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First Steps towards a Joint FAO/WHO Nutrition Committee

Soon a Joint FAO/WHO Expert Committee on Nutrition was created and met for the first time in Geneva in October 1948. The session was opened by Brock Chisholm, Director-General of the WHO and chaired by Lord Horder. The members of the Committee were:

FAO Representatives:

  • - Professor M.J.L. Dols, State Adviser on Nutrition; Professor of Nutritional Science, University of Amsterdam, Netherlands
  • - Lord Holder, Adviser to the Ministry of Food of the United Kingdom, London, UK
  • - Dr. V.N. Patwardhan, Director, Nutrition Research Laboratories, Coonoor, India
  • - Dr. Hazel K. Stiebeling, Chief Bureau of Human Nutrition and Home Economics, US Department of Agriculture, Washington DC, USA
  • - Prof. E.F. Terroine, Directeur du Centre National de Coordination des Etudes et Recherches sur la Nutrition et I’Alimentation, CNRS, Paris, France

WHO Representatives:

  • - Professor G. Bergami, Professor of Biochemistry and Physiology, Director, Istituto della Nutrizione del Consiglio Nazionale delle Ricerche, Rome, Italy
  • - Dr. J.F. Brock, Professor of Medicine, University of Cape Town, Union of South Africa
  • - Professor J. De Castro, Director, Institute of Nutrition, University of Brazil, Rio de Janeiro, Brazil
  • - Dr. W.H. Sebrell, Medical Director, US Public Health Service; Director, Institute of Experimental Biology and Medicine, Bethesda, Md., USA

Observers:

  • - Dr. Lu Gwei-Djen, Department of Natural Sciences, UNESCO
  • - Dr. M. De Viado, Social Security Section, ILO

Secretaries:

  • - Dr. W.R. Aykroyd, Director, Nutrition Division, FAO
  • - Dr. F.W. Clements, Chief, Nutrition Section, WHO

As terms of reference the Expert Committee had two previous agreements adopted by the First World Health Assembly and by the Second Session of the Conference of the FAO, claiming to act as an advisory body to both organisations, working in close collaboration in “those fields of nutrition with which they are mutually concerned...”[1] The FAO had also started collaborative action with the United Nations International Children’s Emergency Fund (UNICEF), integrating feeding programmes with nutritional education involving administrators, public-health officers, medical practitioners, nurses and schoolteachers. The WHO-FAO Expert Committee on Nutrition considered programmes designed to raise the level of nutritional education to be one of the most important targets for better nutritional standards. Initially, two main types of training courses were conducted in member countries and others.[2]

Fellowships were seen as an important part of the general educational work. Three different categories were implemented. First were those granted for extended study, up to a year or more, in a recognised institution, and available to workers who would later participate in nutritional activities and coordinate campaigns in their own countries. They were geared towards medical and public health officers and nurses, administrators, managers associated with food production and food administration. Local leaders called upon to conduct anthropological actions were also included. Other grants went to policy makers and supervisors studying the implementation of nutrition programmes. Finally, other grants were oriented to senior workers in universities and research institutes. The instruction provided by experts in nutrition was considered to be essential for their participation in the programmes promoted by the FAO and the WHO.

Emphasising that the functions of the Nutrition Section of the WHO included the collection, evaluation and distribution of information on recent advances in the science of nutrition, the expert committee recommended that this service be extended to include information on the incidence of deficiency diseases associated with dietary shortcomings. An additional programme of technical assistance to help economic development including food was proposed for 1950 in the ordinary FAO budget, including a provision for nutrition advisory services on a larger scale, training for nutritional workers, the organisation of courses and support for research and provision of equipment and technical innovation at a suitable scale. The FAO Standing Advisory Committee on Nutrition stressed the need for improved food technology, and therefore a Technical Assistance Programme was proposed for further discussion. The WHO presented a nutrition programme for 1951 that aimed to assess a number of nutritional problems, including the evaluation of the nutritional status of population groups, as well as the calculation of caloric and nutritional requirements. Specific diseases, which were considered to represent central problems, were mentioned as a priority, such as: kwashiorkor, nutritional disorders affecting the vision and causing neuropathy and blindness; and loss of resistance to parasitic diseases due to nutritional deficiencies and some types of blood dyscrasia associated with malnutrition.

