede Wenhold

Outline

•  Definition of the concepts of food security, dietary diversity, and biodiversity

•  Different levels of food and nutrition security: global food availability, national food availability, household food security, and individual utilization

•  Causes of food and nutrition insecurity

•  Selected indicators of food and nutrition security

•  Community-based actions to address food and nutrition insecurity

Objectives

At the completion of this chapter you should be able to:

•  Understand the relationship among the following core concepts:

•  Poverty

•  Food security (global, national, household, and individual)

•  Vulnerability to food insecurity

•  Food availability

•  Food access

•  Food utilization

•  Sustainability

•  Nutrition security

•  Dietary diversity

•  Biodiversity

•  Discuss in depth the characteristics of the different levels of food and nutrition security

•  Explain the risk factors for and causes of food insecurity at the global, national, household, and individual levels

•  Describe indicators of food and nutrition insecurity

•  Discuss community-based actions to address food and nutrition security

1. INTRODUCTION

The concept of food and nutrition security has evolved over time. Formerly, the emphasis was purely on the physical availability of food at the global and national levels, but the focus has now shifted to the provision of nutritionally adequate food for individuals and the role of poverty reduction in sustained access to food.

The term “food security” originally focused solely on the availability of food. The underlying reasoning was that if governments ensure that enough food is available for feeding their populations, then hunger will disappear. However, this proved to be a false assumption. During the 1972–1974 food crisis, highly unstable food supplies and prices on the world market emerged as the main problem. This led to the realization that food availability at the national level did not automatically translate into food security at the household level. The concept of food security was thus broadened to include the need for households to have both physical and economic access to the national food supply. In addition, a distinction was made between chronic and transitory food insecurity, giving the concept of food security a temporal dimension. During the 1990s the concept of food utilization also became prominent, with the realization that food security must eventually be considered at the level of the individual. Furthermore, it was recognized that environmental hygiene, safe drinking water, and a sufficient supply of micronutrients were essential to “nutrition security” – that is, an individual’s right of access to nutritionally adequate food. Twenty-first century thinking on food and nutrition security situates the goal of decreasing hunger and malnutrition in the context of sustainable development. Addressing food insecurity thus necessitates a holistic approach that includes the global reduction of poverty (FAO, 2008a; Frankenberger & McCaston, 1998; Weingärtner, 2009). This objective is articulated in the first of the eight Millennium Development Goals of the United Nations, described in section 2.6 of Chapter 1: “Eradicate extreme poverty and hunger.”

2. DEFINING THE CONCEPTS

Food security is more than simply access to enough food to prevent death by starvation. The current understanding of food security accordingly emphasizes the quality of the diet – on the need for dietary diversity and for food that supplies the micronutrients necessary to create and sustain health. Poor people generally lack the resources to either produce or purchase adequate amounts of nutritious food. It therefore follows that poverty is the main cause of food insecurity.

2.1 Forms of Poverty

Because so many of the components of poverty are difficult to measure quantitatively, we tend to think of poverty purely in economic terms, as a lack of adequate wealth. For example, an individual who earns less than US$1 per day is defined as poor, as is a family whose combined income falls below the national poverty line (the minimum income needed by households to cover food and essential non-food expenses). But the concept includes other forms of deprivation. Poor people may, for example, have little or no access to education or to medical treatment when needed. They may lack political freedom or be rendered powerless by the social system within which they live. Any person who is unable to satisfy his or her basic needs is said to be in poverty.

Food poverty refers to a household’s inability to access a nutritionally adequate diet. The food poverty line is based on the per capita cost of purchasing a food basket that provides a balanced diet sufficient to meet the average dietary energy requirements (ADER). A household that cannot afford to spend even this amount is regarded as poor. Critical food poverty refers to the proportion of the population whose income is below that required to access enough food to meet the minimum dietary energy requirements (MDER).

Poverty leads to malnutrition, and malnutrition reduces people’s ability to learn, work, and care for themselves and their families. Thus, not only does poverty produce malnutrition, but a lack of adequate nutrition is itself an underlying cause of poverty.

2.2 Food Security

The Food and Agriculture Organization (FAO) of the United Nations defines food security as a condition that exists “when all people, at all times, have physical, social and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life” (FAO, 2008a). Household food security refers specifically to food security at the family level, with the focus falling on individual members of a household (FAO, 2009). Conversely, food insecurity can be defined as the “limited or uncertain availability of nutritionally adequate and safe foods” as well as the “limited or uncertain ability to acquire acceptable foods in socially acceptable ways” (Bickel et al., 2000). Although food insecurity may simply be caused by the unavailability of food, it may also result from insufficient purchasing power, a lack of the resources required for local food production, and/or the inappropriate distribution or inadequate use of food. Food insecurity may be a chronic condition, or it may reflect seasonal variations in food availability (for example, food shortages prior to the harvest season) or to transitory circumstances.

