|The need to develop an evidence-based National Nutrition
By Dr. Damayanthi Piyadasa Perera PhD (London)
Consultant Nutritionist/Independent Researcher
A need for a National Nutrition Policy (NNP):
I wish to bring to the notice of the Prime Minister and also the Minister of Health, Nutrition & Welfare, a major impediment in the field of nutrition. Sri Lanka lacks a National Nutrition Policy (NNP). Nevertheless, Sri Lanka has developed a National Nutrition Plan of Action (NNPA 1997 - 2001) and to be fair, it must be stated that the above document has covered much ground. However, this exercise has been carried out without developing a proper National Nutrition Policy (NNP) for the country. This, unfortunately is a cart before the horse situation. As a result of a lack of policy, certain important issues have been left out from the last NNPA. Lack of a policy has also led to the implementation of various projects and programmes in the past spending colossal sums of national and donor money without much benefit to the country. If Sri Lanka is to produce a healthy nation fit to face the challenges of the 21st century, there is much to be achieved in the field of nutrition today, starting from developing a sound policy. The following sections highlight a few important issues that deserve the attention of the government.
Time for a scientific audit:
Nutrition is a highly scientific, rapidly changing and an ever-evolving subject. Information regarding Food, Nutrition and diet related Non Communicable Diseases (NCIDs) are undergoing rapid change due to advances in technology and scientific research methods. Information regarding the role of food in preventing certain chronic diseases such as cancer, heart disease, hypertension, diabetes, cataract, osteoporosis etc. (just to name a few) are only beginning to unfold now. Certain nutrition information that was. thought to be correct a decade or two ago have now changed. Similarly certain foods that were thought to be healthy have now been identified as foods that may be detrimental to health.
Currently, the health and nutrition interventions in Sri Lanka are focused largely on under-nutrition. Health and nutrition status of Sri Lankan children has changed and currently both child and adult nutrition status is in a stage of transition. Further, in addition to the problems with regard to under-nutrition in Sri Lanka, there are many new problems and issues pertaining to Food, Nutrition and Public Health that have emerged in recent times that require careful scientific study before arriving at new policy decisions. This rapid change in nutrition related information creates a constant need to upgrade and review nutrition related information and devise policies and programmes based on recent scientific evidence. Therefore, as an integral component the process of developing a National Policy, it is important to perform a scientific audit of current and previous nutrition projects and programmes of the country.
Ad hoc projects & programmes:
Unlike in most other countries, nutrition science is in its infancy in Sri Lanka and there is a dearth of professionally qualified personnel in the field. As a result, there is no professional body to regulate the profession. The above shortcomings have led to numerous setbacks in the field of nutrition. Due to there being only a few professionally qualified personnel in the country there is little international quality nutrition research or programmes conducted in Sri Lanka over the years, various ad hoc projects and programmes (small and large) have been conducted by the ruling government, various local and foreign organizations and NGOs. Such ad hoc programmes and projects are not the answer to the nutrition problems of Sri Lanka. The country needs to develop well-designed and well-coordinated projects and programmes based on recent scientific evidence.
It is heartening to note that the UNF government has identified the need to provide food supplements to certain vulnerable sections of the population (children under three years of age, pregnant and lactating women) through Janasaviya and Samurdhi Programmes (100 Day Revolution, Sunday Times 18-11-O1) and certain programmes have already been initiated under the 100-Day Programme (Progress of the first 25 days Sunday Observer 27/01/02). This is a laudable move and much can be achieved if conducted in the proper manner. However, if the main aim is to eradicate under-nutrition, it is important to launch systematic programmes based on scientific evidence as opposed to handing out some low cost food supplement that may give political mileage in the short term.
If the country is to achieve maximum benefit from the investments in nutrition, it is necessary to develop an evidence-based National Nutrition Policy and then develop projects and programmes to target the identified problems. Although there is only a small amount of local nutrition data, there is a large body of scientific information available internationally, that could be used along with the available local data for planning appropriate nutrition policies and projects for Sri Lanka. Further, in the light of the new evidence available in the field of health, nutrition and disease, it is crucial to evaluate the existing nutrition projects and programmes to determine their suitability to address the nutrition challenges of the 21st century.
Ayurvedic Community Health Assistants:
It has been stated that 100 Ayurvedic Community Health Assistants (CHAs) have been appointed to improve the nutritional status of 400 families under the 100-Day Revolution (Progress of the first 25 days, Sunday Observer 27/01/02). It is a good move to appoint CHAs but the appointment of Ayurvedic CHAs may create some unforeseen problems that would be difficult to correct later. No project or programme will be without any teething problems. Since this is the beginning of the 100-day programme, it will be good to introduce corrective measures as early as possible. The above may be an initiative undertaken by the indigenous medicine section of the Health Ministry. It must be highlighted that the following comments do not undermine the value of Ayurveda as a Complementary Medical Service. Nutrition is a highly scientific subject based on allopathic medicine. There are many practices in Ayurveda that are incompatible with allopathic medicine and contradictory to what is taught in Allopathic Medicine and Nutrition. One such example is the belief of treaty & cold food in Ayurveda according to Ayurveda there are many food restrictions and children and also adults are prevented from eating various nutritious foods. Cultural beliefs and food taboos are difficult to break. Once an incorrect message has been inculcated in the minds of the parents, it may cost much money and take years of health and nutrition education to correct the faulty beliefs. It is therefore important for the government to rethink about this policy. If the health assistants are to be used for improvement of nutrition status in the long-term, it is of paramount importance that they should receive the necessary training in health and nutrition before deployment to the villages. It is reiterated that the intention of the author is not to undermine the value of Ayurveda in any way. The main aim is to highlight the kind of problems that arise as a result of a lack of National Policy on Nutrition. The above is a good example of clash of interests and policy.