The WHO had made provision for fellowships and a number of them had been granted in the field of nutrition, while the FAO made provision for fellowships in its Technical Assistance Programme. In order to achieve an integrative policy and avoid duplication of duties, the mixed experts committee recommended coordination and prior consultation, the aim being to arrange for the training of the different types of specialists needed to deal with the problems of nutrition in any given country or region. This was so the recipients of fellowships, upon their return, could find adequate support from other specialists to develop balanced nutrition programmes in their countries. Training and education was geared towards administrators, physicians, nurses, social workers and schoolteachers. The pattern for regional and national training courses proposed by the FAO and the WHO was similar, sponsored and planned by national governments and held in national institutions. Some specific symposia and seminars to meet local needs and educational programmes for the general population were also included.5

Properly planned and conducted, surveys by the United Nations provided information on social welfare and the economic background. In addition, the FAO published reports and technical surveys on dietary patterns and food consumption levels; the International Labour Organization had published family living studies and the WHO drafted reports on the status of health and nutrition. The experts stressed that the value of this great amount of information on all these subjects was essential and requested coordinated action to publish all information at the same time to ensure its optimum use.

The joint committee also analysed the importance of specific nutritional deficiency diseases and the search for solutions. Endemic goitre was the first one considered. The joint committee urged governments to promote the use of iodised salt in regions in which supplying iodine was practicable as an easy solution with positive results. In association with governments, the WHO planned a further study of all factors intervening in the aetiology of endemic goitre and requested information on areas where endemic goitre had not been prevented by the administration of small amounts of iodine to the population.

Pellagra was a second case that was discussed upon request of the First Health Assembly. The committee had been informed that in some areas classical pellagra had been brought under control by the administration of niacin, even without general dietary improvement. No evidence was available to indicate that classical pellagra was of sufficient importance worldwide to warrant its high priority status in the joint FAO/WHO programmes in the immediate future. However, the formal reporting of cases of pellagra was stimulated and considered accurate.

One of the most widespread nutritional disorders in tropical and subtropical regions was a syndrome known by various names, the most popular one being kwashiorkor, but it was also known as malignant malnutrition, polydeficiency disease, m ’buaki, syndrome, depigmenta- tion-oedёme and infantile pellagra. It was defined as a disease of its own, unlike classical pellagra. The mixed committee rejected the name infantile pellagra, since it was not really a variety of pellagra. Epidemiologically speaking, it affected mostly children, with the highest incidence of the disease occurring in some parts of Africa. Considerable evidence suggested that it was associated with cirrhosis of the liver, a disease present in significant numbers in some parts of Africa and Central America, where kwashiorkor occurred in infants and children. The possible relationship between cirrhosis and the development of primary carcinoma of the liver was also recognised. The Joint Expert Committee recommended an inquiry be held by the WHO on the various signs and manifestations of the disease, including a clinical investigation, in an attempt to define and study clinical features of the disease and food habits, with particular reference being made to diet during pregnancy, lactation, infancy and early childhood.6 The inquiry was to be extended to areas in which the disease did not occur but which featured the similar diet patterns, in order to establish a correlation between food habits and the occurrence or incidence of the disease, defining the role played by other factors, such as tropical parasitism, in determining the variations in clinical manifestations.

The FAO Standing Advisory Committee on Nutrition placed special emphasis at its first meeting on the nutrition of pre-school children, because in some countries this group felt malnutrition more acutely than any other age group. In many parts of the world, weaned children were usually fed a diet that mainly consisted of cereal preparations, complemented with little or no milk at all. The wide prevalence of the aforementioned syndromes - although their aetiology was not clear - was associated with serious dietary deficiencies during early childhood and the experts thought that the ill effects of malnutrition during this time could be felt during adulthood. Therefore, the committee alerted the FAO to the great need for increased supplies of foodstuffs, milk in particular, which could prevent deficiencies in children’s diets. “In regions in which an immediate substantial increase in milk supplies is difficult, the production and use of foods and/or preparations which can act as a partial substitute for milk should be vigorously encouraged”.[3]

The attention of the joint committee was drawn to a related topic, stated in the following passage in the report of the subcommittee on fat- soluble vitamins of the Expert Committee on Biological Standardization, convened by the WHO in London in 1949: “The sub-committee considers that the value and usefulness of the international standards for vitamins might be increased if suitable methods of estimating the different vitamins in foodstuffs were to be proposed by WHO and FAO and recommended for general use”.[4]

Accurate knowledge of the vitamin content of foods was considered a necessity, essential for helping determine the nutrient content of diets. Such knowledge could be obtained only by analytical methods, which, with the technical assistance of the FAO, could be used in the preparation of international food composition tables containing vitamins and minerals. The analysis of vitamins in bodily fluids was another method employed in the assessment of the state of nutrition. Physical, chemical and biological testing methods were used in the analysis of foodstuffs in order to determine the physiological effects and the nutritional value of foods as sources of vitamins for human beings.