The four basic elements of food security are as follows (Riely et al., 1999; Weingärtner, 2009):

1.  Food availability is achieved when sufficient quantities of food are consistently available. Although the term availability can refer to food supplies at the household level, it generally refers to food supplies at the regional or national level. National food availability depends on domestic food production, commercial imports and exports, food aid, and domestic food stocks.

2.  Access to food presumes physical access and depends on the household’s purchasing power and ability to secure foods from the market or from other sources, such as household gardens or in-kind transfers of food.

3.  Food utilization refers an individual’s ability to derive the greatest possible nutritional benefit from food. Food utilization is fundamentally a biological process, dependent not only on the intake of sufficient nutrients but on an individual’s overall health status. But food utilization is also influenced by factors such as the quality and safety of food, its manner of preparation, hygiene and sanitation, an individual’s food habits and preferences, the intra-household distribution of food, and good feeding and caring practices.

4.  Stability, or sustainability, refers to the temporal dimension of food security – that is, to the capacity to maintain the conditions necessary to food security.

To achieve genuine food security, all four elements must be present. Access to food obviously presupposes that food is available, but availability does not guarantee access. In turn, food access is necessary but, in itself, insufficient to ensure adequate food utilization. For effective food utilization, households need a diet that provides sufficient energy and nutrients, as well as safe drinking water and adequate sanitation. In addition, knowledge within the household of food storage and processing techniques, basic principles of nutrition, proper child care, and illness management is crucial to food utilization (Riely et al., 1999; Weingärtner, 2009).

2.3 Vulnerability to Food Insecurity

Vulnerability refers to the risk of food insecurity and, by extension, malnourishment. It is determined not only by the degree to which an individual or group is exposed to factors that place them at risk of becoming food insecure but also by their degree of resilience – their relative ability to cope with events that create instability. Like food insecurity itself, vulnerability may be a temporary condition, arising from changes in the surrounding environment over which people have little or no control, such as a drought, an earthquake, or a war. But vulnerability is very often structural, in the sense that the risk of food insecurity is built into the circumstances of people’s lives. Structural vulnerability results when people must live with conditions that place them at risk and that are either chronic or very slow to change – persistent difficulties in finding employment, for example, or the presence of debilitating health problems, such as HIV/AIDs. Such people are in a precarious position, which undermines their ability to cope with stress, that is, shifts in circumstances that threaten their already tenuous economic status or otherwise upset the balance of their lives. People who are food secure may be exposed to the same risks, but they are able to withstand them (FAO, 2002).

2.4 Nutrition Security

Nutrition security is a somewhat broader concept than food security. To achieve nutrition security, individuals need more than just access to sufficient, safe, and nutritious food. They must also have safe water and adequate sanitation; the ability to access health care services; and knowledge of sound household and community practices in child care, food storage and preparation, and hygiene (UNICEF, 1990).

Nutrition insecurity can present as various forms of malnutrition. The term malnutrition refers to a range of conditions that result from deficiencies, excesses, or imbalances in the consumption of macro- and/or micronutrients. Although we usually associate malnutrition with a lack of nutrition (that is, undernutrition), it can also occur in tandem with overnutrition.

•  Undernutrition reflects an inadequate food intake – one that is deficient in energy, protein, and/or vitamins and minerals – or poor biological utilization of the nutrients consumed, mostly as a result of frequent infections.

•  Overnutrition reflects overall excess (eating too much) or an excess of certain food components such as saturated fats and added sugars (eating too many of the wrong things) in combination with low levels of physical activity, typically resulting in overweight and obesity. Although individuals suffering from overnutrition are almost always food secure, they are not necessarily nutrition secure.

•  Hidden hunger, also known as micronutrient malnutrition, occurs when the diet is deficient in essential micronutrients, i.e., vitamins and minerals.

Infants and young children (under the age of 5) and women who are pregnant and lactating tend to be the most vulnerable to both food and nutrition insecurity. Other vulnerable groups include female-headed households, elderly people, people who have disabilities, individuals living with HIV/AIDS, and victims of events such as natural disasters or civil conflict (Riely et al., 1999; Millennium Project Task Force on Hunger, 2004).

2.5 Overlap of Food Insecurity and Nutrition Insecurity

Food insecurity and nutrition insecurity are closely linked, as Figure 2.1 illustrates. The outer oval represents a nutritionally insecure population, with the ovals within that oval representing specific subsets of that population – the food insecure, the hungry, the undernourished, and the overnourished. The way in which these ovals overlap illustrates the relationships among these various subsets.