Long term programmes: Thriposha:
In addition to the various ad hoc programmes that have been conducted, there are also some long standing programmes such as Thriposha that have been in operation for many years. The Thriposha programme was initiated many years ago and was based on nutrition information that was available nearly two to three decades ago. As mentioned above nutrition information has undergone radical changes since then. It is therefore important to evaluate the Thriposha programme in the light of the new evidence available, before the government makes any long-term decisions with regard to this programme.
There are many problems with regard to Thriposha. Erratic distribution is one such problem and it is good to note that procurement and distribution of Thriposha has been streamlined under the 100-day programme (Progress of the first 25 days, Sunday Observer 27/01/02). However, in addition to the problems of distribution, there are many well-recognized problems in relation to Thriposha, which are beyond the scope of this article. It is not incorrect to state that over the years Thriposha has become more of a political supplement than a nutritional supplement. For people in the field of nutrition and as well as the political field, it has become difficult to imagine a Sri Lanka without Thriposha. However, despite all the shortcomings of the programme, Thriposha is quite popular amongst the mothers of low socio-economic class. Interestingly a new generation of affluent cousins of the humble Thriposha that was originally meant for the low-income group is now appearing in the open market in fancy dresses (packaging). These products were highly promoted using not so ethical, various unsubstantiated claims using high cost Tele Marketing.
There are some scientific as well as ethical questions with regard to these products. Returning to the original subject of Thriposha, although the Thriposha project may have met some of its objectives initially, whether Thriposha or any such complementary foods (the different kind of Poshas advertised in the mass media) are the answer to the kind of under-nutrition the country is faced with at present needs to be evaluated on a scientific basis. Further, in addition to the well- known problems with regard to Thriposha, the new information that is available with regard to nutrition has raised certain important health related questions regarding Thriposha (and similar products) that need to be answered urgently. These potential problems need to be investigated in the interest of the health of the beneficiaries before committing large amounts of money for expanding, modifying or abandoning the programme.
It must be reiterated that the aim of this article is not to criticize any individual project, but to highlight the importance of developing evidence-based National Policies for the country. Given above are only a few examples and there are many issues that needs to be addressed. It is of paramount importance to develop an evidence-based National Nutrition Policy for the country before launching any costly, large-scale nutrition projects or programmes in the future, be it Thriposha or any other programme funded by government or donor finances.
A need for responsible scientific reporting:
There is much confusion in the country at present with regard to some important nutrition related issues. Lately, nutrition related subjects have started to appear in the printed media frequently. It appears that nutrition is everybodys pet topic in Sri Lanka! Unfortunately, in some of these articles, various biased statements and claims have been made in relation to certain important nutrition related issues, misleading and confusing the general public and the policy makers alike. Although the need for balanced reporting has been identified in the field of politics in Sri Lanka, it appears that the same does not unfortunately apply to nutrition. The aim of publishing scientific articles should be in the interest of public health. Therefore, the scientists who contribute to the public media have a moral obligation to provide not only factually correct information but also a balanced view of the subject with a holistic approach. Some of the articles are not of a balanced nature and are even scientifically flawed and have been written in total violation of this concept. It appears that such articles are written not in the interest of public health but with vested interests. This is a newer menace that is cropping up in addition to the unethical food related advertising that exists already. Although the impact of such articles will not be evident immediately, they will create a negative impact on certain important public health issues in time to come. Mentioned afore are only a few key problems in the field of nutrition that warrants the attention of the relevant authorities.
The root cause of most of the problems in the field of nutrition is the lack of a policy, direction and a vision for the country. As an independent researcher, the author has examined the Social, Health & Nutrition situation of the country in depth. The data reviewed by the author during and after doctoral studies indicate that the nature of the nutritional problems faced by the country is changing rapidly. Health & Nutrition data reviewed in detail indicate an urgent need to identify future directions in relation to Nutrition Policy & Programmes of the country before launching any costly, large-scale projects or programmes. The data indicate that unless evidence-based, far-sighted nutrition policies and programmes for the country are developed and implemented as a master of priority, the health of the future generations will be jeopardized. It is time to shape future nutrition policies and programmes of the country based on recent scientific evidence. Once a National Policy is in place it will help immensely in coordinating and streamlining nutrition related activities of the country.
I therefore urge the Hon. Prime Minister and the Minister of Health to initiate action to develop an evidence based National Policy on Nutrition as a matter of priority. Development of a comprehensive, evidence-based National Nutrition Policy will take some time. However, it is possible to initiate action to develop an initial Frame or Reference (FOR) for a national policy within the 100-day programme. Once the Frame of Reference is prepared it can be used as the basis for devising Nutrition Policy which can eventually lead to White Paper on nutrition.
In a nutshell the data reviewed indicate that there is an urgent need to develop evidence-based, effective nutrition policies and programmes for the country with a vision for the future. It is important to develop innovative, sound nutrition policies and programmes that can address not only the existing nutrition problems but also the new & emerging nutrition challenges of this century, at least for the next five decades. The motto Prevention Better Than Cure stands true more than ever before.
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