From the very beginning the Joint Experts Committee expressed their wish to prepare an international codex of analytical methods that would assist scientific workers worldwide to ensure uniform and comparable data was generated regarding the vitamin content of foods and diets. In a number of countries, certain methods for the detection and assessment of some vitamins were officially recognised, including methods for determining the vitamin content of foodstuffs. A global agreement was absolutely necessary for this and for the development of the pharmaceutical industry as well.

The US Association of Agricultural Chemists set out methods that were revised annually under the supervision of expert committees, and also gave detailed techniques for the preparation of various classes of foods prior to the actual assay.[5] Some countries in Western Europe were initiating a project that would prepare joint proposals for the classification, description and methods of food analysis. All these initiatives were able to facilitate the drafting of an international codex, an issue that was central to the standardisation of knowledge on biological products. As a result, the Joint Committee recommended that the FAO initiate work on analytical methods for the determination of vitamins in foodstuffs by a general survey of the problem and by exploring possible procedural methods. Correspondence with national organisations working in the field of food analysis was one of the options mentioned. Once a preliminary survey was drafted, a small expert committee would convene to consider the scope and to outline the methods to be followed by the FAO. At a later stage small groups of highly qualified specialists might be appointed to consider in detail methods for application to individual vitamins in various types of food. Collaboration with UNESCO and international non-governmental organisations, such as the International Union of Nutritional Sciences, were suggested as well.

The manufacture of synthetic vitamins in underdeveloped countries was also discussed at the first session of the Joint Committee held in 1950. Although the most satisfactory way to improve nutrition was considered to be via the supply of ordinary foods in the quantities and proportions needed to ensure a well-balanced diet, and sufficient amounts of all the nutrients needed for health, the experts recognised that there were circumstances in which the addition of vitamins to foods could be of value to prevent deficiencies. In many parts of the world the amount of food needed to supplement cereals or starchy root-based diets and make them nutritionally adequate was not available at the start of the 1950s. It was not a matter of availability, but its high cost, making the foods inaccessible to the majority of the population. As many years would have to elapse before nutritional requirements could be satisfied by the supply of such foods, synthetic vitamins were able to fill the gap in the meantime and help to minimise some of the existing dietary deficiencies. The Joint Committee endorsed the view of the FAO Nutrition Committee, expressed in its meeting in the Philippines, 1948, with reference to the enrichment of rice by thiamine and other nutrients.10 A significant reduction in deaths caused by beriberi was the result. At any rate, the experts stressed that enrichment programmes were not enough and should always be accompanied by other active measures to improve nutrition. On the other hand, the value of synthetic vitamins and vitamin concentrates in the prevention and treatment of food deficiency diseases and deficient states was fully recognised, and therefore the need for vitamins and concentrates for therapeutic purposes became increasingly important in regions in which typical diets were of low nutritive value and deficiency diseases were common.

The Joint FAO/Expert Committee recommended that the WHO assist member governments in deciding whether to undertake the manufacture of synthetic vitamins and provide all the advice needed to establish the industry. Work on calorie requirements had already been completed by the Nutrition Division of the FAO and a report of the Committee on Calorie Requirements was expected after the meeting in Washington, in September 1949. The FAO had intended to continue and expand this work by undertaking the study of nutrient requirements, making full use of data available throughout the world and of the experience gained in different countries. Regional nutrition committees and other nutrition institutions and workers in various regions would be asked to forward any relevant information at their disposal to the FAO.

Naturally, a country’s nutrition policy had to be based upon knowledge of the nutritional situation of the population, together with a consideration of dietary patterns, food supply and the economic context. A selected clinical examination of the population was able to give solid information of the nutritional status of the whole, and laboratory tests had also been devised to provide facts about the biochemical and physical state of organs and tissues. In some cases, laboratory tests were considered complementary to clinical findings.

Some countries had established their own methods of clinical testing and had set out standards to assess the nutritional status of the population, but there were others that were unable to do so due to lack of qualified workers and proper equipment. A series of schedules for use in the assessment of nutritional status prepared by an international group of experts would increase the value of national nutrition surveys, allowing for comparisons between conditions in various countries. Countries that had not already conducted surveys would be encouraged to do so.

The committee realised that there was a need for schedules for at least three types of survey:

  • 1. Rapid surveys for emergency purposes, using observation of gross clinical changes.
  • 2. Routine clinical surveys.
  • 3. Clinical surveys supported by experimental laboratory investigations.

Information on food consumption and dietary patterns had to be collected while the nutritional survey was conducted, and the results of the two types of survey correlated.11 To help these essential research inquiries, FAO experts prepared a booklet on dietary survey methodology and copies were widely distributed among national authorities and experts.12 As a consequence, the Joint FAO/WHO Expert Committee on Nutrition recommended the spread of standardised methods of assessment of nutritional status with the assistance of the FAO and the WHO and, since levels of nutrition differed all over the world, they suggested inquiries be performed at national and regional levels. Further investigation into nutritional status could be carried out by selecting one or more governments in an advisory capacity in different regions to help determine the most suitable methods for application in the region. At the same time, an international study group was expected to be convened by the WHO with the technical assistance of the FAO, to examine the reports from the various national groups and prepare a comprehensive report.

The Joint FAO/WHO Expert Committee noted that there existed national nutrition committees in many countries. They were under different names, status, structures and functions, falling roughly into five categories: those that were identical to national FAO committees; others which were subcommittees of these; others set up under one or more government departments, or by national research councils; and finally, nutrition institutes equipped with advisory and research functions in the field of food policies.13 In some countries the national nutrition organisation was an active body participating in nutrition programmes, whilst in other countries it was less effective or inexistent. According to the FAO-WHO nutrition experts;

National nutrition organizations are an important means of implementing the nutrition policies of FAO and WHO. The committee realizes that each national government must itself decide how this is to be done. It is essential that the various government departments through which FAO and WHO transmit information and requests relating to nutrition should be represented on national nutrition organizations. These organizations can be more effective instruments for the extension of both FAO and WHO nutrition programmes if problems are referred to them by the appropriate government departments.14 [6] [7] [8] [9]

The Joint Experts Committee also discussed the role of nongovernmental organisations, concluding that any organisation able to influence public opinion on the importance of food for health should be encouraged and supported. Therefore, the joint committee strongly recommended activities that would keep those organisations informed of plans and programmes, encourage them to pay attention to the work of the FAO and the WHO and assist in spreading this information to other national societies, as well as to maintain close ties with international scientific organisations, funds and foundations for mutual exchange of technical information.15 Similar policy was stimulated among other international organisations, such as the Organization for European Economic cooperation (OEEC), the Economic Commission for Asia and the Far East (ECAFE) and the Department of Natural Sciences of UNESCO in particular. Food and health became an economic, political and international relations issue.

Another subject discussed by the Joint Experts Committee was that of food regulations. Complex and sometimes even contradictory among the different countries, the situation of food regulations constituted a matter involving social conflict between consumers, authorities, producers, traders and other groups. Legal regulations, as well as norms on food preservation, technical terminology, standards of food quality and composition, all of these elements varied widely from country to country. International standardisation was once more the key to any possible solution. New legislation based on scientific knowledge was being introduced in the food industry and in the market. However, the conflicting nature of food regulations might have been an obstacle to trade in foodstuffs between countries and may have affected the distribution of valuable foods. The first Joint meeting was rich in content and in the definition of controversial issues that straddled the boundary between food and health.

A second Joint FAO/WHO Expert Committee on Nutrition met in Rome in April, 1951. During the biennium 1949-51, the FAO had focused its activities in assisting governments in establishing and carrying out food policies through tools and techniques, as well as raising awareness of the importance of the problems of nutrition and the need for effective measures to solve them. Practical aid to individual governments in the field was also included in some cases. Together with the Economic Division, the FAO revised the situation in many different countries and regions and tried to propose suitable technical plans for overcoming critical situations.

The FAO Food Composition Tables for International Use were published and distributed in 1949. They were used to cover proposals for 35 countries, including all the main foodstuffs classified into 11 groups. Those materials were the starting point of the several WFS published by the FAO in this period and discussed in the previous chapter. They included determination of the calorie requirement levels to be adopted in assessing the adequacy of food supplies and the establishment of the guiding principles for the definition of food consumption targets for 1960, examining these variables country by country, to ensure that all particularities were taken into account. Regional meetings were held in 1949 to give careful consideration to trends in food production, supplies and consumption targets for nations in Latin America, the Near East, Asia and Europe. Tables providing information on the caloric, protein and fat content of foods had also been published in the three official languages at the time in the United Nations: English, French and Spanish, and had been put to practical use in a number of countries. In 1951 this work was extended to include the calculation of the mineral and vitamin content of foods for the Food Composition Tables. Food technology and technical assistance programmes required closely coordinated work in this field of agriculture, fisheries and nutritional patterns, within the several divisions inside the FAO.

Due to its important strategic function, an international report on school feeding was in preparation when the second joint meeting took place, its main purpose being to increase interest in supplementary feeding and provide technical guidance to the governments when initiating school feeding programmes. An FAO nutrition officer visited different countries in Europe in 1950 in order to collect information on this subject, to discuss relevant problems with appropriate experts and coordinate information about the organisation of the existing programmes in the countries. FAO nutrition officers, in association with UNICEF, had given direct assistance in the organisation of school feeding programmes in Greece, the Philippines and Central America.

As a practical means of helping governments and nutrition workers design and carry out effective educational programmes, a great deal of material on this subject was collected, analysed and set out in the handbook Teaching better nutrition. A study of approaches and techniques}6 Among the questions considered in the book were: the organisation of national programmes of nutritional education devoted to the general public and special interest groups; the training of nutrition [10]

workers; the best teaching methods to make nutritional knowledge available; the preparation and handling of teaching materials; and the evaluation of materials and methods implemented to conform nutritional habits to scientific patterns. Information had been directly supplied on request by a number of countries.

On the other hand, following the standardisation aim, a handbook entitled Dietary Surveys: their technique and interpretation11 was published as well. Special attention was paid in the book to the most appropriate techniques to be applied for underdeveloped countries, where little was known about consumption levels.

A nutrition committee for South and East Asia was convened by the FAO in the Philippines in February, 1948, following a second meeting in Rangoon, Burma, in 1950, and two Conferences dealing with the problem of nutrition in Latin America took place in Montevideo (1948) and Rio de Janeiro (1950). Nutritional deficiencies were analysed, as well as training programmes and economic policies regarding prizes, food production, trade, subsidies and other important aspects concerning people’s access to food.

The FAO nutrition representative visited several European countries, including the Scandinavian countries, Finland, Ireland, Austria, Yugoslavia and Portugal, to obtain direct information and discuss national plans with the local authorities. The main purpose of these visits was to discuss food and nutrition problems and appropriate practical measures with government authorities, officers and nutrition workers. An FAO officer acted as attache to the Ministry of Coordination in Greece for three years, to assist with advice and coordination of nutrition activities and the creation of a government nutrition service in the Ministry of Agriculture. The programme was a comprehensive one, including the planning of food production and import programmes based on the nutritional needs of the population, assisting in the development of specific nutrition measures such as school feeding and education in nutrition programmes, and the training of workers to ensure continuity of such activities. The FAO also conducted a preliminary survey of the food and nutritional situation in Turkey in 1949, after a request from the Turkish government for assistance to establish nutrition services. The same FAO delegate working previously in Greece was assigned to Turkey in October 1950. A similar policy was developed by the FAO in Asian, African and American countries. [11]

  • [1] FAO, Report of the second session of the Conference, Washington, 1946.
  • [2] Joint FAO/WHO Expert Committee on Nutrition. Report of the First Session.Geneva, World health Organization Technical Report Series, No. 16, 1950.
  • [3] Ibidem, p. 16.
  • [4] World Health Organization Technical Report Series, 1950, No. 3, p. 9.
  • [5] Joint FAO/WHO Expert Committee on Nutrition. Report of the First Session, 1950,p. 17.
  • [6] Ibidem, p. 20.
  • [7] Dietary surveys. Their technique and interpretation. Washington, FAO, 1949.
  • [8] Joint FAO/WHO Expert Committee on Nutrition. Report of the First Session, 1950, p. 22.
  • [9] Ibidem.
  • [10] Teaching better nutrition. A study of approaches and techniques, Rome, FAO, 1950.
  • [11] Dietary Surveys: their technique and interpretation. Rome, FAO, 1949.
 
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